A hospital may provide emergency medical care, diagnostic testing, intensive treatment, or surgery, which may or may not require admission. Older patients use hospitals more than younger patients; they have more admissions to the hospital from the emergency department and more and longer hospital stays, and they use more resources while in the hospital.
Emergency Department Care
In 2021, the ED visit rate in adults aged 75 and over was 66 visits per 100 people, compared to patients in age groups between ages 1 year and 74, which ranged from 36 to 45 visits per 100 people (1). Older patients tend to be sicker. Some hospitals now have special geriatric EDs staffed with geriatric-trained nurses and physicians, which may be contributing to the reduction in hospital admissions (2, 3). More than half are prescribed new medications. Older adults may use the ED as a substitute for primary care or may come because they are not receiving adequate attention from their primary care physician. ED visits are often caused by a breakdown in the social structure of a frail older patient—eg, absence or illness of their caregiver may result in people calling an ambulance rather than going to their physician's office. However, in many cases, the reasons for visiting the ED are true emergencies.
A visit to an ED may create more stress for older adults because there are typically no special accommodations for them (eg, quiet rooms, lower beds, extra pillows, indirect lighting). However, some hospital systems are creating special geriatric EDs, which are spaces in the regular ED dedicated to the care of older adults. These geriatric EDs have geriatric-trained physician and nursing staff as well as specialized equipment, such as gurneys with pressure-reducing mattresses that reduce risk of pressure injuries and improved lighting and acoustics to promote vision and hearing.
Evaluation of an older adult usually takes longer and requires more diagnostic tests because many older patients do not present with as clear-cut or typical symptoms and signs of a disorder. For example, in patients older than 75, dyspnea, fatigue, and other heart failure symptoms, were more frequently the first symptoms of myocardial infarction than typical chest pain (4).
Factors that are not apparent (eg, polypharmacy, adverse drug effects) may affect an older patient’s presentation. For example, a fall may result from abuse, an adverse drug effect (eg, oversedation), hazards in the home, physical problems (eg, poor vision), depression, or a chronic alcohol use disorder.
Older patients who visit the ED may be cognitively impaired but do not have a formal diagnosis of dementia recorded in their medical record; in some patients, cognitive impairment more consistent with delirium may be unrecognized or unnoticed in the ED (5). When indicated (eg, if an older patient is having difficulty with orientation to person, place, or time), a standardized cognitive assessment should be done in the ED. Cognitive impairment affects the reliability of the patient history as well as the diagnosis, increases the risk of delirium during a hospital stay, and must be considered when planning the patient’s disposition. Knowing whether onset of cognitive impairment is recent helps determine whether the impairment should be fully assessed in the ED. The Assess, Diagnose, Evaluate, Prevent, and Treat (ADEPT) tool, an open access, web-based tool available on the American College of Emergency Physicians (ACEP) emPOC mobile device app may help providers ensure an organized, comprehensive assessment (6). Cognitive impairment of recent onset may indicate sepsis, occult subdural hemorrhage, or an adverse drug effect.
Suicide risk, fall risk, incontinence, nutritional status, and immunization status should be assessed in the ED so that follow-up care can be arranged.
Communication among health care professionals
Good communication among ED physicians and patients, caregivers, family members, primary care physicians, and staff members of long-term care facilities greatly enhances the outcome of older patients with complicated problems. Advance directives should be promptly and clearly communicated to emergency medicine professionals. Baseline information from the patient’s personal physician facilitates assessment and management planning in the ED. Reports to the patient’s primary care physician should describe even simple injuries (eg, ankle sprain, Colles wrist fracture) because such injuries can dramatically affect functional ability and independence.
Disposition
Discharge planning may be complex because acute illness or injury may impair functional ability more in older patients (eg, a simple ankle sprain that would be only an inconvenience for a 20-year-old person may be incapacitating for an older person who does not have good support at home). Discharge planning may be improved when nurses, social workers, and primary care physicians are involved. It should include the following:
Functional status assessment
Strategies to manage problems (eg, depression, alcohol use disorder, impaired functional status) identified during the ED assessment
Determination of whether patients can obtain and take medications as directed and can obtain the necessary follow-up care
Assessment of caregiver capabilities (eg, whether respite services are needed)
Many older patients are hospitalized after they are evaluated in the ED.
Occasionally, older patients are brought to the ED by caregivers who refuse to take them home or who leave, abandoning them in the hospital.
Emergency department care references
1. Centers for Disease Control and Prevention: Emergency Department Visit Rates by Selected Characteristics: United States, 2021. NCHS Data Brief No. 478, August 2023. Accessed September 2024.
2. Hwang U, Dresden SM, Rosenberg MS, et al: Geriatric emergency department innovations: Transitional care nurses and hospital use. J Am Geriatr Soc 66(3):459-466, 2018. doi: 10.1111/jgs.15235
3. Schumacher JG, Hirshon JM, Magidson P, Chrisman M, Hogan T: Tracking the Rise of Geriatric Emergency Departments in the United States. J Appl Gerontol. 2020;39(8):871-879. doi:10.1177/0733464818813030
4. Goch A, Misiewicz P, Rysz J, Banach M: The clinical manifestation of myocardial infarction in elderly patients. Clin Cardiol. 2009 Jun;32(6):E46-51. doi: 10.1002/clc.20354. PMID: 19382276; PMCID: PMC6653078
5. Hustey FM, Meldon SW: The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med. 2002 Mar;39(3):248-53. doi: 10.1067/mem.2002.122057. PMID: 11867976
6. Shenvi C, Kennedy M, Austin CA, Wilson MP, Gerardi M, Schneider S: Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool. Ann Emerg Med. 2020 Feb;75(2):136-145. doi: 10.1016/j.annemergmed.2019.07.023. Epub 2019 Sep 26. PMID: 31563402; PMCID: PMC7945005.
Hospitalization
Almost half of adults who occupy hospital beds are ≥ 65 years of age; this proportion is expected to increase as the population ages. Inpatient hospitals and skilled nursing facilities, home health care related to a hospital stay, and hospice care are estimated to cost Medicare about $212.6 billion in 2025 (1).
Hospitalization can magnify age-related physiologic changes and increase morbidity.
Only seriously ill older patients who cannot be appropriately cared for elsewhere should be hospitalized. Hospitalization itself poses risks to older patients because it involves confinement, immobility, diagnostic testing, and exposure to infectious organisms. When patients are transferred to or from a hospital, medications are likely to be added or changed, leading to a higher risk of adverse effects and of miscommunication of the medication change. Treatment in hospitals can be dehumanizing and impersonal. Acute hospital care should last only long enough to allow successful transition to home care, a skilled nursing facility, or an outpatient rehabilitation program.
The outcome of hospitalization appears to be poorer with increasing age, although physiologic age is a more important predictor of outcome than is chronologic age. Outcome is better for patients hospitalized because of elective procedures (eg, joint replacement) than for those hospitalized because of serious disorders (eg, multisystem organ failure).
A significant number of patients who are ≥ 75 years of age and functionally independent at admission are not functionally independent when they are discharged to skilled nursing facilities. The trend toward abbreviated acute hospital stays followed by subacute care and rehabilitation in a skilled nursing facility may partially explain why these percentages are high. However, even when a disorder is treatable or appears uncomplicated, patients may not return to prehospital functional status. Studies have shown that patients who receive moderate intensity exercise while in the hospital, particularly exercises that focus on walking, resistance, and balance training, did not experience any functional decline during their hospitalization (2). This highlights the importance of ensuring that older adults start physical therapy as soon as possible while in the hospital.
Improving outcomes
The following strategies can help reduce functional decline and improve care of older patients:
Geriatric interdisciplinary team: To identify and meet the complex needs of older patients and to watch for and prevent problems that are common among them and that may develop or worsen during hospitalization
Primary care nurse (one nurse with around-the-clock responsibility for a particular patient): To administer the team’s care plan, to monitor response to nursing and medical care, and to teach and counsel patients, staff members, and family members
Changes in the hospital environment, often made by nurses: For example, to move disruptive patients into the hall near the nursing station or to change roommates for a patient
Rooming-in programs for a family member: To provide better one-on-one care, to relieve staff members of some caregiving tasks, to allay patient anxiety (particularly if patients have delirium or dementia), and to enable a family member to participate actively in the patient’s recovery
High-quality communication among health care professionals: To prevent errors in and duplication of diagnostic procedures and treatments (particularly medications); to implement better systems of communication such as walking rounds and warm handoffs (A warm handoff is a transfer of care that is conducted in person, between 2 members of the health care team, in front of the patient [and family, if present].)
Documentation of medication regimen: To state the indication for each new medication, to maintain a daily list of medications prescribed and received, and thus to avoid using unnecessary medications and help prevent drug interactions
Advance directives: To document the patient’s choice of health care proxy and health care decisions and reduce unwanted and unnecessary care in the hospital, particularly for patients with advanced illnesses. Often, discussions about advanced directives are omitted during visits, missing the opportunity to capture the patient's preferences for care (3)
Early mobilization and participation in functional activity: To prevent physical deterioration due to decreased activity during illness and hospitalization; close collaboration with physical and occupational therapists to create integrated care plans that include targeting functional status in older adults and incorporating mobility and strength training to the extent tolerated by each patient (4)
Discharge planning: To communicate between the hospital, patients and their family members, and the next level of care: providers ensure that appropriate care is continued into the next setting, which may help prevent readmissions (5)
Acute care of the elderly (ACE) units: To provide effective care for hospitalized older adults by using evidence-based practices, including most of the strategies listed above (6)
Advance directives, if already prepared, should be brought to the hospital as soon as possible. Clinicians should reaffirm these choices during acute hospitalization. If directives were not documented, clinicians should make every effort to determine the patient’s wishes.
Problems common among older adults require specific consideration during hospitalization, particularly during postoperative care; many of them can be remembered using the acronym ELDERSS. In the hospital, older patients frequently experience nighttime confusion (sundowning), fracture a bone with no identifiable trauma, fall, or become unable to walk. Hospitalization may precipitate or worsen undernutrition, pressure injuries, urinary incontinence, fecal impaction, and urinary retention. Such problems can prolong convalescence.
ELDERSS: Some Important Issues for Hospitalized Older Adults
Acronym | Issue |
|---|---|
E | Eating (nutritional status) |
L | Lucidity (mental status) |
D | Directives for limiting care (eg, do not resuscitate) |
E | Elimination (incontinence) |
R | Rehabilitation (needed because of bed rest effects) |
S | Skin care (to prevent and treat pressure injuries) |
S | Social services (discharge planning) |
Additionally, hospital-at-home is a home health care alternative to hospital care that enables some patients who need lower level acute care to receive that care in their homes. These patients still require some acute level services, but are generally stable. Examples may include patients who need ongoing intravenous therapy or oncology patients requiring ongoing chemotherapy, This care delivery model has been shown to improve clinical outcomes as well as improved patient satisfaction.
Hospitalization references
1. US Department of Health and Human Services: Fiscal Year 2025 Medicare Budget in Brief
2. Hamed A, Bohm S, Mersmann F, Arampatzis A: Follow-up efficacy of physical exercise interventions on fall incidence and fall risk in healthy older adults: A systematic review and meta-analysis. Sports Medicine Open 4(1):1–19, 2018. doi: 10.1186/s40798-018-0170-z
3. Chan CWH, Wong MMH, Choi KC, et al: What Patients, Families, Health Professionals and Hospital Volunteers Told Us about Advance Directives. Asia Pac J Oncol Nurs. 2019;6(1):72-77. doi:10.4103/apjon.apjon_38_18
4. Resnick B, Boltz M: Optimizing Function and Physical Activity in Hospitalized Older Adults to Prevent Functional Decline and Falls. Clin Geriatr Med 2019;35(2):237-251. doi:10.1016/j.cger.2019.01.003
5. Erlang AS, Schjødt K, Linde JKS, Jensen AL: An observational study of older patients' experiences of involvement in discharge planning. Geriatr Nurs 2021;42(4):855-862. doi:10.1016/j.gerinurse.2021.04.002
6. Rogers SE, Flood KL, Kuang QY, et al: The current landscape of Acute Care for Elders units in the United States. J Am Geriatr Soc. 2022;70(10):3012-3020. doi:10.1111/jgs.17892
Adverse Drug Effects
Hospitalization rates due to adverse drug effects are 4 times higher for older patients compared with younger patients and are associated with increased morbidity and mortality (1). Reasons for these effects include
Polypharmacy (patients prescribed multiple different medications, for example, often defined as 6 or more drugs; associated with poor outcomes such as frailty, prolonged length of hospital stay, and mortality (2)—see also Overview of Drug Therapy in Older Adults)
Age-related changes in pharmacokinetics and pharmacodynamics
Changes in medications (intentional and unintentional) during hospitalization and at discharge (see Drug-Related Problems in Older Adults)
Comorbid conditions requiring multiple different medications
Prevention of adverse drug effects
Maintaining a daily list of medications prescribed and received can help prevent adverse drug effects and drug interactions.
Because distribution, metabolism, and elimination of medications vary widely among older patients, the following should be done:
Medication doses should be carefully titrated.
Creatinine clearance for renally excreted medications should be calculated when doses are adjusted.
Serum medication levels should be measured.
Patient responses should be observed.
Certain medications or medication categories should be avoided in older adults (see table Potentially Inappropriate Drugs in Older Adults). Use of hypnotics should be minimized because tachyphylaxis may occur and risk of falls and delirium is increased; measures to improve sleep hygiene should be tried before medications. Antihistamines have anticholinergic effects and should not be used for sedation. Benzodiazepine use has increased in recent years; however, benzodiazepines are associated with serious adverse effects and increased risk of addiction and should therefore be used with extreme caution. (3) Prescribers should regularly review medications to determine whether doses might be decreased or if a medication could be stopped safely to reduce the number of medications an older adult takes and to reduce the risk of drug interactions.
Adverse drug effects references
1. Alhawassi TM, Krass I, Bajorek BV, Pont LG: A systematic review of the prevalence and risk factors for adverse drug reactions in the elderly in the acute care setting. Clin Interv Aging. 2014 Dec 1;9:2079-86. doi: 10.2147/CIA.S71178. PMID: 25489239; PMCID: PMC4257024.
2. Pazan F, Wehling M: Polypharmacy in older adults: a narrative review of definitions, epidemiology and consequences. Eur Geriatr Med. 2021;12(3):443-452. doi:10.1007/s41999-021-00479-3
3. Gupta A, Bhattacharya G, Balaram K, Tampi D, Tampi RR. Benzodiazepine use among older adults. Neurodegener Dis Manag. 2021 Feb;11(1):5-8. doi: 10.2217/nmt-2020-0056. Epub 2020 Nov 10. PMID: 33172334
Bed Rest Effects
Prolonged bed rest, which can occur during hospitalization, causes deconditioning and is seldom warranted. The resulting inactivity has the following effects:
With complete inactivity, muscle strength decreases significantly over the first several days (1), increasing risk of falls.
Muscles shorten and periarticular and cartilaginous joint structure changes (most rapidly in the legs), limiting motion and contributing to development of contractures.
Aerobic capacity decreases markedly, substantially reducing maximum oxygen uptake.
Bone loss (demineralization) is accelerated.
Risk of deep venous thrombosis is increased.
After even a few days of bed rest, older patients who have reduced physiologic reserves but can still function independently may lose that ability. Even if the loss is reversible, rehabilitation requires extensive, expensive, and relatively lengthy intervention.
In older patients, bed rest can cause vertebral bone loss much faster than in younger patients. The loss incurred from 10 days of bed rest takes 4 months to restore. Nurses should ensure that the hospital aligns care with the American Academy of Nursing's recommendation that walking during the hospital stay is critical for maintaining functional ability in older adults (2019).
Prevention of bed rest effects
Unless prohibited for a specific reason, activity (particularly walking) should be encouraged. If assistance with walking is needed, therapists may provide it at scheduled times. However, physicians, nurses, and family members should also assist patients with walking throughout the day. Hospital orders should emphasize the need for and promote activity.
If immobilization is necessary or results from prolonged illness, procedures to prevent deep venous thrombosis are recommended unless contraindicated.
Rehabilitation is often needed. Realistic goals for rehabilitation at home can be based on the patient’s prehospitalization activity level and current needs; orders for home physical and/or occupational therapy should be considered. Computerized cognitive training (using virtual maze navigation) may mitigate the effects of deconditioning by augmenting cognitive function (2).
Bed rest effects references
1. Shinde S, Bhore PR: Effect of reconditioning exercises program on hospital-acquired deconditioning in elderly hospitalized patients. Adesh Univ J Med Sci Res, 2022;4:20-4.
2. Marusic U, Kavcic V, Pisot R, Goswami N: The Role of Enhanced Cognition to Counteract Detrimental Effects of Prolonged Bed Rest: Current Evidence and Perspectives. Front Physiol. 2019;9:1864. Published 2019 Jan 23. doi:10.3389/fphys.2018.01864
Falls
Age-related changes (eg, baroreceptor insensitivity, decreased body water and plasma volume) result in a tendency to develop orthostatic hypotension. These changes plus effects of bed rest and use of sedatives and certain antihypertensives increase risk of falls (and syncope).
Among hospitalized older patients, the majority of falls occur in the bathroom; often, patients hit hard objects such as sinks or the toilet. Because many of these falls occur at night, reducing the incidence of nocturia due to diuretics and increased fluid intake late in the day may be helpful. Some patients fall while getting out of chairs and hospital beds. Patients are in a strange bed and in a strange environment, and they may easily become confused. Although bed rails may help remind older patients to call for assistance before attempting to get up, bed rails may also tempt patients to climb over or around them and thus may contribute to patient falls. Bed rails are generally discouraged because of the increased fall risk.
Prevention of falls
Usually, beds should be placed at their lowest level with padding on both sides for patients at risk of falls. Bed rails should be removed or kept down unless patients are at risk of rolling out of the bed. The best alternatives to the use of physical or chemical restraints are to identify, carefully analyze, and modify or correct risk factors for falling (including agitation and use of sedative medications) and to closely observe patients at risk. As mentioned, returning beds to their lowest level if they were raised to provide care, placing padding on the floor next to the bed, making sure any fluid spills are cleaned up promptly, and keeping pathways in rooms and hallways clear may also help reduce the risk of falls.
Incontinence
Urinary or fecal incontinence is present in up to 40% of hospitalized patients ≥ 65 years of age, often within a day of admission. Reasons include the following:
An unfamiliar environment
A cluttered path to the toilet
Disorders that impair ambulation
A bed that is too high
Bed rails
Hampering equipment such as IV lines, nasal oxygen lines, cardiac monitors, and catheters
Psychoactive medications that may reduce the perception of the need to void, inhibit bladder or bowel function, or impair ambulation
Medications that may result in urinary incontinence (eg, medications with anticholinergic effects and opioids, causing overflow urinary incontinence; diuretics, causing urge incontinence)
Bedpans may be uncomfortable, especially for patients in the postsurgical period or for patients with chronic arthritis. Patients with dementia or a neurologic disorder may be unable to use the call bell to request toileting assistance.
Fecal impaction, gastrointestinal tract infection (eg, Clostridioides difficile–induced colitis), adverse effects of medications, and liquid nutritional supplements may cause uncontrollable diarrhea.
With appropriate diagnosis and treatment, continence can be reestablished in many cases.
Mental Status Changes
Older patients may appear confused because they have dementia, delirium, depression, or a combination. However, health care professionals must always remember that confusion may have other causes, and its presence requires thorough evaluation.
Confusion may be due to a specific disorder (see table Causes of Delirium). However, it may develop or be exacerbated because the hospital setting exacerbates the effects of acute illness and age-related changes in cognition. For example, older patients who do not have their eyeglasses and hearing aids may become disoriented in a quiet, dimly lit hospital room. Patients may also become confused by hospital procedures, schedules (eg, frequent awakenings in strange settings and rooms), the effects of psychoactive medications, exposure to anesthesia, and the stress of surgery or illness. In an intensive care unit, the constant light and noise can result in agitation, paranoid ideation, and mental and physical exhaustion.
Prevention of mental status changes
Family members can be asked to bring missing eyeglasses and hearing aids. Placing a wall clock, a calendar, and family photographs in the room can help keep patients oriented. The room should be lit well enough to enable patients to recognize what and who is in their room and where they are. When appropriate, staff and family members should periodically remind patients of the time and place. Procedures should be explained before and as they are done. Staff should identify themselves and their role when entering the room.
Use of physical restraints is discouraged. For agitated patients, restraints invariably increase the level of agitation. Identifying and modifying risk factors for agitation and closely observing patients can help prevent or minimize it. Invasive and noninvasive devices attached to patients (eg, pulse oximeters, urinary catheters, IV lines) can also cause agitation; the risk:benefit ratio of these interventions should be considered.
Pressure Injuries
Pressure injuries (also called pressure ulcers) often develop in older hospitalized patients because of age-related changes in the skin. Direct pressure may cause skin necrosis in as few as 2 hours if the pressure is greater than the capillary perfusion pressure of 32 mm Hg. During a typical emergency department visit, pressure injuries can start developing while older patients are lying on a hard stretcher waiting to be examined. After a short period of immobilization (within a few hours), pressures only above those in arterial and venous capillaries are sufficient to cause tissue damage in areas such as the sacrum and heels. Shearing forces result when patients sitting in wheelchairs or propped up in beds slide downward. Incontinence, poor nutrition, and chronic disorders may contribute to pressure injury development.
Prevention of pressure injuries
A protocol to prevent and treat pressure injuries should be started immediately at admission with a risk assessment using a validated tool such as the Braden Scale or the Norton Scale (see table The Norton Scale for Predicting Pressure Ulcer Risk) (1). It should be followed daily by the patient’s care providers and reviewed regularly by an interdisciplinary team. Pressure injuries may be the only reason patients are discharged to a nursing home rather than to the community.
Pressure injuries reference
1. Kiyat I, Ozbas A: Comparison of the Predictive Validity of Norton and Braden Scales in Determining the Risk of Pressure Injury in Elderly Patients. Clin Nurse Spec. 2024;38(3):141-146. doi:10.1097/NUR.0000000000000815
Undernutrition
In the hospital, older patients can become undernourished quickly, or they may be undernourished when admitted. Prolonged hospitalization exacerbates preexisting problems and often results in significant nutritional loss. Undernutrition is particularly serious for hospitalized patients because it makes them less able to fight off infection, maintain skin integrity, and participate in rehabilitation; surgical wounds may not heal as well.
Hospitalization contributes to undernutrition in several ways:
Rigidly scheduled meals, use of medications that may impair hunger and taste, and changes in environment can affect appetite and nutritional intake.
Hospital food and therapeutic diets (eg, low-salt diets) are unfamiliar and often unappetizing.
Eating in a hospital bed with a tray is difficult, particularly when bed rails and restraints limit movement, or when the patient has dysphagia.
Older patients may need help with eating; help may be slow to come, resulting in cold, even less appetizing food.
Older patients may not drink enough water because their thirst perception is decreased, water is difficult to reach, or both; severe dehydration may develop (sometimes leading to stupor and confusion).
Dentures may be left at home or misplaced, making chewing difficult; labeling dentures helps prevent them from being lost or discarded with the food tray.
Prevention of undernutrition
Patients with preexisting nutritional abnormalities should be identified when admitted and be treated appropriately. Physicians and staff members should anticipate nutritional deficiencies in older patients.
The following measures can help:
Rescinding restrictive dietary orders as soon as possible
Monitoring nutritional intake daily
Conferring with patients and family members about food preferences and attempting to tailor a reasonable diet specific to each patient
Encouraging family members to join the patient at mealtimes because people eat more when they eat with others
Making sure patients are fed adequately at all times (eg, ensuring that meals are saved if patients are out of their unit for tests or treatment during mealtime)
Considering use of temporary parenteral or enteral nutrition for patients too sick to swallow
Giving explicit oral fluid orders (eg, providing a fresh and readily accessible bedside water pitcher or other fluids unless fluids are restricted; advising family members, friends, and staff members to regularly offer patients a drink)
Transitions of Care
A care transition is whenever a patient moves from one setting of care to another. In the last decade, significant research has shown that patient care during transitions is fragmented, frequently rushed, and lacks communication between health care professionals, all of which result in poor patient outcomes. Transitions of care are when the greatest numbers of errors occur, increasing the risk of morbidity and mortality, particularly in older adults who cannot always advocate for themselves. Clinicians who provide care to older adults must pay special attention to the many transition points that occur when an older adult comes into the health care system. Best practices include ensuring that (1)
All relevant health records are transferred
Medications (particularly changes) are clearly documented and communicated
The patient and family are fully informed of what to expect in the new health care facility
A warm handoff occurs—at least a telephone call between the discharging and receiving organizations, and ideally, a telephone call between the discharging and receiving health care professional
Transitions of care reference
1. Monkong S, Krairit O, Ngamkala T, Chonburi JSN, Pussawiro W, Ratchasan P: Transitional care for older people from hospital to home: a best practice implementation project. JBI Evid Synth 2020;18(2):357-367. doi:10.11124/JBISRIR-D-19-00180
More Information
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
National Transitions of Care Coalition (NTOCC): Tools for health care professionals, government leaders, patients, and caregivers to raise awareness about transitions of care, increase the quality of care, reduce medication errors, and enhance clinical outcomes
Discharge Planning and Transfers
Early, effective discharge planning has many benefits (1) including
Shortening the hospital stay
Reducing the likelihood of readmission
Identifying less expensive care alternatives
Facilitating placement of equipment (eg, hospital bed, oxygen) in the patient’s home
Helping increase patient satisfaction
Possibly preventing placement in a nursing home
As soon as a patient is admitted, all members of the interdisciplinary team begin discharge planning. A social worker or discharge planning coordinator evaluates the patient’s needs within 24 hours of admission. Nurses help physicians determine when discharge is safe and which setting is most appropriate.
Discharge to home
Patients being discharged to their home need detailed instructions about follow-up care, and family members or other caregivers may need training to provide care. If patients and family members are not taught how to give medications, implement treatment, and monitor recovery, adverse outcomes and readmission are more likely. Writing down follow-up appointments and medication schedules may help patients and family members. At discharge, a copy of a brief discharge summary plan should be given to patients or family members in case they have questions about care before the primary care physician receives the official summary plan.
Discharge to another health care facility
When a patient is discharged to a nursing home or to another facility, a written summary should be sent with the patient, and a full copy should be sent electronically to the receiving institution; also, a phone call should be made to the receiving facility. Ideally, the discharging clinician should call the physician, nurse practitioner, or physician assistant who will be caring for the patient in the new facility. The summary must include complete, accurate information about the following:
The patient’s mental and functional status
Times the patient last received medication
List of medications being currently taken and the dosage, route, and times to be taken
Known medication allergies or adverse reactions
Advance directives, including resuscitation status
Family contacts and support status
Follow-up appointments and tests
A summary of care provided in the hospital including copies of relevant tests and procedures
Names and phone numbers of a nurse and physician who can provide additional information
A written copy of the patient’s medical and social history should accompany the patient during transfer and may also be sent electronically to the receiving facility to ensure that there are no information gaps.
Effective communication between staff members of institutions helps ensure continuity of care. For example, the patient’s nurse can call the receiving institution to review the information shortly before the patient is transferred and can call the nurse who will care for the patient after discharge.
Discharge planning and transfers reference
1. Lilleheie I, Debesay J, Bye A, Bergland A: Experiences of elderly patients regarding participation in their hospital discharge: a qualitative metasummary. BMJ Open 2019;9(11):e025789. Published 2019 Nov 3. doi:10.1136/bmjopen-2018-025789
