Authors: Christine L. Binkley, MD, MPH; Cameron J. Gettel, MD, MHS

Edited By: Angel Li MD; Shan Liu MD, SD

Updated: 9/24/2021

Case Study

An 85 year old female with past medical history significant for hypertension, diabetes and blindness secondary to glaucoma presents by EMS from home after an unwitnessed ground level fall. The patient was using a walker in the bathroom when she fell backward and hit her head on the bathroom door. She denies losing consciousness, but is unsure of the exact circumstances of the fall. She was unable to get back up after the fall. She denies associated headache, dizziness, chest pain, nausea, vomiting, abdominal pain or recent urinary symptoms. She reports falling at least once a week but states these are non-injurious falls. The patient lives alone and has a daughter that lives 30 minutes away.

On exam, the patient is alert and oriented x2 (disoriented to time) and in no acute distress. Head exam reveals a 3x3 cm hematoma to the occiput without underlying crepitus. The facial examination is atraumatic. The patient’s neck, chest, abdomen and extremities are without tenderness or evidence of trauma. A neurological examination reveals 4/5 strength in her bilateral upper extremities and 3/5 in her bilateral lower extremities. The patient’s sensation is intact in all extremities. 

The initial evaluation plan is for labs, urinalysis, chest x-ray, and CT brain/C-spine.

Objectives

By the end of this module, the student will be able to:

1. Discuss the challenges surrounding transitions of care from the emergency department (ED) .
2. Identify essential aspects of a discharge plan for the geriatric patient.
3. Discuss the barriers to care and discharge of geriatric patients from the ED.
4. List strategies for communication with follow-up providers and caregivers.

Introduction

Transitions of care refers to the movement of patients from one site of care to another. Geriatric patients make up 20% of ED visits and the number is continuing to increase with their growing proportion of the population. Every visit to the ED inherently has two transitions of care per visit (i.e., initial care setting to the ED and the ED to the care setting the patient is dispositioned to), and there are several challenges that accompany these transitions for older adults. Geriatric patients are more likely to have multiple comorbidities, as well as cognitive and functional impairments and social limitations. It is imperative that these essential aspects of their history be effectively communicated to each new provider or caregiver that will be continuing the patient’s care. When transitions of care fail, there is increased morbidity and mortality from issues such as medication errors, adverse drug reactions, lack of appropriate follow-up and increased revisits and readmissions. We will focus on the important factors to consider when trying to disposition a patient back to the community (e.g. home) after an ED visit.

Barriers to ED Care and Disposition

Over 20% of older adults that present to the ED will be admitted to the hospital. This represents 46% of all admissions that occur from the ED. It is estimated that one out of every 10 hospital admissions is avoidable with the majority of these preventable admissions occurring in patients 65 years and older. Avoidable admissions are related to multiple different factors surrounding limitations in communication between patient and provider during the ED evaluation, health system deficiencies and attitudes of both the patient and provider. 

Time constraints  innate to the ED may make it difficult for emergency clinicians to spend significant time gathering all necessary information regarding older adult patients. Older adults present to the ED with a longer list of chronic comorbidities and may often have difficulty communicating them to the emergency clinician. Electronic medical records help document a patient’s history but are often fraught with inaccuracies. Geriatric patients also frequently have Alzheimer’s dementia or other cognitive and functional impairments that impact a provider’s evaluation. It is common for providers to assume that geriatric patients have these impairments and subsequently limit attempts to gather the necessary information through history and physical examination, potentially leading to more extensive testing and longer ED lengths of stay. 

Calling the patient’s family or primary caregiver provides invaluable insight into the geriatric patient’s condition, which will help treat them appropriately and effectively. While it can feel time-consuming initially, the useful information that can often be gathered will reduce unnecessary testing and provide important history that the patient may not have been able to convey, while also getting an idea of what the patient’s (and family’s) wishes are regarding the visit. It is also important to gain an understanding of the patient’s home environment as it pertains to their presenting complaint. Did they present with weakness and live in a a second story bedroom? Can family members in the area provide additional support during the vulnerable care transition period until the patient is seen by another medical professional? What access do they have to follow up with their primary care provider or other applicable specialists?

Aspects to Effective Discharge to a Community Setting

As Kessler et al. write in their paper on transitions of care for the geriatric patient from the emergency department, “a poorly communicated plan is the same as no plan at all.” Upon discharge from the ED, geriatric patients are at high risk of adverse health outcomes with a 10% mortality in the first 3 months and a return rate as high as 44% within 6 months. The key to providing an effective discharge plan has several components including:

• Communication of a clear plan based on their presenting complaint
• Medication changes that may have been made during the visit
• Who they need to follow up with and when
• Ensuring understanding of red-flag reasons to return immediately to the ED

These key concepts need to be communicated particularly well to older patients through clear verbal instructions as well as written instructions that are formatted in easy-to-understand wording in large print. It should also be a priority to explain the plan to the patient’s family or primary caregiver. Relaying this information to the patient’s primary care provider through a phone call or email communication is also very helpful in coordinating continuity of care. 

For patients that do not have a support system to help them with outpatient care, it is important to consider how this will affect their discharge planning. Obtaining a case management consult can play an essential role for older patients that are identified as having a barrier to discharge including lack of established follow up, inability to access transportation to follow up, or lack of social support at home. Case managers can help coordinate transportation, obtain home health, or an appointment to establish care with a primary care doctor.

Pearls and Pitfalls

• In older persons, illnesses and injuries leading to ED visits without hospitalization are associated with a meaningful decline in functional status during the following 6 months, identifying the vulnerable care transition period after ED discharge.
• Effective discharge planning for older adult ED patients requires a clearly communicated follow-up plan and red-flag reasons to return immediately to the ED.
• Engagement with the older adult’s family members or caregivers as well as case management colleagues can be particularly helpful in identifying in-home needs and setting up additional resources to ensure adequate care transition.
• When presenting older adult ED patients to senior level residents or attendings, think with the end disposition in mind by addressing patient and family caregiver needs and providing suggested available resources or referrals to promote independence.

Case Study Resolution

The patient’s work-up in the ED comes back negative. You call the patient’s daughter, who reports being increasingly worried about her mother over the last month or so related to her increased falls but is unable to see her more than twice a week. She feels her mother is becoming gradually weaker but has not had an acute change in her function. 

You perform a Timed Up and Go (TUG) test in the ED, which is positive, but the patient overall has a stable gait with the use of a walker. In a shared-decision making fashion, the patient has capacity and desires to go home from the ED. You order home physical therapy for the patient and send a message to the patient’s primary care doctor regarding her ED visit and need for close outpatient follow-up related to her frequent falls. You provide the patient with verbal and written discharge instructions that go over tips for reducing falls as well as return to the ED precautions.

References

1. Ashman JJ, Schappert SM, Santo L. “Emergency Department Visits Among Adults Aged 60 and Over: United States, 2014-2017.” National Center for Health Statistics, CDC, June 2020.
2. Kessler C, Williams MC, Moustoukas JN. “Transitions of Care for the Geriatric Patient in the Emergency Department.” Clin Geriatr Med 29 (2013) 49-69.
3. Nagurney JM, Fleischman W, Han L, Leo-Summers L, Allore HG, Gill TM. “Emergency Department Visits Without Hospitalization Are Associated With Functional Decline in Older Persons. Ann Emerg Med 69 (2017) 426-433.