Admission Gatekeeping and Safe Discharge for the Elderly: Referral by the Emergency Department to the Community Nursing Service for Home Visits

Abstract

Objective To assess the gatekeeping effect and discharge safety in elderly referrals to the community nursing service (CNS) in a major accident & emergency department (AED). Methods Descriptive review analysis of the referrals in 2002–2004. Results Altogether 333 patients were accepted, comprising 5% of the total CNS referrals in the hospital: 323 were aged ≥65 (median age 81), 13.8% were living alone, 21.6% had unscheduled return to the AED within 14 days, and 11.7% in 15–28 days. The ≤14 days and 15–28 days admission to hospital was 15.0% and 6.0%, with 4.8% and 0.6% patients admitted with the same or related diagnosis as the first visit respectively, including missed fractures and stroke. One patient died 17 days after discharge. Eight of the 162 falls returned within 28 days with a second fall. Overall, 317 admissions were avoided with 1,978 bed-days saved. Living alone was strongly associated with unscheduled return and admission ≤14 and ≤28 days, while age was not. The six categories of community nursing care were fall-related, tube care, skin and soft tissue care, pain control, medical and diabetic care. Injections were given for cellulitis, pain, and diabetics. Forty-nine patients had phone follow-ups. Conclusion The gatekeeping effect of AED referrals to CNS remained small. The commonest referrals were falls with head injury. It was safe to discharge the elderly for CNS care. A wide range of home nursing care was feasible. CNS referral could decrease elderly return visits with falls. Living alone was strongly associated with return visit and admission.