Some nursing home seniors don't need the ER

A study shows just how often nursing home residents make unnecessary visits to the ER. Fortunately, there’s a way to fix it.

We've all heard stories of backlogs caused by people turning up at the emergency room with conditions could be treated elsewhere. Now new research reveals that nursing home residents make up a surprising number of those unnecessary visits.

In a study published late last month, researchers from Indiana University looked at the records of nearly five thousand nursing home residents.  All of were diagnosed with dementia.  Over the course of a year, just under half of those nursing home patients were transferred to the local ER for treatment.  You might think that nursing home patients are sicker than other patients, and therefore in greater need of admission to hospital.  But that's not what the study found.  Thirty-six per cent of the nursing home patients sent to the ER for treatment were admitted; almost two thirds (64 per cent) were sent back to the nursing home without being admitted.  

This may be American research but I can tell you it fits my experience.  The patients in the study had many of the same problems I see in patients sent to my ER and most others.  Those admitted to hospital had heart failure, pneumonia, and urinary tract infections.  Some have fractured hips and needed admission for surgery.  But as with this study, a lot of the patients we see don't need to be admitted to hospital.  They include patients who are somewhat dehydrated because they don't feed themselves; short-staffed nursing homes don't have enough personnel to make sure they have enough to eat or drink.  Some have cuts and are transferred to the ER for stitches.  Many patients at nursing homes fall and need x-rays to rule out broken bones.  These kinds of patients don't need to be admitted to hospital.  Many experts say don't need to be transferred to the ER at all.

Nursing home residents with dementia who are admitted to hospital do poorly.  Up to half of those admitted develop acute confusion caused by delirium that is often unrecognized by doctors and nurses.  Delirium doubles an elderly patient's risk of dying within a year of hospitalization.  Nursing home patients  even the ones not admitted to hospital  spend more time in the ER than walk-in patients.  They take longer than other patients to be assessed.  When they're discharged from hospital, they have to wait for a non-emergency ambulance to take them back to the nursing home.  Those sorts of delays tie up stretchers and make it harder to bring patients in from the waiting room.

I think nursing home patients shouldn't have to be transferred to receive care unless absolutely necessary. Nova Scotia has an Extended Care Paramedic Program that enables paramedics with special training to care for seniors at the long-term care facility instead of the ER.  Paramedics assess patients at the nursing home, and provide treatment that ranges from stitching cuts to giving intravenous fluid to treat dehydration.  The program, which won a national award, has prevented more than 70 per cent of nursing home patients from having to be transferred to the ER.

Ontario has put millions into a community paramedicine program in which paramedics target seniors who call 9-1-1 frequently.  Winnipeg set up a similar service for frequent users located in the inner city.  Proponents want to set up a similar program in BC.

For those nursing home patients who need to be sent to hospital, we need to do a better job of meeting their needs.  One way to do that is to build an ER especially designed for frail seniors  especially those with dementia.  Geriatric ERs post signs with bigger letters that are easier for seniors to read.  Non-slip flooring and grab bars help prevent falls.  Specially trained doctors, nurses, nurse practitioners, social workers and physiotherapists work in geriatric ERs.  Hospitals in the U.S. pioneered them.  So far, we haven't seen geriatric ERs in Canada, but we have seen special programs staffed by well-trained experts that target older patients.  Some experts say you need a geriatric ER to take better care of frail seniors and those with dementia.  What we must to do is make best efforts to prevent seniors from making unnecessary trips to the ER.

It starts with the realization that for many seniors - even ones who are frail - a trip to the ER is often unnecessary.


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