Why do so many nursing home residents end up in emergency departments?
This January, Sylvia got a call from a nurse in her mother’s long-term care centre. Her mother, Angela, woke up “extremely agitated and crying in pain,” so the nurses sent her to the emergency department.
Sylvia was worried about how her 92-year-old mom, who has dementia, would react to the trip – the lights, the new faces and the loud noises.
Angela was in the emergency department from 10 a.m. until two the following morning. “They tried to eliminate this, they checked that, and so on,” recalls Sylvia.
“She kept asking where she was and what was happening,” says Sylvia. “She was getting more and more agitated.”
The final test – an X-ray of the spine – revealed that Angela had compression fractures, meaning she must have had a fall in the night. The doctors sent her home and told Sylvia to follow up with her mother’s family physician.
Sylvia thinks that the hospital visit was justified – even if a doctor had been available that morning at the nursing home, they wouldn’t have known what was wrong without the X-ray. But she thinks if there was communication between Angela’s regular primary care provider and the emergency department doctors, many of the tests could have been avoided.
And she’s worried about another emergency department visit, since nurses at her mother’s home often send patients there if a family doctor isn’t available. “The nurses are nervous, they’re overworked, and they’re concerned about their own liability, which is understandable,” says Sylvia.
In most provinces, access to primary care for nursing home residents is extremely variable. Some homes have a primary care provider on site five days a week. In many other homes, doctors do drop-in visits once or more a week.
Nursing staff can usually call a patient’s provider, but sometimes they avoid calling to not overburden the doctor. In other cases, providers are busy seeing other patients so even when they’re called, they suggest the emergency department.
“The arrangements are all over the map,” says Evelyn Williams, president of Ontario Long Term Care Physicians. “It would probably be preferable that in-person assessments with an attending physician or nurse practitioner are available on a daily basis. However, we have got a long way to go to make that happen.”
David O’Brien, senior vice president of Primary and Community Care at Alberta Health Services, agrees that the models for care are “a bit eclectic,” with some patients being cared for by one provider and others by a team of providers, leading to different access levels. But he says the variability is justified – having nurse practitioners available five days a week may work for an urban area, but may be too expensive for a small, rural LTC home. “I’m not sure that one model actually works,” he says.
O’Brien adds that AHS hasn’t yet evaluated the outcomes of the different models of primary care for LTC centres. “We’d like to get to that point, but we’re not there right now,” he says.
Still, Samir Sinha, a geriatrician at Mount Sinai Hospital in Toronto, thinks that more standards for primary care access are necessary. “There needs to be an obligation that…homes be able to get access to a primary care provider on a 24 hour basis,” he says. He also thinks there should be more standards on the type of care residents receive. When he worked in Maryland, U.S., for example, there were state minimum requirements on how often medications need to be reviewed, he points out.
Emergency department visits can worsen health issues
Howard Ovens, chief of the department of emergency medicine at Mount Sinai Hospital, has seen many cases where nursing home residents arrive at emergency departments because the staff nurse didn’t have access to doctors or nurse practitioners who can provide an assessment. He recognizes, however, that he only sees the select group that show up in emergency – he doesn’t see the patients who receive timely care and therefore don’t need to be sent to his hospital.
“They’re taken out of their home, a familiar setting, to a strange environment where they don’t know any of the people,” explains Ovens. “They may not understand where they are or why they’re there.”
Meanwhile, emergency department doctors may perform more tests and treatments than are necessary because they don’t know the patient. Elderly people may want more comfort-oriented care at the end of life rather than have all their health problems diagnosed and responded to, for instance. And, yet, says Ovens, those working in the emergency department sometimes don’t see such directives on a patient’s health record. More often, the directives are available but “inadequate to really understand what their goals of care are.”
In many cases, says Ovens, when patients can’t speak for themselves (in Ontario, 42% of nursing home residents have been diagnosed with dementia), they will already have had procedures done, like an IV put in, before the family has even arrived to discuss the approach. “The emergency department is geared for action. Our default will be to intervene,” says Ovens.
Cindy Forbes, who is pushing for improved access to well-coordinated primary care for seniors in her role as president of the Canadian Medical Association, points out another major problem associated with emergency department transfers. “Hospitalizing elderly people often puts them in the situation where they might be exposed to infections,” she says. And if an infection or other major issue causes a patient to be kept in the hospital for more than a month, in some regions they risk losing their LTC bed.
But Williams points out that even when a primary care provider is available to assess a patient in the nursing home, they may still have to send them to the hospital to access an X-ray or lab work. In many nursing homes, Williams says laboratory staff only pick up samples once a week. There is also the issue of what kind of care is available once the family doctor leaves. “A patient may need to have a nurse who is able to monitor them throughout the night, who may not be available.”
In some small or under-resourced LTC homes, emergency departments may be the most efficient and timely way to provide care, compared to having resources available in homes with small resident numbers, Williams argues. “Perhaps the answer is not to provide more expansive services where it’s difficult, but to provide services better and more efficiently to elderly people in the emergency department.”
Of course, there are times when the emergency department will be the best place for an elderly patient in a health crisis. “If there’s any doubt, the emerg is a very effective place to get a rapid, broad examination done,” says Ovens.
Programs arising to better serve nursing home residents
Across Canada, more and more programs are being funded to bring primary care to patients in long-term care (LTC) facilities. In Nova Scotia, a program called Care By Design “has been heralded as one of the leading models,” says Forbes.
Barry Clarke, a family physician, implemented the program in 2009, after research had shown that 75% of those admitted to a LTC facility were sent to the emergency department at least once a year. (In Netherlands, by comparison, only 5% of nursing home residents visited emergency departments annually.)
A big part of the problem, says Clarke, was that family doctors were spread thin, sometimes seeing several patients in numerous facilities. “It was care by default. Many people couldn’t get access to good primary care when they needed it, so they defaulted to a hospital admission,” explains Clarke.
With the roll out of Care by Design, a family doctor is responsible for patients on one floor of a nursing home, and supported by a team, often including a nurse, pharmacist, and physiotherapist. Standards of Care were also established. Doctors take on call shifts where they are responsible for any emergencies in a larger patient population. “Doctors on call have to be available by phone within 30 minutes,” says Clarke.
The doctor or nurse practitioner can also call on Extended Care Paramedics, who are able to provide some of the tests and treatments that patients were previously sent to the hospital for. “They can do cardiograms, they can do IVs for antibiotics and they can do stitches,” explains Clarke. A recent study found that the extended care paramedics – who are available from 8 a.m. to 8 p.m. – were able to treat 73% of patients on site.
Clarke reports the program has brought emergency transfers down significantly, by 40% to 65%, though his analysis has yet to be published.
Health systems are also working to ensure better communication of health care wishes. Over the last few years, the province of Alberta has implemented a program that aims to bring much more detail and standardization into these conversations. Patients keep a standardized document that comprehensively outlines where they want to be cared for and how much intervention they want, in a standardized green folder. Paramedics have been trained to ask for the folder, says Eric Wasylenko, the program’s medical advisor. He explains program was put in place in part because fully informed people who indicated a wish to remain at home for care, and avoid hospitalization, were still being sent to the hospital.
In Ontario, the government is responding to the access issue by funding up to 30 new nurse practitioners to provide full time care in LTC facilities this fall. The government will add up to 75 nurse practitioners by the end of 2017, according to government spokesperson David Jensen.
Michelle Acorn, the lead nurse practitioner at a hospital clinic for geriatric patients at Lakeridge Health Hospital in Whitby, says that the number is far from what the Nurse Practitioner Association of Ontario and Registered Nurses Association of Ontario have been calling for: one nurse practitioner per home (there are more than 600 LTC facilities in Ontario).
The benefit of having providers on site, says Acorn, is that they are more likely to focus on prevention. For instance, falls may occur because patients may be on too many medications – so providers who have more time with staff can work to implement new strategies and protocols to decrease medications – as Care By Design has done. “A lot of things can be averted if you are proactive versus reactive,” says Acorn.
Physician assistants can also play a role in preventative care. Michael Peirone, a physician assistant in Barrie, sees all of his patients, in several nursing homes, two times a month, in consultation with Dr. Kelley Wright. Their philosophy is that many emergencies can be warded off if early symptoms are noticed. For instance, sudden weight gain could be an early sign of heart failure, but if it’s addressed quickly, an ambulance trip can be avoided.
“I think it’s more common for physicians to pick a day or half a day a week. They run in and put out any fires that have accumulated during the week,” he says. “It’s very crisis-based.”
The names of the patient and her mother have been changed.