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Transitional Care in the Emergency Department. Michael A. LaMantia , MD, MPH Center for Aging and Health Institute on Aging University of North Carolina. Disclosures. Work supported by: NIA Grant # 2T32AG000272-06A2

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Transitional care in the emergency department

Transitional Care in the Emergency Department

Michael A. LaMantia, MD, MPH

Center for Aging and Health

Institute on Aging

University of North Carolina


  • Work supported by:

    • NIA Grant # 2T32AG000272-06A2

    • UNC John A. Hartford Foundation Center of Excellence in Geriatric Medicine and Training


  • Challenges of Care of the Elderly in the ED

  • UNC’s Efforts to Improve Care of Elderly:

    • Understanding our patients/understanding outcomes of their care

    • Coordinating Care with other Providers

  • Areas for Future Research

Transitional care
Transitional Care

  • Definition:

    “A set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same institution.”

    –American Geriatrics Society (2003)

Transitional care1
Transitional Care

  • During transitions, patients are at risk for:

    • Medical errors

    • Service duplication

    • Inappropriate care

    • Critical elements of care plan “falling though the cracks”

      -AGS (2003)

Aging impact on emergency departments
Aging: Impact on Emergency Departments

Elderly patients:

Are more ill at presentation

Arrive by ambulance more frequently

Receive more tests than younger patients

Suffer from more chronic medical comorbidities

Are admitted to the hospital at higher rates

Experienced longer ED stays

Incurred higher medical bills

Return frequently to the ED after having been seen there




  • Elderly patients receive a high volume of resource intensive care in EDs1,2

  • EDs are seeing more patients than ever and are frequently overcrowded

    • According to NHAMCS and AHA: ED utilization increased 26% between 1993-2003 and majority of EDs were at/over capacity at least 50% of time in 2003 3

  • Concern exists that the aging of the baby boom generation will overtax EDs in the future

  • Identification of patients at risk for hospital admission or return to the ED might facilitate interventions to improve care of elderly patients and reduce overcrowding

  • McCusker J, Cardin S, Bellavance F, Belzile E. Return to the emergency department among elders: Patterns and predictors. Acad Emerg Med. 2000;7:249-259.

  • McCusker J, Verdon J. Do geriatric interventions reduce emergency department visits? A systematic review. Journals of Gerontology Series A: Biological and Medical Sciences. 2006;61:53-62.

  • Hunt KA, Weber EJ, Showstack JA, Colby DC, Callaham ML. Characteristics of frequent users of emergency departments. Ann Emerg Med. 2006;48:1-8.

Investments for the future grant unc school of medicine
Investments for the Future GrantUNC School of Medicine

Improving the Health of North Carolina’s Underserved Elders

Jan Busby-Whitehead, MD

J. Stephen Kizer, MD

Carol Giuliani, PhD, PT

Specific aims
Specific Aims

  • To establish and maintain a community-UNC-HCS partnership to improve care of vulnerable elders in Orange County and provide a platform for research and teaching

  • To improve the access to, navigation through, and transitions to and from the UNC-HCS for community-living frail elders including those in long term care facilities

  • To expand community-based preventive services for vulnerable elders in Orange County, through the development of a prevention clinic and balance program

Transitional care of the elderly in the emergency department
Transitional Care of the Elderly in the Emergency Department


  • Create a profile of elders who use the ED

  • Develop an understanding of reasons that:

    • elders seek care in the ED

    • are admitted to the hospital from the ED

    • return to the ED

  • Build and test interventions to streamline and improve the care of elderly patients as they transition into/out of ED

Predicting admission to the hospital or return to the emergency department
Predicting Admission to the Hospital or Return to the Emergency Department

  • Hypothesis: A set of variables can be identified among elderly ED patients that could predict admission or return to the ED

  • Methods: Retrospective chart review with training and validation data sets

    • Reviewed all charts (n=4,873) during 2007 at a single, academic ED serving a large elderly community

    • Chief complaint, triage score, Charlson comorbidity score, vital signs, and demographic data were collected

Methods continued
Methods (continued) Emergency Department

  • Logistic regression models were developed from the 2007 data for:

    • Patient admission

    • Patient return to the ED

  • These models were then applied in a blinded manner to the 2008 data to predict these two outcomes.

  • These predictions were then compared to the actual outcomes for these two endpoints.

  • Receiver Operating Characteristic (ROC) curves were developed and Area Under the Curve (AUC) calculated

Results Emergency Department

  • Five variables were present in final model for patient admission:

    • Age

    • Triage Score

    • Heart Rate

    • Diastolic BP

    • Chief complaint

Chief complaint
Chief Complaint Emergency Department

  • Some chief complaints increase likelihood of admission:

    General Weakness: OR 2.00 (95% CI 1.4-2.8)

    Shortness of Breath: OR 3.27 (95% CI 2.4-4.5)

    Hip Injury: OR 4.70 (95% CI 2.4-9.1)

Chief complaint1
Chief Complaint Emergency Department

  • Some chief complaints increase likelihood of admission:

    General Weakness: OR 2.00 (95% CI 1.4-2.8)

    Shortness of Breath: OR 3.27 (95% CI 2.4-4.5)

    Hip Injury: OR 4.70 (95% CI 2.4-9.1)

  • Some chief complaints decrease likelihood of admission:

    Blood in urine: OR 0.47 (95% CI 0.3-0.9)

    Painful urination: OR 0.09 (95% CI 0.01-0.8)

    Head/neck laceration: OR 0.28 (95% CI 0.1-0.7)

Roc curve for return prediction
ROC Curve for Return Prediction Emergency Department

Conclusions from initial work in emergency department
Conclusions from Initial Work in Emergency Department Emergency Department

  • Our models can provide a reasonably accurate prediction of the probability of admission of elderly patients

    • This might lead to use of an admission prediction tool which would enable an expedited admission process for elderly patients

  • We are unable to produce models that predict return to the ED for elderly patients

Communications initiative
Communications Initiative Emergency Department

  • Partnership between UNC and local NH’s

  • Goal: To develop a bidirectional communication link between NH and ED providers

  • Format:

    • Web-based referral document for NH patients sent to ED that is incorporated into medical record

    • Faxing of ED notes/instructions back to facility on discharge

Communications initiative1
Communications Initiative Emergency Department

  • Challenges:

    • Nursing Home:

      • Staff turnover

      • Staff training

      • Computer access

      • Buy-in from staff and facility

      • “Another form” to fill out

    • Emergency Department:

      • Residents from various departments

      • Demands for time

      • “Another form” to fill out

Next steps ed transitional care research
Next Steps: ED Transitional Care Research Emergency Department

  • RCT of ability of admission prediction tool to affect ED length of stay

  • Validation of Tool elsewhere

  • Refinement Communications Initiative

  • Evaluation of Triage of Elderly Patients

  • Telephone Follow-up of Discharged Elderly

Acknowledgements Emergency Department

  • UNC Futures Group Team:

    • Drs. Jan Busby-Whitehead, J. Stephen Kizer, Charles Cairns, Timothy Platts-Mills, Kevin Biese, Laura Patel, Christine Khandelwal, Debbie Travers, Ellen Roberts

    • Cory Forbach, Brenda McCall, and Sergio Rabinovich

  • UNC Center for Aging and Health:

    • Dr. Laura Hanson

    • Amy Rix

  • UNC Institute on Aging:

    • Drs. Victor Marshall and Daniel Lee

Thank you
Thank You! Emergency Department

  • Questions/Comments?

  • My contact information:

    Michael LaMantia, MD, MPH

    Center for Aging and Health

    CB 7550

    Chapel Hill, NC 27599-7550

    919-966-5945 x 263