Emergency department use among patients from residential aged care facilities under a Hospital in the Nursing Home scheme in public hospitals in Queensland Australia

doi:10.5847/wjem.j.1920-8642.2016.03.004

Abstract

Abstract:

BACKGROUND: Hospital emergency department (ED) use by patients from residential aged care facilities (RACFs) is not always appropriate, and this calls for interventions to avoid some unnecessary uses. This study aims to compare patterns of ED use by RACF patients with and without a Hospital in the Nursing Home (HiNH) program.
METHODS: RACF patients presenting to EDs of a hospital with and a hospital without this program during pre- and post-intervention periods were included. Data on patient demographics and ED presentation characteristics were obtained from the Emergency Department Information System database, and were analysed by descriptive and comparative statistics.
RESULTS: In both hospitals, most RACF residents presenting to EDs were aged between 75-94 years, female, triaged at scale 3 to 5, and transferred on weekdays and during working hours. Almost half of them were subsequently admitted to hospitals. In accordance with the ICD-10-AM diagnostic coding system, diagnoses that consistently ranked among the top three reasons for visiting the two hospitals before and after intervention included Chapter XIX: injury and poisoning and Chapter X: respiratory diseases. Associated with the intervention, significant decreases in the numbers of presentations per 1 000 RACF beds were identified among patients diagnosed with Chapter XI: digestive diseases [rate ratio (95%CI): 0.09 (0.04, 0.22); P<0.0001] and Chapter XXI: factors influencing health status and contact with health services [rate ratio (95%CI): 0.22 (0.07, 0.66); P=0.007].
CONCLUSION: The HiNH program may reduce the incidence of RACF residents visiting EDs for diagnoses of Chapter XI and Chapter XXI.

Key words: Residential aged care, Emergency department, Presenting complaint

Bill Lukin, Li-jun Fan, Jing-zhou Zhao, Jian-dong Sun, Kaeleen Dingle, Rhonda Purtill, Sam Tapp, Xiang-yu Hou. Emergency department use among patients from residential aged care facilities under a Hospital in the Nursing Home scheme in public hospitals in Queensland Australia[J]. World Journal of Emergency Medicine, 2016, 7(3): 183-190.

Figures/Tables 4

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References 20

1	Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med 2008; 52: 126-36.e1. doi: 10.1016/j.annemergmed.2008.08.017 pmid: 18971004
2	Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA. A conceptual model of emergency department crowding. Ann Emerg Med 2003; 42:173-180. doi: 10.1067/mem.2003.302 pmid: 12883504
3	Nasim MU, Mistry C, Harwood R, Kulstad E, Tommaso L. An attending physician float shift for the improvement of physician productivity in a crowded emergency department. World J Emerg Med 2013; 4:10-14. doi: 10.5847/wjem.j.issn.1920-8642.2013.01.002 pmid: 25215086
4	Fan L, Lukin W, Zhao J, Sun J, Hou X-Y. Interventions targeting the elderly population to reduce emergency department utilisation: a literature review. Emerg Med J 2015; 32:738-743. doi: 10.1136/emermed-2014-203770 pmid: 25527472
5	Dwyer R, Gabbe B, Stoelwinder JU, Lowthian J. A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities. Age Ageing 2014: afu117.
6	Briggs R, Coughlan T, Collins R, O'Neill D, Kennelly S. Nursing home residents attending the emergency department: clinical characteristics and outcomes. QJM-Int J Med 2013: hct136.
7	O'Connell B, Hawkins M, Considine J, Au C. Referrals to hospital emergency departments from residential aged care facilities: Stuck in a time warp. Contemp Nurse 2013; 45:228-233.
8	Arendts G, Howard K. The interface between residential aged care and the emergency department: a systematic review. Age Ageing 2010; 39:306-312. doi: 10.1093/ageing/afq008 pmid: 20176712
9	Arendts G, Popescu A, Howting D, Quine S, Howard K. ‘They never talked to me about…': Perspectives on aged care resident transfer to emergency departments. Australas J Ageing 2015; 34:95-102. doi: 10.1111/ajag.12125 pmid: 24372732
10	Buja A, Fusco M, Furlan P, Bertoncello C, Baldovin T, Casale P, et al. Referral patterns in elderly emergency department visits. Ann Ist Super Sanita 2013; 49:395-401. doi: 10.4415/ANN_13_04_13 pmid: 24334786
11	Jones JS, Dwyer PR, White LJ, Firman R. Patient transfer from nursing home to emergency department: outcomes and policy implications. Acad Emerg Med 1997; 4:908-915. doi: 10.1111/j.1553-2712.1997.tb03818.x pmid: 9305434
12	Finucane P, Wundke R, Whitehead C, Williamson L, Baggoley C. Profile of people referred to an emergency department from residential care. Aust N Z J Med 1999; 29:494-499. doi: 10.1111/j.1445-5994.1999.tb00749.x pmid: 10868526
13	Keskinoğlu P, İnan F. Analysis of emergency department visits by elderly patients in an urban public hospital in Turkey. JCGG 2014; 5:127-131.
14	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. J Am Geriatr Soc 2010; 58:510-517. doi: 10.1111/j.1532-5415.2010.02736.x pmid: 20398120
15	Wang HE, Shah MN, Allman RM, Kilgore M. Emergency department visits by nursing home residents in the United States. J Am Geriatr Soc 2011; 59:1864-1872. doi: 10.1111/j.1532-5415.2011.03587.x
16	Finn JC, Flicker L, Mackenzie E, Jacobs IG, Fatovich DM, Drummond S, et al. Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia. Med J Aust 2006; 185:296. pmid: 16948635
17	Arendts G, Dickson C, Howard K, Quine S. Transfer from residential aged care to emergency departments: an analysis of patient outcomes. Intern Med 2012; 42:75-82.
18	Bergman H, Carfield AM. Appropriateness of patient transfer from a nursing home to an acute-care hospital: a study of emergency room visits and hospital admissions. J Am Geriatr Soc 1991; 39:1164-1168. doi: 10.1111/j.1532-5415.1991.tb03568.x pmid: 1960359
19	Hou X-Y, Tollo S, FitzGerald G. What health problems overcrowd hospital emergency departments in Queensland and has this changed over time?: a case study of two hospitals in Queensland 2001-2009. Australas Epidemiol 2011; 18:10.
20	Loeb M, Carusone SC, Goeree R, Walter SD, Brazil K, Krueger P, et al. Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia. JAMA 2006; 295:2503-2510. doi: 10.1001/jama.295.21.2503 pmid: 16757722

Variables	RBWH				LH
Variables	Pre-test (n=449)	Post-test (n=393)	Overall (n=842)	P-value (Pre vs. Post)	Pre-test (n=207)	Post-test (n=265)	Overall (n=472)	P-value (Pre vs. Post)
Age group (years)				0.997				0.006^*
<65	29 (6.5)	26 (6.6)	55 (6.5)		6 (2.9)	24 (9.1)	30 (6.4)
65-74	58 (12.9)	49 (12.5)	107 (12.7)		20 (9.7)	43 (16.2)	63 (13.3)
75-84	137 (30.5)	123 (31.3)	260 (30.9)		72 (34.8)	81 (30.6)	153 (32.4)
85-94	193 (43.0)	169 (43.0)	362 (43.0)		88 (42.5)	101 (38.1)	189 (40.0)
≥95	32 (7.1)	26 (6.6)	58 (6.9)		21 (10.1)	16 (6.0)	37 (7.8)
Gender				0.887				0.053
Male	168 (37.4)	145 (36.9)	313 (37.2)		63 (30.4)	104 (39.2)	167 (35.4)
Female	281 (62.6)	248 (63.1)	529 (62.8)		144 (69.6)	161 (60.8)	305 (64.6)
Australasian Triage Scale (ATS)^?				0.480				0.037^*
ATS 1&2 (seen immediately)	80 (17.8)	78 (19.8)	158 (18.8)		27 (13.0)	54 (20.4)	81 (17.2)
ATS 3-5 (can wait)	369 (82.2)	315 (80.2)	684 (81.2)		180 (87.0)	211 (79.6)	391 (82.8)
Attendance day				1.000				0.402
Weekday	339 (75.5)	296 (75.3)	635 (75.4)		156 (75.4)	190 (71.7)	346 (73.3)
Weekend	110 (24.5)	97 (24.7)	207 (24.6)		51 (24.6)	75 (28.3)	126 (26.7)
Attendance time				0.105				0.005^*
Working hours	284 (63.3)	227 (57.8)	511 (60.7)		135 (65.2)	138 (52.1)	273 (57.8)
After hours	165 (36.7)	166 (42.2)	331 (39.3)		72 (34.8)	127 (47.9)	199 (42.2)
Disposition from ED				0.045^*				<0.0001^*
Admitted^?	256 (57.0)	196 (49.9)	452 (53.7)		95 (45.9)	168 (63.4)	263 (55.7)
Discharged	193 (43.0)	197 (50.1)	390 (46.3)		112 (54.1)	97 (36.6)	209 (44.3)

ICD Chapter	Disease classification	ICD Code range
I	Certain infectious and parasitic diseases	A00-B99
II	Neoplasms	C00-D48
III	Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism	D50-D89
IV	Endocrine, nutritional and metabolic diseases	E00-E90
V	Mental and behavioural disorders	F00-F99
VI	Diseases of the nervous system	G00-G99
VII	Diseases of the eye and adnexa	H00-H59
VIII	Diseases of the ear and mastoid process	H60-H95
IX	Diseases of the circulatory system	I00-I99
X	Diseases of the respiratory system	J00-J99
XI	Diseases of the digestive system	K00-K93
XII	Diseases of the skin and subcutaneous tissue	L00-L99
XIII	Diseases of the musculoskeletal system and connective tissue	M00-M99
XIV	Diseases of the genitourinary system	N00-N99
XV	Pregnancy, childbirth and the puerperium	O00-O99
XVI	Certain conditions originating in the perinatal period	P00-P96
XVII	Congenital malformations, deformations and chromosomal abnormalities	Q00-Q99
XVIII	Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified	R00-R99
XIX	Injury, poisoning and certain other consequences of external causes	S00-T98
XX	External causes of morbidity and mortality	V01-Y98
XXI	Factors influencing health status and contact with health services	Z00-Z99
XXII	Codes for special purposes	U00-U89

ICD Chapter	Pre-test period (RBWH): June-August 2005, n=449			Pre-test period (LH) June-August 2005, n=207			Post-test period (RBWH): June-August 2011, n=393			Post-test period (LH): June-August 2011, n=265
ICD Chapter	Presentations^?, n (%)	Presentation rates^\|\|	Rank	Presentations^?, n (%)	Presentation rates^\|\|	Rank	Presentations^?, n (%)	Presentation rates^\|\|	Rank	Presentations^?, n (%)	Presentation rates^\|\|	Rank
XIX	104 (23.16)	49	1	50 (24.15)	54	1	108 (27.48)	43	1	58 (21.89)	44	1
XVIII	71 (15.81)	33	2	28 (13.53)	30	4	72 (18.32)	29	2	29 (10.94)	22	3
X	51 (11.36)	24	3	41 (19.81)	45	3	39 (9.92)	16	3	47 (17.74)	36	2
IX	42 (9.35)	20	4	42 (20.29)	46	2	31 (7.89)	12	5	27 (10.19)	21	4
XI	40 (8.91)	19	5	5 (2.42)	5	7	14 (3.56)	6	7	23 (8.68)	18	5
XXI	31 (6.90)	15	6	NA			39 (9.92)	16	3	21 (7.92)	16	6
XIV	22 (4.90)	10	7	10 (4.83)	11	5	29 (7.38)	12	6	18 (6.79)	14	7
XII	19 (4.23)	9	8	NA			12 (3.05)	5	8	6 (2.26)	5	9
XIII	19 (4.23)	9	8	4 (1.93)	4	9	NA			NA
V	17 (3.79)	8	10	4 (1.93)	4	9	12 (3.05)	5	8	5 (1.89)	4	10
VI	NA^?			7 (3.38)	8	6	NA			5 (1.89)	4	10
IV	NA			5 (2.42)	5	7	11 (2.80)	4	10	7 (2.64)	5	8

ICD Chapter	Presentation rates^?, n				Estimated difference associated with the intervention
ICD Chapter	Pretest-RBWH	Pretest-LH	Posttest-RBWH	Posttest-LH	Rate ratio (95%CI)	P-value
XIX	49	54	43	44	1.09 (0.79, 1.51)	0.593
XVIII	33	30	29	22	1.20 (0.63, 2.27)	0.586
X	24	45	16	36	0.81 (0.37, 1.79)	0.608
IX	20	46	12	21	1.40 (0.70, 2.82)	0.344
XI	19	5	6	18	0.09 (0.04, 0.22)^*	<0.0001
XXI	15	3	16	16	0.22 (0.07, 0.66)^*	0.007
XIV	10	11	12	14	0.89 (0.32, 2.53)	0.832
XII	9	3	5	5	0.39 (0.10, 1.55)	0.179
XIII	9	4	2	3	0.39 (0.08, 1.98)	0.253
V	8	4	5	4	0.69 (0.14, 3.33)	0.643
VI	3	8	2	4	1.42 (0.31, 6.45)	0.647
IV	5	5	4	5	0.96 (0.25, 3.71)	0.951

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