Abstract
Introduction
Transfers of skilled nursing facility (SNF) residents to emergency departments (ED) are linked to morbidity, mortality and significant cost, especially when transfers result in hospital admissions. This study investigated an alternative approach for emergency care delivery comprised of SNF-based telemedicine services provided by emergency physicians (EP). We compared this on-site emergency care option to traditional ED-based care, evaluating hospital admission rates following care by an EP.
Methods
We conducted a retrospective, observational study of SNF residents who underwent emergency evaluation between January 1, 2017–January 1, 2018. The intervention group was comprised of residents at six urban SNFs in the Northeastern United States, who received an on-demand telemedicine service provided by an EP. The comparison group consisted of residents of SNFs that did not offer on-demand services and were transferred via ambulance to the ED. Using electronic health record data from both the telemedicine and ambulance transfers, our primary outcome was the odds ratio (OR) of a hospital admission. We also conducted a subanalysis examining the same OR for the three most common chronic disease-related presentations found among the telemedicine study population.
Results
A total of 4,606 patients were evaluated in both the SNF-based intervention and ED-based comparison groups (n=2,311 for SNF based group and 2,295 controls). Patients who received the SNF-based acute care were less likely to be admitted to the hospital compared to patients who were transferred to the ED in our primary and subgroup analyses. Overall, only 27% of the intervention group was transported to the ED for additional care and presumed admission, whereas 71% of the comparison group was admitted (OR for admission = 0.15 [9% confidence interval, 0.13-0.17]).
Conclusion
The use of an EP-staffed telemedicine service provided to SNF residents was associated with a significantly lower rate of hospital admissions compared to the usual ED-based care for a similarly aged population of SNF residents. Providing SNF-based care by EPs could decrease costs associated with hospital-based care and risks associated with hospitalization, including cognitive and functional decline, nosocomial infections, and falls.
Introduction
Transfers from skilled nursing facilities (SNF) to the emergency department (ED) account for approximately 14 million ED visits annually, a fifth of which may be avoidable.1 In many cases, ED visits lead to admission, which in turn conveys risks of cognitive and functional decline, nosocomial infections, and falls.2,3 Furthermore, for the frailer subpopulation of SNF residents transferred to the ED, up to 78% of their resulting hospitalizations are potentially avoidable.4 Several solutions have been proposed to reduce admissions for these patients. One is to improve the quality of ED care for seniors and SNF residents through the development of geriatric-focused emergency care, and improved communication between SNFs and EDs.5 Incentive programs have also been established to improve longitudinal management of chronic medical conditions by SNFs, reducing transfers for patients with congestive heart failure (CHF) and diabetes mellitus (DM).6,7Few studies have targeted the scenario that often triggers a transfer: when the SNF resident has an acute medical condition such as a fall, a fever, or an exacerbation of a chronic disease. Many SNFs retain on-call medical staff, but most lack the infrastructure to manage acute unscheduled care, particularly after-hours, and SNF healthcare teams often have little recourse other than to call 911 when patients need evaluation.8-10 One potential intervention to address this scenario is enlisting a physician via telemedicine to evaluate patients with acute care needs at the SNF. Telemedicine consults have been successfully used within EDs for a variety of subspecialties; providing rapid evaluations within the SNF setting could obviate transfers for minor injuries. Prompt evaluations could enable earlier interventions in acute infections and chronic disease exacerbations, potentially preventing the need for ED transfers or facilitating earlier transfers when warranted.