Transitions of Care for the Geriatric Patient in the Emergency Department

Department of Emergency Medicine, Combined Internal Medicine/Emergency, Medicine Residency, University of Illinois-Chicago, 1700 West Taylor, Chicago, IL 60612, USA
Clinics in Geriatric Medicine (Impact Factor: 3.19). 02/2013; 29(1):49-69. DOI: 10.1016/j.cger.2012.10.005
Source: PubMed

ABSTRACT This article reviews and summarizes more than 200 studies regarding key issues surrounding the transition of elderly patients to or from the emergency department (ED), with particular attention paid to the relationship between the ED and nursing homes. Transfers of care often occur with incomplete information, which results in increased morbidity, recidivism, and cost. Transitions of elderly patients could be improved by standardizing hand-offs processes, improving discharge planning for elderly patients, developing metrics for transfers of care and geriatric care quality, and finding sustainable sources of research funding.

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    ABSTRACT: Background Western countries have encountered an increase in elderly patients transferred from residential aged care facilities to emergency departments. This patient cohort frequently experience impaired physical and cognitive function. Emergency department staff require important clinical and personal patient information to provide quality care. International studies show that documentation and handover deficiencies are common. Objective The purpose of this literature review was to explore transitional communication practices, and to consider the specific patient information deemed essential for the management of residents in the emergency department. Methods A literature review was conducted to examine the studies exploring the documentation accompanying elderly people who were transferred from residential aged care facilities to emergency departments. Scopus, OVID Medline and Cinahl Plus data bases were searched using combinations of the following key words: ‘nursing home’, long-term care’, ‘skilled nursing facility’, ‘aged care facility’, ‘communication’, ‘documentation’ ‘emergency department’, ‘emergency room’, ‘hospital’, acute’, ‘transfer’, and ‘transition’. Additional data was located with the use of Google Scholar. Review of titles and exclusion of duplicates identified 69 relevant studies. These 69 papers were independently reviewed by three members of the research team for eligibility in the study, and seven papers formed the final group for review. Results There is currently no consensus regarding what information is essential when residents are transferred from aged care facilities to emergency departments, and practices vary. Key information which should accompany the resident has been reported by various authors include the reason for transfer, past medical history, current medications, cognitive function and advance directives. Some authors also suggest that facility contact details are essential. Without agreement by key stakeholders as to what constitutes ‘essential transfer information’, clinical practices will continue to vary and resident care will be affected. Conclusion This paper identifies frequent communication deficits in the information provided to the emergency department from aged care facilities. There is an imperative to identify suitable items of information which health care professionals agree are essential. Future research should focus on methods to improve the transfer of information between facilities, including consensus regarding what information is essential transfer data.
    International Journal of Nursing Studies 11/2014; 51(11). DOI:10.1016/j.ijnurstu.2014.06.002 · 2.25 Impact Factor
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    ABSTRACT: Background Increasing numbers of residents are transferred from aged care facilities to emergency departments. Frequently, residents arrive with inadequate documentation regarding their presenting complaint or medical history, making it difficult for emergency department staff to make decisions about care. Methods A retrospective review of emergency department records was undertaken for residents transferred from residential aged care facilities to two emergency departments in Melbourne, Victoria in 2012. Results 2880 resident transfers were included in the sample, of which 408 transfers were randomly selected for documentation review. Clinically important documentation was frequently absent including: the reason for transfer to the ED (n = 197, 48.2%); baseline cognitive function (n = 244, 59.7%); and vital signs at time of complaint (n = 285, 69.9%). When the reason for transfer was absent, residents with an altered conscious state had more investigations and spent longer in the emergency department than when the reason for transfer was recorded. Conclusion Inadequate documentation negatively impacted the resident's journey through the emergency department. There is evidence that inadequate documentation contributes to poor patient outcomes. To minimise the gaps in the transfer documentation regular staff development and quality assurance programs may be required in residential aged care facilities.
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    ABSTRACT: Historically, emergency department (ED) patients with pulmonary embolism (PE) have been admitted for several days of inpatient care. Growing evidence suggests that selected ED patients with PE can be safely discharged home after a short length of stay. However, the optimal timing of follow up is unknown. We hypothesized that higher-risk patients with short length of stay (<24 hours from ED registration) would more commonly receive expedited follow up (≤3 days). This retrospective cohort study included adults treated for acute PE in six community EDs. We ascertained the PE Severity Index risk class (for 30-day mortality), facility length of stay, the first follow-up clinician encounter, unscheduled return ED visits ≤3 days, 5-day PE-related readmissions, and 30-day all-cause mortality. Stratifying by risk class, we used multivariable analysis to examine age- and sex-adjusted associations between length of stay and expedited follow up. The mean age of our 175 patients was 63.2 (±16.8) years. Overall, 93.1% (n=163) of our cohort received follow up within one week of discharge. Fifty-six patients (32.0%) were sent home within 24 hours and 100 (57.1%) received expedited follow up, often by telephone (67/100). The short and longer length-of-stay groups were comparable in age and sex, but differed in rates of low-risk status (63% vs 37%; p<0.01) and expedited follow up (70% vs 51%; p=0.03). After adjustment, we found that short length of stay was independently associated with expedited follow up in higher-risk patients (adjusted odds ratio [aOR] 3.5; 95% CI [1.0-11.8]; p=0.04), but not in low-risk patients (aOR 2.2; 95% CI [0.8-5.7]; p=0.11). Adverse outcomes were uncommon (<2%) and were not significantly different between the two length-of-stay groups. Higher-risk patients with acute PE and short length of stay more commonly received expedited follow up in our community setting than other groups of patients. These practice patterns are associated with low rates of 30-day adverse events.
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