According to the Administration on Aging, 1 in 4 patients admitted to a skilled nursing facility are readmitted to the hospital within 30 days at a cost of $4.3 billion dollars. In particular, hospital emergency rooms see a disproportionate number of elderly long-term care residents in their patient population, and this number appears to be increasing. Researchers at the University of California at San Francisco found that the number of emergency room visits by elderly nursing home residents rose by 13% during the decade from 2001 through 2010. In 2010 alone, the UCSF researchers found that that figure had reached 2.1 million.
The Centers for Disease Control published a report showing that 8% of nursing home residents have visited a hospital emergency room within the past 90 days. The most concerning aspect of this trend toward increasing numbers of ER visits is that a sizable percentage of them are preventable. The CDC report, which notes that it presents “the only national information on potentially preventable Emergency Department use among U.S. nursing home residents,” points out that 40% of these emergencies were the result of avoidable illnesses and injuries. Here’s a look at some of the situations that lead to such preventable emergency room visits and some options for minimizing their frequency.
What brings long-term care residents to the ER?
Injuries from falls constitute the largest portion (36%) of those preventable emergencies, according to the CDC report. Symptoms of heart conditions (19%) and pneumonia (12%) were the next most common preventable reasons for emergency visits to the hospital. The remaining 33% of preventable emergencies were made up of a combination of acute problems, including mental status changes, urinary tract infections, gastrointestinal bleeding symptoms, fever, metabolic disturbances, and skin diseases.
How can these ER visits be reduced?
The Center for Medicare Advocacy strongly suggests that the answer to this question is based in staffing levels for nurses and nursing aides at long-term care communities. Their report asserts, “The correlation between the number of nurses (RNs, licensed practical nurses and certified nursing assistants) who provide direct care to residents on a daily basis and high quality of care and quality of life for residents cannot be disputed.”
The Medicare Advocacy Center report is compelling, as it draws on more than a dozen independent studies conducted over the past decade. In the case of accidental falls, it points out, evidence shows that higher staffing levels decrease the overall incidence of falling. This correlation is also present with respect to the various other illnesses and conditions that bring elderly patients to the emergency room. The CDC report comments, “Some of these conditions, such as urinary tract infections, could be more appropriately treated in the nursing home.” They also note that pneumonia, like falls, can often be prevented through more skillful nursing management.
However, when you analyze the research results, it also becomes clear that increasing the number of nurses is not the sole answer to preventing emergency-room visits by long-term care residents. A study by the National Institutes of Health finds that “some care processes were poorly implemented in even the highest-staffed facilities, despite the fact that these had sufficient numbers of Nurses Aides to potentially provide 100 percent of care to all residents.” The lack of continuity of care may also play a part. The CMS points out that the miscommunication between acute and post-acute providers often contributes to readmissions. A revolving door of direct patient care staff members within long-term care facilities can only contribute to those miscommunications. Therefore, long-term care organizations should also consider adjusting their hiring process to decrease turnover by evaluating nursing candidates on their cultural fit for the organization, not just their technical skills. Behavioral assessments, peer interviewing, and job shadowing are all proven ways to do this. Talent management best practices can help long-term care organization reduce readmissions by maintaining adequate staffing levels and a continuity of care.
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