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Are long-term care residents referred appropriately to hospital emergency departments?

Fred Fraser, MD CCFP FCFP
Practises family medicine in Stoney Creek, Ont

Kanwal Shankardass, MB ChB
Practises family medicine in Dundas, Ont

Ralph Epstein, MB BCh CCFP FCFP and Joginder Khera, MB BCh CCFP
Practise family medicine in Hamilton, Ont

Correspondence: Dr Fred Fraser, 15 Mountain Ave S, Stoney Creek, ON L8G 2V6; telephone 905 662-4911; fax 905 662-1688; e-mailfrfraser{at}istar.ca

OBJECTIVE To explore the rate of referrals of long-term care (LTC) residents to emergency departments (EDs) and to determine the appropriateness of the referrals.

DESIGN Retrospective analysis of 2 administrative data sets, paramedic records and hospital records, for the year 2000.

SETTING Catchment area of Hamilton, Ont.

PARTICIPANTS Nineteen LTC facilities and 3 EDs of Hamilton Health Sciences.

MAIN OUTCOME MEASURES Number and appropriateness of referrals were the main outcomes measured; we also examined the timing of and reasons for referrals, arrival status of patients, admissions to hospital, referrals to specialists, and treatments. Unit of analysis was the referral. As no evidence-based guidelines exist for appropriateness of referral, we defined appropriateness as a balance of issues with blinded physician judgment calls on anonymous random subsamples of patients admitted to hospital and those not admitted to determine appropriateness of referrals. Descriptive statistics were used, as well as and t tests.

RESULTS Out of 2473 licensed LTC beds, 606 residents were referred to 1 of 3 EDs of the Hamilton Health Sciences hospitals, giving a referral rate of 24.5%. The average age of these LTC residents was 81.6 years, and 63.2% were women. Peak referral months were late winter; peak days were Tuesday and Friday. Time of arrival to the EDs was reported in 6-hour segments, with just over half (51.2%) of residents arriving during the day and one-third in the evening. Respiratory and cardiovascular problems comprised 48.6% of referrals. At arrival 67.3% of cases were deemed urgent or emergent. Wait times ranged from 0 to 60 hours, with 25% of residents seen within 1 hour, 44% within 2 hours, and 50% within 4 hours. Two-thirds (66.7%) of residents were admitted to hospital and of these 62% stayed 1 week.

CONCLUSION Our results agree with previous studies that cast doubt on the idea that LTC residents are "dumped" on EDs. Most referrals appeared appropriate as defined by criteria established by the physician team and given the number of hospital admissions, diagnostic tests, and treatments provided. Potentially, more acute care could be provided in LTC facilities with enhancement of services. Prospective studies could tell us more.

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