What are the case scenarios that require hospital admission for residents in long-term care facilities?

Hospital Admission Scenarios for Long-Term Care Residents

As an RN in long-term care, you should transfer residents to the hospital when they are clinically unstable requiring aggressive interventions, when critical diagnostic tests or therapies are unavailable in your facility, when comfort measures cannot be assured, or when specific infection-control measures are not available. 1

Clinical Instability Requiring Urgent Transfer

Transfer immediately when residents demonstrate clinical instability and their advance directives indicate aggressive medical or surgical interventions should be initiated. 2, 1 This includes:

• Residents requiring major surgical interventions 2
• Need for specialized procedures like lung, liver, or kidney biopsies 2
• Patients requiring observation following arteriography 2
• Severe illness with hemodynamic instability that cannot be managed with available LTCF resources 1

The key distinction is that clinical instability alone is insufficient—the decision must align with the resident's goals of care and advance directives. 1

Diagnostic Limitations

Transfer when critical diagnostic tests are not available in the LTCF that are essential for diagnosis and management. 2, 1 However, recognize that many conditions can be diagnosed clinically without transfer. For example:

• Cellulitis is diagnosed clinically without requiring cultures (fine-needle aspirates yield positive results in <30% of cases) 2
• Most bacterial infections in LTCF residents respond to broad-spectrum oral antibiotics and can be effectively treated on-site 2

Therapeutic Capacity Limitations

Transfer when required therapy or the intensity of monitoring exceeds LTCF capacity. 2, 1 However, this threshold has evolved significantly:

• Historically, inability to administer intravenous therapy was the most common reason for transfer, particularly for infectious processes 3
• Modern LTCFs increasingly have capacity for parenteral therapies 2
• Some antibiotics (e.g., ceftriaxone) can be given intramuscularly with similar efficacy to IV administration 2
• Oral quinolones achieve systemic concentrations comparable to parenteral routes 2

Transfer is warranted when:

• The frequency of medication dosing and intensity of monitoring exceed staff capacity 2
• Specialized interventions like mechanical ventilation weaning or complex wound care requiring LTACH-level resources are needed 4

Infection-Specific Scenarios

Respiratory Infections

• Most respiratory tract infections present with classical manifestations (cough 75%, fever 62%, rales 55%) and can be managed in the LTCF 2
• Transfer if respiratory distress requires mechanical ventilation or intensive monitoring 1

Urinary Tract Infections

• Typical UTI symptoms (foul-smelling urine, fever) are not sensitive indicators in LTCF residents 2
• Most UTIs respond to oral antibiotics without transfer 2

Skin and Soft Tissue Infections

• Cellulitis and most infected pressure ulcers can be managed on-site 2
• Transfer if surgical debridement is required or if systemic sepsis develops 2

Severe Diarrheal Illness

• C. difficile-associated diarrhea with severe illness (fever, abdominal cramps, bloody diarrhea) may require transfer if complications develop 2
• Outbreaks of invasive enteropathogens (Salmonella, E. coli O157:H7) affecting multiple residents warrant enhanced surveillance but not automatic transfer 2

Infection Control Requirements

Transfer when specific infection-control measures are not available in the LTCF. 2, 1 The primary example is:

• Active tuberculosis requiring negative-pressure ventilation for isolation 2

During COVID-19 or similar pandemics, the calculus changes—residents with confirmed infection should ideally be managed on-site in designated quarantine compartments rather than transferred, to prevent facility-wide spread. 2

Comfort Care Limitations

Transfer when comfort measures cannot be assured in the LTCF. 2, 1 This includes:

• Symptoms associated with widely fluctuating fevers and chills requiring nursing intensity beyond LTCF capacity 2
• Pain management requiring specialized palliative care interventions 2

Notably, this is rare—most comfort care can and should be provided in the LTCF setting. 2

Critical Pitfalls to Avoid

Do not transfer based solely on fever without other parameters. 2 Fever in severely disabled LTCF residents may be caused by noninfectious conditions (drugs, atelectasis, bronchial mucus plugging) readily managed on-site. 2

Avoid unnecessary transfers that increase morbidity. 2 Hospitalization is associated with:

• Increased risk of deconditioning 2
• New pressure ulcers (30% of transferred patients develop them) 3
• Colonization with highly virulent or drug-resistant bacteria 2
• Translocation trauma 2

Studies show LTCF residents with severe functional dependence have very high mortality regardless of care setting, questioning the benefit of hospitalization on clinical outcomes. 2

Recognize that 2-77% of LTCF-to-hospital transfers may be inappropriate, depending on the assessment tool used. 5 Wide variations exist among facilities in transfer rates based primarily on nonclinical criteria including physician practice style, diagnostic capacity, staffing adequacy, and liability concerns. 2

Pre-Transfer Requirements

Before any transfer, establish physician-to-physician communication with the receiving ED, providing complete description of the patient's condition and confirming appropriate resources are available. 1 Ensure advance directives are reviewed and the decision aligns with resident/family goals. 2, 1