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 More Than Half Of ER Visits May Be Needless, Study Suggests

More than half of all the trips taken from America’s skilled nursing centers to emergency rooms saw residents treated and released, raising the possibility that caregivers are too quick to hit the panic button, a new study has found.
 
Researchers from Colorado and Texas looked at data from the National Center for Health Statistics and found that, even though elders are more likely to be sent to emergency rooms (ERs) from care centers (about 1.8 ER trips annually for every elder in a care center, nationally), nearly 54 percent of those sent were discharged—many without further ado.
 
“This is particularly notable given that … residents are more than twice as likely to be admitted to the hospital as ambulatory older adults,” Veterans Affairs researcher Robert Burke, MD, writes for the team in the latest issue of the Journal of the American Medical Directors Association (JAMDA).
 
“Taken at face value, it is striking that ER visits more commonly led to discharge than admission, that nearly two-thirds of … patient ER visits were characterized by normal triage vital signs,” and that nearly one in five visits had no diagnostic testing performed before discharge, he said.
 
The team’s findings come as the Obama administration has begun collecting data on unneeded hospitalizations. In a scant couple of years, providers could risk Medicare reimbursement penalties if their readmission rates go up or remain too high.
 
In a separate editorial in the same issue of JAMDA, researchers led by the Florida Atlantic University medical school’s Joseph Ouslander, MD, say that the Burke team’s findings suggest that falls or even infections in skilled nursing centers “do not have to dictate” trips to the ER.
 
“Unlike definitions of ‘avoidable’ or ‘potentially preventable’ hospitalizations, which are generally based on a series of diagnoses and are of questionable validity given the complexity of decisions to admit older patients to the hospital, Burke et al. suggest that most clinicians would agree that an [ER] visit of a … resident with normal vital signs who is judged not to need any diagnostic testing in the [ER] is likely potentially preventable,” Ouslander and his colleagues say. “We certainly agree.”
 
According to Ouslander and his team, skilled nursing centers should work up plans for separating real emergencies from apparent ones. “Explicit criteria for when a resident can be monitored in the facility, careful monitoring and documentation, and an evaluation of fall risk factors by a clinician (physician, nurse practitioner, or physician assistant), are all consistent with clinical practice guidelines and a publicly available fall management program that includes these strategies.”
 
Regulators can help here, Ouslander writes.
 
“Following such a policy and procedure with careful documentation should be viewed as high-quality care” by surveyors, and an acceptable standard of practice in lawsuits, he says.
 
For Vetter Health Services President Glenn Van Ekeren, though, Burke’s study suggests an answer that’s both really easy—and really hard.
 
“Now more than ever, communication is paramount in expediting the care our residents need, no matter the problem,” Van Ekeren tells Provider in an email interview. “It makes for better outcomes and overall quality of life. Our members are implementing some cutting edge technologies to tackle this head on. And while we have a ways to go, we are trending in the right direction."
 
Bill Myers is Provider’s senior editor. Email him at wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers.
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