How to Create Safe Transitions of Care for Older Patients

With Phil Magidson

Older adults are at a much higher risk of complications after an emergency department (ED) visit compared to younger patients, and there are more challenges associated with transitions of care in these patients. Inadequate support following discharge after an acute illness or injury can lead to functional decline in older adults and compromise their independence. Care transitions are a big part of ED practice and with the national boarding crisis and continued focus on providing high-value care, honing your skills to safely discharge older adults is imperative.

Join Dr. Christina Shenvi and Dr. Phil Magidson to learn about transitions of care and the challenges and processes for ensuring safe transitions of care for older patients. Phil Magidson is a faculty member at Johns Hopkins School of Medicine in Baltimore. He is currently the associate clinical director in the ED at Johns Hopkins Bayview where he spends the majority of his time in the ED however, he also attends the inpatient geriatric consult service.

Key Points

  • Any transition of care has risks, especially for older patients.
    • When discharged home one of the biggest complications is a return visit to the ED. Some studies suggest return rates of up to 20 to 30% after an index ED visit.1-5 But this does not mean they should have been hospitalized.
    • It is also risky to admit patients, older adults who are admitted to the hospital have a 30% chance of developing delirium, which is associated with negative patient outcomes, including falls, increased LOS, as well as cognitive and functional decline. 8,9
  • No individual screening tool can identify high-risk patients but each ED, hospital, and locale have different challenges, stakeholders and resources, and every ED can identify some geriatric screening tool that may benefit their patients.
  • Think about who is at high risk for functional medical decline and be thoughtful about engaging the patient, family members, PCP,  and interdisciplinary team to set up home health resources and follow-up appointments.
    • Up to 85% of the time important information is not communicated during a care transition, leading to higher costs, unnecessary treatments and related morbidity.6,7
    • By some estimates, more than half of older adults discharged from the ED don’t understand their expected course of illness or return precautions. And for those with dementia or delirium, understanding discharge instructions is even more challenging.11,12

References

  1. Lowthian J, Straney LD, Brand CA, Barker AL, Smit Pde V, Newnham H, Hunter P, Smith C, Cameron PA. Unplanned early return to the emergency department by older patients: the Safe Elderly Emergency Department Discharge (SEED) project. Age Ageing. 2016 Mar;45(2):255-61. doi: 10.1093/ageing/afv198. Epub 2016 Jan 12. PMID: 26764254.
  2. Biese K, Massing M, Platts-Mills TF, Young J, McArdle J, Dayaa JA, Simpson R Jr. Predictors of 30-Day Return Following an Emergency Department Visit for Older Adults. N C Med J. 2019 Jan-Feb;80(1):12-18. doi: 10.18043/ncm.80.1.12. PMID: 30622198.
  3. McCusker J, Cardin S, Bellavance F, Belzile E. Return to the emergency department among elders: patterns and predictors. Acad Emerg Med. 2000 Mar;7(3):249-59. doi: 10.1111/j.1553-2712.2000.tb01070.x. PMID: 10730832.
  4. Oliveira J E Silva L, Jeffery MM, Campbell RL, Mullan AF, Takahashi PY, Bellolio F. Predictors of return visits to the emergency department among different age groups of older adults. Am J Emerg Med. 2021 Aug;46:241-246. doi: 10.1016/j.ajem.2020.07.042. Epub 2020 Jul 22. PMID: 33071094.
  5. Grimmer K, Beaton K, Kumar S, Hendry K, Moss J, Hillier S, Forward J, Gordge L. Estimating the risk of functional decline in the elderly after discharge from an Australian public tertiary hospital emergency department. Aust Health Rev. 2013 Jun;37(3):341-7. doi: 10.1071/AH12034. PMID: 23701875.
  6. Cwinn MA, Forster AJ, Cwinn AA, Hebert G, Calder L, Stiell IG. Prevalence of information gaps for seniors transferred from nursing homes to the emergency department. CJEM. 2009 Sep;11(5):462-71. doi: 10.1017/s1481803500011660. PMID: 19788791.
  7. Britton MC, Ouellet GM, Minges KE, Gawel M, Hodshon B, Chaudhry SI. Care Transitions Between Hospitals and Skilled Nursing Facilities: Perspectives of Sending and Receiving Providers. Jt Comm J Qual Patient Saf. 2017 Nov;43(11):565-572. doi: 10.1016/j.jcjq.2017.06.004. Epub 2017 Oct 4. PMID: 29056176; PMCID: PMC5693352.
  8. Johansson YA, et al. Delirium in older hospitalized patients—signs and actions: a retrospective patient record review. BMC Geriatrics. 2018;18(43):1-11.
  9. Siddiqi N, Holt R, Britton AM, Holmes J. Interventions for preventing delirium in hospitalised patients. Cochrane Database of Syst Rev. 2007; Issue 2. Art. No.: CD005563. https://www.scribd.com/document/56840384/Interventions-forPreventing-Delirium-in-Hospital-is-Ed-Patients. Accessed September 26, 2023.
  10. Anderson TS. National trends in potentially preventable hospitalizations of older adults with dementia. J Am Geriatr Soc. 2021;68(10):2240-2248.
  11. Han JH, et al. The effective of cognitive impairment on the accuracy of the presenting complaint and discharge instruction comprehension in older emergency department patients. Ann Emerg Med. 2011;57(6):662-671.
  12. Hastings SN, et al. Older patients’ understanding of emergency department discharge information and its relationship with adverse outcomes.2011;7(1):19-25.
  13. Magidson PD, et al. Prompt outpatient care for older adults discharged from the emergency department reduces recidivism. West J Emerg Med. 2020;21(6):198-204.
  14. Carmel AS, et al. Rapid primary care follow-up from the ED to reduce avoidable hospital admissions. West J Emerg Med. 2017;18(5):870-877.
  15. Guttman A, et al. An emergency department-based nurse discharge coordinator for elder patients: does it make a difference. Acad Emerg Med. 2004;11(12):1318-27.
  16. Dresden SM, Hwang U, Garrido MM, Sze J, Kang R, Vargas-Torres C, Courtney DM, Loo G, Rosenberg M, Richardson L. Geriatric Emergency Department Innovations: The Impact of Transitional Care Nurses on 30-day Readmissions for Older Adults. Acad Emerg Med. 2020 Jan;27(1):43-53. doi: 10.1111/acem.13880. Epub 2019 Dec 1. PMID: 31663245.

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