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Analysis

5 Guidelines for Transferring Nursing Home Residents to Hospitals During the Coronavirus Pandemic

By Christopher Cheney  
   May 12, 2020

The coronavirus is taking a heavy toll on nursing home residents and workers.

During the coronavirus disease 2019 (COVID-19) pandemic, patient transfers between nursing homes and hospitals require heightened consideration, a recent journal article says.

People who are at least 65 and people living in nursing homes are at high risk of serious illness during the COVID-19 pandemic, according the Centers for Disease Control and Prevention (CDC). Nursing home residents face high risk because the facilities have a "congregate nature" and serve older adults with chronic medical conditions, the CDC says.

One-third of COVID-19 deaths in the United States have been residents and workers at long-term healthcare facilities, the New York Times reported this week.

"Many older Americans who require assistance with Activities of Daily Living (ADLs) live in some type of congregate setting. These patients are particularly vulnerable to outbreaks of infectious disease, given close proximity of living quarters, frailty, functional dependence, and co-morbidities," the recent journal article says.

The co-authors of the journal article provide five recommendations for nursing home residents being considered for transfer to a hospital:

1. Medically stable patients who can be properly isolated from other nursing home residents and staff should not be transferred to an emergency department. For these patients, effective communication between nursing home clinicians and the ED can ensure adequate care in the nursing home setting.

2. During the COVID-19 pandemic, nursing homes should encourage residents and their families to complete advance care planning documents.

3. For nursing home residents with a fever and respiratory symptoms, staff should weigh the risks and benefits of transferring the individual to an ED. "This includes an evaluation of the patient's current state of health, patient-centered goals, and an assessment of prognosis in the context of the COVID-19 illness," the journal article says.

4. Nursing home staff should conduct "forward triage" when residents are considered for transfer to an ED. Key elements of forward triage include determining the resident's acuity and the best setting for meeting the resident's needs. An ED physician should be consulted.

5. Warm hand-offs are essential, such as effective communication between nursing home and ED staff before a transfer, and discussions about medical decisions such as the capacity of the nursing home to accept a patient back from the ED. Procedures should be in place that promote communication between EDs and nursing homes.

Care considerations

Nursing homes are equipped to provide care to ill residents, including treatment of pneumonia, urinary tract infections, skin infections, and fevers, a co-author of the journal article told HealthLeaders last week. "We take care of sick residents all the time in nursing homes," said Kathleen Unroe, MD, MHA, an associate professor of medicine at Indiana University School of Medicine and a research scientist at Regenstrief Institute in Indianapolis.

Nursing home residents should only be transferred to another care setting when treatment cannot be provided at the skilled nursing facility, she said.

"This is most often because they are or have gotten sicker—such as needing more oxygen and showing signs of severe infection such as a low blood pressure. It is important to know the resident's goals for care. Many residents, for example those with advanced dementia, have goals of care focused on comfort. When we can treat the symptoms of their illness, then we can care for them in the facility and avoid hospital transfer, including at the end of life."

In many cases of severe illness, transfer of nursing home residents to hospitals is appropriate, Unroe said. "When their clinical condition and goals of care are consistent with needing hospital-level care, we transfer them. Clear communication with the emergency medical service providers and the clinical providers in the emergency department is essential, especially if COVID-19 is suspected."

Forward triage screens nursing home residents prior to transfer to help direct them to the most appropriate resources, she said. "This requires direct, proactive communication between the ED and nursing home providers prior to transfer. For example, a patient who needs a blood transfusion due to worsened anemia found on labs could go directly to a transfusion center, bypassing the ED."

Communication between nursing homes and EDs is pivotal to achieve warm hand-offs of patients, Unroe said.

"Some health systems have secure communication systems, but you can always pick up the phone, call the emergency department, and ask to speak to the physician. In my experience as a nursing home physician, the ED docs are grateful for the call—especially now. We let too much information get dropped during transfers, which has consequences for our frail patients, and this is even more unacceptable now. These warm handoffs can be promoted by simply doing them, over and over, until it becomes our standard practice."

Photo: Kathleen Unroe, MD, MHA, meets with a nursing home resident. Photo credit: Regenstrief Institute

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


KEY TAKEAWAYS

Nursing home residents and staff account for about one-third of U.S. coronavirus deaths, according to the New York Times.

Medically stable nursing home residents who can be properly isolated from other residents and staff should not be transferred to hospitals, a research scientist says.

Effective communication between clinical staff at nursing homes and hospitals is essential when deciding whether to transfer a nursing home resident.


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