This single-center data-analysis assessed incidence, potentially associated risk factors, and usage of resources of inappropriate hospital referrals of LTC residents to a Swiss tertiary hospital ED. The results add to the discussion about new strategies regarding resource management and best possible care. Within the analyzed sample, 6.0% of LTC-facility referrals were assessed as inappropriate. This is relatively low, when compared to 4–55% found in a recent systematic review (14), including studies from Europe, the US, Australia, and Asia (12, 13, 24). Still, admission rates and, alongside, inappropriate ED-visits are rising in Switzerland as well (25). As this comes along with increased morbidity of LTC residents (10) and is most probably also contributing to high healthcare costs (26), we agree with others authors that this topic should get more attention from health policy makers (27).
Mostly patients with low acuteness according to the Swiss triage scale or without the need for an invasive intervention were judged “inappropriate”. The odds of an inappropriate visit for patients with a non-urgent triage was higher when compared to high urgent triage patients.
ED visits of patients with connective tissue diseases (such as systemic lupus erythematosus and scleroderma) were more likely to be assessed inappropriate. Although the total number of patients with rheumatic comorbidities – a condition that might be prone to subacute problem – was very low (n = 7), it can be assumed that diseases of complex organs generally more often require hospitalizations or invasive interventions than connective tissue diseases, and are, therefore, more often necessary. These findings reflect the results from previous investigations, where common reasons for inappropriate visits are described as non-emergent symptoms or condition manageable by a general practitioner (24, 28). On the other hand, the fact that the visit was appropriate does not mean, it was not avoidable: the early detection and treatment of deteriorating symptoms, especially with diagnoses like congestive heart failure, helps prevent exacerbations and avoid ED visits for acute situations no longer controllable in the nursing home.
In our sample, procedures not possible to perform in nursing homes (e.g. radiological examinations, indwelling urethral catheters and other procedures), accounted for more than 10% of all transferred LTC residents. Although these cases were not rated as inappropriate visits, some of these procedures might been manageable in an ambulatory care setting as well. Thus, appropriate visits may be overestimated and improvement of surveillance and adequate risk assessment in acute care situations or changes in conditions of LTC residents may be a factor to focus on, when trying to reduce inadequate ED-referrals of LTC-residents. This could be addressed with better access to primary care providers, be it general practitioners (23) or nurse practitioners, or a structured medical system within the nursing home which provides quicker access to expertise on site. A corresponding initiative with the introduction of nurse practitioners in nursing homes has achieved a reduction in all-cause hospitalizations up to 30% (11). That way, health care expenses may be reduced, as costly ED resources may be avoided. While fortunately the total ED resource consumption by inappropriately admitted patients was, in our sample, significantly lower compared to appropriate admissions, still a total of 49’295 tax points was needed for LTC-facility residents, which may have been more cost-effectively treated elsewhere. Although, consumed nurse work resources as well as laboratory, and – by definition – radiology ED resource consumption of inappropriately admitted patients was smaller compared to the appropriately admitted patients, physicians' work resources did not differ between the study groups. This indicates, that inappropriate ED visits are still resource-intensive consultations.
When reviewing the reports of the inappropriately referred patients, it was found that patients were often transferred for check-ups or examinations, while an acute event was missing in the patients’ history. Other patients were admitted in a critical condition, but they were transferred back to the nursing homes, because the patient wanted to abstain from an invasive intervention. This indicates that some of the admissions might have been avoided by Advanced Care Planning (ACP), i.e. the assessment of and continuous conversation about residents’ and their families wishes for treatment in acute situations, which has been shown to be effective in reducing hospital admissions (29).
Regardless of the status of appropriateness, high multimorbidity with a median score of 6 in the CCI was found for the sample. These findings correspond with other data from Switzerland, where LTC residents have a higher level of multimorbidity than their community-dwelling peers (4). About 85.5% have at least two different diagnoses, 22.8% of them even have five or more different chronic diagnoses (4).
As this further contributes to polypharmacy as well as high admission and hospitalization rates (2, 3, 30), this finding corroborates the importance of interventions like ACP, palliative care, care pathways and geriatric specialist services or the introduction of advanced practice nurses to be considered for the population at risk (11, 31).
Further, hospital admission rates have also been attributed to a variety of non-medical factors including for-profit ownership of the LTC, poor environmental quality or lack of administrative emphasis on staff satisfaction, whereas higher total direct-care nursing hours per resident day, and presence of allied health staff – disproportionately present in publicly owned facilities – were associated with lower transfer rates (32, 33). Taken together, for Switzerland, several barriers need to be addressed: LTC residents often keep their GP during their stay and due to GP’s lack of service hours during nights and weekends or difficulty to offer onsite visits adequate medical assessment is impeded (27, 34). Here, off-hours telemedicine coverage could play a role in the future (35). Importance should also be given to the availability of diagnostic equipment and adequate training for nurses and, further, time for direct-care nursing should be ensured (29, 32, 34, 35).
Limitations
The present investigation is limited by several factors. Firstly, there is little consensus in classifying inappropriate hospitalizations (36) and there are several methods to assess whether an admission is appropriate, and none of them is validated so far. The results may differ according to the instruments used and the use of a single tool may bias the current analysis (14). However, the tool by Finn et al. deemed to be the most suitable to use, because it was specifically designed for ED visits as opposed to hospitalisations, and was used more frequently than others. Still, this instrument has at least one critical step within the decision-procedure: the question whether an observation or procedure is not possible to be performed in an LTC residential facility remains an assumption of the assessor. Although we predefined scenarios for those two items (Additional file 1: decision-tree inappropriate ED-visits), their validity remains unsure, as we could not obtain data about the different resources available at the specific LTC facilities, e.g. access to primary care and possibilities for risk assessments. Thus, the appropriateness status may be confounded for this item. We reduced this risk by using two independent, trained raters. Moreover, neither the specific referring LTC facility nor the specific reasons for the admission was investigated in detail. That way, no further information about the challenges and needs of the LTC-staff or resources accessible to them could be generated. Therefore, no definitive suggestions for improving the link between the LTC facilities and the medical care centres in the catchment area of the ED can be given. Also the lack of data on the topic of palliative care adds to the list of limitations. As data on end-of-life planning of the respective subjects in our sample was not obtained systematically, we could only assume from exemplary reports that ACP may have been insufficiently performed in the LTC-facility.
Last but not the least, this is a retrospective chart review and therefore prone to documentation error.