A E Gatekeeping

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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

Objecti ve: To assess the gatekeeping effect and discharge safety in elderly referrals to the community nursingservice (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 CNSreferrals 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 tohospital 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, skinand soft tissue care, pain control, medical and diabetic care. I njections were given for cellulitis, pain, and

diabetics. Forty-nine patients had phone follow-ups. Conclusion: The gatekeeping effect of AED referrals toCNS 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 elderlyreturn visits with falls. Living alone was strongly associated with return visit and admission. ( Hong Kong j.

emerg.med. 2007;14:74-82)

2002-2004 333

5% 323 65 81 13.8% 21.6% 14

11.7% 15-28 14 15-28 15.0%

6.0% 4.8% 0.6%

17 162 8 28

317 1,978 14 28

6

49

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: [email protected]

Lam Fung Mei, RN, MSc(Nursing)

Cheung Ching, RN



Chiu et al./Community nursing service for the elderly 75

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 KongGovernment 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 H ospital (PMH) i s a majoracute 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 mi llion.

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

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

are healthcare practitioners linking hospitals with

community services to patients' home. They are

caregivers, health educators, and counsellors.11 The

PMH AED has start ed 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 theHong 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 1991 1996 2000 2001 2002 2003 2004 2005 2006

>65 482,040 629,555 729,200 747,052 777,000 795,500 818,800 836,400 859,100

% of population 8.7% 10.1% 10.9% 11.1% 11.4% 11.7% 11.9% 12.1% 12.3%

>80 158,400 167,300 177,000 187,200 203,100

% of population 2.3% 2.5% 2.6% 2.7% 2.9%

≥85 67,300 71,100 75,100 80,500 89,900

% of population 1.0% 1.0% 1.1% 1.2% 1.3%



Hong Kong j. emerg. med. Vol. 14(2) Apr 200776

age home (OAH ) staff and famil y 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 wil ling 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 fi rst index visit were studied.

Results

Pati ent demographics

Altogether 333 referrals were accepted, 57 of them were

active or inactive old CNS cases, wi th an average of

11 cases/month (range 3 to 18 cases/month), and

comprising 5% of the total PMH CNS intake. Two-

thirds 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 theirchildren'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 fall-

related. In addit ion, 41 not primari ly 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.

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




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 cellulitisrequired 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 moni toring, 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 gastroenteri t is, 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.

Outcome (Fi gure 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

group, elderly living alone was found to be strongly

associated wi th return and admission wi thin 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 tackletheir 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 gatekeepi ng 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 CNSintake. 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 unsatisfactory




Figure 2. Outcome of the patients.

Table 2. Unscheduled returns and admissions

Returned Returned Admitted Admitted Where living

≤≤≤≤≤14 days 15-28 days ≤≤≤≤≤14 days 15-28 days (% of total)

Home with family 26 18 14 5 124 (37.2%)Home living alone 19 4 16 3 46 (13.8%)

Old age home 27 17 20 12 163 (49.0%)

Total 72 (21.6%) 39 (11.7 %) 50 (15.0%) 20 (6.0%) 333 (100%)




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.

Retu r n and admissi on requi r i ng ger i atr i cs

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 inthe 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

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

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 monthsbefore 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.

Despi te the three missed cases, the referrals can be

considered safe, as these were selected cases wi th

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. Fal ls are responsibl e 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 H A hospital bed-days,and i t 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 sinussyndrome 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 modi fications 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 f ind signif icantpositive results in fall prevention with reduced rate of

functional decline and death in the intervention group

discharged from the AED.

Looki ng forward for extended CNS servi ces

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

part ies, 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 wi th hepari ni sed catheter i n-si tu,

patency and safety worries

To keep an IV line at home is a concern for many

parties other than the patients alone. The familymembers 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

experience in patient selection and provision of support

servi ces.36 Local home IV safety and case selection

guidelines are necessary.

(b) H ome vi si ting 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 helpimprove the quality of life of the elderly, and help to

reduce unnecessary hospital admissions.39

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 relati onship, and social

values of the carers. No Barthel ADL index had beendocumented 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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