An article on the interaction between Residential Care Facilities and Emergency Departments on behalf of the Special Interest Group for Geriatric Emergency Medicine.

Written by the following members of the IFEM Geriatric Emergency Medicine Special Interest Group: Rosa McNamara, Tim Platts Mills, Maaret Castrén, Carolyn Hullick, Don Melady

Key Points  

• The patient must be at the centre of decisions to transfer to hospital – what matters most to this patient? What is the goal of hospital transfer. Can this goal be achieved in a different way?
• Older people living in Residential Care Facilities (RCFs) should not be denied access to emergency care based on their age or address but on whether they will benefit from care.
• Alternatives to ED transfer are encouraged but must be appropriately supported and appropriate care should not be rationed.
• The ED environment and its effect on residents should be taken into account in decisions to transfer. This includes the risk of acquiring COVID-19 during an ED visit causing an outbreak on return to the RCF.
• If a patient is transferred, information exchange between RCFs and EDs must be robust. Appoint someone from your ED to work with your main RCF providers to develop a simple standardised transfer document.
• For patients sent from the ED back to the RCF, information must also be robust. It should state specific clinical and risk information for COVID-19: (1) Whether a patient was tested for COVID-19 and what the results were of the test. (2) If results are not available, information about when the results will be available and how to obtain the results should be provided. (3) For patients for whom tests results are not available, recommendations should be provided regarding the level of suspicion for COVID-19 and the need for quarantining on return to the RCF.
• ED policies and procedures should be designed to minimize the potential for infection transmission to previously uninfected individuals.
• EDs and RCFs should work together with local and regional health authorities to develop plans for how to deal with a widespread infection within a RCF. This plan should include measures to minimize transmission. Simply separating symptomatic from non-symptomatic patients is inadequate because non-symptomatic individuals can be effective spreaders of COVID-19. Plans should reflect the nuances of care for frail older people and include plans for bringing skilled staff to patients.

Introduction
Emergency Medicine lies at the interface between hospitals and the communities they serve.  This is as true for patients that live in residential care facilities (RCF) as for patients living in other parts of our community.  Indeed, patients transferred from RCF to emergency departments (EDs) have frequently been studied with the particular challenges of communication and continuity of care well described long before COVID-19 emerged.[i]^, [ii]  The COVID-19 pandemic has highlighted many of the deficiencies in health services worldwide particularly in one of our most vulnerable groups of people; those living in RCFs with devastating consequences.[iii]^{, [iv], [v], [vi], [vii], [viii], [ix], [x], [xi]}

Typically, RCF care is delivered in a mix of state, voluntary and private facilities, although the proportions of each type varies from country to country. Countries with older populations have higher numbers of older adults living in RCFs with up to 17% of those aged 85 years and older living such facilities.[xii]

Some countries and regions have successfully prevented widespread COVID-19 infections in RCFs through policies that limit visiting, staff movement, and resident congregation. However, even with these policies, pre-symptomatic transmission, close-proximity living and extensive close physical contact between care staff and residents makes it is difficult to prevent further transmission and outbreak.[xiii] The purpose of this article is to describe best practice for emergency care for patients living in RCFs during the pandemic, with particular attention to measures to minimize the spread of infection.

Transfer of Information
Emergency medicine teams interact with RCFs in the prehospital and ED environments. The key to optimising these interactions is good communication about the patient’s condition, their past medical history, their functional and psychological needs and any previously expressed advance care plans. This is even more important during the pandemic.  When residents are transferred to the ED, often on their own, from RCFs we rely on the information conveyed as patients often have cognitive problems and complex nursing needs, which they are not always able to articulate.  High quality information including current medications, functional baseline, nursing and dietary needs and advance care planning information is critical to aid decision making in the ED as well as contact information for a member of the staff that knows the patient as well as family information.  Local standardised information sets are useful in ensuring that information needs to be available to hospital teams making treatment decisions (see Case Study 3).[xiv]^, [xv]

The decision to transfer a patient to the ED should be consistent with patients’ wishes. When these wishes are unknown, consideration should be given to the recommendations of the patient’s primary care physician or other treating physicians, regular nursing team and family members.  Having this information available ensures that ED staff respect plans already in place.  If this information has not arrived from the RCF, then the ED must contact them to ensure appropriate clinical handover. Where a plan instructs that residents should not be transferred to a hospital, this should be stated explicitly and alternatives to ambulance activation provided. The plans should also articulate whether there are conditions for which transfer to an ED or hospital is acceptable – for example, if a resident needs treatment for a reversible condition that is not otherwise available in the RCF.

Residential Care residents and the Emergency Environment
The ED can be a challenging environment to care for older people with frailty and particularly those with cognitive impairment.  Prior to the COVID-19 pandemic, it was estimated that 13-40% of transfers of RCF residents to EDs were potentially avoidable through the provision of quality clinical care in facilities.[xvi]^{, xiii,[xvii], [xviii]}Avoiding unnecessary transfer is important as hospitalising residents places them at risk of further deterioration and is associated with high rates of delirium, falls, pressure sores, nosocomial infections and medication errors. Albeit necessary, the enhanced infection prevention control measures now in place in most EDs have unfortunately made the environment even more challenging for those with sensory and cognitive impairment. Family members and friends are routinely prohibited from accompanying patients during the ED visit. Patients are now cared for by staff behind barriers of protective equipment that eliminate many of the non-verbal facial cues that help patients to feel reassured. Patients are also more likely to be held in single rooms out of direct vision and away from care providers, further increasing the risk of delirium and of falls. This environment and its effect on patients should form part of the risk benefit assessment when considering hospital transfer for RCF residents.

Outbreak Control Measures and Emergency Medicine
Where RCFs have had outbreaks, the challenge of managing multiple residents who are unwell simultaneously has frequently been compounded by the challenges of staffing affected RCFs. Typically when an outbreak occurs, staff also become unwell, or are advised to self-isolate as contacts of those with COVID-19.  This has meant that as demand for care increases, the availability of staff decreases.  At times when staff are available the skill mix needed to care for many sick patients is not present.  Many of the people working in RCFs are nursing assistants, who are often on low wages. As a result of these low wages, nursing assistants often work multiple jobs and share housing, increasing the risk of infection for themselves and the people they serve. In the first wave of this pandemic increasing demands on community and primary care meant that the availability of personnel to physically attend RCFs to provide support was reduced in many regions. This left staff in RCFs unsupported and at times reporting that they were working outside their usual scope of practice. The usual routes of engaging agency or alternative staff have been curtailed during the COVID-19 pandemic as non-regular staff are advised to limit their work to single institutions to reduce risk of viral spread and some may be fearful of working in an environment where COVID-19 is present.[xix]

There have been various responses to these challenges around the world, with examples of hospital-based teams moving to RCF facilities (see Case Study 1) or with community and military groups providing staffing or assisting with mass transfer of patients from the RCFs to hospitals.[xx] All of these solutions pose their own problems, but denying access to hospital-level care to older people with a potentially reversible deterioration in their health is not justifiable either.

In many healthcare jurisdictions, outbreaks in RCFs have been linked to hospital discharges of patients with COVID-19 infection from EDs.  EDs must consider this risk in discharge planning for older adults who live in RCFs and should do their utmost to minimise the risk of residents using the ED being exposed to COVID-19. Prompt assessment and discharge planning from the ED to minimise time spent in the hospital environment can help mitigate this risk. Prevention of outbreaks in RCFs is a priority as it protects vulnerable residents, and reduces the risk of infection for care providers, visitors, and medical workers. When a patient with confirmed or suspected COVID-19 infection is being discharged, the treatment team should first ensure that the receiving facility has the ability to isolate the patient appropriately and for the duration recommended for their stage of illness and confirm that the RCF team is able to care for this patient.

Major Incident Planning and Residential Care
Major incident plans for RCFs are typically focused on scenarios when mass evacuation is required as a result of actual or threatened damage to the infrastructure – they may not include mass infection scenarios over prolonged time periods, or mass staff illness as has arisen as a result of the current pandemic. In a pandemic scenario, the risks and benefits of mass evacuation to another setting must be considered carefully – a large scale transfer has impact on local ambulance services, the receiving hospitals, and on the wider community who may need care during the evacuation. Local, regional, and national emergency plans should include planning for pandemic support for RCFs.  Planning around access to emergency staffing, adequate personal protective equipment and necessary medication and medical equipment should form parts of such a plan (see Case Study 2).

Consideration should be given to development of emergency response teams who go to the RCF at times of crises – the membership of these can be adapted to meet the skill mix required in the affected facility and have the advantage of maintaining vulnerable people in a familiar environment.[xxi]  Treatment in situ can be considered but the facility must be supported practically if care that is beyond their usual scope is being proposed.  This needs to include appropriate training and available additional personnel.  A unified response to crisis which can focus on treating patients based on need regardless of the funding structure of the RCF should be included in these plans (see Case Study 2).

Conclusion and Key Points
The COVID-19 pandemic has caused particular challenges around care for older people living in RCFs and the interaction between RCFs and EDs. In some parts of the world, more than half of the deaths from COVID-19 are in older people living in RCFs. We feel that institutionalized older adults should receive specific attention and access to focused medical care. Care should honour patient’s wishes while balancing the risk of care in situ versus transfer to the ED. EDs and hospitals should work with RCFs to meet the needs of patients and to ensure the safety of other RCF residents.

Case Study 1: Mobile Hospital, Finland Europe

The Mobile Hospital (LiiSa) is an outreach unit stationed in Espoo Hospital, Espoo, Finland. LiiSa takes calls from Residential Care Facilities (RCF), gives advice, and treats patients at their homes 24 hours a day, 7 days a week.  The catchment area covers 1366 residential care beds. The LiiSa vehicle is built on a Sports Utility Vehicle base and is equipped with wide range of medications, near patient blood testing using the i-STAT device and basic urine analysis equipment. The LiiSa nursing team can consult RCF doctors, Home Hospital doctors or ED doctors depending on time of day and the needs of their patient. They can also take covid19 swabs, where indicated, so that patients who will need quarantine can be identified at an early stage. Experienced registered nurses from Espoo Home Hospital-unit work in LiiSa-unit, one at a time. LiiSa does not transport patients.  Using this approach, transports to the Emergency Department were reduced by 95%, including over 20% of the patients’ problems which could be dealt with via telephone consultation.

Case Study 2: Regional Response Plan to outbreak management in residential aged care facility, New South Wales, Australia

The Aged Care Emergency (ACE) service works with Residential Aged Care Facilities (RCF) in regional New South Wales, Australia, including the metropolitan region of Greater Newcastle along with regional and rural communities. The region approximately 50,000 square miles, with a population of 912,000, of which 74,000 people are aged 75 and older.

ACE supports RCFs to manage acutely unwell residents through training and education, telephone support, evidence based algorithms for common symptoms as well as  a community of practice that fosters the network, empowering RCF staff to manage their residents. Each RCF has a home ED . Prior to the COVID-19 pandemic the ACE programme significantly impacted hospital admissions and transfers to the ED, with the rate of hospital admissions and ED visits approximately 20% lower with the program in place.

As part of the regional COVID response, the ACE community of practice was rapidly engaged, moving to virtual weekly meetings depending on demand. 147 RCFs could participate along with members of the Local Health District and Primary Health Network. Guidelines were created. The weekly meeting gave public health, infection control, mental health and many other expert groups access to a large number of RCFs at once. It was also an opportunity to clarify expectations on managing unwell COVID patients in RCFs and how and where this would occur.

Essential Elements of the Aged Care Emergency Program

A 24‐hour nurse‐led telephone consultation service for staff in RCFs provided by RNs in the ED during the day and after hours by RNs from the local general practice organization.

Evidence‐based algorithms for common acute symptoms and problems experienced by residents from RCFs, developed in consultation with multidisciplinary hospital‐ and community‐based providers along with RCF clinical leaders and the ambulance service.

If transfer is required, the telephone call also clarifies the reason for transfer to hospital through establishing the resident’s goals of ED care.

Once in the ED, the resident receives proactive case management under the guidance of specialist aged care nurses.

Empowerment of RCF staff occurs through education in communication techniques including effective clinical handover, recognition of the deteriorating patient, and the evidence‐based ACE algorithms.

Case Study 3 National Nursing Home Transfer Document, Ireland Europe

The National Clinical Programme for Older People in Ireland commissioned research with the aim of developing an evidence-based and person centred national transfer document for use when an older person is being transferred from Residential Care Facilities (RCFs) to acute care settings.

This went through various stages of development which included  review of best available evidence stakeholder focus groups and expert panel review.  Following a pilot study involving twenty-eight RCF and three acute care sites staff, feedback from ED and acute medicine was positive and the document was launched.

The National transfer document is divided into two parts Transfer Document and Health Profile/Passport.  The first section follows an ISBAR format and prompts transfer of critical information for clinical decision making in the acute setting.  It is completed at the time of transfer.  The second section ‘the patient passport’ contains information about the individual preferences and routines, dietary needs and functional baseline.  This can form part of the regularly updated patient file in RCFs with a copy enclosed at the time of transfer to the acute setting. The document is available in paper and electronic formats for RCFs to use.

References

[i] Tsai, H. H., & Tsai, Y. F. (2018). Development, validation and testing of a nursing home to emergency room transfer checklist. Journal of Clinical Nursing, 27(1-2), 115-122.

[ii] O’Keeffe, J., Barber, J., Lang, D., Barry, J. J., Hughes, G., & O’Shea, D. (2017). Developing a National Patient Transfer Letter for use by both the Nursing Home (NH) & Acute Hospital (AH) Sectors. International Journal of Integrated Care, 17(5).

[iii] Comas-Herrera, A., Zalakaín, J., Litwin, C., Hsu, A. T., Lane, N., & Fernández, J. L. (2020). Mortality associated with COVID-19 outbreaks in care homes: early international evidence. LTCcovid. org, International Long-Term Care Policy Network.

[iv] Fallon, A., Dukelow, T., Kennelly, S. P., & O’Neill, D. (2020). COVID-19 in nursing homes. QJM: An International Journal of Medicine, 113(6), 391-392.

[v] Burton, J. K., Bayne, G., Evans, C., Garbe, F., Gorman, D., Honhold, N., … & Templeton, K. (2020). Evolution and impact of COVID-19 outbreaks in care homes: population analysis in 189 care homes in one geographic region. medRxiv

[vi] Li, Y., Temkin‐Greener, H., Shan, G., & Cai, X. (2020). COVID‐19 infections and deaths among Connecticut nursing home residents: facility correlates. Journal of the American Geriatrics Society, 68(9), 1899-1906.

[vii] Lloyd-Sherlock, P., Ebrahim, S., Geffen, L., & McKee, M. (2020). Bearing the brunt of covid-19: older people in low and middle income countries.

[viii] Stall, N. M., Jones, A., Brown, K. A., Rochon, P. A., & Costa, A. P. (2020). For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths. CMAJ, 192(33), E946-E955.

[ix] Hsu, A. T., Lane, N., Sinha, S. K., Dunning, J., Dhuper, M., & Kahiel, Z. (2020). Impact of COVID-19 on residents of Canada’s long-term care homes–ongoing challenges and policy response. LTCcovid org, International Long-Term Care Policy Network, CPEC-LSE.

[x] Inzitari, M., Risco, E., Cesari, M., Buurman, B. M., Kuluski, K., Davey, V., … & Bettger, J. P. (2020). Nursing Homes and Long Term Care After COVID-19: A New ERA?.

[xi] Hanratty, B., Burton, J. K., Goodman, C., Gordon, A. L., & Spilsbury, K. (2020). Covid-19 and lack of linked datasets for care homes.

[xii] Platts-Mills, T. F., Biese, K., LaMantia, M., Zamora, Z., Patel, L. N., McCall, B., … & Kizer, J. S. (2012). Nursing home revenue source and information availability during the emergency department evaluation of nursing home residents. Journal of the American Medical Directors Association, 13(4), 332-336.

[xiii] Arons, M. M., Hatfield, K. M., Reddy, S. C., Kimball, A., James, A., Jacobs, J. R., … & Tanwar, S. (2020). Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. New England journal of medicine.

[xiv] Hullick, C. J., Hall, A. E., Conway, J. F., Hewitt, J. M., Darcy, L. F., Barker, R. T., … & Attia, J. R. (2020). Reducing Hospital Transfers from Aged Care Facilities: A Large-Scale Stepped Wedge Evaluation. Journal of the American Geriatrics Society.

[xv] Williams, M. V. (2019). Improving the Transfer Process from the Skilled Nursing Facility to the Emergency Department: Adding a Communication Hand-off Tool (Doctoral dissertation, The University of North Carolina at Charlotte).

[xvi] Morphet J, Innes K, Griffiths DL, Crawford K, Williams A. Resident transfers from aged care facilities to emergency departments: can they be avoided? Emerg Med Australas. 2015 Oct;27(5):412-8. doi: 10.1111/1742-6723.12433. Epub 2015 Jun 21.

[xvii] Burkett, E., Carpenter, C. R., Hullick, C., Arendts, G., & Ouslander, J. G. (2020). It’s time: delivering optimal emergency care of residents of aged care facilities in the era of COVID‐19. Emergency Medicine Australasia..

[xviii] Royal Commission into Aged Care Quality and Safety: Impact of COVID-19 on Aged Care Services.  June 2020 Available at //agedcare.royalcommission.gov.au/system/files/2020-08/AWF.600.01794.0001.pdf (Last accessed 16 Nov. 20)

[xix] O’Neill, D., Briggs, R., Holmerová, I., Samuelsson, O., Gordon, A. L., & Martin, F. C. (2020). COVID-19 highlights the need for universal adoption of standards of medical care for physicians in nursing homes in Europe. European Geriatric Medicine, 11(4), 645-650

[xx] Comas-Herrera, A., Ashcroft, E., & Lorenz-Dant, K. (2020). International examples of measures to prevent and manage COVID-19 outbreaks in residential care and nursing home settings. International Long Term Care Policy Network [online]: Available from ltccovid. org/wp-content/uploads/2020/05/International-measures-to-prevent-and-manage-COVID19-infections-in-care-homes-11-May-2. pdf.

[xxi] McNamara R, Donnelly K, Boyle N, et al. Community frailty response service: the ED at your front door. Emergency Medicine Journal 2020;37:714-716.