Are Hospital/ED Transfers Less Likely Among Nursing Home Residents With Do-Not-Hospitalize Orders?

Nakashima, Taeko; Young, Yuchi; Hsu, Wan‐Hsiang

doi:10.1016/j.jamda.2016.12.004

Cited by 26 publications

(32 citation statements)

References 20 publications

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“…Advance directives help physicians and NH staff to make appropriate decisions, thus decreasing inappropriate ED transfers, unwanted resuscitation and hospital admissions [10, 36, 41, 49, 51–55]. Studies show that NH residents hope that they will not be hospitalised, particularly at the end of life, when transfer to a hospital is distressing to both the resident and the family [56–58]. Evans et al found that when physicians complied with the wishes of their patients, there was a 20% increase in the number of patients dying in the NH, rather than in the hospital [59].…”

Section: Resultsmentioning

confidence: 99%

“…In the ED, advance directives are useful to clinicians who often need to make treatment decisions without detailed knowledge of the patient’s history and wishes [10, 36, 49, 55, 57, 58]. Advance directives were available in 44% of the patients presenting at the ED, 64% had a do not resuscitate order, 60% had a health care proxy documented and 12% had a living will documented [52].…”

Section: Resultsmentioning

confidence: 99%

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Appropriateness of transferring nursing home residents to emergency departments: a systematic review

et al. 2019

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BackgroundElderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable.MethodsSystematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract.ResultsSeventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital.ConclusionsThe definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient’s autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.Electronic supplementary materialThe online version of this article (10.1186/s12877-019-1028-z) contains supplementary material, which is available to authorized users.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Appropriateness of transferring nursing home residents to emergency departments: a systematic review

et al. 2019

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“…35e38 However, approximately 4 of 10 nursing home residents fail to have any advance care plan documented. 39,40 A major barrier to advance care planning is choosing the correct time to initiate it. Discussions occurring too early may not accurately reflect patient preferences over time and discussions that occur too late fail to protect patients from receiving care that was not consistent with their wishes.…”

Section: Discussionmentioning

confidence: 99%

Nursing Home Residents Face Severe Functional Limitation or Death After Hospitalization for Pneumonia

Griffith

Levy

Parikh

et al. 2020

Journal of the American Medical Directors Association

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Objectives: Pneumonia is a common cause of hospitalization for nursing home residents and has increased as a cause for hospitalization during the COVID-19 pandemic. Risks of hospitalization, including significant functional decline, are important considerations when deciding whether to treat a resident in the nursing home or transfer to a hospital. Little is known about postdischarge functional status, relative to baseline, of nursing home residents hospitalized for pneumonia. We sought to determine the risk of severe functional limitation or death for nursing home residents following hospitalization for treatment of pneumonia. Design: Retrospective cohort study. Setting and Participants: Participants included Medicare enrollees aged 65 years, hospitalized from a nursing home in the United States between 2013 and 2014 for pneumonia. Methods: Activities of daily living (ADL), patient sociodemographics, and comorbidities were obtained from the Minimum Data Set (MDS), an assessment tool completed for all nursing home residents. MDS assessments from prior to and following hospitalization were compared to assess for functional decline. Following hospital discharge, all patients were evaluated for a composite outcome of severe disability (4 ADL limitations) following hospitalization or death prior to completion of a postdischarge MDS. Results: In 2013 and 2014, a total of 241,804 nursing home residents were hospitalized for pneumonia, of whom 89.9% (192,736) experienced the composite outcome of severe disability or death following hospitalization for pneumonia. Although we found that prehospitalization functional and cognitive status were associated with developing the composite outcome, 53% of residents with no prehospitalization ADL limitation, and 82% with no cognitive limitation experienced the outcome. Conclusions and Implications: Hospitalization for treatment of pneumonia is associated with significant risk of functional decline and death among nursing home residents, even those with minimal deficits prior to hospitalization. Nursing homes need to prepare for these outcomes in both advance care planning and in rehabilitation efforts.

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“…Advance care planning (ACP) is defined as “the ability to enable individuals to define goals and preferences for future medical treatment and care, to discuss these goals and preferences with family and healthcare providers, and to record and review these preferences if appropriate.” ACP has been associated with a decrease in hospitalizations and use of resources, lower levels of unwanted life‐sustaining treatments, increasing patient and family satisfaction with care, an increasing number of residents dying in their NH instead of in hospital, and increasing compliance with patients’ end‐of‐life care wishes …”

Section: Introductionmentioning

confidence: 99%

“…5 ACP has been associated with a decrease in hospitalizations and use of resources, lower levels of unwanted life-sustaining treatments, increasing patient and family satisfaction with care, an increasing number of residents dying in their NH instead of in hospital, and increasing compliance with patients' end-of-life care wishes. [6][7][8][9] In the present study, "ACP" is used as an umbrella term and includes all forms of forms of ACP, regulated by law or not. Currently, two forms of ACP occur together in Flemish NH.…”

Section: Introductionmentioning

confidence: 99%

Initiation of advance care planning in newly admitted nursing home residents in Flanders, Belgium: A prospective cohort study

Paque

Ivanova

Elseviers

et al. 2018

Geriatrics Gerontology Int

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Aim To describe (i) the timing of initiation of advance care planning (ACP) after nursing home admission; (ii) the association of dementia and physical health with ACP initiation; and (iii) if and how analgesic use and use of lipid modifying agents is related to ACP, in a cohort of newly admitted residents. Methods A prospective, observational cohort study of nursing home residents was carried out. Data were collected 3 months, 15 months (year 1) and 27 months (year 2) after admission, using a structured questionnaire and validated measuring tools. Results ACP was never initiated during the 2‐year stay for 38% of the residents, for 22% ACP was initiated at admission, for 21% during year 1 and for 19% during year 2 (n = 323). ACP initiation was strongly associated with dementia, but not with physical health. Residents without dementia were more likely to have ACP initiation at admission or not at all, whereas ACP initiation was postponed for residents with dementia. Between admission and year 2, analgesic use increased (from 34% to 42%), and the use of lipid‐modifying agents decreased (from 28% to 21%). Analgesic use increased more in residents with ACP initiation during year 1 and year 2. The use of lipid‐modifying agents was not associated with ACP. Conclusions The timing of ACP initiation differed significantly for residents with and without dementia, which highlights the importance of an early onset of ACP before residents lose their decision‐making capacity. ACP conversations might create opportunities to discuss adequate pain and other symptom treatment, and deprescribing at the end of life. Geriatr Gerontol Int 2019; 19: 141–146.

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Are Hospital/ED Transfers Less Likely Among Nursing Home Residents With Do-Not-Hospitalize Orders?

Cited by 26 publications

References 20 publications

Appropriateness of transferring nursing home residents to emergency departments: a systematic review

Appropriateness of transferring nursing home residents to emergency departments: a systematic review

Nursing Home Residents Face Severe Functional Limitation or Death After Hospitalization for Pneumonia

Initiation of advance care planning in newly admitted nursing home residents in Flanders, Belgium: A prospective cohort study

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