Article, Emergency Medicine

Communication gaps in nursing home transfers to the ED: impact on turnaround time, disposition, and diagnostic testing

a b s t r a c t

Introduction: This study aims to determine the source of communication gaps in history of present illness (HPI), medical history, and advanced directives in nursing home (NH) patients transferred to the emergency department (ED). We also attempt to determine if these gaps create differences in patient turnaround time (TAT), Disposition decision, or diagnostic testing.

Methods: A convenience sample of patients transferred from NHs to a level 1 community trauma center was enrolled by the physicians caring for them. The physicians assessed the adequacy and source of the history for each patient. The patient’s chart was then retrospectively reviewed to determine disposition, ED TAT, and diagnostic tests ordered.

Results: One hundred patients were enrolled. Physicians found that NH paperwork contained adequate HPI 35% of the time. Patients could provide their own HPI 28% of the time. In 32% of patients, adequate HPI could not be obtained from the patient, NH paperwork, or NH personnel. Comparing patients in whom adequate HPI was available (n = 68) to those in whom HPI was not available (n = 32), there was no difference in TAT (146 vs 173 minutes, P = .22), admissions (60% vs 66%, P = .66), or diagnostic testing (P = .89-1.0).

Conclusion: Emergency department physicians often do not have adequate HPI in patients transferred from NHs. The absence of adequate information does not affect patient TAT, disposition decision, or ED diagnostic testing.

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The population of elders who reside in nursing homes (NHs) in the United States has shown a small but steady increase each year since 2000 [1]. This increase is partly a result of increasing numbers of individuals requiring short-term or rehabilitation stays, but it is also because of an increasingly aging population [1]. Although NHs are designed to care for their residents’ day-to-day needs and often have the capacity to administer medications and therapies for more acute processes, they are not equipped to initially diagnose and stabilize new medical problems or acute exacerbations of chronic problems. Therefore, NH residents are frequently transferred to emergency departments (EDs). These visits account for over 2.2 million ED visits annually [2].

Communication of critical information including history of present illness (HPI), medical history (MH), and advanced directives during this transfer process has been shown to be deficient in several studies

? Previous presentations of data: PA ACEP, Gettysburg, PA, April 2012, National ACEP, Denver, CO, October 2012.

?? Reprints not available from the authors.

* Corresponding author.

E-mail address: [email protected] (R. Jeanmonod).

[3-6]. Several factors play a role in making communication during care transfers challenging. One such factor is the degree of underlying disability of the transferred resident. The Centers for Medicare and Medicaid Services Nursing Home Data Compendium shows that compared with US NH residents in 2000, current residents have higher levels of functional impairment but less overall cognitive impairment [1]. That said, less than a third of NH residents are categorized as having “no cognitive impairment,” and about half have moderate to severe cognitive impairment [1]. nursing home patients with cognitive impairment are more likely to visit the ED than their unimpaired counterparts [7]. This means that NH residents often have more complex medical problems (functional impairment) and are less likely to be able to provide their own historical information because of cognitive impairment.

Nursing home factors also play a role. Approximately two-thirds of US NHs are for profit, 27% are nonprofit, and 6% are government run [1]. There is no standardization across groups in terms of level of care provided in the NH, indications for transfer to an ED, or paperwork included in that transfer. This results in heterogeneous processes that vary from NH to NH and ED to ED.

Patients transferred to US EDs from NHs have been shown to be more likely to have additional testing, to be admitted to the hospital, and to die as compared with patients who were not transferred from

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NHs [2]. However, it is unclear what role communication gaps play in outcomes in this high-risk population. In addition, although studies have investigated the transfer of critical information between NHs and EDs during care transfers, these have been retrospective chart reviews, which may make it difficult to identify where communica- tion gaps originate or how they impact care [5,8-10]. Clearly, interfacility paperwork has been shown to be lacking, but what contribution does cognitive impairment on the part of the patients, poor transfer of information from Prehospital personnel, and lack of adequate knowledge from the NH staff in telephone communications play? This study aims to determine the source of communication gaps in HPI, MH, and advanced directives in NH patients transferred to the ED. We also attempt to determine if these gaps create differences in patient turnaround time (TAT), likelihood of admission, or number of diagnostic tests ordered.


Study design

The study is an exploratory prospective cohort of patients transferred from NHs to a single ED. It was reviewed by the institutional review board and found to be exempt.

Study setting and population

The study site is a level 1 community trauma center with an ED census of 75000. The site is the primary teaching hospital for an emergency medicine residency with 40 residents. The ED receives regular transfers from 15 NHs of which all but 1 are within a 10-mile radius from the hospital. A convenience sample of patients transferred from these NHs to the ED was enrolled.

Study protocol and measurements

Emergency department physicians (residents and attending physicians) caring for transferred NH patients prospectively complet- ed a survey regarding the presence or absence of necessary historical information (power of attorney [POA] information, Medication lists, advanced directives, MH) and the perceived adequacy of the HPI and its source. Some sample questions are the following:

      • “Did you feel the patient provided adequate history regarding the reason for transfer?”
      • “Did you feel the paramedics provided adequate history of the event leading to transfer?”
      • “Did you call the nursing home for further information?”
      • “Did you feel the nursing home provided adequate information regarding the reason for transfer on the phone?”
      • “Did the paperwork contain the patient’s advanced directives/DNR status?”
      • “Did the paperwork contain the patient’s MH?”
      • “Did the paperwork contain a complete medication list?”

Emergency department physicians chose from a closed list of possibilities for each question (“yes,” “no,” or “n/a”). There was also an area on the survey for the physician to free-text comments regarding the patient’s transfer information. No proscribed definition of “adequate” was given to the physician for the purposes of the survey. This was intentionally done because the minimum necessary amount of information to evaluate a patient may vary from patient to patient, and we felt the perception of adequacy by the treating provider is an important variable to define.

Nursing home patient charts were then retrospectively reviewed to determine whether the patient was admitted to or discharged from the hospital. The electronic ED record (Horizon Clinicals 10.3.1;

McKesson Corporation, San Francisco, CA) was used to abstract time of presentation to the ED as well as time of disposition. These parameters were used to calculate TAT. The end of the ED visit was based on the time the ED physician electronically dispositioned the patient (admit, discharge, transfer). The time the patient physically left the ED was not used for these calculations, as occasionally, patients would wait for an hour or more for an ambulance to transfer them back to the NH after discharge, and rarely, inpatients would be boarded in the ED.

The electronic ED record was also used to abstract the extent of testing performed in these NH patients. Emergency department testing was categorized as general blood tests (with subcategories of “complete blood count,” “chemistries,” and “troponin”), tests for infectious evaluation (with subcategories of “urine studies” and “blood cultures,”), and other ancillary tests (with subcategories of “EKG,” “plain film radiography,” and “computed tomography”).

All data were entered into a standardized Excel spreadsheet by trained data abstractors. Survey items were analyzed using descrip- tive statistics. The subset of patients from whom physicians did not feel they received adequate information from the patient, the patient’s transfer paperwork, or the NH in telephone communica- tions were compared with those in whom the physician felt ade- quate history was available. These 2 groups were compared using nonparametric analyses to determine differences in TAT. They were also compared by ?2 test and Fisher exact test to determine differ- ences in Disposition decisions (admission vs discharge) and amount of ED testing.


A convenience sample of 100 patients was enrolled during a 4- month period from July through November of 2011. The mean patient age was 83.5 years (SD +-13), and 73% were female.

On patient arrival, prehospital personnel were able to provide

some history regarding the event bringing the patient to the hospital in 40% of cases, and in 26% of cases, this prehospital information was the only information the physician ever received regarding the patient. In the remaining cases, either the personnel provided inadequate history of the event (22%) or had left the ED before the ED physician had a chance to speak with them (37%). It is important to note that, at our institution, prehospital personnel do not leave paper documentation on the chart when they transport a patient to the ED. Any history from prehospital personnel is either gathered from verbal communications with the personnel or obtained second hand from the nurse who took report from the prehospital personnel.

There was no one source from which ED physicians found they could reliably obtain the full HPI. The most reliable source was the NH transfer paperwork, which was only felt to adequately explain the HPI 35% of the time. Patients themselves could provide their HPI just 28% of the time. Emergency department physicians attempted to contact personnel at the NH to obtain more history in 36 cases but found this adequate in only 21%. Although some patients had several sources of adequate HPI, in 32% of patients, it could not be obtained from the patient, the NH transfer paperwork, or the NH personnel. Of these 32 cases, prehospital personnel were able to provide a chief complaint, and verbal report that was considered useful by the clinician, but in 6 patients, there was no useful history pertaining to the patient’s presentation from any source.

In addition to the deficits found in the NH transfer paperwork in regard to the HPI, the paperwork also failed to mention advanced directives or code status in 53% of cases. The paperwork did report the patient’s power of attorney/next of kin 66% of the time, but the ED physician did not call the POA in 52 of those patients. In contrast, the NH transfer paperwork almost always included the patient’s MH and current medication list (Fig. 1).

Fig. 1. Elements present in NH transfer paperwork.

Patients in whom adequate HPI was available from the patient, the NH paperwork, or verbal communications with the NH (n = 68) had a median TAT of 146 minutes (interquartile range, 111.5-209.5) as compared with 173 minutes (interquartile range, 122.5-218.5) in those patients in whom HPI was not available from these sources (n = 32, P = .22). We also compared patients who could provide their own history with those who could not with the a priori assumption that less time would be taken trying to ascertain the history for those patients with minimal cognitive impairment, but we found no difference in TAT (P = .53).

Sixty-two percent of the patients enrolled were admitted to the hospital. There was no difference in admission rate between patients in whom adequate HPI was available from the patient, NH paperwork, or NH communications as compared with those in whom adequate HPI was not available (P = .66). Presence or absence of advanced directive paperwork also did not have any relationship to patient’s admission or discharge status (P = .30).

Nursing home patients transferred to the ED underwent many diagnostic tests (Fig. 2). Seventy-seven percent had blood chemistries, 76% had a complete blood cell count, 72% had plain radiographs, 69% had an electrocardiogram, 57% had a troponin, 50% underwent

computed tomography, 43% had urine studies, and 36% had blood cultures drawn. Between patients in whom an adequate HPI was obtained and in those in whom it was not, there was no difference in the ordering of general blood tests (P = .92), tests for infectious evaluation (P = 1.0), or other ancillary tests (P = .89) (Fig. 2).


To our knowledge, this is the first study examining the differences in information gaps based on the source of history provided in NH patients transferred to EDs. Prehospital personnel are typically the first to provide information related to the HPI and did so in 40% of cases. Prior studies often exclude this useful source of information, which may skew the utility of creating and implementing a transfer form. Certainly, the information provided by prehospital personnel is often a good starting point in initiating the evaluation of ED patients. It is important to remember, however, that word-of-mouth information transfer from one person to another can often be unreliable and verbal transfer of information from NH personnel to prehospital personnel to ED nursing staff to the ED physician is suboptimal. In our institution, prehospital personnel do not leave behind any paperwork at the end

Fig. 2. Diagnostic testing in NH transfers.

of their call, and all information that they have gathered is given verbally to the nurse. Theoretically, this information should be transcribed into nursing documentation within the record and be accessible to the physician, but this additional person interposed into the process will often result in incomplete or inaccurate information. An additional issue is the difficulty in “closing the feedback loop” with prehospital personnel regarding their transfers. Although a provider may have the ability to address difficulties with information transfer with a given medic when the medic next brings in a patient over the course of a shift, this is clearly not reliable. Therefore, the more common way to address these issues if they are addressed at all is to inform the prehospital medical director of any perceived deficiencies. Steps taken to improve these issues are not widely known, and the ED provider rarely has any follow-up regarding policy or procedure change.

Despite being a useful bridge to introducing the patient arriving from an NH, prehospital personnel were not available to the physician in nearly an equal number of cases. Variables that may influence this phenomenon include multiple different prehospital agencies trans- ferring NH patients to the ED or the overall state of ED crowding.

Regardless of reason, this first step in information gathering was significantly underused by physicians. Often prehospital personnel will leave the treatment room to complete paperwork and move on to their next call once report has been given to nursing staff, creating an additional medium for information to be dropped and forcing physicians to rely on other sources of information to initiate the evaluation. It is unlikely to be efficient for prehospital personnel to wait in treatment rooms during peak times in the ED until the next physician is available, nor may it be efficient for a physician to interrupt their current task to receive each ambulance as it arrives. Further investigation is needed to master this balance and better define the important role prehospital personnel play in information transfer in this vulnerable population.

Consistent with prior studies, NH patients were unreliable sources of their own HPI, leading physicians to rely upon other sources of information including transfer paperwork, NH telephone conversa- tions, and conversation with the patient’s POA. Transfer paperwork was the most consistent (35%) information source in providing a complete HPI but was most often not complete or not helpful. This has also been demonstrated in prior studies [5,8-11]. When NHs use transfer forms rather than free-text communications, more critical information makes it to the hands of the treating provider, but documentation is still incomplete in many instances [5,8-11]. Some institutions have attempted to combat this by creating a standardized transfer form designed to reflect what ED personnel consider critical information. The implementation of transfer forms has been shown to significantly improve the transfer of critical information, including HPI, with varying levels of efficacy. Cwinn et al [5] showed only an absolute improvement in critical information transfer of 18.6%, whereas Dalawari et al [9] showed 43% improvement with utilization. Cwinn et al retrospectively reviewed the prevalence and efficacy of the Ottawa Hospital Association’s single-page transfer form in NH transfers. Dalawari et al examined the effectiveness of the current transfer forms used by the various NHs that transfer patients to the St Louis University ED. Neither study prospectively examined the implementation of a standardized transfer form. One key difference between these 2 studies is that Cwinn et al examined the effects of the implemented transfer form immediately after implementation (as with most prior studies) compared with Dalawari et al examining these effects multiple years after implementation [5,9-11]. This may represent a teaching effect, where some amount of time must pass during a “ramping up” phase to see maximal benefit from such an implementation. In spite of this, even in a best-case scenario, only 75% of paperwork has been shown to be complete [9].

With approximately two-thirds of patients and two-thirds of

transfer paperwork not providing an adequate HPI in our study, one

would expect that most physicians would contact the NH to obtain more information. Surprisingly, this was not the case, as only one-third of physicians contacted the transferring NH. The few times that NHs were called by physicians, they were often unable to provide an adequate HPI regarding their residents’ transfer. We did not query physicians as to why they did not take initiative in calling NHs regarding their patients. One theory that links both of these findings is that physicians may find these telephone calls time consuming, frustrating, or unfruitful. Nursing homes are often unprepared for these calls, rerouting the call to different areas of the NH and having difficulty finding the staff member responsible for the transferred patient. If the physician is busy and the attempt at contact is unhelpful 40% of the time, it is likely that the physician will not prioritize telephone contact with the NH above other tasks for which he or she is responsible. Another theory is that the physician feels that the information will not “make any difference.” If the physician feels that the patient will likely require a lengthy evaluation regardless of complaint due to severity of underlying illness and comorbidity, he or she may decline wasting time with a telephone call that will not alter evaluation.

Physicians likewise did not call the POA in more than 80% of the encounters in which a contact was available to them. This is a lost opportunity. Certainly, the POA may provide additional information regarding the HPI, but at least as importantly, the POA may be able to answer critical questions regarding code status and advanced directives. This information, which was not present on nearly half of transfer paperwork, may arguably be the most crucial piece of information in protecting patient autonomy and respecting the patient’s wishes. Although our study did not show differences in disposition based on written advanced directive information, dispo- sition may be influenced by direct contact with the POA. Discussions with the POA may also influence the extent of testing and interventions on these patients. As the cost of health care becomes increasingly scrutinized, overaggressive, unwanted measures (and their sequelae) may no longer be reimbursed. As shown in larger studies, our studied NH population was heavily tested, with more than three-fourths of the patients having at least 1 blood test and half undergoing computed tomography. It was beyond the scope of our study to attempt to determine whether these tests were ordered appropriately, but it is conceivable that contact with the POA may have changed some of these evaluation decisions.

As in a prior study, we found that more complete information regarding transferred NH patients did not translate into improve- ments in ED TAT or alter patient disposition [9]. Although it seems self-evident that improved and more complete information should result in more efficient use of resources, tailoring of evaluations to HPI, and ultimately shorter through-put times, our data showed no difference in TAT in patients with adequate (as per the treating physician) vs inadequate HPIs. It is unclear why this is the case. It may be that the higher illness burden in NH patients compels physicians to embark upon more in-depth evaluations regardless of chief complaint and HPI, or it may be a factor of nursing driven order sets designed to improve ED through-put. Covariants that may be influencing this result include ED crowding (affecting door-to-doctor time, time to testing, physician and nursing efficiency), physician experience (altering level of testing completed), patient diagnosis (altering testing required), nursing efficiency (affecting time to testing and treatment), and time consumed by obtaining intravenous access or diagnostic testing. Any of these variables has the potential to influence our and others’ results. Discerning the individual impact of these items on TAT and amount of diagnostic testing was beyond the scope of our study.

Regardless of the finding by us and others, which suggests that

better transfer information does not alter ED TAT or disposition, this should not discourage attempts at implementation at better commu- nication, such as standardized transfer forms or Internet-assisted transfers [9,11]. There are other important outcomes, such as

reduction of Medical error, reduction in spending, mortality out- comes, and patient and Physician satisfaction outcomes that have not been the subject of investigation as yet but warrant investigation.


This study is limited by its small sample size. The number of patients included in the study (n = 100) would be adequate to detect differences in TAT of 30 minutes for this number of patients if the TAT data points were normally distributed (? = .05; power, 0.9; effect size, 0.67). However, time data are generally nonparametric, and nonparametric analyses tend to have less statistical power than parametric analyses. Therefore, the possibility of a type II error in comparison outcomes such as TAT is relatively higher than the above would suggest, and there may be true differences in TAT between groups that were not appreciated.

It is also limited by enrollment of a convenience sample. There is the possibility that providers might enroll patients only when they did not feel busy or that they might preferentially enroll patients in whom they felt the communication was inadequate (enrollment bias). Every attempt was made to encourage providers to enroll any patient transferred to the ED from an NH during the study period, but any study relying on convenience sampling has its limitations. There are inherent limitations regarding the retrospective nature of calculating ED TAT that may not be included in the electronic health record and, thus, could not be included in the study, such as the effects of ED crowding, the availability of Hospital beds, or the staffing model in the ED.

An additional limitation is the inability to standardize how ED physicians deemed the HPI to be “adequate.” This was a subjective measure recorded in the survey as a binary response. Although this is not an objective measure such as those employed in retrospective transfer paperwork analyses, we feel that a physician-centered assessment of the adequacy of information transfer between the NH and ED is a valuable piece of information that might help better understand the communication gaps in the transfer process beyond measures of TAT, diagnostic testing, and disposition.

Finally, this study is limited in that only one level 1 trauma community hospital was included, resulting in less applicability to all populations. With this comes less diversity in patient demographics, medicolegal environment, and local standard of care.


Emergency physicians infrequently use all of the information resources available to them–particularly direct communication with the NH staff or the patient’s POA. The absence of adequate patient information obtained by physicians does not significantly affect patient TAT, disposition decision, or amount of testing in the ED. Further research is warranted to investigate other outcomes.


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