Practice Essentials: Long Term Care Patients in the Emergency Department

The Case:

An 86-year old female from a long-term care (LTC) facility is transferred to the Emergency Department (ED). She is primarily Russian speaking. The transfer note lists a history of hypertension, osteoporosis, osteoarthritis, and advanced dementia. She arrives alone by EMS to the ED with the transfer sheet saying, “chest pain”. She is wandering around the ED and the nursing team is having a difficult time keeping her in her room. You don’t know the historical features of this chest pain, her cognitive baseline, her advanced care planning wishes, or the reasons for transfer other than “chest pain”.

We see a large number of older persons in the ED. If you ask the average emergency medicine (EM) physician, there will likely be a gross overestimate of the number of LTC patients we see on shift. This overestimation probably comes from the perceived time and effort of assessing those complex patients. This post will help you be more confident and efficient in managing these patients. 

Appropriate transfers or not?

There has been a longstanding debate on the appropriateness of LTC transfers to the ED. In one study in Ontario, approximately 25% of nursing home residents went to an ED annually. Between 1/3 to 1/2 resulted in hospital admission.^​1​ Estimates of inappropriate referrals to hospital vary dramatically based on the country and the specific study. In 2000, an analysis of nineteen LTC facilities and 3 EDs in Hamilton, Ontario showed that most referrals appeared appropriate. They reported 1.66 LTC residents per 24-hour day for 3 EDs, which was 0.07% of the LTC residents in the area.^​2​

Many studies focus on the increased ED and resource use by LTC patients relative to community-dwelling older adults, and claim many of these referrals are preventable.^​3–5​ It should not be a surprise that LTC residents sometimes visit the ED and require hospitalizations: LTC residents are often medically complex and frail. So, we would expect increased EMS use, investigations, ED LOS, and admission rate for these patients compared to community-dwelling older people. 

As part of my training, I spent time at a behaviour and dementia unit at a LTC facility. I witnessed the challenges in managing LTC patients, gained an appreciation for the realities of care, and learned the perspective of the LTC physician. These are complex patients, with behaviors and cognitive impairment that make assessing symptoms difficult. One of the most complex tasks is deciding why and when to transfer a patient to the ED.

The LTC and the EM physician will often have different perspectives on “appropriateness of transfer” for these patients. From the LTC perspective, there may be a concern about a change in the patient’s condition and a lack of certainty about the consequences, for example a fall with suspected head impact. Timely investigations are usually not possible at LTC centres, and this may be the only reason for an ED visit. Consider how often we order investigations on the patients we receive from LTC. Then ask yourself if you would have transferred this patient if you couldn’t get these investigations. Furthermore, the staffing is surprisingly minimal in these institutions: there may only be one clinician (an RN) for 35-50 residents; personal service workers or care aids with no clinical training provide most of the care. LTC residents do not have access to a doctor daily but are seen on a weekly basis. The on-call physician most certainly does not know this patient and has limited telephone information provided to them when they make the decision to transfer. As we know, this is a population marked by complexity and uncertainty, and difficult for a single provider to sort out, even under ideal conditions.  

LTC to ED transfer documentation 

The intent of this post is to focus on an approach to LTC patients in the ED. But it is important to acknowledge that the information provided to the ED staff for LTC patients is variable, and sometimes does not include what physicians want or need to know. One study looked at LTC transfer documentation compared to the information required for emergency physicians over a one-year period. Physicians were asked, “what information do you want from a LTCH?” The most frequently requested information included:^​6​

• Reason for transfer (provided 77.5% of the time)
• Past medical history (provided 92% of the time)
• Cognitive status (provided 24% of the time)
• Advanced directives for level of care and resuscitation (provided 62% of the time)
• Emergency contact information (provided 76% of the time)

Standardized communication would be helpful to ensure the important information is provided at the time of transfer. This unfortunately is not universal and will require multiple stakeholders’ involvement and motivation to promote change. 

Changing our approach to LTC patients in the ED

It is essential to get a complete history from a staff member in the LTC institution. The “reason for transfer” recorded on the transfer sheet is often inadequate (if present at all). Realistically, it may be difficult to convey in one, concise, hastily written paragraph without planning, all the complexities associated with the decision to transfer this frail, cognitively impaired, polymorbid patient to the ED.

To help acquire a history and guide the work-up in LTC patients, here are some pearls to apply on shift:

1. Call the LTC facility early in the patient visit. Probably the best person to give you the information you need is the person who decided to send the patient. Accurate information can dramatically change the trajectory for any patient encounter, resulting in a different chief complaint, different diagnostics being ordered, and a different disposition. The earlier you call, the more likely you are to reach the staff that sent/knows the patient. 
2. On the phone call, consider the following points:
   • Ask directed, basic questions. Remember that care staff at nursing homes are likely not all RNs, and do not have acute medicine training. For example: 
     • Instead of “What is Mr. A’s cognitive/functional baseline?”, ask “What does Mr. A normally do every day?” or “What has changed about Mr. A that led to the hospital transfer?” or “When was Mr. A last his normal self?”
   • Ask that high-yield question that you usually ask most patients: “What was the main reason you decided to transfer this resident to the ED?”  
   • Ask about family contacts. Are they aware of the patient’s ED visit and what is their level of involvement? An answer that the patient’s family is aware and on their way to the hospital is very different from an answer that the patient’s POA lives in a different province and hasn’t seen them in years.
   • Ask early on if there are any anticipated barriers to discharge back to the LTC facility. 

What to consider when discharging a patient from ED to LTC?

Communication goes two ways. As much as we want important information provided when we receive transfers, the LTC needs to receive it at discharge. This is for the well-being of the patient. The standard of care for transfer back to LTC should include the following:

• Send a legible note back. Spending two minutes to create a brief Word document, outlining the treatment completed, investigations, and any follow-up required, does a great service to the patient and to your colleague to whom you are transferring care. It will prevent repeat visits and adverse events for the patient. 
• Print the investigations that were completed in the ED. Often the LTC facilities cannot access this on their electronic medical record system. 
• Most LTC residents do not have access to a doctor on a daily basis. Keep this in mind when establishing disposition plans, to ensure your expectations on follow-up and observation are realistic. The patient may need that extra dose of their new prescription before they leave, etc.

I would argue that patients from LTC should not take significantly more time than other older persons we see in the ED. However, the approach to the patient should be targeted and we need to be strategic to involve the care facility. Consider the next three LTC transfers you see in the ED. Was this transfer really avoidable? What would have to be in place within our healthcare system to have avoided it? If those things are not currently in place, then it wasn’t avoidable! 

Case Conclusion

Before seeing the patient (you know you don’t speak her language and she has dementia) you call the LTC facility. After what seems like a long time on hold (but shorter and less frustrating than trying to get an unhelpful history from the patient), you speak with the nurse who cares for the patient daily. You practice your questions from #2 above and learn that the decision to transfer was made by “an agency nurse” who doesn’t know the resident but noticed her rubbing her chest. On hearing this description over the phone, the on-call doctor (who also doesn’t know the patient) thought she should be assessed further. The primary nurse says the wandering and exit-seeking behaviours occur daily but the patient responds to alternate stimulation such as having a pile of pillowcases to fold and re-fold or listening to 1940s music on Spotify. The nurse provides the phone number for the patient’s daughter, who is her substitute decision maker. You speak to her and ask her to come to the ED. On arrival, she notices no difference in her mother: the chest-rubbing behaviour has been chronic for years and worsens when she is around new people. The daughter confirms that her goal for her mother is comfort care, “although I’ve never really said that to the staff at the nursing home.” Given all this, you and the daughter agree there is little value in attempting bloodwork or an ECG (for which she would have to be restrained). You type up a quick Word document to accompany the patient back, outlining your management plan, and suggesting that the advanced care plan for this resident be modified.

References

This post was copyedited by Kim Vella.

Reviewing with the Staff

Rebecca’s post highlights – as does the current COVID-19 pandemic – that nursing home residents are among the most vulnerable and needful users of ED services. Because of their institutional care site, their (frequent) cognitive impairment, and their social and medical complexity, they require quite a different skill set from our “usual” ED patients. She gives excellent pointers about navigating this complicated transition of care, especially how essential it is for the ED doc to talk directly with a clinician, usually a nurse, at the care home. This step, though sometimes time-consuming, leads to much better care for the patient AND ultimately makes the ED doc’s job clearer and easier.

For more about Nursing home transfers in the time of COVID-19, check out this resource: https://gedcollaborative.com/article/jgem-volume-1-issue-5/

Dr. Don Melady

Emergency Physician at Mount Sinai Hospital, Toronto; Director of the fellowship in Geriatric Emergency Medicine at Schwartz-Reisman Emergency Medicine Institute, Mount Sinai Hospital.

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Rebecca Schonnop

Dr. Rebecca Schonnop is an Emergency Medicine resident at the University of Alberta in Edmonton. During her residency training she completed a Geriatric Emergency Medicine Clinical Fellowship through the University of Toronto. She has a particular interest in caring for older persons in the ED, and medical education.

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