Abstract
BACKGROUND/OBJECTIVES
The Emergency Department (ED) is an important source of health care for nursing home residents. The objective of this study was to characterize ED use by nursing home residents in the United States (US).
DESIGN
Analysis of the National Hospital Ambulatory Medical Care Survey
SETTING
US Emergency Departments, 2005-2008
PARTICIPANTS
Individuals visiting US EDs, stratified by nursing home and non-nursing home residents.
INTERVENTIONS
None
MEASUREMENTS
We identified all ED visits by nursing home residents. We contrasted the demographic and clinical characteristics between nursing home residents and non-nursing home residents. We also compared ED resource utilization, length of stay and outcomes.
RESULTS
During 2005-2008, nursing home residents accounted for 9,104,735 of 475,077,828 US ED visits (1.9%; 95% CI: 1.8-2.1%). The annualized number of ED visits by nursing home residents was 2,276,184. Most nursing home residents were elderly (mean 76.7 years, 95% CI: 75.8-77.5), female (63.3%), and non-Hispanic White (74.8%). Compared with non-nursing home residents, nursing home residents were more likely have been discharged from the hospital in the prior seven days (adjusted OR 1.4, 95% CI: 1.1-1.9). Nursing home residents were more likely to present with fever (adjusted OR 1.9; 95% CI: 1.5-2.4) or hypotension (systolic blood pressure ≤90 mm Hg, OR 1.8; 95% CI: 1.5-2.2). Nursing home patients were more likely to receive diagnostic test, imaging and procedures in the ED. Almost half of nursing home residents visiting the ED were admitted to the hospital. Compared with non-nursing home residents, nursing home residents were more likely to be admitted to the hospital (adjusted OR 1.8; 95% CI 1.6-2.1) and to die (adjusted OR 2.3; 95% CI 1.6-3.3).
CONCLUSIONS
Nursing home residents account for over 2.2 million ED visits annually in the US. Compared with other ED patients, nursing home residents have higher medical acuity and complexity. These observations highlight the national challenges of organizing and delivering ED care to nursing home residents in the US.
Keywords: emergency service, nursing homes, geriatrics
INTRODUCTION
The Emergency Department (ED) often plays an important role in care of nursing home residents, facilitating acute care for unexpected illness or injury as well as providing a pathway for hospital admission.1-3 Comprised of mostly elderly individuals, nursing home residents may pose challenges for ED clinical management. Nursing home residents often have multiple comorbidities, complex medical histories, cognitive impairment or dementia and limited ability to physiologically compensate for critical illness.4-9 Limits in vision, hearing and cognition may alter their ability to communicate symptoms, medical history or even basic personal information.4,5 In addition, information exchange between the nursing home and ED is often poor, complicating care coordination between the two settings.10-13 Because hospitalization of the elderly presents additional hazards such as increased delirium and falls, and because of the costs of care outside the nursing home are substantial, many institutions have sought opportunities to reduce avoidable ED visits and hospitalizations.14-16
Despite its importance in the care of nursing home residents, there are few published national studies characterizing ED use by nursing home residents in the US. Prior descriptions of ED use by nursing home patients have been limited to single EDs or nursing homes or settings outside the US.3,17-22 Information describing the number, acuity, reasons for presentation, tests and interventions, or outcomes of nursing home residents presenting to the ED could illuminate the national challenges of providing emergency care to this population. In addition, these insights could reveal opportunities for improving quality of nursing home resident care in the ED, hospital or the nursing home, potentially leading to strategies to reduce nursing home resident ED visits and hospitalizations.
In this study we sought to determine the characteristics of Emergency Department visits by nursing home residents in the US.
METHODS
Study Design
This study was approved by the Institutional Review Board of the University of Alabama at Birmingham. We conducted a cross-sectional analysis using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS).23
Data Source
Operated by the National Center for Health Statistics, NHAMCS is a national probability sample of ED and outpatient visits at hospitals across the US.23 The goal of the NHAMCS ED survey is to describe ED visits nationally. Using a four-stage probability design, the survey samples geographically defined areas, hospitals within these areas, emergency service areas within the emergency departments of the hospitals, and patient visits to the emergency services areas. The study systematically selects all patients from selected ED facilities for an assigned four-week period. The National Center for Health Statistics (NCHS) works with each hospital to abstract clinical data from selected charts. For this effort we used the 2005-2008 NHAMCS public-use data set.
Selection of Patients
For this analysis we identified all ED visits by nursing home residents. NHAMCS contains a variable “nursing home origin” that differentiates ED visits by nursing home residents from other individuals. Prior to 2005, NHAMCS combined nursing home residents with those residing in “other institutions,” including prisons, mental hospitals, group homes for the mentally retarded or physically disabled, etc. Beginning in 2005, NHAMCS categorized nursing home residents separately. Because this study focused on nursing home residents (separate from other institutionalized individuals), we opted to limit the analysis to the 2005-2008 data set.
Outcomes and Covariates
We characterized ED visits for nursing home residents and other patients using variables available in the NHAMCS data set. We identified demographic characteristics of ED patients, including age, sex, race, ethnicity, hospital geographic region and population setting, and mode and time of arrival. We used the composite race/ethnicity variable available in the data set. Geographic regions were Northeast, Midwest, West and South. (States of each region are listed in Appendix 1.) Population setting consisted of hospitals in Metropolitan Statistical Areas (MSA) and non-MSAs. Mode of arrival included walk-in, transport by public service (police car, social service vehicle, beach patrol, etc.) and ambulance. We grouped time of arrival to the 8-hour intervals 7 am-3 pm, 3 pm-11 pm, and 11 pm-7 am.
Clinical characteristics included the presence of a fever or hypotension on ED triage, visit to the ED within the prior 72 hours, discharge from the hospital within the prior week, and ED visits related to injury, poisoning or adverse event. Following prior convention, we defined fever as either an elevated temperature ≥100.4 degrees Fahrenheit.24-26 NHAMCS did not report the route of temperature measurement. We defined hypotension as systolic blood pressure ≤90 mm Hg. NHAMCS does not collect triage respiratory rate or oxygen saturation. We identified the performance of diagnostic (blood or urine) or imaging (x-ray, CT, MRI, ultrasound) tests, procedures (-e.g., intravenous access or endotracheal intubation) and the administration of medications.
Outcomes for each ED visit included length of ED stay, admission to the hospital, admission destination, hospital discharge status, and ED visit diagnoses. Admission destinations included critical care unit, operating room or catheterization lab, and other units. Hospital discharge status included alive, dead and unknown. Data abstractors identify the three most prominent documented diagnoses for each ED visit. The NCHS later converts these diagnoses to International Classification of Disease, ninth edition (ICD-9) codes. Up to three ICD-9 ED diagnoses are recorded for each visit in NHAMCS. NHAMCS does not contain ICD-9 procedural codes.
Data Analysis
We analyzed the data using descriptive statistics, annualizing all frequency estimates. We incorporated sampling design and weight variables to calculate nationally weighted estimates and their corresponding 95% confidence intervals. We used ultimate cluster design (single stage sampling) in variance and 95% confidence interval calculations, utilizing “masked” stratum and primary sampling unit identifiers provided with the NHAMCS public-use data set. Prior efforts have demonstrated that variance estimates using these methods are conservative.27
We calculated the national number of ED visits by nursing home residents. We compared demographic and clinical characteristics and outcomes between nursing home and non-nursing home residents. We grouped ED diagnoses by major ICD-9 category. (Specific diagnostic groups listed in Table 3.) We also identified clinically relative secondary diagnostic subgroups; for example, myocardial infarction, stroke, shock and sepsis. (Specific diagnostic groups listed in Table 3.) For the diagnostic subgroup “infection,” we used a previously published taxonomy of infection-related ICD-9 codes.24-26 (Appendix 2)
TABLE 3. Diagnoses of Emergency Department Visits by US Nursing Home Residents, 2005-2008.
Odds ratios for nursing home vs. non-nursing home, unadjusted and adjusted for age-decile, sex, and race and ethnicity category.
| Characteristic | Nursing Home Residents (n=2,276,184 annual ED visits) |
Non-Nursing Home Residents (n= 116,493,273 annual ED visits) |
Odds Ratio Nursing Home vs. Non-Nursing Home |
Odds Ratio Nursing Home vs. Non-Nursing Home Adjusted for Age-Decile, Sex, Race/Ethnicity |
||||
|---|---|---|---|---|---|---|---|---|
| % | (95% CI) | % | (95% CI) | OR | (95% CI) | OR | (95% CI) | |
| 001-139.9 Infectious and Parasitic Diseases | 3.6 | (2.6-4.6) | 4.4 | (4.2-4.7) | 0.8 | (0.6-1.1) | ‡1.7 | (1.2-2.3) |
| 140-239.9 Neoplasms | 1.4 | (0.98-2.10) | 0.6 | (0.5-0.7) | ‡2.5 | (1.6-3.8) | 1.2 | (0.7-1.8) |
|
240-279.9 Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders |
13.2 | (11.78-14.87) | 4.4 | (4.2-4.6) | ‡3.3 | (2.9-3.7) | ‡1.6 | (1.4-1.8) |
| 250-250.9, 251.0-251.2 Diabetic, Hyperglycemic and Hypoglycemic Conditions |
4.1 | (3..02-5.24) | 1.6 | (1.5-1.7) | ‡2.6 | (2.0-3.5) | ‡1.5 | (1.1-2.0) |
|
280-289.9 Diseases of the Blood and Blood-
Forming Organs |
3.8 | (2.9-4.6)(3.0-4.7) | 1.2 | (1.1-1.3) | ‡3.2 | (2.4-4.1) | ‡1.4 | (1.1-1.8) |
| 290-319.9 Mental Disorders | 9.8 | (8..43-11.45) | 5.5 | (5.2-5.8) | ‡1.9 | (1.6-2.2) | ‡2.6 | (2.1-3.2) |
| 320-359.9 Diseases of the Nervous System | 3.8 | (2.8-4.8)(2.9-5.0) | 3.4 | (3.1-3.6) | 1.1 | (0.9-1.5) | ‡1.4 | (1.1-2.0) |
| 345-345.91, 649.40-649.44, 779.0, 780.3- 780.39 - Epilepsy, Seizures and Convulsions |
1.3 | (0.98-2.01.9) | 1.1 | (0.991.0-1.21) | 1.3 | (0.8-1.9) | ‡2.3 | (1.5-3.6) |
| 360-389.9 Diseases of the Sense Organs (-e.g, Eyes, Ears) | **0.6 | (0.3-0.910) | 4.4 | (4.2-4.7) | **0.1N/A | (0.1-0.2) | **0.4N/A | (0.2-0.6) |
| 390-459.9 Diseases of the Circulatory System | 20.9 | (18.54-23.64) | 6.6 | (6.2-7.0) | ‡3.7 | (3.2-4.4) | 1.1 | (0.9-1.2) |
| 410-414.9 Acute Myocardial Infarction and Ischemic Heart Disease |
2.7 | (1.7-3.69-3.8) | 1.2 | (1.0-1.3) | ‡2.3 | (1.6-3.4) | 0.7 | (0.5-1.1) |
| 426-427.9 - Dysrhythmias | 4.2 | (3.32-5.21) | 0.95 | (0.879-1.04) | ‡4.6 | (3.6-5.8) | 1.2 | (0.9-1.5) |
| 425, 425.1-425.2, 425.4-425.9, 428-428.9 Acute Heart Failure and Cardiomyopathies | 5.4 | (4.2-6.63-6.8) | 0.94 | (0.879-1.03) | ‡6.0 | (4.7-7.6) | 1.2 | (0.98(1.0-1.5) |
| 430-437.9 Hemorrhagic and Thrombotic Stroke |
3.0 | (2.3-4.02-3.9) | 0.7 | (0.6-0.8) | ‡4.5 | (3.3-6.1) | 1.1 | (0.8-1.5) |
| 460-519.9 Diseases of the Respiratory System | 15.5 | (13.6-17.4)(13.7-17.5) | 13.7 | (13.2-14.1) | 1.2 | (1.00.99-1.3) | ‡1.3 | (1.1-1.5) |
| 464-466.19, 480-488.9, 507-507.8, 510-510.9, 513-513.1 Pneumonia, Aspiration Pneumonitis and Other Infections |
9.3 | (7.9-10.68.0-10.7) | 6.2 | (5.9-6.65) | ‡1.5 | (1.3-1.8) | ‡1.6 | (1.3-1.9) |
| 490-493.92 Asthma, COPD and Chronic Bronchitis | 2.5 | (1.89-3.43) | 4.0 | (3.8-4.2) | ‡0.6 | (0.5-0.8) | ‡0.7 | (0.5-0.9) |
| 518.5, 518.81-518.85, 799.0-799.1 Asphyxia and Respiratory Failure |
2.9 | (2.2-4.02.0-3.9) | 0.40.38 | (0.32-0.44) | ‡8.0 | (5.6-11.5) | ‡2.6 | (1.8-3.7) |
| 520-579.9 Diseases of the Digestive System | 8.4 | (7.1-9.87) | 8.4 | (8.1-8.6) | 1.0 | (0.8-1.2) | 0.9 | (0.8-1.1) |
|
580-629.9 Diseases of the Genitourinary
System |
14.9 | (13.21-16.87) | 7.1 | (6.9-7.4) | ‡2.3 | (2.0-2.6) | ‡1.8 | (1.5-2.1) |
| 584-586 - Acute and Chronic Renal Failure | 33.0 | (2.2-3.8) | 0.5 | (0.4-0.6) | ‡6.4 | (4.8-8.6) | ‡2.3 | (1.6-3.2) |
| 590-590.9, 599.0 Pyelonephritis, kidney and urinary tract infections |
10.0 | (8.3-11.65-11.8) | 3.0 | (2.9-3.1) | ‡3.6 | (3.0-4.3) | ‡2.2 | (1.8-2.7) |
|
630-679.9 Complications of Pregnancy,
Childbirth, and the Puerperium |
**99.80.2 | (99.5-100.1)(0.05-0.85) | 98.41.6 | (98.3-98.5)(1.5-1.7) | **0.1N/A | (0.0-0.5) | **1.1N/A | (0.3-4.6) |
|
680-709.9 Diseases of the Skin and
Subcutaneous Tissue |
3.4 | (2.5-4.2)(2.6-4.3) | 4.9 | (4.7-5.1) | ‡0.7 | (0.5-0.9) | 1.0 | (0.8-1.4) |
| 681-686.9 Cellulitis and skin infections | 2.1 | (1.4-2.8)(1.5-2.9) | 3.1 | (3.0-3.3) | ‡0.7 | (0.5-0.9) | 0.9 | (0.6-1.3) |
|
710-739.9 Diseases of the Musculoskeletal
System and Connective Tissue |
4.5 | (3.3-5.6)(3.4-5.8) | 7.7 | (7.4-8.0) | ‡0.6 | (0.4-0.7) | ‡0.5 | (0.4-0.7) |
| 740-759.9 Congenital Anomalies | **0.0 | (0.0-0.0) | 0.10.15 | (0.12-0.192) | **N/A | **N/A | ||
|
760-779.9 Certain Conditions Originating in
the Perinatal Period |
**0.0 | (0.0-0.0) | 0.10.07 | (0.1-0.1)(0.05-0.09) | **N/A | **N/A | ||
|
780-799.9 Symptoms, Signs, and Ill-Defined
Conditions |
31.0 | (28.54-33.65) | 25.5 | (24.6-26.3) | ‡1.3 | (1.2-1.5) | ‡0.8 | (0.7-1.00.97) |
| 780.0-780.2, 780.97 Syncope, Coma and Altered Mental Status |
5.3 | (4.21-6.54) | 1.5 | (1.4-1.6) | ‡3.7 | (3.0-4.6) | ‡1.3 | (1.05-1.7) |
| 276.5-276.52, 458-458.9, 785.5-785.51, 785.59, 958.4, 995.0, 999.4 Shock, Hypovolemia, Dehydration, Hypotension and Anaphylaxis |
8.1 | (6.8-9.49-9.5) | 1.6 | (1.5-1.7) | ‡5.4 | (4.5-6.5) | ‡2.6 | (2.0-3.2) |
| 800-950.9 Injury | 18.0 | (16.4-19.7) | 23.8 | (23.3-24.3) | ‡180.7 | (16.4-19.7)(0.6-0.8) | 23.80.9 | (23.3-24.3)(0.8-1.01) |
| 800-804.9, 850.-854.9, 959.0-959.09 Head and brain injuries |
2.1 | (1.3-2.8)(1.4-3.0) | 1.9 | (1.8-2.0) | 1.1 | (0.7-1.6) | 1.1 | (0.7-1.7) |
| 805-806.9, 952.-952.9 Spinal cord injuries | **0.4 | (0.12-0.97) | 0.20.15 | (0.1-0.2)(0.12-0.18) | **2.8N/A | (1.3-6.2) | **1.2N/A | (0.5-2.7) |
| 860.-869.9 Chest, abdomen and pelvis injuries | **0.01 | (0.0-0.100) | 0.10.11 | (0.1-0.1)(0.09-0.14) | **0.1N/A | (0.0-1.0) | **0.2N/A | (0.0-1.2) |
| 807-839.9, 885-887.7, 895-897.7, 900-904.9, 925-929 Extremity fractures and injuries | 5.4 | (4.2-6.5)(4.3-6.6) | 3.8 | (3.6-3.9) | ‡1.4 | (1.1-1.8) | 1.1 | (0.9-1.5) |
| 940-949.9 Burns | **0.14 | (-0.00.07-0.45)-0.3) | 0.43 | (0.4-0.5)(0.39-0.48) | **0.3N/A | (0.1-1.1) | **0.7N/A | (0.2-2.1) |
| 960-989.9 Poisonings and Toxic Effects | **0.3 | (0.1-0.6) | 0.90.94 | (0.9-1.0)(0.86-1.02) | **0.3N/A | (0.1-0.6) | **N/A0.9 | (0.9-1.0) |
| 996-999.9 Complications of Medical Care | 1.1 | (0.6-1.6) | 0.50.51 | (0.5-0.6)(0.46-0.57) | ‡2.2 | (1.4-3.5) | 1.3 | (0.8-2.1) |
|
Infection (including lung, kidney, skin infections and sepsis - see Appendix 2 for ICD-9 code ranges) |
23.7 | (21.3-26.21) | 16.5 | (16.1-16.9) | ‡1.6 | (1.4-1.8) | ‡1.6 | (1.4-1.8) |
| 003.1, 022.3, 031.2, 038-038.9, 040.82, 422.92, 449, 659.3, 670.20-670.24, 673.3, 771.81, 771.83, 785.52, 790.7, 995.90-995.94 Sepsis, Septicemia, Bacteremia and Septic Shock |
3.8 | (2.8-4.9) | 0.20.23 | (0.2-0.3)(0.19-0.26) | ‡17.6 | (13.1-23.6) | ‡6.2 | (4.1-9.5) |
Ref = referent category. ED = Emergency Department. MSA = metropolitan statistical area. OR = Odds Ratio. CI = Confidence Interval.
Significant at p<0.05.
Based upon fewer than 30 raw observations - estimate considered unreliable; ORs not calculated for these variables.28
We compared the proportion of each characteristic between nursing home and non-nursing home residents using univariate odds ratios. Because of the differences in age and sex between nursing home and non-nursing home residents, we repeated the comparisons using logistic regression, adjusting by age decile (<50 years, 50-59, 60-69, 70-79, ≥80), sex, and composite race/ethnicity. Because the National Center for Health Statistics considers inferences based upon fewer than 30 raw observations to be unreliable, we did not calculate unadjusted or adjusted odds ratios for low frequency events.28 We also performed a sensitivity analysis, repeating the comparisons in the subset of patients age ≥60 years old only. We analyzed data using Stata v.11.2 (Stata, Inc., College Station, Texas).
RESULTS
During 2005-2008 nursing home residents accounted for 9,104,735 of 475,077,828 (1.9%; 95% CI:1.8-2.1%) ED visits in the United States. The annualized number of ED visits by nursing home residents was 2,276,184 (95% CI: 2,045,215-2,507,153)
Most nursing home residents visiting the ED were elderly (mean age 76.7 years, 95% CI: 75.8-77.5), female and non-Hispanic White. (Table 1) Most were treated at EDs located in MSA settings and in the South US geographic region. Over 80% of nursing home residents arrived at the ED by ambulance; compared with non-nursing home residents, nursing home residents were over 13 times more likely to arrive by ambulance. Compared with non-nursing home residents, nursing home residents were more likely to have been discharged from a hospital within the prior seven days (adjusted OR 1.4; 95% CI: 1.1-1.9). Fever and hypotension (SBP≤90 mm Hg) on ED presentation were present in 7% and 8% of nursing home residents, respectively, and were more common than in non-nursing home residents.
TABLE 1. Characteristics of Emergency Department Visits by US Nursing Home Residents, 2005-2008.
Odds ratios for nursing home vs. non-nursing home, unadjusted and adjusted for age-decile, sex, and race and ethnicity category.
| Characteristic | Nursing Home Residents (n=2,276,184 annual ED visits) |
Non-Nursing Home Residents (n=116,493,273 annual ED visits) |
Odds Ratio Nursing Home vs. Non-Nursing Home |
Odds Ratio Nursing Home vs. Non-Nursing Home Adjusted for Age-Decile, Sex, Race/Ethnicity |
||||
|---|---|---|---|---|---|---|---|---|
| % | (95% CI) | % | (95% CI) | OR | (95% CI) | OR | (95% CI) | |
| Age (mean, 95% CI) | 76.7 | (75.8-77.5) | 35.9 | (35.2-36.3) | *†40.8 | (39.8-41.8) | †N/A | |
| Sex | ||||||||
| Female | 63.3 | (60.9-65.6) | 54.0 | (53.5-54.5) | Ref | --- | †N/A | |
| Male | 36.7 | (34.4-39.1) | 46.0 | (45.5-46.5) | 0.7 | (0.6-0.8) | ||
| Race and Ethnicity | ||||||||
| Non-Hispanic White | 74.8 | (71.5-77.9) | 61.0 | (58.4-63.5) | Ref | --- | †N/A | |
| Non-Hispanic Black | 16.4 | (13.7-19.4) | 22.2 | (19.7-24.9) | 0.6 | (0.5-0.7) | ||
| Hispanic | 6.2 | (4.4-8.7) | 13.2 | (11.4-15.2) | 0.4 | (0.3-0.5) | ||
| Asian, Hawaiian, Pacific Islander, American Indian, Alaskan, Multiple Races |
2.6 | (1.8-3.8) | 3.7 | (3.1-4.3) | 0.6 | (0.4-0.8) | ||
| Hospital Geographic Region | ||||||||
| Northeast | 23.5 | (19.6-27.8) | 18.8 | (16.7-21.2) | ‡1.7 | (1.3-2.2) | ‡1.7 | (1.3-2.1) |
| Midwest | 25.1 | (20.7-30.1) | 22.4 | (18.7-26.6) | ‡1.5 | (1.2-1.9) | ‡1.6 | (1.3-2.0) |
| South | 37.9 | (33.0-43.1) | 40.3 | (36.2-44.7) | ‡1.3 | (1.0-1.6) | ‡1.6 | (1.3-2.0) |
| West | 13.6 | (11.0-16.6) | 18.4 | (14.8-22.7) | Ref | --- | Ref | --- |
| Hospital Metropolitan Location | ||||||||
| MSA | 80.8 | (69.6-88.6) | 84.7 | (75.7-90.8) | Ref | --- | Ref | --- |
| Non-MSA | 19.2 | (11.4-30.4) | 15.3 | (9.2-24.3) | ‡1.3 | (1.1-1.6) | 1.1 | (0.9-1.3) |
| Mode of Arrival | ||||||||
| Walk-In | 12.9 | (11.2-14.8) | 78.8 | (77.7-79.9) | Ref | --- | Ref | --- |
| Public Service | 3.1 | (2.2-4.4) | 1.7 | (1.4-2.0) | ‡11.4 | (8.0-16.2) | ‡12.6 | (8.8-17.9) |
| Ambulance | 80.3 | (77.6-82.7) | 14.3 | (13.5-15.1) | ‡34.4 | (29.3-40.2) | ‡13.6 | (11.6-16.0) |
| Unknown | 3.7 | (2.6-5.2) | 5.2 | (4.6-5.9) | ‡4.4 | (3.1-6.1) | ‡3.4 | (2.5-4.6) |
| Time of Arrival | ||||||||
| 7a-3p | 44.4 | (41.1-47.8) | 39.7 | (39.1-40.2) | Ref | --- | Ref | --- |
| 3p-11p | 39.8 | (36.3-43.4) | 44.5 | (43.8-45.2) | ‡0.8 | (0.7-0.9) | 1.0 | (0.9-1.3) |
| 11p-7a | 15.8 | (13.2-18.7) | 15.9 | (15.3-16.4) | 0.9 | (0.7-1.1) | 1.3 | (0.981.0-1.6) |
|
Seen at Emergency Department
Within Prior 72 Hours |
||||||||
| No | 82.5 | (79.7-84.9) | 80.4 | (77.4-83.0) | Ref | --- | Ref | --- |
| Yes | 3.0 | (2.3-3.8) | 3.6 | (3.4-3.8) | 0.8 | (0.6-1.0)5) | 1.0 | (0.7-1.3) |
| Unknown | 14.6 | (12.2-17.3) | 16.0 | (13.4-19.1) | 0.9 | (0.7-1.1) | 0.9 | (0.8-1.1) |
|
Discharged from Hospital
Within Prior 7 Days |
||||||||
| No | 60.8 | (56.1-65.4) | 63.2 | (59.7-66.6) | Ref | --- | Ref | --- |
| Yes | 4.0 | (3.2-5.1) | 2.1 | (1.9-2.3) | ‡2.0 | (1.5-2.6) | ‡1.4 | (1.1-1.9) |
| Unknown | 35.1 | (30.6-39.9) | 34.7 | (31.3-38.2) | 1.1 | (0.9-1.2) | 1.0 | (0.9-1.1) |
|
Fever on ED Triage (Temperature <96.8 or ≥100.4°F) |
||||||||
| No | 92.9 | (91.4-94.2) | 94.4 | (94.1-94.7) | Ref | --- | Ref | --- |
| Yes | 7.1 | (5.8-8.6) | 5.6 | (5.3-5.9) | ‡1.3 | (1.04-1.6) | ‡1.9 | (1.5-2.4) |
|
Hypotension on ED Triage
(Systolic Blood Pressure <90 mmHg) |
||||||||
| No | 92.0 | (90.7-93.2) | 91.1 | (90.3-92.0) | Ref | --- | Ref | --- |
| Yes | 8.0 | (6.8-9.3) | 8.9 | (8.0-9.7) | 0.9 | (0.7-1.1) | ‡1.8 | (1.5-2.2) |
Ref = referent category. ED = Emergency Department. MSA = metropolitan statistical area. OR = Odds Ratio. CI = Confidence Interval.
Mean difference and 95% confidence interval.
Odds ratios for age, sex, race and ethnicity not adjusted.
Significant at p<0.05.
Over 90% of nursing home residents received diagnostic tests, over 70% received imaging tests, over 70% underwent procedures, and approximately 70% received medications in the ED. (Table 2) Diagnostic tests, imaging tests and procedures were more common in nursing home residents than other ED patients.
TABLE 2. Diagnostic and Imaging Tests, and Interventions for Emergency Department Visits by US Nursing Home Residents, 2005-2008.
Odds ratios for nursing home vs. non-nursing home, unadjusted and adjusted for age-decile, sex, and race and ethnicity category.
| Characteristic | Nursing Home Residents (n=2,276,184 annual ED visits) |
Non-Nursing Home Residents (n=116,493,273 annual ED visits) |
Odds Ratio Nursing Home vs. Non-Nursing Home |
Odds Ratio Nursing Home vs. Non-Nursing Home Adjusted for Age-Decile, Sex, Race/Ethnicity |
||||
|---|---|---|---|---|---|---|---|---|
| % | (95% CI) | % | (95% CI) | OR | (95% CI) | OR | (95% CI) | |
|
Performance of Diagnostic
Screening Tests in ED |
||||||||
| No | 7.6 | (6.4-8.9) | 28.2 | (26.7-29.8) | Ref | --- | Ref | --- |
| Yes | 92.4 | (91.1-93.6) | 71.8 | (70.2-73.3) | ‡4.8 | (4.1-5.7) | ‡1.9 | (1.6-2.2) |
| Unknown | 0.8 | (0.1-1.5) | 2.1 | (1.8-2.5) | 1.4 | (0.6-3.2) | 1.0 | (0.5-2.0) |
|
Performance of Imaging Tests
in ED |
||||||||
| No | 28.2 | (25.9-30.5) | 55.8 | (54.7-56.9) | Ref | --- | Ref | --- |
| Yes | 71.8 | (69.5-74.1) | 44.2 | (43.1-45.3) | ‡3.2 | (2.9-3.6) | ‡1.5 | (1.3-1.7) |
| X-ray | ||||||||
| No | 14.6 | (12.7-16.8) | 22.3 | (21.4-23.2) | Ref | --- | Ref | --- |
| Yes | 85.4 | (83.2-87.3) | 77.7 | (76.8-78.6) | ‡1.7 | (1.4-2.0) | ‡1.3 | (1.1-1.5) |
| CT Scan | ||||||||
| No | 65.0 | (61.5-68.4) | 71.8 | (70.7-72.9) | Ref | --- | Ref | --- |
| Yes | 35.0 | (31.6-38.5) | 28.2 | (27.1-29.3) | ‡1.4 | (1.2-1.6) | 1.0 | (0.9-1.2) |
| MRI | ||||||||
| No | 99.3 | (98.7-99.6) | 98.7 | (98.6-98.9) | Ref | --- | Ref | --- |
| Yes | **0.7 | (0.4-1.3) | 1.3 | (1.1-1.4) | **N/A0.6 | (0.3-1.0) | **N/A0.5 | (0.3-0.8) |
| Ultrasound | ||||||||
| No | 97.2 | (96.1-98.0) | 93.3 | (92.7-93.8) | Ref | --- | Ref | --- |
| Yes | 2.8 | (2.0-3.9) | 6.7 | (6.2-7.3) | ‡0.4 | (0.3-0.6) | ‡0.7 | (0.5-0.991.0) |
|
Performance of Procedures in
ED |
||||||||
| No | 28.2 | (25.7-30.9) | 51.5 | (49.1-53.8) | Ref | --- | Ref | --- |
| Yes | 71.8 | (69.1-74.3) | 48.5 | (46.2-50.9) | ‡2.7 | (2.4-3.0) | ‡1.6 | (1.4-1.7) |
| Provision of Medications in ED | ||||||||
| No | 28.5 | (26.1-31.0) | 20.9 | (19.9-21.9) | Ref | --- | Ref | --- |
| Yes | 69.2 | (66.4-71.9) | 77.0 | (76.0-78.1) | ‡0.66 | (0.59-0.73) | ‡0.76 | (0.68-0.84) |
| Unknown | 2.2 | (1.4-3.5) | 2.1 | (1.7-2.5) | 0.798 | (0.50-1.3) | 0.768 | (0.42-1.10) |
Ref = referent category. ED = Emergency Department. MSA = metropolitan statistical area. OR = Odds Ratio. CI = Confidence Interval.
Mean difference and 95% confidence interval.
Significant at p<0.05.
Based upon fewer than 30 raw observations - estimate considered unreliable; ORs not calculated for these variables.28
Common ED diagnoses for nursing home residents included infection and sepsis (23.7%), circulatory diseases (20.9%), injury (18.0%), respiratory diseases (15.5%) and genitourinary diseases (14.9%). (Table 3) Common infections affecting nursing home residents included pneumonia, aspiration pneumonitis and other pulmonary infections, and pyelonephritis, kidney and other urinary tract infections. Infections and sepsis were more likely in nursing home than non-nursing home residents. Nursing home residents were over six times more likely to present with sepsis. Shock and related diagnoses were present in 8.1%. Nursing home residents were more likely to present with seizures, respiratory failure, chronic and acute renal failure, and shock and related conditions. (Table 3)
ED length-of-stay was almost five hours for nursing home residents. (Table 4) Almost half of nursing home residents were admitted to the hospital. Compared with other patients, nursing home residents were almost twice as likely to be admitted to the hospital (adjusted OR 1.8; 1.6-2.0). Approximately 6.9% of admitted nursing home residents died in the hospital. Compared with other patients, admitted nursing home residents were more than twice as likely to die in the hospital (OR 2.3; 95% CI: 1.6-3.3).
TABLE 4. Outcomes of Emergency Department Visits by US Nursing Home Residents, 2005-2008.
Odds ratios for nursing home vs. non-nursing home, unadjusted and adjusted for age-decile, sex, and race and ethnicity category.
| Characteristic | Nursing Home Residents (n=2,276,184 annual ED visits) |
Non-Nursing Home Residents (n=116,493,273 annual ED visits) |
Odds Ratio Nursing Home vs. Non-Nursing Home |
Odds Ratio Nursing Home vs. Non-Nursing Home Adjusted for Age-Decile, Sex, Race/Ethnicity |
||||
|---|---|---|---|---|---|---|---|---|
| % | (95% CI) | % | (95% CI) | OR | (95% CI) | OR | (95% CI) | |
| Length of ED Stay (minutes, 95% CI) | 289 | (270-309) | 199 | (193-206) | *‡90 | (73-107) | *‡48 | (26-60) |
| Admitted to Hospital | ||||||||
| No | 51.8 | (48.6-54.9) | 86.9 | (86.0-87.7) | Ref | --- | Ref | --- |
| Yes | 48.2 | (45.1-51.4) | 13.1 | (12.3-14.0) | ‡6.2 | (5.5-6.9) | ‡1.8 | (1.6-2.0) |
|
Admission Destination
(of admitted patients) |
||||||||
| Critical Care Unit | 19.5 | (16.4-23.0) | 15.5 | (13.9-17.2) | ‡1.3 | (1.01-1.6) | 1.2 | (0.961.0-1.5) |
| Operating Room/Cath Lab | 1.2 | (0.7-2.2) | 5.2 | (4.6-5.9) | ‡0.2 | (0.1-0.4) | ‡0.4 | (0.2-0.7) |
| Other Bed/Unit | 79.3 | (75.8-82.4) | 79.4 | (77.5-81.1) | Ref | --- | Ref | --- |
|
Discharge Outcome
(of admitted patients) |
||||||||
| Alive | 81.2 | (77.2-84.7) | 86.4 | (83.7-88.6) | Ref | --- | Ref | --- |
| Dead | 6.9 | (5.2-9.0) | 1.9 | (1.7-2.2) | ‡3.8 | (2.7-5.3) | ‡2.3 | (1.6-3.3) |
| Unknown | 11.9 | (8.7-16.0) | 11.7 | (9.5-14.4) | 1.1 | (0.8-1.4) | 1.0 | (0.8-1.4) |
ED = Emergency Department. MSA = metropolitan statistical area. OR = Odds Ratio. CI = Confidence Interval.
Mean difference and 95% confidence interval.
Significant at p<0.05.
Based upon fewer than 30 raw observations - estimate considered unreliable; ORs not calculated for these variables.28
When repeating the analysis with patients ≥60 years old only, we observed similar associations between nursing home and non-nursing home residents.
DISCUSSION
Our study provides new national perspectives of ED use by nursing home residents in the US. We found that nursing home residents were prominent users of the ED, accounting for over 2.2 million ED visits annually. Based upon an estimated 1.4 million nursing home residents in the US, our data suggest that each year there are approximately 1.6 ED visits for every nursing home resident in the US.29,30 While accounting for less than 2% of total ED visits, nursing home residents exhibited higher acuity and were more likely to be admitted to the hospital than non-nursing home residents and exhibited higher mortality. Nursing home residents were also more likely to have been discharged from the hospital within the prior seven days. Nursing home residents were large users of emergency care resources, with higher rates of ambulance transport, diagnostic testing, imaging and procedures, and longer ED length-of-stay.
The observations of this series highlight broader questions regarding the appropriateness of ED visits by nursing home residents. Hospitalization of the elderly may result in a spectrum of unwanted effects such as reduced muscle strength, vasomotor instability, reduce ventilatory capacity, and the increased risks of acute delirium or falls.14,15 In addition, significant costs are associated with health care delivered outside of the nursing home setting.16,31 Many authors have evaluated the appropriateness or preventable nature of nursing home resident ED visits or hospitalizations, pointing to the similar assessment or care that could be provided in the nursing home setting.32-40 For example, in a review of 200 nursing home resident hospitalizations, Ouslander, et al. found that 67% were potentially avoidable.40
While not directly evaluating the appropriateness of ED referral or hospitalization, our study offers several relevant observations. The most prominent observation was that nursing home residents were more likely than non-nursing home residents to have been discharged from the hospital within the prior seven days. While the higher readmission rate may represent the natural progression of disease, it may also reflect inadequate or incomplete hospital treatment, inadequate coordination of care between hospital and nursing homes, or inadequate advanced care planning involving discussions with nursing home residents and their family members about goals of care and the benefits and risks of specific medical treatments and repeat hospitalizations. On the other hand, our study also underscores the high acuity of nursing home patients presenting to the ED, with comparatively higher prevalence of injury, fever, hypotension, shock, sepsis and hospital admission than other ED patients. Many of these high acuity cases may benefit from theexpert diagnostic and stabilizing care offered by the ED. While organized systems of nursing home-based care may prevent some ED visits, the ED will still play an important role in caring for the sickest nursing home residents.
Early diagnosis, primary and preventive care could play key roles in reducing nursing home resident ED visits. For example, almost quarter of the nursing home resident ED visits were associated with infections. Early involvement of physicians or physician extenders could advance infection diagnosis and treatment to the earliest stages of disease. Intrator, et al. found that at nursing homes with special care units and more physicians and physician extenders, residents were less likely to be hospitalized.41 Evercare programs in the United Kingdom and United States have utilized nurse practitioner-coordinated intensive primary care to reduce ED visits and hospitalizations.42,43 Ouslander, et al. found that a multi-component intervention could reduce the number of hospital admissions for nursing home residents.44
Most previous descriptions of ED use by nursing home patients have been limited to single EDs or nursing homes or settings outside the US.3,17-22 An abstract utilized NHAMCS data prior to 2005, when the survey aggregated nursing home residents with other institutionalized residents (prisons, mental hospitals, groups homes for mentally retarded or physically disabled, etc).45 The 2004 National Nursing Home Survey provided limited perspectives of nursing home resident ED use, finding that eight percent of US nursing home residents (123,600) had an ED visit in the previous 90 days.36 Our contrasting study identified a much higher number of annual ED visits by nursing home residents, and the additional data elements of the NHAMCS data set allowed deeper descriptions of the ED course and hospital outcomes of this population.
Our observations underscore the acuity and complexity of nursing home residents as well as the ED clinical and operational challenges posed by these individuals. Many ED clinicians may not feel comfortable caring for older patients, and many EDs are not structured to care for older adults.14,46 One potential strategy to improve nursing home resident care is to organize ED care regionally in a manner similar to current systems of major trauma, ST-segment myocardial infarction and stroke care with the goal of improved outcomes.47-49 With adequate triage guidance, ambulances could potentially transport nursing home residents to centers with expertise in and resources to support specialty nursing home resident care. The transition of care and medical information is often a challenge in the transfer of nursing home residents to the ED.10 Established community patterns of nursing home to ED referral could also help to enhance care coordination for these patients. Descriptions of specialized Geriatric Emergency Departments and consult teams exist, but there are only limited evaluations of their effectiveness.50-54
Limitations of this study include the retrospective nature and the probability sample design of the NHAMCS data set. However, the methodology of the NHAMCS study is rigorous, and the data set has been widely used in similar analyses for over 15 years.24,55,56 While we estimated the number of nursing home residents visiting the ED, due to the absence of individual identifiers, we could not estimate rates of ED use. Although we associated initial presentation with final patient outcome, the data set did not contain adequate variables to fully account for important confounders.
While a focus of Medicare and a potential measure of care quality, the NHAMCS data did not have information on 30-day readmissions.57,58 While we were able to study 7-day readmissions, because NHAMCS did not have individual identifiers, we could not determine the diagnoses of prior hospitalizations nor patterns of readmission by individual nursing home residents.
There were fewer nursing home resident ED visits in the West geographic region of the US. We attribute this observation to the smaller nursing home population in the Western US, which has the lowest number of nursing homes, nursing home beds and nursing home residents.59
Because NHAMCS collects only three diagnoses per patient, we may have missed additional relevant conditions that were not reported. Abstractors may have varied in the selection and identification of ED diagnoses. There was no way to independently validate the NHAMCS classification of nursing home resident. While our study characterized ED visits, we could not determine the appropriateness or preventable nature of these visits.
CONCLUSION
In the United States nursing home residents comprise over 2.2 million ED visits annually. Compared with non-nursing home residents, nursing home residents have higher medical acuity and complexity. These observations highlight the national challenges of organizing and delivering ED care to nursing home residents in the US and support alternate models for the emergency care of this population.
| Elements of Financial/Personal Conflicts |
*Author 1 Henry Wang |
Author 2 Manish Shah |
Author 3 Richard Allman |
Etc. Meredith Kilgore |
||||
|---|---|---|---|---|---|---|---|---|
| Yes | No | Yes | No | Yes | No | Yes | No | |
| Employment or Affiliation | X | X | X | X | ||||
| Grants/Funds | X | X | X | X | ||||
| Honoraria | X | X | X | X | ||||
| Speaker Forum | X | X | X | X | ||||
| Consultant | X | X | X | X | ||||
| Stocks | X | X | X | X | ||||
| Royalties | X | X | X | X | ||||
| Expert Testimony | X | X | X | X | ||||
| Board Member | X | X | X | X | ||||
| Patents | X | X | X | X | ||||
| Personal Relationship | X | X | X | X | ||||
APPENDIX 1. Hospital Geographic Regions Defined By the National Hospital Ambulatory Care Survey (NHAMCS).
| Region | States |
|---|---|
| Northeast | Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont |
| Midwest | Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin |
| South | Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia |
| West | Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming |
APPENDIX 2. Emergency Department Diagnosis Codes Denoting Infection.
International Classification of Diseases, ninth edition (ICD-9) codes associated with an infection.24-26
| Infection Category |
ICD-9 Code | ICD-9 Code Description |
|---|---|---|
| Parasitic | 001 | Cholera |
| 002 | Typhoid/paratyphoid fever | |
| 003 | Other salmonella infection | |
| 004 | Shigellosis | |
| 005 | Other food poisoning | |
| 008 | Intestinal infections due to Escherichia coli | |
| 008.1 | Intestinal infections due to Arizona group of paracolon bacillus | |
| 008.2 | Intestinal infections due to Aerobacter aerogenes | |
| 008.3 | Intestinal infections due to Proteus (mirabilis morganii) | |
| 008.4 | Intestinal infections due to unspecified bacteria | |
| 008.5 | Bacterial enteritis, unspecified | |
| 009 | Ill-defined intestinal infection | |
| 013 | CNS tuberculosis | |
| 018 | Miliary tuberculosis | |
| 020 | Plague | |
| 021 | Tularemia | |
| 022 | Anthrax | |
| 023 | Brucellosis | |
| 024 | Glanders | |
| 025 | Melioidosis | |
| 026 | Rat-bite fever | |
| 027 | Other bacterial zoonoses | |
| 032 | Diphtheria | |
| 033 | Whooping cough | |
| 034 | Streptococcal throat/scarlet fever | |
| 035 | Erysipelas | |
| 036 | Meningococcal infection | |
| 037 | Tetanus | |
| 038 | Septicemia | |
| 039 | Actinomycotic infections | |
| 040 | Other bacterial diseases | |
| 041 | Bacterial infection in other diseases not specified | |
| 098 | Gonococcal infections | |
| 100 | Leptospirosis | |
| 101 | Vincent’s angina | |
| 112 | Candidiasis, of mouth | |
| 112.4 | Candidiasis, of lung | |
| 112.5 | Candidiasis, disseminated | |
| 112.8 | Candidiasis, of other specified sites | |
| 114 | Coccidioidomycosis | |
| 115 | Histoplasmosis | |
| 116 | Blastomycotic infection | |
| 117 | Other mycoses | |
| 118 | Opportunistic mycoses | |
| Nervous | 320 | Bacterial meningitis |
| 321 | Cryptococcal meningitis | |
| 321.1 | Meningitis in other fungal diseases | |
| 324 | CNS abcess | |
| 325 | Phlebitis of intracranial sinus | |
| 360 | Purulent endophthalmitis | |
| 376 | Acute inflammation of orbit | |
| 380.14 | Malignant otitis externa | |
| 383 | Acute mastoiditis | |
| Circulatory | 420.99 | Acute pericarditis due to other specified organisms |
| 421 | Acute or subacute endocarditis | |
| Respiratory | 461 | Acute sinusitis |
| 462 | Acute pharyngitis | |
| 463 | Acute tonsillitis | |
| 464 | Acute laryngitis/tracheitis | |
| 465 | Acute upper respiratory infection of multiple sites/not otherwise specified | |
| 475 | Peritonsillar abscess | |
| 481 | Pneumococcal pneumonia | |
| 482 | Other bacterial pneumonia | |
| 485 | Bronchopneumonia with organism not otherwise specified | |
| 486 | Pneumonia, organism not otherwise specified | |
| 491.21 | Acute exacerbation of obstructive chronic bronchitis | |
| 494 | Bronchiectasis | |
| 510 | Empyema | |
| 513 | Abscess of lung and mediastinum | |
| Digestive | 522.5 | Periapical abscess without sinus |
| 522.7 | Periapical abscess with sinus | |
| 526.4 | Inflammatory conditions of the jaw | |
| 527.3 | Abscess of the salivary glands | |
| 528.3 | Cellulitis and abscess of oral soft tissue | |
| 540 | Acute appendicitis | |
| 541 | Appendicitis not otherwise specified | |
| 542 | Other appendicitis | |
| 562.01 | Diverticulitis of the small intestine without hemorrhage | |
| 562.03 | Diverticulitis of the small intestine with hemorrhage | |
| 562.11 | Diverticulitis of colon without hemorrhage | |
| 562.13 | Diverticulitis of colon with hemorrhage | |
| 566 | Abscess of the anal and rectal regions | |
| 567 | Peritonitis | |
| 569.5 | Intestinal abscess | |
| 569.61 | Infection of colostomy or enterostomy | |
| 569.83 | Perforation of intestine | |
| 572 | Abscess of liver | |
| 572.1 | Portal pyemia | |
| 575 | Acute cholecystitis | |
| Genitourinary | 590 | Kidney infection |
| 599 | Urinary tract infection not otherwise specified | |
| 601 | Prostatic inflammation | |
| 604 | Orchitis and epididymitis | |
| 614 | Female pelvic inflammation disease | |
| 615 | Uterine inflammatory disease | |
| 616.3 | Abscess of Bartholin’s gland | |
| 616.4 | Other abscess of vulva | |
| Pregnancy | 634 | Spontaneous abortion, complicated by genital tract and pelvic infection |
| 635 | Legally induced abortion, complicated by genital tract and pelvic infection |
|
| 636 | Illegally induced abortion, complicated by genital tract and pelvic infection |
|
| 637 | Unspecified abortion, complicated by genital tract and pelvic infection | |
| 638 | Failed attempted abortion, complicated by genital tract and pelvic infection |
|
| 639 | Complications following abortion and ectopic and molar pregnancies | |
| 646.6 | Infections of genitourinary tract in pregnancy | |
| 658.4 | Infection of amniotic cavity | |
| 670 | Major puerperal infection | |
| 675.1 | Abscess of breast | |
| Skin | 681 | Cellulitis, finger/toe |
| 682 | Other cellulitis or abscess | |
| 683 | Acute lymphadenitis | |
| 685 | Pilonidal cyst, with abscess |
APPENDIX 1.
APPENDIX 2.
Footnotes
FINANCIAL AND OTHER CONFLICT OF INTERESTS The authors report no financial or other conflicts of interest.
Conflict of Interest Disclosures:
AUTHOR CONTRIBUTIONS HEW, MNS, RMA and MK conceived and designed the study. HEW acquired data and performed the statistical analysis. All authors participated in interpretation of data. HEW drafted the manuscript, and MNS, RMA and MK participated in critical revision of the manuscript’s intellectual content. Dr. Wang had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
SPONSOR’S ROLE None
REFERENCES
- 1.Wofford JL, Schwartz E, Byrum JE. The role of emergency services in health care for the elderly: a review. The Journal of Emergency Medicine. 1993;11:317–26. doi: 10.1016/0736-4679(93)90053-a. [DOI] [PubMed] [Google Scholar]
- 2.Wofford JL, Schwartz E, Timerding BL, Folmar S, Ellis SD, Messick CH. Emergency department utilization by the elderly: analysis of the National Hospital Ambulatory Medical Care Survey. Acad Emerg Med. 1996;3:694–9. doi: 10.1111/j.1553-2712.1996.tb03493.x. [DOI] [PubMed] [Google Scholar]
- 3.Arendts G, Howard K. The interface between residential aged care and the emergency department: a systematic review. Age and Ageing. 2010;39:306–12. doi: 10.1093/ageing/afq008. [DOI] [PubMed] [Google Scholar]
- 4.Han JH, Morandi A, Ely W, et al. Delirium in the nursing home patients seen in the emergency department. Journal of the American Geriatrics Society. 2009;57:889–94. doi: 10.1111/j.1532-5415.2009.02219.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Han JH, Shintani A, Eden S, et al. Delirium in the emergency department: an independent predictor of death within 6 months. Annals of Emergency Medicine. 2010;56:244–52. e1. doi: 10.1016/j.annemergmed.2010.03.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Han JH, Wilson A, Ely EW. Delirium in the older emergency department patient: a quiet epidemic. Emerg Med Clin North Am. 2010;28:611–31. doi: 10.1016/j.emc.2010.03.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009;16:193–200. doi: 10.1111/j.1553-2712.2008.00339.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Milzman DP, Rothenhaus TC. Resuscitation of the geriatric patient. Emerg Med Clin North Am. 1996;14:233–44. doi: 10.1016/s0733-8627(05)70248-0. [DOI] [PubMed] [Google Scholar]
- 9.Heffernan DS, Thakkar RK, Monaghan SF, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trauma. 2010;69:813–20. doi: 10.1097/TA.0b013e3181f41af8. [DOI] [PubMed] [Google Scholar]
- 10.Cwinn MA, Forster AJ, Cwinn AA, Hebert G, Calder L, Stiell IG. Prevalence of information gaps for seniors transferred from nursing homes to the emergency department. CJEM. 2009;11:462–71. doi: 10.1017/s1481803500011660. [DOI] [PubMed] [Google Scholar]
- 11.Terrell KM, Brizendine EJ, Bean WF, et al. An extended care facility-to-emergency department transfer form improves communication. Acad Emerg Med. 2005;12:114–8. doi: 10.1197/j.aem.2004.10.013. [DOI] [PubMed] [Google Scholar]
- 12.Terrell KM, Miller DK. Challenges in transitional care between nursing homes and emergency departments. J Am Med Dir Assoc. 2006;7:499–505. doi: 10.1016/j.jamda.2006.03.004. [DOI] [PubMed] [Google Scholar]
- 13.Gillespie SM, Gleason LJ, Karuza J, Shah MN. Health care providers’ opinions on communication between nursing homes and emergency departments. J Am Med Dir Assoc. 2010;11:204–10. doi: 10.1016/j.jamda.2009.09.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Hwang U, Morrison RS. The geriatric emergency department. Journal of the American Geriatrics Society. 2007;55:1873–6. doi: 10.1111/j.1532-5415.2007.01400.x. [DOI] [PubMed] [Google Scholar]
- 15.Creditor MC. Hazards of hospitalization of the elderly. Annals of Internal Medicine. 1993;118:219–23. doi: 10.7326/0003-4819-118-3-199302010-00011. [DOI] [PubMed] [Google Scholar]
- 16.Grabowski DC, O’Malley AJ, Barhydt NR. The costs and potential savings associated with nursing home hospitalizations. Health Aff (Millwood) 2007;26:1753–61. doi: 10.1377/hlthaff.26.6.1753. [DOI] [PubMed] [Google Scholar]
- 17.Ackermann RJ, Kemle KA, Vogel RL, Griffin RC., Jr. Emergency department use by nursing home residents. Annals of Emergency Medicine. 1998;31:749–57. doi: 10.1016/s0196-0644(98)70235-5. [DOI] [PubMed] [Google Scholar]
- 18.Ingarfield SL, Finn JC, Jacobs IG, et al. Use of emergency departments by older people from residential care: a population based study. Age and Ageing. 2009;38:314–8. doi: 10.1093/ageing/afp022. [DOI] [PubMed] [Google Scholar]
- 19.Gruneir A, Bell CM, Bronskill SE, Schull M, Anderson GM, Rochon PA. Frequency and pattern of emergency department visits by long-term care residents--a population-based study. Journal of the American Geriatrics Society. 2010;58:510–7. doi: 10.1111/j.1532-5415.2010.02736.x. [DOI] [PubMed] [Google Scholar]
- 20.Jones JS, Dwyer PR, White LJ, Firman R. Patient transfer from nursing home to emergency department: outcomes and policy implications. Acad Emerg Med. 1997;4:908–15. doi: 10.1111/j.1553-2712.1997.tb03818.x. [DOI] [PubMed] [Google Scholar]
- 21.McCloskey R, van den Hoonaard D. Nursing home residents in emergency departments: a Foucauldian analysis. Journal of Advanced Nursing. 2007;59:186–94. doi: 10.1111/j.1365-2648.2007.04319.x. [DOI] [PubMed] [Google Scholar]
- 22.Kerr HD, Byrd JC. Nursing home patients transferred by ambulance to a VA emergency department. Journal of the American Geriatrics Society. 1991;39:132–6. doi: 10.1111/j.1532-5415.1991.tb01614.x. [DOI] [PubMed] [Google Scholar]
- 23.National Center for Health Statistics [Accessed July 3, 2006];Ambulatory health care data. at http://www.cdc.gov/nchs/about/major/ahcd/ahcd1.htm.
- 24.Wang HE, Shapiro NI, Angus DC, Yealy DM. National estimates of severe sepsis in United States emergency departments. Critical Care Medicine. 2007;35:1928–36. doi: 10.1097/01.CCM.0000277043.85378.C1. [DOI] [PubMed] [Google Scholar]
- 25.Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29:1303–10. doi: 10.1097/00003246-200107000-00002. [DOI] [PubMed] [Google Scholar]
- 26.Weycker D, Akhras KS, Edelsberg J, Angus DC, Oster G. Long-term mortality and medical care charges in patients with severe sepsis. Crit Care Med. 2003;31:2316–23. doi: 10.1097/01.CCM.0000085178.80226.0B. [DOI] [PubMed] [Google Scholar]
- 27.Hing E, Gousen S, Shimizu I, Burt C. Guide to using masked design variables to estimate standard errors in public use files of the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Inquiry. 2003;40:401–15. doi: 10.5034/inquiryjrnl_40.4.401. [DOI] [PubMed] [Google Scholar]
- 28.Centers for Disease Control and Prevention [Accessed May 30];Ambulatory Health Care Data. Reliability of Estimates. 2011 at http://www.cdc.gov/nchs/ahcd/ahcd_estimation_reliability.htm.
- 29.The Kaiser Family Foundation [Accessed Jan. 28, 2011];United States: Total Number of Residents in Certified Nursing Facilities, 2008. 2011 statehealthfacts.org. at http://www.statehealthfacts.org/profileind.jsp?ind=408&cat=8&rgn=1.
- 30.Nursing Facilities, Staffing, Residents and Facility Deficiencies. 2005 1999 Through. Accessed at http://www.pascenter.org/documents/OSCAR2005.pdf.
- 31.Boockvar KS, Gruber-Baldini AL, Stuart B, Zimmerman S, Magaziner J. Medicare expenditures for nursing home residents triaged to nursing home or hospital for acute infection. Journal of the American Geriatrics Society. 2008;56:1206–12. doi: 10.1111/j.1532-5415.2008.01748.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Gruneir A, Silver MJ, Rochon PA. Emergency Department Use by Older Adults: A Literature Review on Trends, Appropriateness, and Consequences of Unmet Health Care Needs. Med Care Res Rev. 2010 doi: 10.1177/1077558710379422. [DOI] [PubMed] [Google Scholar]
- 33.Finn JC, Flicker L, Mackenzie E, et al. Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia. The Medical Journal of Australia. 2006;184:432–5. doi: 10.5694/j.1326-5377.2006.tb00313.x. [DOI] [PubMed] [Google Scholar]
- 34.Jensen PM, Fraser F, Shankardass K, Epstein R, Khera J. Are long-term care residents referred appropriately to hospital emergency departments? Can Fam Physician. 2009;55:500–5. [PMC free article] [PubMed] [Google Scholar]
- 35.Arendts G, Reibel T, Codde J, Frankel J. Can transfers from residential aged care facilities to the emergency department be avoided through improved primary care services? Data from qualitative interviews. Australasian Journal on Ageing. 2010;29:61–5. doi: 10.1111/j.1741-6612.2009.00415.x. [DOI] [PubMed] [Google Scholar]
- 36.Caffrey C. Potentially preventable emergency department visits by nursing home residents: United States, 2004. NCHS Data Brief. 2010:1–8. [PubMed] [Google Scholar]
- 37.Saliba D, Kington R, Buchanan J, et al. Appropriateness of the decision to transfer nursing facility residents to the hospital. Journal of the American Geriatrics Society. 2000;48:154–63. doi: 10.1111/j.1532-5415.2000.tb03906.x. [DOI] [PubMed] [Google Scholar]
- 38.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. Journal of the American Geriatrics Society. 1991;39:1164–8. doi: 10.1111/j.1532-5415.1991.tb03568.x. [DOI] [PubMed] [Google Scholar]
- 39.Jablonski RA, Utz SW, Steeves R, Gray DP. Decisions about transfer from nursing home to emergency department. J Nurs Scholarsh. 2007;39:266–72. doi: 10.1111/j.1547-5069.2007.00179.x. [DOI] [PubMed] [Google Scholar]
- 40.Ouslander JG, Lamb G, Perloe M, et al. Potentially avoidable hospitalizations of nursing home residents: frequency, causes, and costs. J Am Geriatr Soc. 2010;58:627–35. doi: 10.1111/j.1532-5415.2010.02768.x. [DOI] [PubMed] [Google Scholar]
- 41.Intrator O, Castle NG, Mor V. Facility characteristics associated with hospitalization of nursing home residents: results of a national study. Med Care. 1999;37:228–37. doi: 10.1097/00005650-199903000-00003. [DOI] [PubMed] [Google Scholar]
- 42.Kane RL, Flood S, Bershadsky B, Keckhafer G. Effect of an innovative medicare managed care program on the quality of care for nursing home residents. The Gerontologist. 2004;44:95–103. doi: 10.1093/geront/44.1.95. [DOI] [PubMed] [Google Scholar]
- 43.Gravelle H, Dusheiko M, Sheaff R, et al. Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data. BMJ. 2007;334:31. doi: 10.1136/bmj.39020.413310.55. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Ouslander JG, Lamb G, Tappen R, et al. Interventions to Reduce Hospitalizations from Nursing Homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project. J Am Geriatr Soc. 2011;59:745–53. doi: 10.1111/j.1532-5415.2011.03333.x. [DOI] [PubMed] [Google Scholar]
- 45.Hing RE. Emergency Department Use by the Elderly Living in Nursing Homes. Abstr AcademyHealth Meet. 2005:22. abstract no. 3537. [Google Scholar]
- 46.McNamara RM, Rousseau E, Sanders AB. Geriatric emergency medicine: a survey of practicing emergency physicians. Ann Emerg Med. 1992;21:796–801. doi: 10.1016/s0196-0644(05)81024-8. [DOI] [PubMed] [Google Scholar]
- 47.MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. New Engl J Med. 2006;354:366–78. doi: 10.1056/NEJMsa052049. [DOI] [PubMed] [Google Scholar]
- 48.Jollis JG, Roettig ML, Aluko AO, et al. Implementation of a Statewide System for Coronary Reperfusion for ST-Segment Elevation Myocardial Infarction. JAMA. 2007;298:2371–80. doi: 10.1001/jama.298.20.joc70124. [DOI] [PubMed] [Google Scholar]
- 49.Xian Y, Holloway RG, Chan PS, et al. Association Between Stroke Center Hospitalization for Acute Ischemic Stroke and Mortality. JAMA. 2011;305:373–80. doi: 10.1001/jama.2011.22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Salvi F, Morichi V, Grilli A, et al. A geriatric emergency service for acutely ill elderly patients: pattern of use and comparison with a conventional emergency department in Italy. Journal of the American Geriatrics Society. 2008;56:2131–8. doi: 10.1111/j.1532-5415.2008.01991.x. [DOI] [PubMed] [Google Scholar]
- 51.Salvi F, Morichi V, Grilli A, Giorgi R, De Tommaso G, Dessi-Fulgheri P. The elderly in the emergency department: a critical review of problems and solutions. Internal and Emergency Medicine. 2007;2:292–301. doi: 10.1007/s11739-007-0081-3. [DOI] [PubMed] [Google Scholar]
- 52.Gold S, Bergman H. A geriatric consultation team in the emergency department. Journal of the American Geriatrics Society. 1997;45:764–7. doi: 10.1111/j.1532-5415.1997.tb01485.x. [DOI] [PubMed] [Google Scholar]
- 53.Sinoff G, Clarfield AM, Bergman H, Beaudet M. A two-year follow-up of geriatric consults in the emergency department. Journal of the American Geriatrics Society. 1998;46:716–20. doi: 10.1111/j.1532-5415.1998.tb03806.x. [DOI] [PubMed] [Google Scholar]
- 54.Hastings SN, Heflin MT. A systematic review of interventions to improve outcomes for elders discharged from the emergency department. Acad Emerg Med. 2005;12:978–86. doi: 10.1197/j.aem.2005.05.032. [DOI] [PubMed] [Google Scholar]
- 55.Shah MN, Bazarian JJ, Lerner EB, et al. The epidemiology of emergency medical services use by older adults: an analysis of the National Hospital Ambulatory Medical Care Survey. Acad Emerg Med. 2007;14:441–7. doi: 10.1197/j.aem.2007.01.019. [DOI] [PubMed] [Google Scholar]
- 56.Beckmann KR, Melzer-Lange MD, Gorelick MH. Emergency department management of sexually transmitted infections in US adolescents: results from the National Hospital Ambulatory Medical Care Survey. Annals of Emergency Medicine. 2004;43:333–8. doi: 10.1016/j.annemergmed.2003.10.034. [DOI] [PubMed] [Google Scholar]
- 57.Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305:675–81. doi: 10.1001/jama.2011.123. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 58.Ashton CM, Del Junco DJ, Souchek J, Wray NP, Mansyur CL. The association between the quality of inpatient care and early readmission: a meta-analysis of the evidence. Med Care. 1997;35:1044–59. doi: 10.1097/00005650-199710000-00006. [DOI] [PubMed] [Google Scholar]
- 59.Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing Home Survey: 2004 overview. Vital Health Stat. 2009;13:1–155. [PubMed] [Google Scholar]