Hong Kong Journal of Emergency Medicine

Admission gatekeeping and safe discharge for the elderly: referral by the emergency department to the community nursing service for home visits

SLH Chiu

, FM Lam

, C Cheung

Objective: To assess the gatekeeping effect and discharge safety in elderly referrals to the community nursing service (CNS) in a major accident & emergency department (AED). Methods: Descriptive review analysis of the referrals in 2002-2004. Results: Altogether 333 patients were accepted, comprising 5% of the total CNS referrals in the hospital: 323 were aged 65 (median age 81), 13.8% were living alone, 21.6% had unscheduled return to the AED within 14 days, and 11.7% in 15-28 days. The 14 days and 15-28 days admission to hospital was 15.0% and 6.0%, with 4.8% and 0.6% patients admitted with the same or related diagnosis as the first visit respectively, including missed fractures and stroke. One patient died 17 days after discharge. Eight of the 162 falls returned within 28 days with a second fall. Overall, 317 admissions were avoided with 1,978 bed-days saved. Living alone was strongly associated with unscheduled return and admission 14 and 28 days, while age was not. The six categories of community nursing care were fall-related, tube care, skin and soft tissue care, pain control, medical and diabetic care. Injections were given for cellulitis, pain, and diabetics. Forty-nine patients had phone follow-ups. Conclusion: The gatekeeping effect of AED referrals to CNS remained small. The commonest referrals were falls with head injury. It was safe to discharge the elderly for CNS care. A wide range of home nursing care was feasible. CNS referral could decrease elderly return visits with falls. Living alone was strongly associated with return visit and admission. (Hong Kong j. emerg.med. 2007;14:74-82)

2002-2004 5% 6.0% 317

323

65 4.8% 17 1,978 6 11.7% 0.6% 15-28 162 14

81

333 13.8% 14 8 28 49

21.6% 15-28 28

14 15.0%

Correspondence to: Chiu Lai Hong, Simon, MRCP(UK), FHKAM(Emergency Medicine), MHA
(NSW)

Princess Margaret Hospital, Accident & Emergency Department, Lai Chi Kok, Kowloon, Hong Kong Email: chiulh@ha.org.hk Lam Fung Mei, RN, MSc(Nursing) Cheung Ching, RN

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Keywords: Community nurse service, elderly, gatekeeping, safe discharge

Background
Both elderly hospitalisation rate and cost are high. 1 With multiple chronic medical conditions and increased susceptibility to accidents, elderly 65 are proportionately the most frequent users of emergency medical care and will increase rapidly with an aging population.2-5 According to data from the Hong Kong Government Census and Statistics Department, elderly 65 reached 12.3%, and those 80 reached 2.9% in the mid-2006 census (Table 1).6 In addition, 10.7% of the elders >60 are living alone, and 3.4% living with persons other than spouse and children. 7-9 By 2031, 24% of the Hong Kong population will be 65, with male life expectancy 82.3 years and female 87.8 years.10 The Princess Margaret Hospital (PMH) is a major acute hospital in the Kowloon West region of Hong Kong, with 999 acute beds, 20 accident & emergency department (AED) observation beds, and 256 convalescent beds, serving a population of 0.8 million. In 2004, 25.2% of the AED first attendance was 65 years of age. The average length of stay of patients aged 65 from 2002-04 in PMH acute beds was 6.24 days, and convalescent beds, 9.01 days. Community nurses

are healthcare practitioners linking hospitals with community services to patients' home. They are caregivers, health educators, and counsellors. 11 The PMH AED has started a more structured patient referral to the Community Nursing Service (CNS) since 25 March 2002 to reduce admission and to ensure safe patient discharge.

Methods
This was a descriptive review analysis of all patients from 25 March 2002 to 31 December 2004, excluding the period of severe acute respiratory syndrome (SARS) from April till June 2003, accepted by the CNS upon discharge. Data were retrieved from the Accident & Emergency Information System (AEIS) and the Community Based Nursing System (CBNS) of the Hong Kong Hospital Authority (HA). A community nurse joined the senior doctor observation ward round at 9-10 am daily, except Sundays and public holidays, to discuss and take over the doctor's referrals. The CNS nurse could be contacted by phone till 5:00 pm. The CNS nurse took up the role of asking a detailed history from the old

Table 1. Mid-year elderly population of Hong Kong Age >65 % of population >80 % of population 85 % of population 1991 482,040 8.7% 1996 629,555 10.1% 2000 729,200 10.9% 2001 747,052 11.1% 2002 777,000 11.4% 158,400 2.3% 67,300 1.0% 2003 795,500 11.7% 167,300 2.5% 71,100 1.0% 2004 818,800 11.9% 177,000 2.6% 75,100 1.1% 2005 836,400 12.1% 187,200 2.7% 80,500 1.2% 2006 859,100 12.3% 203,100 2.9% 89,900 1.3%

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age home (OAH) staff and family on the patient's premorbid activities of daily living (ADL), emotion, social support, and the OAH or home environment. A referral form would be completed for all referrals. The criteria for patients to be discharged to CNS care were: 11 (1) The community nurse found the patient safe to be managed at home; (2) the patient and family members were willing to accept home care with nurse visits and (3) the patient and/or family were willing to pay the $80/visit. All unscheduled returns and admissions to the hospital within 14 days and 15-28 days of the first index visit were retrieved. Their chief complaints and diagnosis were compared with those of the first visit. Patients died within 28 days of the first index visit were studied.

comprising 5% of the total PMH CNS intake. Twothirds were female and 323 (97.0%) were aged 65 (median 81, range 44-105) (Figure 1), 13.8% were living alone, 49.0% were from private or subsidised OAH, 37.2% were living with spouse and/or their children's family. Forty-nine were followed up by telephone, with 29 supplemented by home visits. In the 31 months, 45,430 of the 76,116 (59.7%) AED attendance aged 65 were admitted.

Nature of referrals
1. Care for fall (total 162) The majority, 162 (48.6%), of the referrals were fallrelated. In addition, 41 not primarily referred for fall but found to have high risk of fall, were offered fall prevention care. The injuries were 92 head and facial injury, 22 back injury, 13 fractures (11 limb and 2 rib injury, including a missed fractured neck of femur and a fractured pubic ramus), and 17 other injuries on the limbs or the chest. The remaining 18 had no significant wounds, but had low blood pressure detected, probably the result of antihypertensive treatment. Care provided by CNS included wound management or removal of stitches in 116, and fall prevention in 122.

Results
Patient demographics
Altogether 333 referrals were accepted, 57 of them were active or inactive old CNS cases, with an average of 11 cases/month (range 3 to 18 cases/month), and

Figure 1. Age distribution of the Community Nursing Service referrals.

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2. Skin and soft tissue care, including non-fall injury (total 43) The majority or 28 patients had pressure sore and/or acute or chronic leg ulcers. There were 10 cellulitis, 1 abscess, and 4 burns and scald. Three cellulitis required intravenous (IV) antibiotics for 2-3 days. 3. Tube care (total 29) Four had dislodged feeding tubes with difficult reinsertion or retention in place, 13 had permanent Foley catheter blockage and/or urinary tract infection, and 12 had acute retention of urine on a temporary Foley catheter. 4. Pain management (total 27) Twenty-seven patients had acute or acute-on-chronic back, limb, or joint pain not due to recent injury, and seven of them required intramuscular non-steroidal anti-inflammatory drug for 2-4 days. No morphine had been given for a patient with metastatic bone pain. 5. Diabetic care (total 14) All had fasting and before lunch sugar monitoring, diet advice and drug care (supervision on drug taking for forgetfulness, impaired vision, etc) and 12 needed insulin injection or injection technique supervision. 6. Medical cases (total 42) There were 19 dizziness, 6 gastroenteritis, and 5 chronic obstructive pulmonary disease (COPD). The others were lacunar infarct, hypertension, hypotension, chest pain, lower limb weakness, hypokalemia, bradycardia, and epilepsy. The dizzy elderly had either phone follow-up for symptom assessment, or home visit for blood pressure monitoring after antihypertensive drug change or dose modification, fall prevention and drug care.

group, elderly living alone was found to be strongly associated with return and admission within 14 days (p<0.01; p<0.001) and 28 days (p<0.025; p<0.001). Age 75 was not associated with increased admissions within 14 and 28 days (p=1). 2. Outcome for fall, acute pain, dizziness, and COPD Only 8 of the 162 falls returned with a second fall within 28 days, but none of the 70 admissions within 28 days were due to a second fall. Three of the 27 with acute pain were admitted within 14 days, 2 of the 19 dizzy patients were admitted within 14 days and 2 of the 5 COPD patients were admitted within 14 days. 3. Mortality One 83-year-old man died of upper gastrointestinal bleeding 17 days after a minor head injury.

Discussion
The main goal of CNS referral is to reduce hospital admission and to ensure safe patient discharge. If not admitted, these elderly still need some forms of treatment and follow-ups. The waiting time in the relevant specialties is long and cannot serve to tackle their presenting symptoms. To arrange a follow-up in AED is a dilemma, as most of the elderly need an escort and special transport to the hospital again. Therefore, community nurse visits remain a logical arrangement.

The gatekeeping effect and bed-days saved

The gatekeeping effect in 2002-04 was small, with only an average of 11 cases referred per month in PMH AED (which had an average yearly first attendance of 130,000, with 25% aged 65 years, i.e. 2,700/ month) and comprising only 5% of the total CNS intake. In the old practice, these 333 patients would have been hospitalised because they were so frail, or just because no carer was available. The admission rate within 14 days was 50/333 (15.0%), but only 16 of them were admitted with the same or related diagnosis as the first visit. The 16 patients admitted 14 days with the same or related diagnosis as the first visit were considered unavoidable due to unsatisfactor y

Outcome (Figure 2 and Table 2)

1. Returns and admissions For those admitted after unscheduled return within 14 days, 32.0% were living alone, compared with 13.8% of the total referrals being for lone dwellers. By the Chi square test, comparing with the non-living alone

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Figure 2. Outcome of the patients.

Table 2. Unscheduled returns and admissions Returned 14 days Home with family Home living alone Old age home Total 26 19 27 72 (21.6%) Returned 15-28 days 18 4 17 39 (11.7 %) Admitted 14 days 14 16 20 50 (15.0%) Admitted 15-28 days 5 3 12 20 (6.0%) Where living (% of total) 124 (37.2%) 46 (13.8%) 163 (49.0%) 333 (100%)

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improvement and/or social reasons and should be hospitalised earlier. Therefore, the admissions avoided were 317, and the bed-days saved were only 317 x 6.24 = 1,978.

Return and admission requiring geriatrics intervention

Our CNS referrals were selected cases with medium risk of return and admission. Our 28 day admission of 21.0% can be regarded as comparable to those articles reviewed by Aminzadeh, who found that there were 6-17% hospital admission, 16% AED return, and 29% AED return in age >75 within one month.5 High elderly return and readmission seem to be a universal 'normal' circumstance,5,12 as it could be expected that even if they had been admitted to hospital and discharged from hospital in good shape, their chronic symptoms would still be recurring. We can foresee that bed-days saved within 28 days do not guarantee that bed-days can be saved in the long run. The AED is unable to work alone on AED return and admission, the problems of return and admission need the help of the geriatricians to carry out comprehensive evaluation for the elderly and support by their outreaching services thereafter. It is only when home care service or outreaching health service is given a higher priority in the overall healthcare strategy that the problems of elderly return and hospital admission can be reduced. The finding by Luk et al that Community Geriatric Assessment Team (CGAT) intervention in the Hong Kong West with outreach visits to private OAH could significantly reduce AED attendance, acute hospital admission, and specialist clinic follow-up is a good strategy to be referred to.13

man who returned with vomiting of coffee ground material 15 days after the first visit for a minor head injury after a fall. He died of gastrointestinal bleeding two days after admission. His bleeding was probably due to the aspirin started after a stroke six months before this AED attendance. 2. Missed diagnosis and unscheduled returns The three missed diagnoses were a fractured neck of femur, a fractured pubic ramus, and a minor stroke. Despite the three missed cases, the referrals can be considered safe, as these were selected cases with medium risk of return and admission compared with the overall elderly AED attendance. 3. Community nurse visit can help fall prevention in high risk elderly Elderly fall occupied the major portion (48.6%) of the referrals to the CNS. Falls are responsible for a significant number of deaths and morbidities in the elderly. 8,18-20 Gillespie found that 30% community living people over 65 would suffer a fall each year, and 10% of the falls resulted in fracture.21 In Hong Kong, local studies showed similar fall tendency in the elderly.22,23 In 2001, accidental falls of the elderly accounted for 3.3% (316,000) of the total HA hospital bed-days, and it is estimated that HA may incur an annual cost of HK$ 1 billion for the acute care and rehabilitation services for falls.19 Fall and gait disorder are accumulated effects of physical, psychological, social, environmental and other factors. The 162 elderly falls referred in this review can be considered safe and rewarding, as it was found that only 8 of them returned with a second fall, and none of the 70 admissions within 28 days were due to a second fall. Among these 8 falls, one had sick sinus syndrome with repeated syncope. Therefore, it is reasonable to assume that many falls had been prevented, and the falls so prevented could be attributed to the efforts of our community nurses in correcting the extrinsic factors of fall by walking exercise with walking stick or walking frame, education to the patients and the OAH staff, particularly in bathtub and toilet transfer skill, home and environment

Safety
1. Mortality It can be considered safe with only one death within 28 days in the 333 CNS referrals. Caplan, Chin, Richardson and Rosenfeld found that risks were particularly high in the elderly after an emergency visit, with an average mortality rate of 9-12% in three months. 14-17 Caplan found a mortality of 3% in one month.14 The death in our review was an 83-year-old

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safety modifications such as wall-bars to assist walking, and liaison with related community resources. Another 41 elderly, whose primary referring diagnosis was not fall, were helped with fall prevention. The study by Tinetii,24 Close,25 and McCusker26 did find significant positive results in fall prevention with reduced rate of functional decline and death in the intervention group discharged from the AED.

experience in patient selection and provision of support services. 36 Local home IV safety and case selection guidelines are necessary. (b) Home visiting hours can be extended The 9 am to 5 pm home visiting hours make some referrals impossible, especially for those who need 6-12 hourly antibiotics, a second dose of insulin, or twice daily pain control. Transport of frail patients in severe pain or with pain of terminal illnesses to hospital could induce a lot of unnecessary pain too. Pain control would be optimal if a regular evening schedule can be offered. Allowing the CNS to administer a safe dose of morphine is another issue worth exploring. 3. Phone follow-up Phone follow-up for the elderly after discharge from the AED saves time and labour for home visits, and the results are encouraging. Wong et al found that the intervention group who received two follow-up protocol-driven calls, 1-2 days and 3-5 days after AED discharge, were associated with a lower AED revisit rate. 37 A next-day telephone follow-up or a phone follow-up supplemented by selective visits, is valuable in recognising difficulties and mobilising relevant services.38 A centralised telephone follow-up might help improve the quality of life of the elderly, and help to reduce unnecessary hospital admissions.39

Looking forward for extended CNS services

1. CNS, CGAT and AED collaboration with agreed guidelines, and access to Hospital Authority electronic patient record (HA ePR in the OAH) Strengthening the support from CNS/CGAT would be a reasonable design to alleviate AED attendance and hospital occupancy.27 In addition to gatekeeping, the AED observation ward can be a venue for the CNS/ CGAT to screen the elderly for key conditions and to start the appropriate interventions to prevent future admissions.4,25,28-31 Agreed guidelines between the above parties, and access to ePR in the OAH would facilitate these teams to carry out continuity of care, and might encourage AED doctors to refer more elderly patients for home care. Telemedicine can also be explored for delivering multidisciplinary care.32 2. Injection service can be expanded In the 31 months, only 3 patients were given home IV antibiotics, and 7 patients had intramuscular analgesic for acute pain. Some breakthrough in current practice is necessary: (a) Intravenous access with heparinised catheter in-situ, patency and safety worries To keep an IV line at home is a concern for many parties other than the patients alone. The family members or the OAH staff might find it difficult to accept an IV catheter in-situ at home/OAH. Some doctors, not feeling safe, are reluctant to refer the patient for home IV antibiotics. Some experience had found that the use of intravenous antibiotics at home was effective, safe, and comfortable to the patients, had an important economic impact33-35 and acceptable complication rate, and would likely improve with

Limitations of the review

AED return visits of the frail elderly are very often due to multiple factors including the patients' premorbid ADL, mental state, social and community environment, home/ OAH environment, family relationship, and social values of the carers. No Barthel ADL index had been documented in the case records. To match the cases with multiple complicated physical, psychological and social environmental factors among those living alone, living with family or at OAH for tests of significance of association in unscheduled return and admission within 14 and 28 days is exceedingly difficult. Furthermore, those referred but refused to accept CNS visits were not counted and analysed.

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