| dc.description.abstract | Introduction:
Nursing Home (NH) residents are among the most vulnerable members of society. High rates of multimorbidity, functional dependence and frailty lead to high levels of health and social care needs in this cohort. As our population ages, the number of people living in NHs has increased. When they become unwell, the Emergency Department (ED) often acts as an access point to the acute hospital. ED presentations have been associated with adverse outcomes. The aims of this project were to: 1) describe characteristics and outcomes of NH residents attending the ED and factors influencing these outcomes, 2) review the prevalence and impact of polypharmacy and potentially inappropriate medications (PIMs) on outcomes for NH residents attending the ED, 3) examine the impact of the first wave of the COVID-19 pandemic on NH residents and staff, 4) review outcomes following the establishment of a dedicated NH Liaison service in an acute hospital.
Methods
1. All NH residents aged 50 years and older attending the ED of an urban university teaching hospital over one year (01/10/2019-30/09/2020) were included. Data was collected through medical record review and included demographics, comorbidities, medications, baseline functional ability (Barthel Index, BI) and frailty status (Clinical Frailty Scale, CFS). Details of ED attendance, discharge disposition, and length of stay (LOS) and discharge destination for those admitted to hospital was analysed. Twelve-month outcomes included ED reattendance and mortality.
2. Participants were grouped according to the number of medications prescribed and three levels of polypharmacy examined (5 or more medications, 10 or more medications, and 15 or more medications). Medications were further classified into PIM and non-PIM prescriptions according to STOPP version 2, STOPPFrail and Beers' Criteria.
3. The impact of the COVID-19 pandemic was analysed through distribution of surveys to NHs across three Community Healthcare Organisations (CHOs) to detail occupancy, size, COVID-19 outbreak, outbreak timing, total symptomatic/asymptomatic cases and outcomes for residents from 29/02/2020-22/05/2020.
4. The impact of a dedicated NH Liaison service was analysed through review of Health Information and Quality Authority (HIPE) data. This compared NH resident hospital admissions before the establishment of this service (2014-2017), following the development of the role of Advanced Nurse Practitioner (ANP) in Gerontology (2018-2019) and expansion to a dedicated team (2020-2022).
Results:
Characteristics and outcomes of older NH residents attending the ED:
There were 515 ED attendances by 341 individual NH residents over the study period. Mean age was 78.6 years (50-103, SD+/-10.9 years). Over half (56.3%, n = 192) were female. Mean CFS score was 6.6 (3-9, SD+/-0.9), mean BI score 9 (0-20, SD+/-7.8) and mean CCI score 5.3 (0-12, SD+/-2.1). Almost half (49.0%, n = 167) had a documented dementia diagnosis. At presentation, 92.8% (n=474) had a Manchester Triage System (MTS) score of 1-3 (mean 2.5, range 1-5, SD+/-0.7) indicating a need for urgent review. Most attendances occurred out-of-hours (OOH) (61.6%, n = 317). The most common presenting complaint was "generally unwell" (29.9%, n = 154). This was associated with higher 12-month mortality than other presentations (42.8% vs 33.7%, p = 0.048). Delirium was recorded in 31.8% (n = 164) and was associated with greater illness acuity (mean MTS 2.3 vs 2.7, p <0.001), admission rates (81.7% vs 53.4%, p <0.001) and 12-month mortality (50.6% vs 30.0%, p <0.001).
Polypharmacy and potentially inappropriate medications:
An average of 12.7 medications (0-31, SD+/-5.3) per patient were prescribed. Polypharmacy (≥5 medications) was identified in 95.6% of presentations (n = 460) with 72.3% (n = 348) prescribed ≥10 medications. A higher proportion of those prescribed ≥5 (62.2% vs 40.0%, p = 0.046) and ≥10 medications (64.7% vs 52.3%, p = 0.013) presented OOH. Those prescribed ≥5 medications had a higher level of acuity (MTS 2.4 vs 2.8, p = 0.049) and longer mean ED LOS than those with <5 medications (14.0 vs 10.8 hours, p = 0.035). Those in all polypharmacy groups had a higher inpatient LOS (10.1 vs 5.4 days, p = 0.015 for ≥5 vs <5 medications; 10.8 vs 7.2 days, p = 0.009 for ≥10 vs <10 medications; 12.5 vs 8.3 days, p = 0.035 for ≥15 vs <15 medications).
At least one PIM was identified in 99.0% (n = 475) according to STOPP version 2, in all (100.0%, n = 480) according to STOPPFrail and 97.5% (n = 468) according to Beers' criteria. Mean proportion of PIMs per patient was 59.1% (0-100%, SD+/-18.7%), 68.9% (0-100%, SD+/-18.3%) and 35.0% (0-100%, SD+/-17.2%) according to STOPP version 2, STOPPFrail and Beers' Criteria respectively. STOPP version 2 and STOPPFrail demonstrated a higher proportion of PIMs in those with a falls history (61.2% vs 57.1%, p = 0.014 and 70.7% vs 67.2%, p = 0.039). Beers' criteria found those with delirium (31.7% vs 36.8%, p = 0.001) and those admitted (33.2% vs 38.1%, p = 0.003) had a lower proportion of PIMs. There was a lower mean proportion of PIMs in residents who died at 12 months using all tools (STOPP version 2: 54.5% vs 61.5%, p <0.001, STOPPFrail: 64.8% vs 71.0%, p <0.001, Beers': 29.5% vs 37.6%, p <0.001).
The impact of COVID-19 on NH residents and staff:
Surveys were returned from 62.2% (28/45) of NHs. Three-quarters (21/28) had COVID-19 outbreaks (1,741 residents, 1,972 beds). Resident incidence was 43.9% (764/1,741). Case fatality rate (CFR) was 27.6% (211/764). Similar proportions of residents in NHs with ‘early-stage’ (<28 days) versus 'later-stage' outbreaks developed COVID-19. Of 395 NH staff across 12 sites with confirmed COVID-19, 24.7% (99/398) were asymptomatic. There was a significant correlation between the proportion of staff with symptomatic COVID-19 and resident numbers with confirmed/suspected COVID-19 (Spearman’s rho = 0.81, P <0.001).
The impact of a dedicated NH Liaison Team:
In the four years prior to the development of a NH Liaison service, NH residents accounted for 1.04-2.04% of total admissions per year with an average LOS of 10.63-12.33 days. An ANP-led in-reach service commenced in 2018. There were 353 NH resident admissions that year with an average LOS of 11.8 days. In 2019, there were 329 admissions and average LOS was 12.1 days. Readmissions decreased from 37.1% in 2018 to 24.0% in 2019. The NH Liaison Team was established in 2020 and allowed residents be admitted under a specialist geriatric service. There were 250 NH resident admissions in 2020 with an average LOS of 8.9 days. Readmission rate decreased to 10.0%. In 2021 there were 251 admissions, average LOS was 10.3 days and readmission rate was 12.7%. In 2022 admissions increased to 385 NH residents but average LOS decreased to 7.3 days. Readmission rate was 16.1%.
Conclusion:
These findings show NH residents presenting to the ED are a frail and complex cohort. Multimorbidity and polypharmacy are common. They are unwell at presentation, requiring urgent assessment and are frequently admitted to hospital. The COVID-19 pandemic highlighted this vulnerability. There are opportunities to enhance care for NH residents accessing the ED. This includes developing pathways for common presentations and presentations associated with an increased likelihood of adverse outcomes, improved recognition and management of delirium, regular medication review including deprescribing, education around PIMs, increased gerontological input in the ED and specialist teams to manage NH residents’ care in hospital and follow up on discharge. | en |
