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Repeated Hospital Transfers and Associated Outcomes by Residency Time Among Nursing Home Residents in Taiwan
JAMDA xxx (2016) 1e5
JAMDA journal homepage: www.jamda.com
Original Study
Repeated Hospital Transfers and Associated Outcomes by Residency Time Among Nursing Home Residents in Taiwan Hsiu-Hsin Tsai RN, PhD a, b, Yun-Fang Tsai RN, PhD a, c, d, *, Chia-Yih Liu MD b, e, f a
School of Nursing, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan Department of Psychiatry, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan c Department of Nursing, Chang Gung University of Science and Technology, Tao-Yuan, Taiwan d Department of Psychiatry, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan e School of Medicine, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan f Department of Psychology, National Cheng Chi University, Taipei, Taiwan b
a b s t r a c t Keywords: Repeated hospital transfer nursing home residency
Background: Nursing home residents’ repeated transfers to hospital are costly and can lead to in-hospital complications and high mortality for frail residents. However, no research has examined the trajectory of residents’ symptoms over their nursing home residency and its relationship to hospital transfer. Aim: The purpose of this retrospective chart-review study was to examine associations between nursing home residents’ characteristics, including length of residency, and repeated hospital transfers as well as the trajectory of transfers during residency. Design: For this retrospective study, we reviewed 583 residents’ charts in 6 randomly selected nursing homes from northern Taiwan. Data were analyzed by descriptive statistics, chi-squared tests, and 1-way analysis of variance. Results: About half of nursing home residents who had been transferred to hospital (n ¼ 320) were transferred more than twice during their residency (50.97%). Residents who had been transferred 1, 2, 3, or 4 times differed significantly in length of residency (F ¼ 3.85, P ¼ .01), physical status (F ¼ 2.65, P ¼ .05), medical history of pneumonia (c2 ¼ 13.03, P ¼ .01), and fractures (c2 ¼ 8.52, P ¼ .04). Residents with different numbers of transfers differed significantly in their reasons for transfer, that is, falls (c2 ¼ 13.01, P ¼ .01) and tube problems (c2 ¼ 8.87, P ¼ .03). Among 705 total transfers, fever was the top reason for transfer, and transfer prevalence increased with nursing home residency. Conclusion: To decrease the chance of residents’ hospital transfer, nursing home staff should be educated about recognizing and managing fever symptoms, infection-control programs such as influenza vaccination should be initiated, and fall-prevention/education programs should be started when residents first relocate to nursing homes. Ó 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Nursing home (NH) residents are expected to experience changes in their health status as a result of their advanced age. Changes in health status are often due to residents’ cognitive and functional impairment, fragility, and medical comorbidities; these changes commonly result in transfers from the NH to the hospital.1 However, frail NH residents who are transferred suffer from in-hospital
The research was supported by the Ministry of Science and Technology (NSC 101-2314-B-182-032-MY3) and the Chang Gung Hospital (BMRP849). The authors declare no conflicts of interest. * Address correspondence to Yun-Fang Tsai, RN, PhD, School of Nursing, Chang Gung University 259, Wen-Hwa 1st Road Kwei-Shan, Tao-Yuan, Taiwan 333. E-mail address: [email protected] (Y.-F. Tsai). http://dx.doi.org/10.1016/j.jamda.2016.06.019 1525-8610/Ó 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
complications, leading to high mortality rates (up to 34%).2 Most studies on the problem of NH-to-hospital transfers have focused on transfer prevalence,1,3 residents’ diagnosis or symptoms prompting transfer,4e6 and the outcomes of transfer.5,7 The hospitalization rate of NH residents, or the NH-to-hospital transfer rate, in a systematic review of 59 studies conducted in North America was 9% to 59%.8 These high rates and variability were due to different approaches to classifying hospitalization, for example, excluding or including avoidable or inappropriate hospitalizations.8 Another possible factor affecting the NH-to-hospital transfer rate is NH residents’ later hospital readmission because the symptom triggering the original transfer was not adequately treated. Such repeat transfers may challenge residents’ care quality and be costly. Indeed, an early study found that 16.8% of NH residents were transferred to the
2
H.-H. Tsai et al. / JAMDA xxx (2016) 1e5
emergency department 2 to 3 times/year and 7.9% of residents were transferred 4 to 6 times/year.9 In more recent research, 23.9% of NH residents were transferred to hospital within 1 week of a previous transfer, 37% were transferred within 2 weeks of their initial emergency department visit,10 7% had multiple transfers within 90 days,11 and 6.4% made repeat visits within 6 months.12 Although these studies provide useful data on the problems associated with and possible strategies to manage NH residents’ repeated hospital admissions, they only followed residents for a short time, which may not have accounted for seasonal effects on admission.12,13 Additionally, no research could be found on relationships between details of repeated hospital admissions and length of NH residents’ residency. These relationships are important because older adults need time to adapt to their relocation to an NH. Indeed, relocating to an NH stresses elderly residents as they adapt to their new environment.14e16 This stress may affect residents’ health, contributing to different reasons for transfer to hospital. This possibility is supported by previous findings that NH-to-hospital transfers are highest for new NH admissions but decrease with longer NH residency.8,17 Furthermore, the majority of elderly NH residents have chronic diseases that change over time,4 which may contribute to a different transfer trajectory. Indeed, residents of long-term care facilities in a systematic review were more commonly transferred to hospital for infections (5.3%e24%), particularly of the respiratory and urinary systems (12%e37%), cardiovascular illness (11%e28%), and fall-related injuries (12%e23%).10 Similarly, common reasons for NH residents’ transfer to hospital in another review were congestive heart failure, circulatory problems, respiratory problems, genitourinary problems, and infection.8 Although these reviews provide useful data on the reasons for NH-to-hospital transfers, little is known about the trajectory of these symptoms with different residency durations. Furthermore, the majority of these studies were conducted in Western countries, and their findings may differ from those in Asian countries.10 Over patients’ illness trajectory, members of healthcare teams must combine their efforts to manage patients’ symptoms and determine the eventual outcome. Although illness trajectories are uncertain at any given time, they can be understood in retrospect.4 Understanding the trajectory of NH-to-hospital transfers may provide useful data for providing patient-centered care. The purpose of this study was to explore associations between NH residents’ characteristics and repeated hospital transfers and the trajectory of Taiwanese NH residents’ common reasons (signs and symptoms) for hospital transfer by length of residency. Methods Data for this retrospective chart-review study were collected from October 2013 through October 2014 from 6 randomly selected NHs in northern Taiwan. Data were collected on NH residents’ demographic and clinical characteristics as well as details of hospital transfer. Hospital transfer was defined in this study as transfer of an NH resident to a hospital regardless of whether the resident was admitted or seen/treated and sent back to the NH. Demographic data included age, gender, physical and cognitive status, medical history, and duration of residency. Medical history included cerebrovascular disease, dementia, cancer, pneumonia, and other conditions. Participants’ physical, cognitive, and consciousness status were measured at both admission and the latest status assessment. Physical status was measured using the Chinese Barthel Index (CBI),18,19 which assesses performance of activities of daily living, and cognitive status was measured by the Chinese Mini-Mental State Examination (MMSE).20,21 Data were also collected from residents’ charts on whether they had a nasogastric (NG) tube, Foley catheter, or tracheal tube. Details of transfers
included time, reason (symptoms) for transfer, number of NH to hospital transfers, and the outcome of each transfer. Statistical Analysis Data were analyzed using SPSS, version 20 (IBM Corp, Armonk, NY). Descriptive statistics were used to examine participants’ characteristics; continuous variables (participants’ age, NH residency, CBI scores, and MMSE scores) were analyzed by means and standard deviations; categorical variables (gender and reasons for transfer) were analyzed by number and frequency. NH residents’ data were analyzed retrospectively for 4 years based on a mean duration of 2.6 years between NH admission and death.22 Differences in bivariate comparisons were analyzed using chi-squared tests. Differences in variables by number of hospital transfers (1, 2, 3, 4) were analyzed by analysis of variance. Differences in variables by residency and number of transfers were analyzed by Scheffe post hoc test. Statistical significance was set at P < .05. Results The 583 NH resident participants’ mean age was 69.36 years [standard deviation (SD) ¼ 6.10, range ¼ 16e107], and about half (54.9%) had transferred to hospital on average 2.20 times (SD ¼ 2.03, range ¼ 1e18). Residents who had never been transferred (n ¼ 263) were significantly younger (t ¼ 5.98, P ¼ .02), had fewer comorbidities (t ¼ 2.58, P ¼ .01), and had better CBI scores (t ¼ 10.98, P ¼ .02) than residents who had been transferred at least once (n ¼ 320). However, the never transferred and transferred groups did not differ significantly in MMSE scores (t ¼ 0.58, P ¼ .45), gender (c2 ¼ 0.20, P ¼ .65), length of residency (t ¼ 1.89, P ¼ .06), or medical history (c2 ¼ 2.73, P ¼ .06), except for pneumonia (c2 ¼ 10.17, P < .01) and asthma (7.43, P ¼ .01). More residents who had been transferred had an NG tube (c2 ¼ 14.11, P < .001), a Foley catheter (c2 ¼ 7.73, P ¼ .01), or a tracheal tube (c2 ¼ 5.88, P ¼ .002) than residents who had never been transferred. The 320 residents in the transfer group had been transferred 705 times. Among these 320 residents, 5.8% were transferred but sent back to the NH without being admitted to the hospitaldthe top reason for these nonadmitted residents being transferred was for a fall (18%). About half the transfer group had been transferred to hospital more than twice (50.97%), including 79 who had been transferred twice (24.69%), 37 who had been transferred 3 times (11.59%), and 47 who had been transferred more than 4 times (14.69%) (Table 1). Residents who experienced different numbers of transfers differed significantly in their NH residency (F ¼ 3.85, P ¼ .01), CBI scores (F ¼ 2.65, P ¼ .05), history of pneumonia (c2 ¼ 13.03, P ¼ .01), fractures (c2 ¼ 8.52, P ¼ .04) and having an NG tube (c2 ¼ 4.86, P ¼ .03), Foley catheter (c2 ¼ 12.76, P ¼ .01), or tracheal tube (c2 ¼ 9.20, P ¼ .03). Residents with different numbers of transfers also differed significantly in their reasons for transfer, that is, due to falls (c2 ¼ 13.01, P ¼ .01) and tube problems (c2 ¼ 8.87, P ¼ .03). However, residents who experienced different numbers of transfers did not differ significantly by time from NH admission to first hospital transfer (F ¼ 0.41, P ¼ .75) and length of hospital stay (F ¼ 0.67, P ¼ .57) (Table 1). Furthermore, Scheffe post hoc analysis revealed that residents with 4 transfers differed significantly from those who had 1 transfer in terms of their NH residency, and residents who had 1 transfer differed significantly from those who had 2 transfers in their physical status (CBI score) at chart review (Table 1). Of the 705 transfers analyzed, about one third (33.1%) were within the first year of NH residency (Table 2). Furthermore, the mean interval between transfers decreased with number of transfers. The mean times between transfers were 297.67 339.02 days, 229.67 235.45 days, and 156.64 162.30 days for residents with 2, 3,
H.-H. Tsai et al. / JAMDA xxx (2016) 1e5
3
Table 1 Nursing Home Residents’ Characteristics by Number of Transfers to Hospital Characteristic Demographics Age, y (M SD) Gender (n, %) Male Female NH residency, days (M SD) Cognitive status, MMSE score At admission (M SD) At chart review (M SD) Physical status (CBI score) At admission (M SD) At chart review (M SD) Nasogastric tube (n, %) No Yes Tracheal tube (n, %) No Yes Foley catheter (n, %) No Yes Medical history Comorbidities Pneumonia (n, %) No Yes Fracture (n, %) No Yes First transfer since admission, d (M SD) Reason for transfer Fall (n, %) No Yes Tube problems (n, %) No Yes Outcome Length of stay, d (M SD)
F/c2 (P)
Total (N ¼ 320)
One Time (n ¼ 157)
Two Times (n ¼ 79)
Three Times (n ¼ 37)
Four or More Times (n ¼ 47)
71.61 14.94
72.19 14.13
70.92 15.41
70.92 15.68
71.38 16.50
169 (52.8) 151 (47.2) 1591.3 1219.4
77 (49.0) 80 (51.0) 1399.3 1226.3
45 (57.0) 34 (43.0) 1688.4 1248.9
20 (54.1) 17 (45.9) 1607.4 1020.5
27 (57.4) 20 (42.6) 2056.5* 1178.1
3.85 (.01)
9.84 10.55 9.53 10.43
10.07 10.52 9.40 10.52
7.59 8.52 8.22 9.26
16.21 12.10 14.85 11.44
5.67 9.76 7.33 10.45
1.58 (.19) 1.49 (.22)
20.21 27.05 19.35 26.66
24.04 29.64 23.67 28.94
16.57 25.94 14.21y 24.15
20.08 24.64 20.64 26.23
14.78 20.71 13.98 22.04
2.03 (.11) 2.65 (.05) 4.86 (.03)
182 (57.2) 136 (42.8)
97 (62.6) 58 (37.4)
44 (55.7) 35 (44.3)
20 (54.1) 17 (45.9)
21 (44.7) 26 (55.3)
290 (90.6) 30 (9.4)
145 (92.3) 12 (7.7)
74 (93.7) 5 (6.3)
34 (91.9) 3 (8.1)
37 (78.7) 10 (21.3)
232 (73) 86 (27)
125 (79.4) 32 (20.6)
60 (75.9) 19 (24.1)
21 (56.8) 16 (43.2)
28 (59.6) 19 (40.4)
2.61 1.45
2.71 1.46
2.67 1.53
2.70 1.53
3.04 1.37
266 (83.1) 54 (16.9)
140 (89.2) 17 (10.8)
66 (83.5) 13 (16.5)
28 (75.7) 9 (24.3)
32 (68.1) 15 (31.9)
275 (85.9) 45 (14.1) 819.87 1060.93
137 (87.3) 20 (12.7) 847.50 1139.08
62 (78.5) 17 (21.5) 872.72 1111.55
31 (83.8) 6 (16.2) 666.05 806.97
45 (95.7) 2 (4.3) 758.70 876.35
300 (93.8) 20 (6.2)
145 (92.4) 12 (7.6)
71 (89.9) 8 (10.1)
37 (100) 0 (0)
47 (100) 0 (0)
309 (96.6) 11 (3.4)
152 (96.8) 5 (3.2)
78 (98.7) 1 (1.3)
37 (100) 0 (0)
42 (89.4) 5 (10.6)
11.13 9.78
10.78 9.420
10.61 9.46
12.24 10.96
11.17 9.67
0.16 (.92) 1.86 (.60)
9.20 (.03)
12.76 (.01)
2.73 (.06) 13.03 (.01)
8.52 (.04)
0.41 (.75)
13.01 (<.01)
8.87 (.03)
0.67 (.57)
*Residents with 4 transfers to hospital differed significantly from those with 1 transfer in terms of NH residency. y Residents with 2 transfers to hospital differed significantly from those with 1 transfer in terms of CBI score at chart review.
and 4 transfers, respectively. The mean times between initial transfer (T1) and repeat transfers were 297.67 (T2eT1), 507.95 (T3eT1), and 636.15 (T4eT1), where T2, T3, and T4 refer to the second, third, and fourth transfers, respectively. Our comparison of reasons (residents’ symptoms) for transfer by length of NH residency showed that the top reason for hospital transfer was fever, accounting for 38.16% of the 705 transfers. Other reasons for transfer (in decreasing frequency) were dyspnea (shortness of breath, 21.42%), vomiting (8.79%), altered consciousness (8.65%), and coffee ground vomiting (5.39%) (Figure 1). Our analysis of trends in reasons for transfer by NH residency showed that the frequency of fever as a reason for hospital transfer increased with longer residency. Altered consciousness tended to increase with length of
residency, whereas falls/fall-related injuries and hyperglycemia tended to decrease with length of residency (Figure 1). Discussion Our study contributes to understanding NH-to-hospital transfers in an Asian context by documenting the trajectory of transfers by length of residency and details of NH residents’ repeated transfers to hospital. We found that fever was the top reason for residents’ transfers regardless of their length of residency, and its prevalence as a reason for transfer increased with residency. Our finding on fever is consistent with fever or infection as a common reason for North American NH residents to be transferred,8 possibly because living in
Table 2 Number of Nursing Home-to-Hospital Transfers by Length of Residency NH Residency, mo
One Transfer (n ¼ 157), n (%)
Two Transfers (n ¼ 79), n (%)
Three Transfers (n ¼ 37), n (%)
Four or More Transfers (n ¼ 47), n (%)
Total Transfers (n ¼ 705), n (%)
<12 12e24 24e36 36 Total
77 (49.0) 27 (17.2) 12 (7.6) 41 (26.2) 157
68 (43.0) 25 (15.8) 14 (8.8) 51 (32.4) 158
37 (33.3) 20 (18.0) 18 (16.2) 36 (32.5) 111
51 (18.3) 36 (12.9) 48 (17.2) 144 (51.6) 279
233 108 92 272
(33.1) (15.3) (13.0) (38.6)
4
H.-H. Tsai et al. / JAMDA xxx (2016) 1e5
Fig. 1. Reasons (residents’ symptoms) for nursing home-to-hospital transfer by length of residency.
an institutional setting increases the chance of infection. These results suggest that the chance of NH-to-hospital transfers would be decreased by educating NH staff to recognize and manage fever symptoms and by programs to protect NH resident against infections, for example, influenza vaccination programs.23 Our finding that fever as a reason for transfer by year of residency was 33.0% to 42.7% is higher than the 5.3% to 24% range reported in a review of NHs in the United States, United Kingdom, Canada, and Australia.10 This difference may be due to country-level differences in health care systems, health insurance, or the number of persons sharing rooms. Further research is suggested to compare variations in infection rate by NH room occupancy. Furthermore, the mean age of residents in our sample is younger (69.36 years) than in a previous report from Canada12 and 3 systematic reviews.2,10,24 This difference is due to those studies including only geriatric populations 65 years old.2,10,12,24 In our study, we included all NH residents, with 33% being under 65 years old. Another finding of our study was that the top 5 reasons for NH-tohospital transfers were fever, dyspnea, gastritis/enteritis/vomiting, altered consciousness, and coffee ground vomiting, similar to systematic review findings that NH transfers were commonly due to respiration problems, infections, cardiovascular problems, genitourinary problems, and gastrointestinal bleeding.8,10 Our results also echo a report that the highest-ranked signs/symptoms for NH nurses to transfer residents to hospital were altered consciousness, chest pressure/tightness, shortness of breath, decreased oxygenation, and muscle or bone pain.25 We also found that falls/fall-related injuries as a reason for transfer decreased with length of residency and that falls were rarely a reason for transfer for residents with 3 transfers. These findings may be due to residents’ functional status decreasing with NH residency,3 thus limiting their activities and decreasing their chance of falling. However, strategies to prevent falls should be emphasized when residents first relocate to an NH. We also found that falls were the top reason for transfer among the 5.8% of residents who were transferred to the hospital but sent back without being admitted. These residents may have been sent back because they did not need further treatment once a radiograph or other examination confirmed they had no broken bones. Furthermore, in our sample of NH residents, those with a medical history of fractures were transferred to hospital significantly more times than those without such a history. It is interesting to note that this group of residents and those without a history of fracture did not differ significantly in falls as a reason for hospital transfer (t ¼ 3.69, P ¼ .06). However, the 2 groups with and without a history of fracture differed significantly in tarry stool as a reason for hospital transfer (t ¼ 14.33, P < .001). This difference in transfer reason may have been due to the medicine26 (such as Nonsteroidal anti-inflammatory drugs) used to treat fracture-related symptoms (such as pain). This result
suggests that NH nurses could minimize transfers by carefully monitoring residents with a history of fracture for side effects of medicine used to treat fractures. NH-to-hospital transfers were most common for our participants in their first year of residency, possibly due to NH residents’ needing time to adapt to their new home or because of their unstable condition due to chronic diseases such as diabetes.16 Our participants experienced on average 2.20 (SD ¼ 2.03, range ¼ 1e18) NH-to-hospital transfers, which is higher than the mean of 1.4 transfers (SD ¼ 0.74) reported from Hong Kong.11 Our participants’ transfer rates (26.9% and 28.0% for residents transferred once and 2 times, respectively) were also higher than those reported from Hong Kong (17.9% and 6.9% for residents transferred once and 2 times, respectively).11 These different findings may be due to different follow-up times. Data were gathered in our study over 4 years, whereas the follow-up time in the other study was 90 days.11 Further research is suggested with longer follow-up times. Furthermore, our participants’ mean length of hospital stay was 11.13 days, which is higher than Taiwan’s average hospital stay of 8.94 days.7 This difference may be due to the majority of NH residents being elderly and frail, contributing to higher average hospital stays. Our participants’ hospital stay was also longer than 5 days recently reported for NH residents in Australia or 3 days for residents in Norway,2,13,24 but lower than 18 days reported in an old study when hospital stays were longer.27 Our finding that the time between initial and repeat transfers ranged from 297.67 (T2eT1) to 636.15 (T4eT1) days is far longer than the average of 37.2 days for Canadian NH residents.12 This difference may be due to differences in health systems or the shorter follow-up time in the Canadian study, only 6 months. Our 4-year follow-up was sufficient to include seasonal effects and changes in residents’ health status. Cross-country research is suggested to compare these outcomes. Conclusion Fever was the top reason for NH residents’ transfer to hospital, regardless of length of residency, and the prevalence of transfer increased with length of residency, likely due to increased risk of infections or contagion in an institutional setting. To decrease the chance of NH-to-hospital transfer, we recommend educating NH staff to recognize and manage signs of infection or initiating infectioncontrol programs such as influenza vaccination. References 1. Arendts G, Howard K. The interface between residential aged care and the emergency department: a systematic review. Age Ageing 2010;39:306e312. 2. Graverholt B, Riise T, Jamtvedt G, et al. Acute hospital admissions among nursing home residents: A population-based observational study. BMC Health Serv Res 2011;11:126. 3. McConnell ES, Pieper CF, Sloane RJ, Branch LG. Effects of cognitive performance on change in physical function in long-stay nursing home residents. J Gerontol A Biol Sci Med Sci 2002;57:M778eM784. 4. Corbin JM, Strauss A. A nursing model for chronic illness management based upon the Trajectory Framework. Sch Inq Nurs Pract 1991;5:155e174. 5. Basic D, Hartwell TJ. Falls in hospital and new placement in a nursing home among older people hospitalized with acute illness. Clin Interv Aging 2015;10: 1637e1643. 6. Wagner LM, Dionne JC, Zive JR, Rochon PA. Fall risk care processes in nursing home facilities. J Am Med Dir Assoc 2011;12:426e430. 7. Ministry of Health & Welfare (Taiwan). Available at: https://www.gender.ey. gov.tw/gecdb/Stat_Statistics_DetailData.aspx?sn¼P9FjL3GCbF7yB3lDgZAomQ% 3d%3d&d¼m9ww9odNZAz2Rc5Ooj%2fwIQ%3d%3d. Accessed January 5, 2016. 8. Grabowski DC, Stewart KA, Broderick SM, Coots LA. Predictors of nursing home hospitalization: A review of the literature. Med Care Res Rev 2008;65:3e39. 9. Jones JS, Dwyer PR, White LJ, Firman R. Patient transfer from nursing home to emergency department: Outcomes and policy implications. Acad Emerg Med 1997;4:908e915. 10. Dwyer R, Gabbe B, Stoelwinder JU, Lowthian J. A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities. Age Ageing 2014;43:759e766.
H.-H. Tsai et al. / JAMDA xxx (2016) 1e5 11. Tang M, Woo J, Hui E, et al. Utilization of emergency room and hospitalization by Chinese nursing home residents: A cross-sectional study. J Am Med Dir Assoc 2010;11:325e332. 12. Gruneir A, Bell CM, Bronskill SE, et al. Frequency and pattern of emergency department visits by long-term care residentsdA population-based study. J Am Geriatr Soc 2010;58:510e517. 13. Crilly J, Chaboyer W, Wallis M, et al. An outcomes evaluation of an Australian Hospital in the Nursing Home admission avoidance programme. J Clin Nurs 2011;20:1178e1187. 14. Wilson SA. The transition to nursing home life: A comparison of planned and unplanned admissions. J Adv Nurs 1997;26:864e871. 15. Brooke V. How elders adjust. Geriatr Nurs 1989;10:66e68. 16. Lee DT, Woo J, Mackenzie AE. The cultural context of adjusting to nursing home life: Chinese elders’ perspectives. Gerontologist 2002;42:667e675. 17. Carter MW, Porell FW. Nursing home performance on select publicly reported quality indicators and resident risk of hospitalization: Grappling with policy implications. J Aging Soc Policy 2006;18:17e39. 18. Mahoney FI, Barthel DW. Functional evaluation: The Barthel Index. Md State Med J 1965;14:61e65. 19. Chen YJ, Dai YT, Yang CT, et al. A Review and Proposal on Patient Classification in the Long-Term Care System. Taipei, Taiwan: Department of Health; 1995.
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20. Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189e198. 21. Liu GK, Dai DD, Lin RT, Lai CL. Epidemiology of dementia in Taiwan. Res Appl Psychol 2000;7:157e169. 22. Hjaltadóttir I, Hallberg IR, Ekwall AK, Nyberg P. Predicting mortality of residents at admission to nursing home: A longitudinal cohort study. BMC Health Serv Res 2011;11:86. 23. Graverholt B, Forsetlund L, Jamtvedt G. Reducing hospital admissions from nursing homes: A systematic review. BMC Health Serv Res 2014;14:36. 24. Arendts G, Dickson C, Howard K, Quine S. Transfer from residential aged care to emergency departments: An analysis of patient outcomes. Intern Med J 2012; 42:75e82. 25. Ashcraft AS, Owen DC. From nursing home to acute care: Signs, symptoms, and strategies used to prevent transfer. Geriatr Nurs 2014;35:316e320. 26. Hreinsson JP, Kalaitzakis E, Gudmundsson S, Björnsson ES. Upper gastrointestinal bleeding: incidence, etiology and outcomes in a population-based setting. Scand J Gastroenterol 2013;48:439e447. 27. Bergman H, Clarfield AM. Appropriateness of patient transfer from a nursing home to an acute-care hospital: A study of emergency room visits and hospital admissions. J Am Geriatr Soc 1991;39:1164e1168.
JAMDA journal homepage: www.jamda.com
Original Study
Repeated Hospital Transfers and Associated Outcomes by Residency Time Among Nursing Home Residents in Taiwan Hsiu-Hsin Tsai RN, PhD a, b, Yun-Fang Tsai RN, PhD a, c, d, *, Chia-Yih Liu MD b, e, f a
School of Nursing, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan Department of Psychiatry, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan c Department of Nursing, Chang Gung University of Science and Technology, Tao-Yuan, Taiwan d Department of Psychiatry, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan e School of Medicine, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan f Department of Psychology, National Cheng Chi University, Taipei, Taiwan b
a b s t r a c t Keywords: Repeated hospital transfer nursing home residency
Background: Nursing home residents’ repeated transfers to hospital are costly and can lead to in-hospital complications and high mortality for frail residents. However, no research has examined the trajectory of residents’ symptoms over their nursing home residency and its relationship to hospital transfer. Aim: The purpose of this retrospective chart-review study was to examine associations between nursing home residents’ characteristics, including length of residency, and repeated hospital transfers as well as the trajectory of transfers during residency. Design: For this retrospective study, we reviewed 583 residents’ charts in 6 randomly selected nursing homes from northern Taiwan. Data were analyzed by descriptive statistics, chi-squared tests, and 1-way analysis of variance. Results: About half of nursing home residents who had been transferred to hospital (n ¼ 320) were transferred more than twice during their residency (50.97%). Residents who had been transferred 1, 2, 3, or 4 times differed significantly in length of residency (F ¼ 3.85, P ¼ .01), physical status (F ¼ 2.65, P ¼ .05), medical history of pneumonia (c2 ¼ 13.03, P ¼ .01), and fractures (c2 ¼ 8.52, P ¼ .04). Residents with different numbers of transfers differed significantly in their reasons for transfer, that is, falls (c2 ¼ 13.01, P ¼ .01) and tube problems (c2 ¼ 8.87, P ¼ .03). Among 705 total transfers, fever was the top reason for transfer, and transfer prevalence increased with nursing home residency. Conclusion: To decrease the chance of residents’ hospital transfer, nursing home staff should be educated about recognizing and managing fever symptoms, infection-control programs such as influenza vaccination should be initiated, and fall-prevention/education programs should be started when residents first relocate to nursing homes. Ó 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Nursing home (NH) residents are expected to experience changes in their health status as a result of their advanced age. Changes in health status are often due to residents’ cognitive and functional impairment, fragility, and medical comorbidities; these changes commonly result in transfers from the NH to the hospital.1 However, frail NH residents who are transferred suffer from in-hospital
The research was supported by the Ministry of Science and Technology (NSC 101-2314-B-182-032-MY3) and the Chang Gung Hospital (BMRP849). The authors declare no conflicts of interest. * Address correspondence to Yun-Fang Tsai, RN, PhD, School of Nursing, Chang Gung University 259, Wen-Hwa 1st Road Kwei-Shan, Tao-Yuan, Taiwan 333. E-mail address: [email protected] (Y.-F. Tsai). http://dx.doi.org/10.1016/j.jamda.2016.06.019 1525-8610/Ó 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
complications, leading to high mortality rates (up to 34%).2 Most studies on the problem of NH-to-hospital transfers have focused on transfer prevalence,1,3 residents’ diagnosis or symptoms prompting transfer,4e6 and the outcomes of transfer.5,7 The hospitalization rate of NH residents, or the NH-to-hospital transfer rate, in a systematic review of 59 studies conducted in North America was 9% to 59%.8 These high rates and variability were due to different approaches to classifying hospitalization, for example, excluding or including avoidable or inappropriate hospitalizations.8 Another possible factor affecting the NH-to-hospital transfer rate is NH residents’ later hospital readmission because the symptom triggering the original transfer was not adequately treated. Such repeat transfers may challenge residents’ care quality and be costly. Indeed, an early study found that 16.8% of NH residents were transferred to the
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emergency department 2 to 3 times/year and 7.9% of residents were transferred 4 to 6 times/year.9 In more recent research, 23.9% of NH residents were transferred to hospital within 1 week of a previous transfer, 37% were transferred within 2 weeks of their initial emergency department visit,10 7% had multiple transfers within 90 days,11 and 6.4% made repeat visits within 6 months.12 Although these studies provide useful data on the problems associated with and possible strategies to manage NH residents’ repeated hospital admissions, they only followed residents for a short time, which may not have accounted for seasonal effects on admission.12,13 Additionally, no research could be found on relationships between details of repeated hospital admissions and length of NH residents’ residency. These relationships are important because older adults need time to adapt to their relocation to an NH. Indeed, relocating to an NH stresses elderly residents as they adapt to their new environment.14e16 This stress may affect residents’ health, contributing to different reasons for transfer to hospital. This possibility is supported by previous findings that NH-to-hospital transfers are highest for new NH admissions but decrease with longer NH residency.8,17 Furthermore, the majority of elderly NH residents have chronic diseases that change over time,4 which may contribute to a different transfer trajectory. Indeed, residents of long-term care facilities in a systematic review were more commonly transferred to hospital for infections (5.3%e24%), particularly of the respiratory and urinary systems (12%e37%), cardiovascular illness (11%e28%), and fall-related injuries (12%e23%).10 Similarly, common reasons for NH residents’ transfer to hospital in another review were congestive heart failure, circulatory problems, respiratory problems, genitourinary problems, and infection.8 Although these reviews provide useful data on the reasons for NH-to-hospital transfers, little is known about the trajectory of these symptoms with different residency durations. Furthermore, the majority of these studies were conducted in Western countries, and their findings may differ from those in Asian countries.10 Over patients’ illness trajectory, members of healthcare teams must combine their efforts to manage patients’ symptoms and determine the eventual outcome. Although illness trajectories are uncertain at any given time, they can be understood in retrospect.4 Understanding the trajectory of NH-to-hospital transfers may provide useful data for providing patient-centered care. The purpose of this study was to explore associations between NH residents’ characteristics and repeated hospital transfers and the trajectory of Taiwanese NH residents’ common reasons (signs and symptoms) for hospital transfer by length of residency. Methods Data for this retrospective chart-review study were collected from October 2013 through October 2014 from 6 randomly selected NHs in northern Taiwan. Data were collected on NH residents’ demographic and clinical characteristics as well as details of hospital transfer. Hospital transfer was defined in this study as transfer of an NH resident to a hospital regardless of whether the resident was admitted or seen/treated and sent back to the NH. Demographic data included age, gender, physical and cognitive status, medical history, and duration of residency. Medical history included cerebrovascular disease, dementia, cancer, pneumonia, and other conditions. Participants’ physical, cognitive, and consciousness status were measured at both admission and the latest status assessment. Physical status was measured using the Chinese Barthel Index (CBI),18,19 which assesses performance of activities of daily living, and cognitive status was measured by the Chinese Mini-Mental State Examination (MMSE).20,21 Data were also collected from residents’ charts on whether they had a nasogastric (NG) tube, Foley catheter, or tracheal tube. Details of transfers
included time, reason (symptoms) for transfer, number of NH to hospital transfers, and the outcome of each transfer. Statistical Analysis Data were analyzed using SPSS, version 20 (IBM Corp, Armonk, NY). Descriptive statistics were used to examine participants’ characteristics; continuous variables (participants’ age, NH residency, CBI scores, and MMSE scores) were analyzed by means and standard deviations; categorical variables (gender and reasons for transfer) were analyzed by number and frequency. NH residents’ data were analyzed retrospectively for 4 years based on a mean duration of 2.6 years between NH admission and death.22 Differences in bivariate comparisons were analyzed using chi-squared tests. Differences in variables by number of hospital transfers (1, 2, 3, 4) were analyzed by analysis of variance. Differences in variables by residency and number of transfers were analyzed by Scheffe post hoc test. Statistical significance was set at P < .05. Results The 583 NH resident participants’ mean age was 69.36 years [standard deviation (SD) ¼ 6.10, range ¼ 16e107], and about half (54.9%) had transferred to hospital on average 2.20 times (SD ¼ 2.03, range ¼ 1e18). Residents who had never been transferred (n ¼ 263) were significantly younger (t ¼ 5.98, P ¼ .02), had fewer comorbidities (t ¼ 2.58, P ¼ .01), and had better CBI scores (t ¼ 10.98, P ¼ .02) than residents who had been transferred at least once (n ¼ 320). However, the never transferred and transferred groups did not differ significantly in MMSE scores (t ¼ 0.58, P ¼ .45), gender (c2 ¼ 0.20, P ¼ .65), length of residency (t ¼ 1.89, P ¼ .06), or medical history (c2 ¼ 2.73, P ¼ .06), except for pneumonia (c2 ¼ 10.17, P < .01) and asthma (7.43, P ¼ .01). More residents who had been transferred had an NG tube (c2 ¼ 14.11, P < .001), a Foley catheter (c2 ¼ 7.73, P ¼ .01), or a tracheal tube (c2 ¼ 5.88, P ¼ .002) than residents who had never been transferred. The 320 residents in the transfer group had been transferred 705 times. Among these 320 residents, 5.8% were transferred but sent back to the NH without being admitted to the hospitaldthe top reason for these nonadmitted residents being transferred was for a fall (18%). About half the transfer group had been transferred to hospital more than twice (50.97%), including 79 who had been transferred twice (24.69%), 37 who had been transferred 3 times (11.59%), and 47 who had been transferred more than 4 times (14.69%) (Table 1). Residents who experienced different numbers of transfers differed significantly in their NH residency (F ¼ 3.85, P ¼ .01), CBI scores (F ¼ 2.65, P ¼ .05), history of pneumonia (c2 ¼ 13.03, P ¼ .01), fractures (c2 ¼ 8.52, P ¼ .04) and having an NG tube (c2 ¼ 4.86, P ¼ .03), Foley catheter (c2 ¼ 12.76, P ¼ .01), or tracheal tube (c2 ¼ 9.20, P ¼ .03). Residents with different numbers of transfers also differed significantly in their reasons for transfer, that is, due to falls (c2 ¼ 13.01, P ¼ .01) and tube problems (c2 ¼ 8.87, P ¼ .03). However, residents who experienced different numbers of transfers did not differ significantly by time from NH admission to first hospital transfer (F ¼ 0.41, P ¼ .75) and length of hospital stay (F ¼ 0.67, P ¼ .57) (Table 1). Furthermore, Scheffe post hoc analysis revealed that residents with 4 transfers differed significantly from those who had 1 transfer in terms of their NH residency, and residents who had 1 transfer differed significantly from those who had 2 transfers in their physical status (CBI score) at chart review (Table 1). Of the 705 transfers analyzed, about one third (33.1%) were within the first year of NH residency (Table 2). Furthermore, the mean interval between transfers decreased with number of transfers. The mean times between transfers were 297.67 339.02 days, 229.67 235.45 days, and 156.64 162.30 days for residents with 2, 3,
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Table 1 Nursing Home Residents’ Characteristics by Number of Transfers to Hospital Characteristic Demographics Age, y (M SD) Gender (n, %) Male Female NH residency, days (M SD) Cognitive status, MMSE score At admission (M SD) At chart review (M SD) Physical status (CBI score) At admission (M SD) At chart review (M SD) Nasogastric tube (n, %) No Yes Tracheal tube (n, %) No Yes Foley catheter (n, %) No Yes Medical history Comorbidities Pneumonia (n, %) No Yes Fracture (n, %) No Yes First transfer since admission, d (M SD) Reason for transfer Fall (n, %) No Yes Tube problems (n, %) No Yes Outcome Length of stay, d (M SD)
F/c2 (P)
Total (N ¼ 320)
One Time (n ¼ 157)
Two Times (n ¼ 79)
Three Times (n ¼ 37)
Four or More Times (n ¼ 47)
71.61 14.94
72.19 14.13
70.92 15.41
70.92 15.68
71.38 16.50
169 (52.8) 151 (47.2) 1591.3 1219.4
77 (49.0) 80 (51.0) 1399.3 1226.3
45 (57.0) 34 (43.0) 1688.4 1248.9
20 (54.1) 17 (45.9) 1607.4 1020.5
27 (57.4) 20 (42.6) 2056.5* 1178.1
3.85 (.01)
9.84 10.55 9.53 10.43
10.07 10.52 9.40 10.52
7.59 8.52 8.22 9.26
16.21 12.10 14.85 11.44
5.67 9.76 7.33 10.45
1.58 (.19) 1.49 (.22)
20.21 27.05 19.35 26.66
24.04 29.64 23.67 28.94
16.57 25.94 14.21y 24.15
20.08 24.64 20.64 26.23
14.78 20.71 13.98 22.04
2.03 (.11) 2.65 (.05) 4.86 (.03)
182 (57.2) 136 (42.8)
97 (62.6) 58 (37.4)
44 (55.7) 35 (44.3)
20 (54.1) 17 (45.9)
21 (44.7) 26 (55.3)
290 (90.6) 30 (9.4)
145 (92.3) 12 (7.7)
74 (93.7) 5 (6.3)
34 (91.9) 3 (8.1)
37 (78.7) 10 (21.3)
232 (73) 86 (27)
125 (79.4) 32 (20.6)
60 (75.9) 19 (24.1)
21 (56.8) 16 (43.2)
28 (59.6) 19 (40.4)
2.61 1.45
2.71 1.46
2.67 1.53
2.70 1.53
3.04 1.37
266 (83.1) 54 (16.9)
140 (89.2) 17 (10.8)
66 (83.5) 13 (16.5)
28 (75.7) 9 (24.3)
32 (68.1) 15 (31.9)
275 (85.9) 45 (14.1) 819.87 1060.93
137 (87.3) 20 (12.7) 847.50 1139.08
62 (78.5) 17 (21.5) 872.72 1111.55
31 (83.8) 6 (16.2) 666.05 806.97
45 (95.7) 2 (4.3) 758.70 876.35
300 (93.8) 20 (6.2)
145 (92.4) 12 (7.6)
71 (89.9) 8 (10.1)
37 (100) 0 (0)
47 (100) 0 (0)
309 (96.6) 11 (3.4)
152 (96.8) 5 (3.2)
78 (98.7) 1 (1.3)
37 (100) 0 (0)
42 (89.4) 5 (10.6)
11.13 9.78
10.78 9.420
10.61 9.46
12.24 10.96
11.17 9.67
0.16 (.92) 1.86 (.60)
9.20 (.03)
12.76 (.01)
2.73 (.06) 13.03 (.01)
8.52 (.04)
0.41 (.75)
13.01 (<.01)
8.87 (.03)
0.67 (.57)
*Residents with 4 transfers to hospital differed significantly from those with 1 transfer in terms of NH residency. y Residents with 2 transfers to hospital differed significantly from those with 1 transfer in terms of CBI score at chart review.
and 4 transfers, respectively. The mean times between initial transfer (T1) and repeat transfers were 297.67 (T2eT1), 507.95 (T3eT1), and 636.15 (T4eT1), where T2, T3, and T4 refer to the second, third, and fourth transfers, respectively. Our comparison of reasons (residents’ symptoms) for transfer by length of NH residency showed that the top reason for hospital transfer was fever, accounting for 38.16% of the 705 transfers. Other reasons for transfer (in decreasing frequency) were dyspnea (shortness of breath, 21.42%), vomiting (8.79%), altered consciousness (8.65%), and coffee ground vomiting (5.39%) (Figure 1). Our analysis of trends in reasons for transfer by NH residency showed that the frequency of fever as a reason for hospital transfer increased with longer residency. Altered consciousness tended to increase with length of
residency, whereas falls/fall-related injuries and hyperglycemia tended to decrease with length of residency (Figure 1). Discussion Our study contributes to understanding NH-to-hospital transfers in an Asian context by documenting the trajectory of transfers by length of residency and details of NH residents’ repeated transfers to hospital. We found that fever was the top reason for residents’ transfers regardless of their length of residency, and its prevalence as a reason for transfer increased with residency. Our finding on fever is consistent with fever or infection as a common reason for North American NH residents to be transferred,8 possibly because living in
Table 2 Number of Nursing Home-to-Hospital Transfers by Length of Residency NH Residency, mo
One Transfer (n ¼ 157), n (%)
Two Transfers (n ¼ 79), n (%)
Three Transfers (n ¼ 37), n (%)
Four or More Transfers (n ¼ 47), n (%)
Total Transfers (n ¼ 705), n (%)
<12 12e24 24e36 36 Total
77 (49.0) 27 (17.2) 12 (7.6) 41 (26.2) 157
68 (43.0) 25 (15.8) 14 (8.8) 51 (32.4) 158
37 (33.3) 20 (18.0) 18 (16.2) 36 (32.5) 111
51 (18.3) 36 (12.9) 48 (17.2) 144 (51.6) 279
233 108 92 272
(33.1) (15.3) (13.0) (38.6)
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H.-H. Tsai et al. / JAMDA xxx (2016) 1e5
Fig. 1. Reasons (residents’ symptoms) for nursing home-to-hospital transfer by length of residency.
an institutional setting increases the chance of infection. These results suggest that the chance of NH-to-hospital transfers would be decreased by educating NH staff to recognize and manage fever symptoms and by programs to protect NH resident against infections, for example, influenza vaccination programs.23 Our finding that fever as a reason for transfer by year of residency was 33.0% to 42.7% is higher than the 5.3% to 24% range reported in a review of NHs in the United States, United Kingdom, Canada, and Australia.10 This difference may be due to country-level differences in health care systems, health insurance, or the number of persons sharing rooms. Further research is suggested to compare variations in infection rate by NH room occupancy. Furthermore, the mean age of residents in our sample is younger (69.36 years) than in a previous report from Canada12 and 3 systematic reviews.2,10,24 This difference is due to those studies including only geriatric populations 65 years old.2,10,12,24 In our study, we included all NH residents, with 33% being under 65 years old. Another finding of our study was that the top 5 reasons for NH-tohospital transfers were fever, dyspnea, gastritis/enteritis/vomiting, altered consciousness, and coffee ground vomiting, similar to systematic review findings that NH transfers were commonly due to respiration problems, infections, cardiovascular problems, genitourinary problems, and gastrointestinal bleeding.8,10 Our results also echo a report that the highest-ranked signs/symptoms for NH nurses to transfer residents to hospital were altered consciousness, chest pressure/tightness, shortness of breath, decreased oxygenation, and muscle or bone pain.25 We also found that falls/fall-related injuries as a reason for transfer decreased with length of residency and that falls were rarely a reason for transfer for residents with 3 transfers. These findings may be due to residents’ functional status decreasing with NH residency,3 thus limiting their activities and decreasing their chance of falling. However, strategies to prevent falls should be emphasized when residents first relocate to an NH. We also found that falls were the top reason for transfer among the 5.8% of residents who were transferred to the hospital but sent back without being admitted. These residents may have been sent back because they did not need further treatment once a radiograph or other examination confirmed they had no broken bones. Furthermore, in our sample of NH residents, those with a medical history of fractures were transferred to hospital significantly more times than those without such a history. It is interesting to note that this group of residents and those without a history of fracture did not differ significantly in falls as a reason for hospital transfer (t ¼ 3.69, P ¼ .06). However, the 2 groups with and without a history of fracture differed significantly in tarry stool as a reason for hospital transfer (t ¼ 14.33, P < .001). This difference in transfer reason may have been due to the medicine26 (such as Nonsteroidal anti-inflammatory drugs) used to treat fracture-related symptoms (such as pain). This result
suggests that NH nurses could minimize transfers by carefully monitoring residents with a history of fracture for side effects of medicine used to treat fractures. NH-to-hospital transfers were most common for our participants in their first year of residency, possibly due to NH residents’ needing time to adapt to their new home or because of their unstable condition due to chronic diseases such as diabetes.16 Our participants experienced on average 2.20 (SD ¼ 2.03, range ¼ 1e18) NH-to-hospital transfers, which is higher than the mean of 1.4 transfers (SD ¼ 0.74) reported from Hong Kong.11 Our participants’ transfer rates (26.9% and 28.0% for residents transferred once and 2 times, respectively) were also higher than those reported from Hong Kong (17.9% and 6.9% for residents transferred once and 2 times, respectively).11 These different findings may be due to different follow-up times. Data were gathered in our study over 4 years, whereas the follow-up time in the other study was 90 days.11 Further research is suggested with longer follow-up times. Furthermore, our participants’ mean length of hospital stay was 11.13 days, which is higher than Taiwan’s average hospital stay of 8.94 days.7 This difference may be due to the majority of NH residents being elderly and frail, contributing to higher average hospital stays. Our participants’ hospital stay was also longer than 5 days recently reported for NH residents in Australia or 3 days for residents in Norway,2,13,24 but lower than 18 days reported in an old study when hospital stays were longer.27 Our finding that the time between initial and repeat transfers ranged from 297.67 (T2eT1) to 636.15 (T4eT1) days is far longer than the average of 37.2 days for Canadian NH residents.12 This difference may be due to differences in health systems or the shorter follow-up time in the Canadian study, only 6 months. Our 4-year follow-up was sufficient to include seasonal effects and changes in residents’ health status. Cross-country research is suggested to compare these outcomes. Conclusion Fever was the top reason for NH residents’ transfer to hospital, regardless of length of residency, and the prevalence of transfer increased with length of residency, likely due to increased risk of infections or contagion in an institutional setting. To decrease the chance of NH-to-hospital transfer, we recommend educating NH staff to recognize and manage signs of infection or initiating infectioncontrol programs such as influenza vaccination. References 1. Arendts G, Howard K. The interface between residential aged care and the emergency department: a systematic review. Age Ageing 2010;39:306e312. 2. Graverholt B, Riise T, Jamtvedt G, et al. Acute hospital admissions among nursing home residents: A population-based observational study. BMC Health Serv Res 2011;11:126. 3. McConnell ES, Pieper CF, Sloane RJ, Branch LG. Effects of cognitive performance on change in physical function in long-stay nursing home residents. J Gerontol A Biol Sci Med Sci 2002;57:M778eM784. 4. Corbin JM, Strauss A. A nursing model for chronic illness management based upon the Trajectory Framework. Sch Inq Nurs Pract 1991;5:155e174. 5. Basic D, Hartwell TJ. Falls in hospital and new placement in a nursing home among older people hospitalized with acute illness. Clin Interv Aging 2015;10: 1637e1643. 6. Wagner LM, Dionne JC, Zive JR, Rochon PA. Fall risk care processes in nursing home facilities. J Am Med Dir Assoc 2011;12:426e430. 7. Ministry of Health & Welfare (Taiwan). Available at: https://www.gender.ey. gov.tw/gecdb/Stat_Statistics_DetailData.aspx?sn¼P9FjL3GCbF7yB3lDgZAomQ% 3d%3d&d¼m9ww9odNZAz2Rc5Ooj%2fwIQ%3d%3d. Accessed January 5, 2016. 8. Grabowski DC, Stewart KA, Broderick SM, Coots LA. Predictors of nursing home hospitalization: A review of the literature. Med Care Res Rev 2008;65:3e39. 9. Jones JS, Dwyer PR, White LJ, Firman R. Patient transfer from nursing home to emergency department: Outcomes and policy implications. Acad Emerg Med 1997;4:908e915. 10. Dwyer R, Gabbe B, Stoelwinder JU, Lowthian J. A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities. Age Ageing 2014;43:759e766.
H.-H. Tsai et al. / JAMDA xxx (2016) 1e5 11. Tang M, Woo J, Hui E, et al. Utilization of emergency room and hospitalization by Chinese nursing home residents: A cross-sectional study. J Am Med Dir Assoc 2010;11:325e332. 12. Gruneir A, Bell CM, Bronskill SE, et al. Frequency and pattern of emergency department visits by long-term care residentsdA population-based study. J Am Geriatr Soc 2010;58:510e517. 13. Crilly J, Chaboyer W, Wallis M, et al. An outcomes evaluation of an Australian Hospital in the Nursing Home admission avoidance programme. J Clin Nurs 2011;20:1178e1187. 14. Wilson SA. The transition to nursing home life: A comparison of planned and unplanned admissions. J Adv Nurs 1997;26:864e871. 15. Brooke V. How elders adjust. Geriatr Nurs 1989;10:66e68. 16. Lee DT, Woo J, Mackenzie AE. The cultural context of adjusting to nursing home life: Chinese elders’ perspectives. Gerontologist 2002;42:667e675. 17. Carter MW, Porell FW. Nursing home performance on select publicly reported quality indicators and resident risk of hospitalization: Grappling with policy implications. J Aging Soc Policy 2006;18:17e39. 18. Mahoney FI, Barthel DW. Functional evaluation: The Barthel Index. Md State Med J 1965;14:61e65. 19. Chen YJ, Dai YT, Yang CT, et al. A Review and Proposal on Patient Classification in the Long-Term Care System. Taipei, Taiwan: Department of Health; 1995.
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20. Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189e198. 21. Liu GK, Dai DD, Lin RT, Lai CL. Epidemiology of dementia in Taiwan. Res Appl Psychol 2000;7:157e169. 22. Hjaltadóttir I, Hallberg IR, Ekwall AK, Nyberg P. Predicting mortality of residents at admission to nursing home: A longitudinal cohort study. BMC Health Serv Res 2011;11:86. 23. Graverholt B, Forsetlund L, Jamtvedt G. Reducing hospital admissions from nursing homes: A systematic review. BMC Health Serv Res 2014;14:36. 24. Arendts G, Dickson C, Howard K, Quine S. Transfer from residential aged care to emergency departments: An analysis of patient outcomes. Intern Med J 2012; 42:75e82. 25. Ashcraft AS, Owen DC. From nursing home to acute care: Signs, symptoms, and strategies used to prevent transfer. Geriatr Nurs 2014;35:316e320. 26. Hreinsson JP, Kalaitzakis E, Gudmundsson S, Björnsson ES. Upper gastrointestinal bleeding: incidence, etiology and outcomes in a population-based setting. Scand J Gastroenterol 2013;48:439e447. 27. Bergman H, Clarfield AM. Appropriateness of patient transfer from a nursing home to an acute-care hospital: A study of emergency room visits and hospital admissions. J Am Geriatr Soc 1991;39:1164e1168.