The emergency care model: A new paradigm for skilled nursing facilities

The population of individuals age 65 and older is increasing in the United States. One third of these individuals will utilize nursing home care before death. Nursing home residents (“NHR”) average 1.8 emergency department visits annually. Improving the quality of nursing home care is of vital importance. This project describes a new paradigm for the management of acute emergent health issues affecting NHR. The model features a multidisciplinary team coordinated by emergency providers resulting in a 55% reduction in unplanned hospital admissions compared to skilled nursing facility regional data. Additionally, a reduction in ancillary lab costs was observed. Implementation of this paradigm on a national scale could result in a projected cost savings in excess of $10 billion per year for the Center for Medicare and Medicaid Services (“CMS”).     

Evaluation of a Veteran-specific Clinic Video Telehealth Pilot Project

Clinical video telehealth (CVT) combined with telemonitoring for homebound veterans with chronic illnesses may improve outcomes for veterans with a chronic condition cared for at home. This retrospective chart review examined the number of emergency room visits, admissions, length of stay, scheduled home visits, and unscheduled home visits. An independent t test found fewer emergency room visits during CVT care compared with after CVT care and an increased number of unscheduled home visits after CVT compared with before CVT. As CVT expands, more research will be added to the growing body of knowledge. Positive findings indicate that CVT should be further studied in the chronically ill homebound population.     

Effect of nurse staffing on rehospitalizations and emergency department visits among short-stay nursing home residents: A Cross-sectional study using the US Nursing Home Compare database

The aim of this study was to examine the effect of nurse staffing on both rehospitalizations and emergency department emergency department visits among short-stay nursing home residents in the United States. Data for 11,132 US nursing homes were drawn from the 2016 Nursing Home Compare. We found that the Five-Star Quality Rating System's staffing rating is a significant predictor for the rates of rehospitalization and emergency department visit among short-stay nursing home residents. The results also showed the importance of registered nurse staffing in nursing home caring for short-stay residents. Administrators and policy-makers can employ the findings to formulate management strategies that will reduce rehospitalizations and emergency department visits among nursing home residents.     

Telephone interventions by nursing students: improving outcomes for heart failure patients in the community

Community care for heart failure patients is difficult due to multiple comorbidities, polypharmacy, and advanced age of patients. Studies show that hospital admissions and emergency room visits decrease with increased nursing interventions in home and community settings. The purpose of this study(1) was to assess the effectiveness of regular telephone interventions by nursing students on outcomes of heart failure patients in the home. Senior students were paired with community nursing staff and assigned 2 heart failure patients to follow up by telephone calls for 12 to 14 weeks. Patients who received telephone interventions had fewer hospital readmissions (13%) than the comparison group (35%). Patients in the telephone intervention group also had fewer overt heart failure symptoms as measured by the Minnesota Living With Heart Failure Questionnaire.     

Factors influencing emergency hospital admissions from nursing and residential homes: positive results from a practice‐based audit

Background and aims Emergency admissions of frail older people in care homes, many of whom have dementia, are critical events which should be avoided if possible. To identify and influence factors related to emergency admissions and place of death. Method Design of study: Completed audit cycle. Setting: Jenner Health Centre patients in six local care homes. Data collection over 12 months in 05/6, repeated in 08/9. Emergency admissions, admitting health professional, assessment prior to admission, length of hospital stay, annual visit workload and place of death. Results Admission numbers fell from 91 (194 patients) in 05/6 to 52 (183 patients) in 08/9, related to a fall in admissions by general practitioners (GPs) and out of hours (OOH). The proportion of admissions by care home staff doubled. There was a highly significant difference (P < 0.001), between GPs and OOH in patients visited prior to admission in 05/6 which persisted in 08/9 (P < 0.01). A hospital stay >72 hours was significantly more likely if patients were visited prior to admission. In 05/6, 55% of deaths occurred in the care home rising to 75.5% in 08/9 (total numbers deaths unchanged). There was a highly significant difference (P < 0.001 05/6 and 08/9), between deaths in nursing compared with residential homes. GP visits to nursing home patients rose by 10.3% but visits to residential home patients fell by 5.4%. Conclusions The aims of the audit were achieved with a 43% reduction in emergency admissions and a 45% reduction in deaths in hospital but at the expense of a 12% increase in visits. Improved anticipatory planning and increased medical and nursing support for patients and staff in residential homes may help to further reduce emergency admissions and deaths in hospital in future.     

Does Mandatory Inpatient Alcohol Detoxification Reduce Emergency Department Recidivism,Hospital Admissions,and Emergency Medical Services Transports for Patients with Chronic,Severe Alcohol Dependence?

Background: In Massachusetts, patients with chronic alcohol dependence can be committed to 30 days of mandatory inpatient alcohol detoxification (MAD). Study Objectives: To examine the effects of MAD on the number of emergency department (ED) visits, hospital admissions, and emergency medical service (EMS) transports. Methods: This retrospective study identified patients in our urban ED committed to MAD. We compared the number of ED visits and admissions to our hospital and Boston EMS transports to any facility in the 1, 3, and 6 months pre- and post-MAD, excluding the 30-day MAD period. Paired t tests were used for analysis of mean values across time. Results: Ten subjects were enrolled. Comparing pre- and post-MAD, the mean number of ED visits fell 6.5 to 2.7 (p = 0.05) in the first month, 14.2 to 9.3 (p = 0.18) in 3 months, and 25.6 to 17.7 (p = 0.15) in 6 months. Mean number of hospital admissions declined: 1.3 to 0.1 (p = 0.03) in 1 month, 2.3 to 0.9 (p = 0.06) in 3 months, and 3.2 to 1.9 (p = 0.08) in 6 months. Mean number of EMS transports fell 4.6 to 2.3 (p = 0.21) in the first month, 9.2 to 5.6 (p = 0.14) in 3 months, and 13.9 to 10.0 (p = 0.26) in 6 months pre- and post-MAD. Conclusions: MAD was associated with an immediate reduction in ED visits and hospital admissions that did not remain statistically significant long term, and a non-significant reduction in EMS transports.     

Advance directives and mortality rates among nursing home residents in Taiwan: A retrospective,longitudinal study

BackgroundNo data-based evidence is available regarding the best time for nursing home nurses to obtain residents’ signatures on advance directives, especially for do-not-resuscitate directives, the most common type of advance directive. This information is needed to enhance the low prevalence of advance directives in Asian countries.ObjectivesThe purposes of this study were to understand (1) the timing between nursing home admission and signing a do-not-resuscitate directive, (2) the factors related to having a do-not-resuscitate directive, and (3) the association between having a do-not-resuscitate directive and nursing home residents’ mortality in Taiwan.DesignRetrospective, longitudinal design.SettingSix nursing homes in Taiwan.ParticipantsNursing home residents (N = 563).MethodsData were collected by retrospective chart review with 1-year follow-up. Factors related to having a do-not-resuscitate directive were analyzed by multiple logistic regression, while associations between signing a do-not-resuscitate directive (resuscitation preference) and mortality were examined by Cox proportional hazard regression models.ResultsThe mean interval between nursing home admission and signing a do-not-resuscitate directive was 840.65 days (2.30 years), which was longer than the time from admission to first transfer to hospital (742.4 days). Having a do-not-resuscitate directive was related to whether the resident had a nasogastric tube (odds = 2.57) and the number of transfers to hospital (odds = 1.18). Among the 563 residents, 55 (9.77%) had died at the 1-year follow-up. Having a do-not-resuscitate directive was associated with a greater risk of death (unadjusted hazard ratio, 2.03; 95% confidence interval, 1.10–3.98; p = 0.02), but this risk did not persist after adjusting for age (hazard ratio, 1.89; 95% confidence interval, 0.99–3.59; p = 0.05).ConclusionEarly research recommendations to sign an advance directive, particularly a do-not-resuscitate order, on nursing home admission may not be the best time for Chinese nursing home residents. Our results suggest that the best time to sign a do-not-resuscitate directive is as early as possible and no later than 2 years (742 days) after admission if residents had not already done so. Residents on nasogastric tube feeding should be particularly targeted for discussions about do-not-resuscitate directives.     

Unprecedented heat-related deaths during the 2003 heat wave in Paris: consequences on emergency departments

In August 2003, France sustained an unprecedented heat wave that resulted in 14,800 excess deaths. The consequences were maximal in the Paris area. The Assistance Publique–H?pitaux de Paris reported more than 2600 excess emergency department visits, 1900 excess hospital admissions, and 475 excess deaths despite a rapid organization. Indeed, simple preventice measures before hospital admissions are only able to reduce mortality which mostly occurred at home and in nursing homes.     

A review of 2004, and with the new year comes a new look

In August 2003, France sustained an unprecedented heat wave that resulted in 14,800 excess deaths. The consequences were maximal in the Paris area. The Assistance Publique–Hôpitaux de Paris reported more than 2600 excess emergency department visits, 1900 excess hospital admissions, and 475 excess deaths despite a rapid organization. Indeed, simple preventice measures before hospital admissions are only able to reduce mortality which mostly occurred at home and in nursing homes.     

Influence of post-COVID-19 deconfinement on psychiatric visits to the emergency department

ObjectiveDuring the deconfinement period after the coronavirus disease-2019 (COVID-19) pandemic, the number and characteristics of psychiatric visits changed in our emergency department (ED). We aimed to assess changes in the number of visits and characterize the profiles of these patients.MethodsIn this retrospective observational study, we examined the number of psychiatric ED visits and their proportion among the total number of ED visits. We also evaluated psychiatric visits characteristics during a one-month period after the declaration of deconfinement, and we compared those characteristics to characteristics observed during the same month over the previous 4 years.ResultsThe number of psychiatric visits to our emergency department during deconfinement was similar to the number observed in the same month of previous years. However, the proportion of psychiatric visits to our emergency department among all visits to the ED rose during deconfinement to a level never before observed. The mean proportion of psychiatric admissions to all ED admissions rose from 3.5% in past years to 5.3% during deconfinement (p = 0.013). Moreover, during deconfinement, more visits (80%) were without an acute intoxication compared to past years (58.5%; p = 0.031). Also, in the deconfinement period, more visits lacked a follow-up consultation organized at discharge (40%) compared to the historical period (25%, p = 0.036).ConclusionsThe deconfinement period after the first wave COVID-19 changed the number and type of psychiatric emergency medicine consultations at our hospital, suggesting a psychiatric impact of confinement during this pandemic. These findings will be of interest to practitioners and politicians in the coming months.     

Community surveillance of falls among the elderly using computerized EMS transport data

Because falls are common among the elderly and are associated with high morbidity and mortality, community surveillance has been recommended. The purpose of this study was to characterize the impact of falls among the elderly on emergency medical transport services (EMS) and to explore the potential for community surveillance of falls through the use of computerized EMS data. Computerized EMS data and United States census data for 1990 for persons aged ≥65 in Forsyth County, NC, were used to produce EMS transport rates for falls and to make comparisons by age, gender, race, and residence (nursing home vs community). A fall was reported as the cause for EMS summons in 15.1% (613 of 4,058) of cases. Transport rates in 1990 for falls were 7.8 per 1,000, 25.4 per 1,000, and 58.5 per 1,000 for the age groups of 65 to 74 years, 75 to 84 years, and 85 years and older. Rates were higher for females than for males (17.1 per 1,000 v 8.1 per 1,000) and higher for whites than for African-Americans (14.3 per 1,000 v 10.3 per 1,000). Rates for nursing home residents were four times that of community residents (70.6 per 1,000 v 16.0 per 1,000). Over 50% of nursing home fallers were transported between midnight and 0400 compared with 25% of community dwellers. EMS summons for older adults reporting a fall accounts for a significant portion (15%) of all transports in this county. Computerized EMS data demonstrated patterns of falls among the elderly that are consistent with known demographic factors. The potential for using computerized EMS data as a practical means of community surveillance should be further explored.     

Evaluation of an interprofessional care coordination model: Benefits to health professions students and the community served

Background/Purpose: An innovative care coordination program was developed to enhance wellness among low-income older adults living in subsidized apartment buildings and to provide rich interprofessional education experiences for health professions students.MethodsProgram effectiveness for the residents was measured through an evaluation of participation, services used, and healthcare utilization. Educational effectiveness was measured through a change in health concepts and perceptions of interprofessional practice.FindingsHealth care utilization among participating residents showed an 8.6% reduction in emergency department visits and 9.8% reduction in hospital admissions. Students demonstrated improved knowledge in motivational interviewing (p = .02); diabetes (p = .02); hypertension (p≤.01); and frailty (p≤.01). Changes in students perception of interprofessional practice were significant in two areas; Teamwork and Collaboration (p≥.00); and Person Centeredness (p = .00).DiscussionThis care coordination model may be an effective approach to reduce care resource utilization among medically complex lower income older adults and provides a rich interprofessional learning experience for students.     

Impact of older age and nursing home residence on clinical outcomes of US emergency department visits for severe sepsis

Purpose

The purpose of this study is to compare the impact of older age and nursing home residence on the incidence and morbidity of severe sepsis.

Materials and Methods

This was a retrospective analysis of 19 460 emergency department visits from the 2005 to 2009 National Ambulatory Medical Care Surveys with diagnosis of infection with or without severe sepsis (acute organ dysfunction). Clinical outcomes included intensive care unit (ICU) admission, hospital length of stay (LOS), and in-hospital mortality.

Results

Older adults (age ≥ 65 years) were 5-fold more likely to have infections classified as severe sepsis than younger adults (6.5% vs 1.3%), and nursing home residents were 7-fold more likely to have a severe sepsis diagnosis compared with nonnursing home residents (14% vs 1.9%). Among visits for severe sepsis, older adults, compared with younger adults, had modestly higher rates of ICU admission (27% vs 21%), hospital LOS (median, 6 vs 5 days), and in-hospital mortality (24% vs 16%). Nursing home residents with severe sepsis, compared with nonnursing home residents, had significantly higher rates of ICU admission (40% vs 21%), hospital LOS (median, 7 vs 5 days), and in-hospital mortality (37% vs 15%).

Conclusions

Older adults and particularly nursing home residents have a disproportionately high incidence of and morbidity from severe sepsis.     

Outcome measures correlated with falls in nursing home residents—A pilot study

Most fall risk and normal values are collected from the community-dwelling population, which is not representative of nursing home residents. The purpose of this study was twofold: 1) to determine the relationship of clinical impairment and activity limitation variables to the number of falls in nursing home residents; and 2) to determine the amount of variability that can be explained for the number of falls from these predictor variables. Seventeen active nursing home residents (83.7 ± 11.7 years) consented to participate. Mini-Mental Status Examination (MMSE), lower extremity handheld dynamometry, ankle plantar flexion (PF)/dorsiflexion (DF) active range of motion (AROM), hand grip strength, gait speed (GS), Timed Up and Go (TUG), and 5 Times Sit-to-Stand (5TSTS) were recorded in a single visit. Regression analysis was performed to identify the better clinical outcome tool to determine falls. This was followed by a stepwise multiple regression model to predict the criterion variable—number of falls. Of the clinical impairment measures collected, significant correlations with past falls include the following: right DF AROM (?0.436; p = 0.040) and right DF strength (?0.504; p = 0.023). Of the activity limitation measures collected, significant correlations with past falls include the following: 5TSTS (0.585; p = 0.007); TUG time (0.475; p = 0.027); and GS (0.457; p = 0.032). The stepwise multiple regression model explained 59% of the variance using right DF AROM, right DF strength, 5TSTS, and TUG time. These measures are benchmarks for the community dwelling population. The present study indicates that these measures might also be useful in determining fall risk screening for ambulatory nursing home residents.     

Do nursing homes reduce hospital use?

This study applies data from the Manitoba Longitudinal Study on Aging for two purposes. First examined were the hospital-utilization patterns of elderly nursing home admissions during the 2 years before and 2 years after entrance into a facility. In addition, use of the hospital by these new admissions and by long-term nursing home residents was compared with that of the use by the elderly living in the community. When age, sex, and mortality rate are taken into account, the results indicate that, although both new admissions and long-term nursing home residents are sicker than their community counterparts, they are significantly less frequently hospitalized.     

A before and after study of the impact of Specialist Workers for Older People

Background  Case management of vulnerable older people by Community Matrons has been introduced into the UK. A locally designed case management approach, The Specialist Workers for Older People (SWOP) Service, was implemented by a Central England Primary Care Trust. Here we report an evaluation of this service.
Methods  Before and after study of 418 people (207 before; 211 after) aged ≥75 at high risk of emergency hospital admission. SWOPs carry out assessments of social and medical needs, produce individual care plans, coordinate care and refer to appropriate agencies. Univariable analysis was used to determine the association of SWOPs on changes in hospital admission rates and primary care workload.
Results  There was a non-significant reduction in hospital admissions from 0.91 to 0.67 per patient. There was a significant increase in routine GP surgery visits, from an average 1.3 to 2.6 per patient. The number of emergency home visits decreased from an average 2.8 to 1.1 per patient ( P  < 0.001).
Conclusions  Case management might reduce hospital admissions and is potentially a cost-effective service. However, not all case management schemes are successful. With the introduction of Community Matrons, it is important to understand what elements of the SWOP service contributed to its success.     

A before and after study of the impact of Specialist Workers for Older People

Background Case management of vulnerable older people by Community Matrons has been introduced into the UK. A locally designed case management approach, the Specialist Workers for Older People (SWOP) Service, was implemented by a Central England Primary Care Trust. Here, we report an evaluation of this service. Methods Before and after study of 418 people (207 before; 211 after) aged ≥75 at high risk of emergency hospital admission. SWOPs carry out assessments of social and medical needs, produce individual care plans, co‐ordinate care and refer to appropriate agencies. Univariable analysis was used to determine the association of SWOPs on changes in hospital admission rates and primary care workload. Results There was a non‐significant reduction in hospital admissions from 0.91 to 0.67 per patient. There was a significant increase in routine general practitioner surgery visits, from an average 1.3 to 2.6 per patient. The number of emergency home visits decreased from an average 2.8 to 1.1 per patient (P < 0.001). Conclusions Case management might reduce hospital admissions and is potentially a cost‐effective service. However, not all case management schemes are successful. With the introduction of Community Matrons, it is important to understand what elements of the SWOP service contributed to its success.     

Cost-effectiveness of including cromolyn sodium in the treatment program for asthma: a retrospective, record-based study

The treatment of chronic mild to moderately severe asthma is expensive for families and for society. Controlling the costs of asthma-related medications, physician visits, emergency room visits, and hospital admissions is therefore an important consideration. A retrospective, record-based study was undertaken to determine the costs of treating asthma in patients for whom cromolyn sodium was included in the routine treatment plan (n = 27) and those for whom treatment did not include cromolyn sodium (n = 26). Significant reductions in the number of emergency room visits and hospital admissions were obtained in patients who were treated with cromolyn sodium. The estimated average cost of emergency room visits was $33 a year for the patients given cromolyn sodium compared with $624 a year for patients in the comparison group. The estimated average cost of hospital admissions was reduced by $1,298 for the cromolyn sodium group compared with a $357 reduction for the comparison group. Computed for the entire course of treatment, the average (+/- SD) daily cost of medications for the comparison group was $0.84 +/- $0.37 versus $0.93 +/- $0.25 for the cromolyn sodium treatment group. Thus dramatic savings in costs of emergency room visits and hospitalizations when cromolyn sodium was included in therapy were effected at a small increase in the overall cost of medications. Analyzed visit by visit, the average daily cost of treatment that included cromolyn sodium decreased while that of the comparison group increased. We conclude that including cromolyn sodium in a regular anti-asthma regimen is a cost-effective and therapeutically effective treatment strategy.     

Do Patients With Advanced Cognitive Impairment Admitted to Hospitals With Higher Rates of Feeding Tube Insertion Have Improved Survival?

ContextResearch is conflicting on whether receiving medical care at a hospital with more aggressive treatment patterns improves survival.ObjectivesThe aim of this study was to examine whether nursing home residents admitted to hospitals with more aggressive patterns of feeding tube insertion had improved survival.MethodsUsing the 1999–2007 Minimum Data Set matched to Medicare claims, we identified hospitalized nursing home residents with advanced cognitive impairment who did not have a feeding tube inserted prior to their hospital admissions. The sample included 56,824 nursing home residents and 1773 acute care hospitals nationwide. Hospitals were categorized into nine groups based on feeding tube insertion rates and whether the rates were increasing, staying the same, or decreasing between the periods of 2000–2003 and 2004–2007. Multivariate logit models were used to examine the association between the hospital patterns of feeding tube insertion and survival among hospitalized nursing home residents with advanced cognitive impairment.ResultsNearly one in five hospitals (N = 366) had persistently high rates of feeding tube insertion. Being admitted to these hospitals with persistently high rates of feeding tube insertion was not associated with improved survival when compared with being admitted to hospitals with persistently low rates of feeding tube insertion. The adjusted odds ratios were 0.93 (95% confidence interval [CI]: 0.87, 1.01) and 1.02 (95% CI: 0.95, 1.09) for one-month and six-month posthospitalization survival, respectively.ConclusionHospitals with more aggressive patterns of feeding tube insertion did not have improved survival for hospitalized nursing home residents with advanced cognitive impairment.