Life Matters Media
Quality of life at the end of life

TROUBLING REPORT: Many Nursing Home Residents Undergo Unnecessary Transfers To ER

BY DANIEL GAITAN | daniel@lifemattersmedia.org 

Nearly half of long-term nursing home residents will undergo at least one transfer to an emergency department this year, regardless of their cognitive status or need.

Although a high percentage of long-term nursing home residents are sent to emergency departments, only about a third are admitted to the hospital, according to a report from the Indiana University Center for Aging Research and the Regenstrief Institute.

Researchers led by Dr. Michael LaMantia examined medical records of 4,500 nursing home residents 65 and older with consecutive nursing home stays of 90 days or more.

Dr. Michael LaMantia

Dr. Michael LaMantia

Dementia severity was not associated with higher likelihood of transfer to the emergency department or with transfer resulting in hospitalization. Instead, age, race, having two or more chronic diseases and “Do Not Resuscitate” status influenced the amount of time until first emergency department visit.

Average time from entry into a long-term nursing facility to an emergency department for those with advanced dementia was 258 days; 250 days for individuals with early to moderate cognitive impairment; and 202 days for those with no dementia.

Study results were published online in the Journal of Post-Acute and Long-Term Care Medicine ahead of print publication.

LaMantia, a Regenstrief Institute investigator, spoke with Life Matters Media about his findings.

Why focus on emergency department visits?

We were very interested in how dementia severity might influence use of the emergency department among long-stay nursing home residents.

Dementia is a condition that affects a lot of older adults in this country and is associated with large health care expenditures – there’s been a lot of interest among policy makers and leaders at the Centers for Medicare and Medicaid Services to try to improve care in the nursing home environment.

We looked at use of the emergency department by older adults that had 90 or more consecutive days of residence in nursing homes. We looked at patterns of emergency department use over a 10 year period of time. Over that period, we saw that half of all long-stay nursing home patients use the emergency department in a year.

It’s interesting that we looked at those patients and saw that most of them were not admitted to the hospital. We then dove deeper and looked at dementia severity, and we found that severity does not predict time to the first emergency department visit by long-stay nursing home residents.

We then dove even deeper and saw that age, race, the number of patient conditions and hospitalizations, and DNR status does influence time to emergency department visits.

Why isn’t cognitive status a big influence?

It’s a very interesting question, but we don’t have the ability from the data that we have to say why that is.

But it raises questions for people who are taking care of these patients, for family members who are involved in the care of loved ones, and for policy makers. If patients with advanced dementia seemingly have the same patterns of care as patients with no dementia or early to moderate dementia, why is that?

What effect to do you hope your report has on nursing homes and health care providers?

My hope is that it brings to light that we really need to understand on a population level the factors that put our patients at risk for unnecessary emergency department use.

Understanding that the emergency department is not an easy place for many people, but especially older adults with cognitive impairment.

We need to have discussions with our patients and our patients’ caregivers on the goals of care for our long-staying nursing home residents, and in particular, those with advancing cognitive impairment.

You also found that among nursing home residents sent to the ED, people with advanced stage dementia were more likely to receive a diagnosis of a urinary tract infection. Why is this?

We found that when we looked at the diagnoses associated with the emergency department visit that patients with advanced dementia were more likely to have a diagnosis of urinary tract infection.

We don’t know the reason behind this diagnosis being assigned. It may be because these older adults are more likely to have urinary tract infections, which could be unrelated to the care they’re receiving in the nursing home environment.

Or it could be because older adults frequently experience asymptomatic bacteriuria and pyuria. Essentially, older adults will have urinalyses that make it look like they have an infection when they don’t.

When an older adult is sent to the emergency department and doctors are looking for what’s wrong with them, they do lots of tests. They may find a urinalysis that looks like an infection, because it’s the only thing they can come up with. They assign a diagnosis of urinary tract infection as the reason for the visit.

People without dementia may be better able to tell you why they are there, and so doctors are able to formulate a better diagnosis and reason for visit.