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Patient Transfer from Nursing Home to Emergency Department: Outcomes and Policy Implications Jeffrey S. Jones, MD, Paul R. Dwyer; MD, Lynn J. White, MS, Russ Firman. MD
I
ABSTRACT .....................................................................................................................................................
Objective: To describe the process and outcomes of nursing home (NH) residents transferred to hospital EDs. Methods: This was a prospective, observational study conducted at 2 Midwestern community teaching hospitals during a 12-month period. All elder patients (>64years of age) transferred to hospital EDs from regional NHs were eligible for the study. Hospital records were used to abstract relevant descriptive and clinical data. Need for ambulance use was graded prospectively using 3 categories of urgency developed in other studies. Transfers were considered ’‘appropriate” based on outcome measures or if the problem necessitated diagnostic and/or therapeutic procedures not available in the NH. Transfer documentation was evaluated using a standardized 18-item checklist. Results: A total of 709 consecutive NH patients made 1,012 ED visits. Their mean age was 83.4 years (range 65- 100); 76% were female. The majority of patients (94%) were transferred by ambulance. Ambulance transfer was classified as emergent (16% of patients), urgent (45%), or routine (39%). There were 319 (45%) patients subsequently admitted to the hospital. Approximately 77% (546/709) of the NH transfers were considered appropriate by the emergency physician (EP). Sixty-seven patients (1 0%) were transferred without any documentation. For those patients with transfer documentation. 6 common discrepancies were identified. Conclusion: Although the majority of NH transfers in this population were appropriate, many patients were transferred without adequate documentation for the EP. Key words: elders; geriatrics; aged; patient transfer; nursing home; emergency department; outcome. Acad. Emerg. Med. 1997; 4:908-915.
I Concomitant with the burgeoning geriatric population tients slowly recover and are eventually discharged to the is the growth of nursing home (NH)populations. While community. Others may never be discharged. Judging a only 4.5% of America’s elder population reside in a NH patient’s change in health status is difficult in part because facility, 25% to 40% of all elders will require institution- of the training level of the NH staff. Many NHs are staffed alization in such a facility sometime in their lives.’ As predominantly by unlicensed workers with little or no forhealth care expenses mirror this growth, interest in cost- mal medical training.* Transfer of patients to an ED is effective care of the elder NH patient is steadily increas- necessary to provide simple medical care not available in the patients’ NH facilities.’-3 ing. Ambulance transfer to the ED is both physically and A “nursing home” is defined as an extended-care facility that provides intermediate or skilled nursing care to emotionally difficult for the NH patient and his or her individuals whose mental or physical conditions require family. Elder NH residents frequently have complicated care and services, above the level of room and board.’ health histories. However, due to low reimbursement polThe organization and extent of medical care provided in icies, the patient may not have a regular physician familiar these extended-care facilities vary greatly. Some NH pa- with his or her problems.2” Typically, care for acute illness .............. ... ............... is rendered in an episodic fashion by an emergency physician (EP) who is unfamiliar with the patient. The transFrom Burtenvodh Hospital. Grand Rapids, MI. D e p a m e n t of Emer- fer is expensive in terms of transportation, ED evaluation, gency Medicine (JSJ, PRD); and Akron General Medical Cenfer; hospital admission, and readmission to the NH.’ Finally, Akron, OH, D e p a m e n t of Emergency Medicine (JJW, RF). when admitted to the acute care hospital, the elder patient Received: December 12, 19%; revision received: February 20, 1997; faces the additional risk of iatrogenic illnessP accepted: March 17. 1997: updated: March 29. 1997. To develop guidelines to reduce the incidence of inappropriate ED transfers, we must understand the process Prior presentation: SAEM annual meeting, Washington, DC. May 1994. and outcomes of transferred patients. Little is known conAddress for correspondence and reprints: Jeffrey S. Jones, MD. Decerning the medical problems that necessitate transfer of partment of Emergency Medicine, Buttenvorth Hospital, I 0 0 Michigan Avenue, NE, Grand Rapids. MI 49503. Far: 616-732-3730; e-mail: an elder patient from an extended-care facility to an ED.’ We conducted a prospective study to examine the
[email protected]
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Nursing Home Transfers to ED, Jones et al.
priateness of these NH transfers (demographics, severity of illness, and emergency services required) and the quality of medical information sent with the patient.
I
METHODS ..........
.......................................
Study Design: This was a prospective, observational study conducted at 2 community teaching hospital EDs during 1993. The study evaluated the demographics, severity of illness, emergency services resources required, and quality of medical information sent with patients >64 years old who were transferred from NH facilities to these EDs. All conditions and procedures of the study protocol were approved by the institutional review boards at both participating hospitals. Setting: The study took place at Butterworth Hospital in Grand Rapids, MI, and Akron General Medical Center, OH. Both institutions are community teaching hospitals that have a heterogeneous mix of insured and uninsured patients. The combined ED census was approximately 80,000 adult patient visits during the 12-month study period. Nursing Home Population: Only patients transferred from skilled nursing or intermediate care facilities were evaluated. Patients who were repeatedly transferred to the ED during the study period were noted, but only the first ED visit was used in the final analysis. We used the following definitions: A skilled nursing care facility (SNF) is a NH that has been certified by Medicare or Medicaid as meeting federal standards within the meaning of the Social Security Act. The SNF primarily provides full-time skilled nursing care to injured, disabled, or sick persons, usually on a convalescent or longterm basis. An intermediate care facility (ICF) also meets federal standards for certification but provides less extensive health-related care. Residents in an ICF are not fully capable of living by themselves but not in need of 24hour care. In many states, the ICF is operated according to a medical model and is located in a NH that also provides skilled care. Elder patients transferred from other residential facilities (i.e., boarding homes, adult foster care, domiciliary care) have their own unique referral practices and were excluded from this study. Measurements: Data were obtained from 3 sources. The ED records of all study patients were analyzed for demographic, diagnostic, and treatment data. Medical charts were reviewed by a research assistant at each institution who was trained using a set of practice medical records. The abstractor was blinded to the specific purpose of the study. Standardized abstraction forms were used to guide data collection. Two of the investigators met frequently with the abstractors to resolve questions.
The second data source, the transfer form and other documentation sent by the nursing home with the patient, was reviewed using an 18-item checklist. This checklist was derived after review of the medical literature and input from members of the SAEM Geriatric Emergency Medicine Task Force. Third, a I-page questionnaire was completed by the treating physician during the NH patient’s evaluation in the E D (Appendix A). This form was attached to the chart during patient registration. Each question had a set of specific responses. Physicians were asked to determine the need for ambulance use, the appropriateness of NH transfer, and whether the NH sent along appropriate patient information. The need for ambulance use was graded using 3 categories of urgency used in other s t ~ d i e s ~ .and * * ~defined as emergency (death or permanent morbidity will result if there is no treatment within 1 hour), urgent (threat exists to life or bodily functions if care is delayed >I2 hours), or nonurgent (evaluation and treatment could have waited until another day). The “appropriateness” of NH transfers was determined using the 3 criteria used by Bergman and Cla~-field.~ Transfers resulting in hospital admission were considered appropriate. Transfers to the ED with return to the NH without hospital admission were judged appropriate if, based on the EP‘s assessment, the problem necessitated diagnostic and/or therapeutic procedures unavailable in the NH. Since death in the ED is typically an index of illness severity, this was the third category considered appropriate.
Data Analysis: All data were recorded in an epidemiologic database (Epi Info, USD Inc., Stone Mountain, GA) for retrieval and data analysis. Descriptive statistics (mean & SD, frequency tables) were used to characterize the survey results. The 95% confidence intervals (CIS) were calculated based on the exact binomial distribution.
I
RESULTS
.....
..........
.......
A total of 709 NH patients made 1,012 consecutive transfers to the ED. This represents 1.3% of all adult ED visits during the study period. There were 119 patients ( I 6.8%) who were transferred 2-3 times, and 56 (7.9%) 4-6 times. The mean patient a g e was 83.4 2 6.6 years (range 65-100); 76% of the patients were female. Patients were sent from 96 NH facilities (55-MI; 41-OH). The majority of these referring NHs (96%) were independent, forprofit facilities. The mean facility size was 96 beds (range 35-180). Eighty-five NHs (89%) had a mixture of skilledcare and intermediate-care beds. Eleven (1 1%) were certified as intermediate-care beds only. None of the NHs had any type of organizational relationship to the hospitals or EDs participating in the study. Ninety-four percent of the NH transfers were done by
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ACADEMIC EMERGENCY MEDICINE SEP 1997 VOL 4/NO 9
" r n
25 rn
-
c.
.-g 20
-3
k
15
CI 0
& 10 5 0
00000400
04000800
0800120016001200 1600 2000 Time of Presentation
20002400
I FIGURE 1. Time of ED presentation by nursing home patients.
urgent in 49% (95% CI 45-53%), and routine in 35% (95% CI 3 1-39%) of the cases. Sixty-seven elder patients (10%; 95% CI 8-12%) were transferred to the ED without any documentation from the NH. For those 642 patients who had some transfer documentation, the medical information generally provided in the transfer form is listed in Table 3. Common discrepancies were a lack of documentation of advance directives, immunizations, baseline mental status or functional abilities, diet, recent vital signs, or past medical history. Additional problems identified prospectively by treating EPs included: recent x-rays and ECG.s not transferred with patients, advance directives not followed in NH, no critical care plan, and patients transferred without appliances (hearing aid, glasses). And finally, the on-call NH physician was not successfully contacted by telephone prior to the transfer in at least 84 cases (12%; 95% CI 9- 15%).
I ...................................................................... DISCUSSION ambulance, usually staffed by paramedics. Patients typically presented during afternoon and evening hours (Fig. 1). The transfers were evenly distributed by day of the week. In Table 1, the common reasons given by the NH personnel for ED transfer are listed. The most common presenting complaint was evaluation after a fall. Tube dysfunction (accounting for 4.2% of all transfers) included urinary catheter, feeding tube, and tracheostomy problems. Nonspecific symptoms included such complaints as weakness and dizziness, fatigue, and anorexia. The remaining 23% of patients had 3 1 different presenting complaints, such as dehydration, seizures, epistaxis, hyperglycemia, constipation, rash, and palpitations. The primary ED diagnoses are listed in Table 2. Traumatic injuries accounted for the majority of NH transfers, followed by infections, complications of diabetes mellitus, dehydratiodelectrolyte abnormalities, and cerebrovascular disease. The majority of patients (83%) had >1 ED diagnosis. Of the 709 NH transfers, 319 patients (45%) were subsequently admitted to the hospital, 16 died in the ED; and 5 were transferred to another hospital for admission. The mean length of hospital stay was 15.1 5 31.6 days (range 3-124). Although 369 patients (52%) were returned to the NH after ED evaluation, the majority of all NH transfers (77%; 95% CI 74-80%) were considered appropriate. Generally these patients required rapid laboratory or radiologic evaluation not available in the NH. Examples of inappropriate NH transfers included patients with uncomplicated cystitis, simple lacerations, infected sebaceous cyst, bronchitis. conjunctival hemorrhage, and chronic musculoskeletal pain. Ambulance transfer (666 patients) was classified as emergent in 16% (95% CI 13-19%).
Each year >25% of patients living in NHs are transferred to a hospital or an ED for evaluation and treatment."." In addition, recurrent transfers occur for some patients, leading to the ping-pong pattern between NHs and hospitals." Approximately 17% of our patients were transferred 2-3 times during the year, and 8% were transferred 4-6 times. These recurrent transfers probably reflect multiple factors, including the number and complexity of older patients' medical problems, altered cognition, functional impairments (e.g., limited mobility), and inappropriate placement of patients in NH facilities that are underequipped to meet their complex medical needs. The most frequent reason for transfer to the E D was related to falls and associated injuries (Table 1). InterestI
TABLE 1 Common Reasons Given by the Nursing Home for Patient Transfer to the ED ..............................................................................
Fall Altered mental status Dyspnea, cough Nausea, vomiting Abdominal pain Fever Laceration Tube dysfunction Chest pain Focal neurologic deficits Nonspecific symptoms Extremity trauma Nontraumatic joint pain Back pain Miscellaneous*
87 (1 2.3%) 66 (9.3%) 56 (7.9%) 51 (7.2%) 43 (6.1%) 42 (5.9%) 33 (4.7%) 30 (4.2%) 29 (4.1%) 26 (3.7%) 24 (3.4%) 22 (3.1%) 19 (2.7%) 17 (2.4%) 164 (23.1%)
*Includes all categories below 2% and represents 3 1 different presenting complaints, such as dehydration. seizures. epistaxis, hyperglycemia, constipation, rash, and palpitations,
Nursing Home Transfers to ED, Jones et al.
ingly, a substantial number of fall-related injuries occurred in nonambulatory patients (e.g., falls while sitting or transfemng to bed). This finding differs from previous work in NH residents associating mobility with increased risk of and underscores the need to develop separate prevention strategies for this group. Despite the ability of many NHs to provide IV fluids, antibiotics, and nebulizer treatments, residents were typically transferred to the ED prior to initiation of therapy. Perhaps some interventions (e.g., IV hydration and IV antibiotics) were deemed too complex by the attending physicians for the NH to provide or were presumed unnecessary because of low patient acuity. A recent report suggested that financial constraint may be another possible explanation for the low use of IV fluids and antibiotics in NHs.” Although Medicaid reimburses the supply pharmacy for medications (i.e., fluids or antibiotics) ordered, nursing time is reimbursed under a direct charge for normal room and board. Therefore, the extra time needed to administer and monitor a patient with IV fluids may be inadequately reimbursed. In the present study, 12% of the elder patients were transferred to the ED without the charge nurse successfully contacting the attending physician or the physician on-call for the NH. This is consistent with the study by Brooks et al.,” who reported that fewer than one third of NH residents were examined by a physician before the decision to transfer. In fact, in 68% of their NH transfers, the physicians only telephoned the facility, and the mean interval between notification by the NH and a return call from the physician was 5 hours. This degree of physician involvement is generally consistent across NHs studied in urban or suburban setting^.^.^,'^ Although many transfers (77%) were considered by the EPs to be appropriate in this study, a reduction in transfer rate may reduce health costs and limit the risk of iatrogene~is.~.’~ Ideally, the examination of an acutely ill NH patient should take place in the NH, in a timely manner, by a physician or midlevel practitioner familiar with the patient’s condition.” Zimmer et al.I5 successfully instituted an innovative program that provided financial incentives through Medicare to care for acutely ill patients in the skilled nursing facility. Another approach by Kane et a1.l6 has also shown promising results by providing medical care to NH patients using nurse practitioners and physician assistants. Similar studies are needed to analyze the cost-effectiveness and clinical outcomes of treating acute illness in the NH without the disruption created by a transfer to a new clinical setting. The majority of the patients in our study population were transported by ambulances staffed by paramedics. Ambulance use was obtained for emergencies, for bedridden patients who were difficult to transport sitting, for disruptive patients requiring supervision, and for inexplicable reasons in patients with minor complaints. Even
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I
TABLE 2 Primary ED Diagnoses Given to Nursing Home Patients (ICD-9 Categories)*
Fracture Urinary tract infection Complications of diabetes mellitus Heart failure Chronic obstructive pulmonary disease Pneumonia and influenza Open wound Cerebrovascular disease Ischemic heart disease Dehydration Tube replacements Electrolyte disorders Contusions Hypertension Medication side effects Miscellaneous
85 (12.0%) 77 (10.8%) 54 (7.6%) 46 (6.5%) 40 (5.6%) 37 (5.2%) 35 (5.0%) 33 (4.7%) 31 (4.4%) 29 (4.1%) 28 (3.9%) 24 (3.4%) 20 (2.8%) 16 (2.3%) 10 (1.4%) 144 (20.3%)
*The majority of patients (83%) had > I ED diagnosis.
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TABLE 3 Information Provided in Nursing Home (NH) Transfer Documentation (n = 642) ..............................................................................
NH facility name and address Reason for transfer Current medications Nearest relative or guardian Dosages of prescription medications Name of NH physician on call Recent history leading to transfer NH charge nurse name/phone number Drug allergies Insurance information Name of primary physician Previous medical history Usual mental status Diet Description of functional status Recent vital signs Record of immunizations Advance directives
556 (86.6%) 494 (76.9%) 488 (76.0%) 466 (72.6%) 450 (70.1%) 428 (66.7%) 418 (65.1%) 415 (64.6%) 405 (63.1%) 386 (60.1%) 375 (58.4%) 339 (52.8%) 300 (46.7%) 278 (43.3%) 213 (33.2%) 207 (32.2%) 90 (1 4.0%) 51 (7.9%)
without treatments e n route, these ambulance trips are generally quite expensive.2 Emergency medical services (EMS) agencies, at least i n some areas, have reacted to the growing number of geriatric patients with nonemergent problems by using only attendants to transfer elder patients. These personnel are not radio-directed by a base physician, as are paramedics, and may provide little more than mere transport.’ Other EMS systems are using vehicles specifically designated as convalescent care vehicles for the routine transfer of elder patients from one facility to another.” Clinical judgment will be needed to determine what level of transportation is indicated for any particular medical condition, taking into consideration patient and family preferences. Regardless of how a N H patient is transferred to the ED, the process can be done efficiently and professionally
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with good communication between facilities as to what is the nation. At the option of the state, surveyors are inneeded. More commonly, however, there is a breakdown structed to question: in communication as to the history, presence of advance If staff reported a significant change in medical status directives, record of immunizations, and baseline cognito the supervising physician, did the physician answer tive and functional status (Table 3). Many of the problems the call? are the result of differences in mind-sets and models of Are residents sent to hospital EDs routinely because the care used in emergency medicine and NH facilities.” The facility does not always have a physician on call for process could be greatly improved by a universal transfer medical emergencies? form that provides necessary information to the ED on For what reasons are residents sent to hospital EDs?” transfer of the patient. However, the development of such a transfer form would require the collaboration between EPs, nurses, out-of-hospital personnel, geriatricians, and I LIMITATIONS AND FUTURE OUESTIONS ..... the staff of extended-care facilities. In 1995, the SAEM Geriatric Emergency Medicine Task Force, using the pre- Any study of NH facilities or transfers is hampered by liminary results of this study, produced a 1-page transfer the different levels of care provided by these facilities. form that can be adapted for universal use in local com- The term “nursing home” may designate a facility that not only has long-term care beds but also provides evalmunities (Appendix B).” The federal antidumping law contained in the Consol- uation services and rehabilitation, as well as varying levels idated Omnibus Budget Reconciliation Act (COBRA) of acute care. Different admission criteria also lead to does not apply to NH patients transferred to the ED. Un- varying degrees of patient dependency and dissimilar der this legislation, NHs are not considered emergency casemixes. The level of training and the number of medtreatment facilities.” Therefore, they are not required to ical and nursing staff are important variables. Finally, the adhere to these more rigorous standards, such as providing organizational relationship with the acute care hospital, its an appropriate screening examination prior to patient proximity, and its availability of housestaff vary from one transfer. National standards for care in NHs are based on NH to another. These limitations should be considered public policy set forth in the Nursing Home Reform Act before applying the results of this study to other teaching of 1987. This law, as part of the Omnibus Budget Rec- and community EDs. Another difficulty concerns the accuracy of the proonciliation Act (OBRA), is often referred to as OBRA 87. (It became effective in 1990.20)Although these regulations spective data collection (Appendix A). The 1-page quesaddress a broad range of general and administrative as- tionnaire was completed by >75 treating physicians at the pects of NH care, several areas may have an impact on 2 institutions during the study period. The physicians were not blinded to the study objectives or the planned data resident transfers and transfer documentation. The regulations state that the facility must maintain a analysis. This knowledge may have resulted in some comprehensive, accurate assessment of each resident’s data’s being interpreted in a manner that fit the physician’s medical history, current medical status, functional status, belief system. It is also possible that our respondents ofsensory and physical impairments, nutritional status, med- fered answers they believed we were interested in obtainications and treatments, psychosocial and cognitive status, ing (i.e.. response bias). We attempted to minimize this and advance directives. If a resident’s condition deterio- by providing specific definitions for terms used in the surrates or complications develop, documentation must also vey (e.g., categories of urgency), by providing sets of multiple-choice responses for each question, and by inshow why such situations were medically unavoidable.”” A medical fact sheet summarizing this information would dicating that there were no expected answers. The categories of urgency are difficult to determine provide adequate transfer documentation necessary for the for patients in the ED with undifferentiated symptoms. We ED evaluation. OBRA 87 also requires NH facilities to have written chose to define urgency using the treating physician’s perpolicies regarding emergency care, patient transfers, and spective in terms of time until medical care was needed discharges. The medical director is given the responsibil- (i.e., emergent, urgent, nonurgent). Criteria based on the ity for monitoring and ensuring implementation of these patient’s perspective have been developed in response to policies and providing oversight and supervision of phy- the need to take into account nonmedical factors that afsician services and the medical care of residents.” When fect the patient’s choice of the ED as the site of care.23 the medical director receives a report of possible inade- Although the definitions of critical medical endpoints quate medical care, or inappropriate hospital transfer, he have differed slightly from one set of criteria to another, or she is responsible for evaluating the situation and tak- they have been generally ~ o m p a r a b l e . ” . ~ ~ ing appropriate steps to correct the problem. As of OcAs public policy continues to influence the flow of tober 1990, federal and state surveyors began using these patients between NHs and hospitals, future research will guidelines for their inspection tours of NHs throughout be needed to determine the impact of changing patterns
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Nursing Home Transfers to ED, Jones et al.
on emergency care admissions. For example, as hospitals face increasing competition, many may seek ways to tap the elder market.24 Some hospital managers are making broader transfer agreements with NH administrators, facilitating easy hospital admission of acutely ill NH residents if the NHs will readmit them expeditiously. A NH’s most expensive patients (in staff contact hours) may soon be among the most profitable diagnostic patient groups admitted to hospitals for short stays.24 Finally, future investigations might consider the impact of a uniform transfer form on the quality of NH documentation, the physician decision-making process in transferring NH patients, characteristics of recurrent transfers (ping-ponging) among elder NH patients, the cumulative effect of OBRA 87 on NH transfers, and the ethical considerations of a do-not-transfer policy for terminally ill or severely demented residents. These questions will have to be addressed in order to develop models of medical care appropriate for the increasing number of elder patients entering NHs in the United States.
I , .CONCLUSION ........... ............. Although 77% of NH transfers in this population are appropriate, many patients are transferred without adequate documentation. Common discrepancies were a lack of documentation of advance directives, immunizations, baseline mental status or functional abilities, diet, recent vital signs, and past medical history. Additional problems identified by treating EPs included: recent x-rays and ECGs were not transferred with patients, advance directives were not followed in the NH, there was no critical care plan, patients were transferred without their appliances, and the on-call NH physician was not contacted prior to the patient’s transfer. This study was supported in part by a grant from the SAEM Geriatric Emergency Medicine Task Force and the John A. Hartford Foundation. New York. The authors gratefully acknowledge the staff of the Cook Research and Education Institute for their assistance with the data collection.
I REFERENCES 1. Tresch DD, Simpson WM. Burton JR. Relationship of long-term and acute-care facilities: the problem of patient transfer and continuity of care. J Am Geriatr SOC. 1985; 33:819-26. 2. Kerr HD. Byrd JC. Nursing home patients transferred by ambulance to a VA emergency department. J Am Geriatr SOC.1991; 39:132-6. 3. Gillick M. Steel K. Referral of patients from long-term to acute-care
facilities. J Am Geriatr Soc. 1983; 31:74-8. 4. Health and Public Policy Committee of the American College of Physicians. Long-term care of the elderly. Ann Intern Med. 1984; 100: 760-3. 5. Bergman H, Clarfield AM. Appropriateness of patient transfer from a nursing home to an acute-care hospital: a study of emergency room visits and hospital admissions. J A m Geriatr SOC.1991: 39:1164-8. 6. Steel K. Iatrogenic disease on a medical service. I Am Geriatr SOC. 1984; 32445-9. 7. Eliastam M. Elderly patients in the emergency department. Ann Emerg Med. 1989; 18:1222-9. 8. Radernaker AW, Powell DG, Read JH. Inappropriate use and unmet need in paramedic and non-paramedic ambulance systems. Ann Emerg Med. 1987; 16:553-6. 9. Lowenstein SR, Crescenzi CA, Kern DC, et al. Care of the elderly in the emergency department. Ann Emerg Med. 1986; 15528-35. 10. Lewis MA, Cretin S, Kane RL. The natural history of nursing home patients. Gerontologist. 1985; 25:382-8. 11. Brooks S, Warshaw G, Hasse L. Kues JR. The physician decisionmaking process in transferring nursing home patients to the hospital. Arch Intern Med. 1994; 154:902-8. 12. Tinetti ME, Liu W, Ginter SF. Mechanical restraint use and fallrelated injuries among residents of skilled nursing facilities. Ann Intern Med. 1992; 116:369-74. 13. Wells BG, Middleton B, Lawrence G, et al. Factors associated with the elderly falling in intermediate care facilities. Drug Intel1 Clin Pharmacol. 1985; 19:142-5. 14. Ouslander JG. Reducing the hospitalization of nursing home residents. J Am Geriatr SOC. 1988; 36:171-3. 15. Zimmer JG, Eggert GM, Treat A, Brodows B. Nursing homes as acute care providers: a pilot study of incentives to reduce hospitalizations. J Am Geriatr SOC.1988; 36:124-9. 16. Kane RL, Garrard J. Buchanan IL, Rosenfeld A, Skay C. McDermott S. Improving primary care in nursing homes, J Am Geriatr SOC. 1990; 39~359-67. 17. Wofford JL, Schwartz E. Byrum JE. The role of emergency services in health care for the elderly: a review. J Emerg Med. 1993; 1 1 :31726. 18. Sanders AB, Wilzke DB, Jones IS, Richmond K, Kidd A. Principles of care and application of the geriatric emergency care model. In: Sanders AB (ed). Emergency Care of the Elderly Person. St. Louis. MO: Beverly Cracorn Publications, 1996, pp 59-93. 19. Omnibus Budget Reconciliation Act (OBRA) 1989, Sections 6018 and 621 1. Amending Social Secunty Act and 42 U.S.C. 1395dd at Sections 1866 and 1867. 20. The Federal Register, vol 56, no. 187, September 26. 1991, pp 48865-921. 21. Ouslander JG. Osterweil D. Physician evaluation and management of nursing home residents. Ann Intern Med. 1994; 121:584-92. 22. Elon RD. Omnibus Budget Reconciliation Act of 1987 and its implications for the medical director. Clin Geriatr Med. 1995; 1 1:41927. 23. Gifford MJ, Franaszek JB, Gibson G. Emergency physicians’ and patients’ assessments: urgency of need for medical care. Ann Emerg Med. 1980; 9:502-7. 24. Rubenstein LZ, Ouslander J G , Wieland D. Dynamics and clinical implications of the nursing home-hospital interface. Clin Geriatr Med. 1988; 4:471-91.
(The appendixes appear on the following pages.)
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APPENDIX A One-page Prospective Questionnaire 1. Please grade the need for ambulance use by circling one of the following categories of urgency. A. Emergency (death or permanent morbidity will result if there is no treatment within 1 hour) B. Urgent (threat exists to life or bodily functions if care is delayed >12 hours) C. Nonurgent (evaluation and treatment could have waited until another day). 2. Was the transfer from NH to ED appropriate? (Yes/No/ Unsure) 3. If the NH transfer was appropriate, indicate why: A. Transfer resulted in hospital admission B. Patient required diagnostic and/or therapeutic procedures unavailable in the NH C. Death in ED D. Other reason, please specify:
4. Was there transfer documentation from the NH? (Yes/No/ Unsure)
5 . Was the transfer information adequate? (YedNoNnsure)
6. Identify any problems with NH transfer process (Circle all that apply): A. Inadequate transfer information B. Recent x-rays and/or ECGs not transferred with patient C. Advance directives not foflowed in NH D. Patient transferred without appliances (hearing aid, glasses) E. On-call NH physician was not contacted by telephone prior to patient’s transfer F. Other problem, please specify:
APPENDIX B Universal Nursing Home Transfer Form (Reproduced with permission from: Sanders AB (ed). Emergency Care of the Elder Person. St. Louis, MO: Beverly Cracom Publications, 1996.)
Nursing Home Transfers to ED, Jones er al.
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Jursing Home to Hospital Transfer Form lame 'ransferring facility rddress
DOB
Gender Religion Phone
Iates of stay ;S4
Medicare #
Insurance 8
lesponsible relafiveiguardian iddress 'hysician
Phone Phone
Ither physician lateitime of transfer 3eason for transfer 'hysician orders on transfer 4ospitalsifacilities discharged within 60 days idvance directives Mica1 care plan Vlergies
Nurse
Phone
Fiecent vital signs
Immunizations
dedications Ither treatments (PT, resp. diet, etc.) Jast medical history 3imary diagnosis Secondary diagnosis Surgical history robaccoialcohol 3ASELINE INFORMATION 4mbulation 4ctivities of Daily. Living 3athing 3ressing
Transfer Continence
ToiIe t ing
Feeding
Disabilities 4mputation Paralysis
Contracture Decubitus ulcer
Impairments Speech Hearing
Vision Sensation
Usual Mental Status Alert
Oriented
Wanders
Combative
Confused
Withdrawn
Other Mini-mental status Appliances/supports (e.g., wheelchair. cane, walker. prosthesis) Other information to emergency providers
