Annals of Long Term Care

BACKGROUND

As stated in our previous article on nursing home (NH) transfer, published in the May 2005 issue, a major complaint of NHs involves transfer of NH residents to and from the emergency room (ER),1 especially when it happens after hours when administrative staff are no longer in the facility. At the same time, the ER staff can encounter great difficulty in determining the exact reason why the NH resident was sent to the ER. Often, little is known concerning the medical problems that necessitate the transfer.2 Nursing home residents have complex needs due to their numerous comorbidities and psychosocial needs. Therefore, effective communication between NHs and the ER is essential.

In the University of Texas Medical Branch hospital ER, the geriatric clinical nurse specialist and the emergency room clinical nurse specialist collaborated to develop a one-page “Resident Transfer Form” (Figure). The form, which the NH nurse can fill out quickly during an emergency, provides ER staff with a clear description of the situation. This form has been in use for four years, and is monitored monthly for compliance. Emergency room staff are pleased with the form, and it has reportedly reduced the number of problems related to NH transfer.

DEVELOPMENT OF THE TRANSFER FORM

To understand the problem, we formed a collaborative project between the geriatric clinical nurse specialist (GCNS)/nursing home liaison (NHL) and the ER clinical nurse specialist (ERCNS). We surveyed approximately 120 ER nursing personnel who worked 12-hour shifts using an open-forum discussion. To include as many nurses as possible, we held four meetings with both day and night shifts, each approximately one week apart. We asked the following questions:

• What information do you need from the nursing home?
• What information do you receive from the nursing home?
• What information do you provide to the nursing home at discharge?
• What issues and concerns do you have when caring for a nursing home resident?
(Tables I-IV)

Among the seven most frequently mentioned items needed from the NH were medical history, list of current medications, Do-Not-Resuscitate status, and phone number of the originating nursing home (Table I). These items of information were deemed very important because “without knowing the fundamental data such as baseline functional and mental status, the physician may begin a new and extensive workup” that is not needed. On the other hand, not performing a needed workup can lead to a major error.3

With regard to information received from the NH, respondents said they frequently either: (1) did not receive any information from the emergency medical services (EMS); or (2) received an inadequate verbal report (Table II). Sometimes the EMS provided a form listing the resident’s diagnoses, none of which were related to the resident’s ER visit. They also consistently received lists of medications, many of which had been discontinued. Needed medical information was buried in reams of NH records, which the ER staff has no time to peruse without delaying appropriate treatment disposition.

Interestingly, while most survey participants said they gave the NH a full report upon patient discharge, some admitted to making no report (Table III). Information in these “full reports” varied wildly. Some nurses focused their reports on specific aspects of care, such as treatment provided in the ER, while others reported sending discharge forms with lists of discharge medications and follow-up care needed. Still others said they asked the social worker to call the NH to let them know what medications were filled by the pharmacy and the mode of transportation with which the resident would be returned to the NH. Clearly, these reports were inconsistent at best.

Our survey asked about issues and concerns in caring for NH patients (Table IV) to uncover any biased attitudes toward the elderly; we found just the opposite.