Falls Prompt Most ED Visits by Nursing Home Residents

Bruce Jancin is with the Denver bureau of Elsevier Global Medical News.

NEW ORLEANS — Falls constitute by far the most common reason for emergency department visits by nursing home residents, according to a national survey.

After injuries from falling, which accounted for an estimated 14% of all nursing home patients' ED visits in 2004, the list of the top five reasons for a trip to the ED was rounded out by chest pain and pneumonia (accounting for 4.5% of visits each), followed by psychiatric symptoms (3.7%), and cardiac conditions other than acute coronary syndrome (3.2%), Scott Wilber, MD, reported at the annual meeting of the Society for Academic Emergency Medicine.

Some investigators have asserted that up to one-half of ED visits by nursing home residents are for problems that could have been treated effectively by a visiting primary care physician. But the new national survey data suggest that nursing home patients who go to the ED typically do so for trauma and serious medical conditions. They tend to be on the more medically complex end of the spectrum, said Dr. Wilber, director of the emergency medicine research center at Northeastern Ohio Universities College of Medicine, Rootstown.

His analysis of data from the 2004 National Nursing Home Survey indicated that within the 90 days before the survey, 8.3% of nursing home residents had made a visit to the ED.

In a multivariate logistic regression analysis, the significant risk factors for ED visits by nursing home patients were issues related to the presence of a gastrointestinal or genitourinary device, being on more than nine medications, weight loss, pressure ulcers, male gender, and having no advance directive.

“These findings are not especially surprising,” said Bill Kubat, vice president of the Sioux Falls, S.D.–based Good Samaritan Society. “A nurse can do the basic assessment after a fall but cannot make a diagnosis. If the physician is called and there is a suspicion of an injury, the usual directive is to send the patient to the ED.”

On the other hand, he said, “if we can identify any factors that might predispose someone to falls—such as multiple medication use or a history of falling—we can take precautions early on and prevent falls from happening.” This calls for a multidisciplinary approach to reducing sedation, strengthening muscles, correcting vision problems, improving lighting, and making sure residents have slip-proof footwear.

Kubat also suggested that “access to a physician or PA who can come to the facility and see residents in-house would eliminate many unnecessary ED visits.”

Communication between the nursing home and the acute care facility is also important. “This information can make sure that the [nursing] facility has the equipment, medications, and other support the resident will need to stay safe and avoid ED visits due to accidents or adverse events,” said Mr. Kubat. Two-way communication should also ensure that ED staff know what medications the person is taking, what diagnoses he or she has, and the person's preferences.