Critical Review of Transitional Care Between Nursing Homes and Emergency Departments
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INTRODUCTION
Emergency departments (EDs) are major providers of nursing home (NH) residents. Urgent on-site physician evaluation, radiology and laboratory testing, and intravenous therapy, are not available in most NHs.1,2 As a result, NH residents who suffer acute illnesses or injuries are generally transported to an ED for evaluation and management. Indeed, each year nearly 25% of NH residents are transferred at least once to an ED.3
Transitional care has been defined as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.”4 Regrettably, healthcare settings, such as NHs and EDs, operate independently of one another, often providing care without the benefit of information from the other site of care.5-7 Poorly executed transitions are associated with inefficiencies and duplication of services that increase the cost of care and lead to greater utilization of health services.8 Most importantly, ineffective transitions put NH residents at considerable risk of receiving inappropriate or dangerous care.6
An NH resident travels a typical route during an episode of emergency care. There are five domains with intra-domain and inter-domain transitions:
1. NH domain before ED visit
2. Ambulance domain before ED visit
3. ED domain
4. Ambulance domain after ED visit
5. NH domain after ED visit
Intra-domain transitions occur during changes of shift, for example, when an emergency physician transfers care of the patient to the oncoming emergency physician at the end of his/her shift. Residents arrive at the ED domain through an NH-to-ED transition. The ED domain is then a branch point, where residents are admitted to the hospital, die in the ED, or are released back to the NH via an ED-to-NH transition.
NH residents are frequently seen in the ED and are a challenge to properly care for. Given these circumstances, we originally planned to conduct a systematic review of interventional studies that were designed to improve transitions between NHs and EDs. However, after encountering the paucity of interventional articles, we decided to critically review articles pertaining to transitions at the NH-ED interface. This review is focused on providing context and suggestions for future research.
METHODS
We defined “relevant article” as one that discussed, analyzed, or intervened in transitional care between NHs and EDs after the decision has been made to transfer the resident. A librarian with searching expertise and the authors independently searched for relevant English language articles in MEDLINE, Cumulative Index to Nursing & Allied Health Literature (CINAHL), and The Cochrane Library. Appropriate subject headings and text words were used, and the “exploding” technique was performed to maximize inclusion of all indexed articles.
As an example, our MEDLINE search strategy began with the following MeSH headings: “Nursing Homes” and “Long-Term Care,” which were combined using the Boolean search operator “OR.” The findings were combined using “AND” with the following terms: “Emergency Service, Hospital,” “Emergency Medicine,” “Emergency Medical Services,” “Emergency Treatment,” “Emergency Department,” “Emergency Room,” “Transportation of Patients,” “Patient Transfer,” or “Transitional Care.”
After each search, the titles and abstracts (if available) were read independently by the searchers to determine possible relevance to the study topic. Potentially relevant articles were then examined for relevance.
References
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