TRANSITIONAL CARE: HOW TO MOVE ELDERLY PATIENTS THROUGH THE

EMERGENCY DEPARTMENT

Michael A. LaMantia, MD, MPHKevin Biese, MD, MAT

Ellen Roberts, PhD, MPHJan Busby-Whitehead, MD

University of North Carolina at Chapel HillDivision of Geriatric MedicineCenter for Aging and Health

Department of Emergency Medicine

THE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

OUTLINE• Aging: Global and American Perspectives

• Elderly Patients and the ED

• Case 1 — Getting it Wrong

• Transitional Care: Definitions and Quality Indicators

• Case 2 — Getting it Right

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LEARNING OBJECTIVES

• To identify ways in which the care of older patients in the ED differs from that of younger patients

• To define key components of effective transitional care of elderly patients

• To identify potential strategies to improve the coordination of care for elderly patients who are seen in the ED

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AGING: INTERNATIONAL AND DOMESTIC SCOPE (1 of 2)

• Baby Boom generation Born between 1946 and 1964

Quickly approaching age of retirement

• World Health Organization (WHO) report (2002): Age cohort >60 is fastest-growing population segment

worldwide Decreases in fertility rates and increases in life expectancy

will change age compositions of many nations

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AGING: INTERNATIONAL AND DOMESTIC SCOPE (2 of 2)

• WHO and United Nations estimate: 35% of Japan’s population >60 in 2025 34% of Italy’s population >60 in 2025 China’s population >60 will increase from 134 million in

2002 to 287 million in 2025

• WHO calls for “healthy and active ageing” to be key worldwide policy concern

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AGING: IMPACT ON ED

Compared with younger patients, the elderly:• Are more ill at presentation• Arrive by ambulance more frequently• Receive more tests• Suffer from more chronic medical comorbidities• Are admitted to the hospital at higher rates• Experience longer ED stays• Incur higher medical bills• Return more frequently to the ED

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CASE 1 (1 of 6)

Mr. S: Friday, 7:30 pm• 85-year-old with a past medical history of moderate

dementia arrives via ambulance from an assisted living facility

• Arrives with no paperwork or medication administration list

• Patient can’t give chief complaint• Person on call from the facility who knows patient has

gone home• Grandson states patient has been coughing and that

doctor at facility suspected pneumonia

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CASE 1 (2 of 6)• Past medical history:

Coronary artery disease Hypertension Moderate dementia

• Allergies: no known drug allergies

• Medications (grandson believes he remembers these): Metoprolol Aricept Aspirin 81 mg/day Simvastatin

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CASE 1 (3 of 6)Physical exam:

• BP 130/70, pulse 76, respirations 18, oxygen saturation 96% on room air, afebrile

• Patient slightly confused (this is change from baseline according to grandson)

• Pupils equal/round/reactive to light, moist mucous membranes

• Regular S1 S2, no murmurs/rubs/gallops

• Some very mild crackles at right base, otherwise clear; normal work of breathing

• Rest of exam: unremarkable

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CASE 1 (4 of 6)• Labs:

White blood cells: 10.0 (differential: neutrophils 8.7, lymphocytes 1.0, eosinophils 0.3)

Hemoglobin: 12.0 Hematocrit: 36.0 Platelets: 350

• Blood chemistry: within normal limits

• Chest x-ray: Possible developing right lower lobe infiltrate vs. atelectasis. Clinical correlation recommended.

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CASE 1 (5 of 6)

• Pneumonia Severity Index score: 105 points ― Risk Class IV ― approximately 8%9% mortality

• You recommend hospitalization, but:

Grandson states he holds health care power of attorney and patient would not wish to be hospitalized. He wishes to take patient home and care for him there. Patient is confused but agreeable.

You prescribe course of levofloxacin and ask that they see their primary care provider on Monday

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CASE 1 (6 of 6)

• Patient goes home and does well for 3 days

• He does so well, family does not follow up with primary care provider on Monday

• Tuesday evening: Patient returns with skin bruising and blood in his urine

Platelets: within normal limit

INR: 7.2

• When the patient’s pills are brought from home, it is discovered he is taking warfarin

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CASE 1 — BREAKDOWN

• What went well?

• What could have gone better?

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DEFINITION OFTRANSITIONAL CARE

“A set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same institution.”

Slide 14American Geriatrics Society (2003)

RISKS OF TRANSITIONS• Medical errors

• Service duplication

• Inappropriate care

• Critical elements of care plan “falling though the cracks”

Slide 15American Geriatrics Society (2003)

CONCEPTUAL MODEL OF EFFECTIVETRANSITIONAL CARE

Communication between sending and receiving clinicians

Preparation of the caregiver and patient for transition

Reconciliation of medication lists Arranging a plan for follow-up of outstanding tests Arranging an appointment with receiving physician Discussing warning signs that might necessitate

more emergent evaluation

Slide 16Coleman (2003)

HOW TO IMPROVETRANSITIONAL CARE (1 of 6)

Suggestions:

• Changes to health care delivery systems For example, use of nurses to follow patients and/or expanding

Program of All-Inclusive Care of the Elderly programs

• Adoption of information transfer technology

• Changes to health care policy For example, pay for coordination of care or make providers

responsible for coordinating transitional care

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HOW TO IMPROVETRANSITIONAL CARE (2 of 6)

Society for Academic Emergency Medicine (SAEM) Geriatric Task Force:

• Developed at recommendation of SAEM and American College of Emergency Medicine

• Identified and adopted quality measures to allow assessment of care provided to elderly patients

• Quality measures were vetted by/at:SAEM Geriatric Task ForceSAEM annual meetingAmerican Geriatric Society annual meeting

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HOW TO IMPROVETRANSITIONAL CARE (3 of 6)

Quality Measures 14: If nursing home patient goes to ED, then paperwork should state:

• Reason for transfer• Code status• Medication allergies• Contact information for:

Nursing home Primary care or on-call MD Resident’s health care power of attorney or closest

family member

Terrell et al. Acad Emerg Med. 2009;16:441-449.Slide 19

HOW TO IMPROVETRANSITIONAL CARE (4 of 6)

Quality Measures 56:

• If nursing home patient goes to ED, then paperwork should include: Patient’s medication administration record

• If nursing home patient goes to ED for requested studies, then: Document the performance of requested tests or the reason why

such tests were not performed

Slide 20Terrell et al. Acad Emerg Med. 2009;16:441-449.

HOW TO IMPROVETRANSITIONAL CARE (5 of 6)

Quality Measures 79:

• If nursing home patient goes to ED and then will be released from the ED, then: ED provider should speak with the nursing home provider,

primary care provider, or on-call MD for the nursing home prior to discharge

• If nursing home patient goes to ED and then will be released from the ED, then written paperwork should state: ED diagnosis Tests performed with results (and tests with pending results)

Slide 21Terrell et al. Acad Emerg Med. 2009;16:441-449.

HOW TO IMPROVETRANSITIONAL CARE (6 of 6)

Quality Measures 1011:

• If nursing home patient goes to ED and then is released back to the nursing home, then: The patient should receive the recommended follow-up The recommended changes to the patient’s medications or plan of

care should be followed (or the reason why not followed should be documented)

Slide 22Terrell et al. Acad Emerg Med. 2009;16:441-449.

CASE 2 (1 of 3)

Mrs. J: Saturday morning, 4 am• 92-year-old woman who presents from local nursing home

for “evaluation of increasingly combative behavior”• Past medical history:

Parkinsonism Diabetes Urinary incontinence Chronic back pain secondary to osteoarthritis and degenerative joint

disease• Little accompanying paperwork ― no medication

administration record• Call to the facility ― the staff who are there don’t know the

patient ― they give you her son’s phone number

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CASE 2 (2 of 3)

• Vital signs: BP 124/78, pulse 84, respirations 16, afebrile

Elderly woman lying on stretcher. Awake, but does not interact much with you or other staff.

Remainder of exam: within normal limits Labs and urinalysis: unrevealing

• Reach son ― he is thankful and says he will be over in about 1 hour

• Patient awakens and starts to pull at lines ― request is made for risperidone 1.0 mg

• Patient receives risperidone, calms down, and eventually goes to sleep

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CASE 2 (3 of 3)

• Son arrives ― you offer hospitalization ― he says that is not what his mother would want

• He asks that she be transferred back to the nursing home and that you provide a prescription for risperidone

• What do you do?

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REVIEW QUESTIONS,VIGNETTE 1 (1 of 2)

• Mr. S is an 85-year-old man with mild dementia who is sent to the ED from an assisted living facility without a medication record. When the facility is called, the staff do not know why Mr. S. was sent.

• Lab work and chest X-ray reveal a mild leukocytosis and a right lower lobe infiltrate.

• The patient’s vital signs are within normal limits and he is breathing easily. He is, however, slightly more confused than usual, according to his grandson. 

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REVIEW QUESTIONS,VIGNETTE 1 (2 of 2)

• The patient’s grandson states that he holds the patient’s health care power of attorney and that Mr. S. would not wish to be hospitalized.

• The decision is made to discharge the patient home to the care of his grandson with levofloxacin. 

• In 3 days, Mr. S returns to the ED with skin bruising and blood in his urine. His platelets are WNL, but his INR is 7.2.

• When his pills are brought from home, it is found that he is taking warfarin.

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VIGNETTE 1, QUESTION 1Which of the following is not considered to be a quality indicator for a patient transfer from a nursing home to the ED? Select the one best answer.

A. Contact information for the facilityB. Medication listC. Reason for visitD. Resuscitation/code statusE. Vaccination history

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VIGNETTE 1, QUESTION 2In the above scenario, which provider action could have best prevented the patient from returning to the ED with hematuria? Select the one best answer.

A. Asking the patient whether he was on warfarin.B. Communicating with the referring physician from

the assisted living facility.C. Confirming the patient’s medication allergies.D. Suggesting that the patient have his INR checked

in 1 week’s time.

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VIGNETTE 1, QUESTION 3Which one precautionary action, listed below, would have been the best action taken to increase the safety of the patient’s discharge to his grandson’s home?

A. Ensuring that the patient’s grandson understands the warning signs for bringing his grandfather back to the ED

B. Explaining to the patient the list of commonly prescribed drugs that interact with levofloxacin

C. Making sure the patient and his grandson understand the need to follow up with the patient’s primary care doctor within 1 week

D. Speaking with the patient’s referring physician when the decision was made to discharge the patient home

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REVIEW QUESTIONS,VIGNETTE 2 (1 of 2)

• Mrs. J. is a 92-year-old woman with parkinsonism, chronic back pain, and urinary incontinence who is sent to the ED because of increasingly combative behavior. She has no accompanying paperwork.

• She is lying on a stretcher with a subdued affect. Vital signs are within normal limits, and physical exam, blood work, and radiographic studies are unrevealing.

• Mrs. J becomes agitated and pulls at her lines and catheter. She is given 1.0 mg of risperidone, which calms her down.

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REVIEW QUESTIONS,VIGNETTE 2 (2 of 2)

• When the patient’s son arrives he states that his mother would not wish to be hospitalized. He asks for her to be transferred back to her nursing home with a prescription for risperidone.

• The next night, Mrs. J returns to the ED after suffering a fall, with a resulting foreshortened and externally rotated right leg. Reviewing the medication record from the nursing home, you see that she takes cyclobenzaprine in addition to the risperidone that was prescribed last evening.

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VIGNETTE 2, QUESTION 1

When the patient was initially transferred from her nursing home to the ED, which piece of information would have affected her care in the ED?

A. Contact information for the facilityB. Medication listC. Occupational historyD. Resuscitation/code status

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VIGNETTE 2, QUESTION 2

In the above scenario, which emergency provider action contributed to the patient’s return to the ED with a fractured hip? Select the one best answer.

A. The provider asked that the patient’s Foley catheter be removed before the patient’s transfer back to the nursing home.

B. The provider did not ask the patient which medications she was taking.

C. The provider did not confirm medication allergies before discharging the patient.

D. The provider did not speak with the referring physician before the patient’s transfer back to the facility.

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ANSWER KEY

• Case 1 Question 1: E Question 2: B Question 3: D

• Case 2 Question 1: B Question 2: D

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ACKNOWLEDGMENTSAND DISCLAIMER

• This project was supported by funds from the American Geriatrics Society John A. Hartford Geriatrics for Specialists Grant.  This information or content and conclusions are those of the authors and should not be construed as the official position or policy of the American Geriatrics Society or John A. Hartford Foundation, nor should any endorsements be inferred.

• The UNC Center for Aging and Health and UNC Department of Emergency Medicine also provided support for this activity. This work was compiled and edited through the efforts of Jennifer Link, BA.

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