Annals of Long Term Care

Care transitions between Emergency Departments (EDs) and nursing homes (NHs) are often poorly coordinated, putting patients at risk for adverse consequences. Studies suggest that in over 90% of all NH-to-ED patient transitions, information essential to adequate emergency care is lacking. Communication by ED staff when patients are discharged back to NHs is often substandard as well. EDs often use electronic or paper discharge templates designed for ambulatory, community-dwelling patients, which are not sufficient for NH residents. This article presents a case to illustrate some of the pitfalls commonly encountered during poorly coordinated NH-to-ED care transitions. Projects to improve poorly coordinated care transitions that include the recently developed quality indicators by the Society for Academic Emergency Medicine’s Geriatric Task Force are discussed. (Annals of Long-Term Care: Clinical Care and Aging 2010;18[4]:17-19)

Emergency Departments (EDs) are frequent providers of care for nursing home (NH) residents.¹ Nearly one in four NH residents is transitioned to the ED every year.² Unfortunately, poor communication is often a hallmark of these care transitions.^3,4 Studies suggest that 10% of all NH residents arrive in the ED with no information at all, while in the remaining 90%, information essential to adequate emergency care is missing.^5-7 Poor communication during care transitions can lead to higher costs, increased healthcare utilization, and unnecessary duplication of services.^8-11 The following case illustrates some of the problems typically encountered during poorly coordinated NH-to-ED care transitions.

Case Presentation
Mr. J is a 79-year-old male who arrives by emergency medical services (EMS) to the ED in respiratory distress from a local long-term care facility. EMS reports that the patient developed respiratory distress about one hour earlier. They placed the patient on high-flow oxygen and obtained intravenous access during transport. They have no further information regarding the medical history but were given some paperwork from the NH to bring to the ED. They are not sure whether Mr. J has any advance directives.

On arrival, Mr. J appears emaciated, diaphoretic, and in severe respiratory distress. He does not respond to verbal stimuli. His oxygen saturation is 85% on a 100% nonrebreather mask. His respiratory rate is 32 breaths per minute, pulse is 134 beats per minute, and blood pressure is 70/40mm Hg. A percutaneous endoscopic gastrostomy (PEG) feeding tube is noted. The only information available is a lengthy photocopy of the NH chart that was brought by EMS. As preparations for endotracheal intubation and hemodynamic support are made, the emergency physician quickly goes through the chart and is unable to locate advance directives. Mr. J suddenly develops ventricular fibrillation. There is no palpable pulse. Advanced cardiac life support (ACLS) measures are initiated, and there is a return of spontaneous circulation. The patient is successfully intubated and placed on a ventilator. Vasopressors are initiated.

The emergency physician begins to review the NH chart. Most of the 24-page chart contains demographic information, progress notes, physical therapy assessments, and scattered laboratory results. In between is found a list of medical problems. Mr. J has advanced Alzheimer’s disease, as well as metastatic prostate cancer. He is bed-bound, nonverbal, and receives feedings and hydration through his PEG tube.

The emergency physician contacts the NH and speaks with the nurse who was caring for Mr. J. She is not his usual nurse and just came on duty an hour before Mr. J decompensated. She is not aware of his advance directives, but she looks in the patient’s chart and finds them. According to these documents, Mr.