What approach should be taken for the usage of emergency departments by skilled nursing facility patients with complex medical conditions, such as dementia, heart disease, or diabetes, and potential polypharmacy?

Emergency Department Usage by Skilled Nursing Facility Patients

Skilled nursing facility patients with complex conditions should be managed through a structured geriatric emergency department approach that emphasizes multidisciplinary coordination, medication reconciliation, and alternatives to ED transfer when clinically appropriate, with the goal of reducing iatrogenic complications and optimizing care setting selection.

Core Framework for ED Management

Multidisciplinary Staffing Requirements

The geriatric ED must implement specialized staffing protocols to address the unique needs of SNF patients 1:

• Geriatric-trained physicians providing 24-hour coverage with at least 4 hours of annual CME focused on geriatric care 1
• Specialized nursing staff with minimum 2 years geriatric experience and 8 hours of geriatric-specific continuing education 1
• Pharmacist involvement for all patients with polypharmacy (>5 medications) or high-risk medications 1
• Social workers and case managers for care coordination and discharge planning 1
• Geriatric consultation services available to identify patients suitable for outpatient management versus admission 1

Medication Management Protocol

All SNF patients presenting to the ED require immediate comprehensive medication reconciliation 1:

• Complete medication list involving patient, caregivers, and SNF staff 1
• Screen for polypharmacy (>5 medications, present in 40% of patients >65 years) 1
• Identify high-risk medications with anticholinergic properties 1
• Recognize that 50-60% drug-drug interaction risk exists with 5 medications, rising to 90% with ≥10 medications 1

For admitted patients: Mandatory multidisciplinary team referral including pharmacist to minimize drug-drug interactions and reduce polypharmacy burden during hospitalization and at discharge 1

For discharged patients: Refer to primary physician for medication review when polypharmacy or high-risk medications identified 1

Disease-Specific Considerations

Heart Disease Management

For SNF patients with heart failure presenting to the ED 1:

• Prioritize surveillance for congestion, infections, electrolyte imbalances, and mental status changes—the most common rehospitalization triggers 1
• Ensure ACE inhibitor or ARB therapy for left ventricular systolic dysfunction is continued 1
• Coordinate care transitions with comprehensive documentation of current medications and recent clinical status 1

Diabetes Management

SNF patients with diabetes require tailored glycemic targets 1:

• Avoid relying on A1C due to acute illness and conditions interfering with interpretation 1
• Target A1C <8.5% (69 mmol/mol) for most SNF residents to balance hypoglycemia risk with avoiding symptomatic hyperglycemia 1
• Monitor for dehydration, electrolyte abnormalities, and hyperglycemic hyperosmolar syndrome when glucose >300 mg/dL 1
• Simplify insulin regimens to reduce hypoglycemia risk and medication errors 1

Dementia and Polypharmacy

Critical concern: Polypharmacy increases dementia risk and is associated with cognitive decline 2:

• Significant interactions exist between polypharmacy and anticholinergics, H2-receptor antagonists, and multiple comorbidities 2
• Patients with dementia are less likely to experience polypharmacy but require careful medication review when it occurs 3
• Prolonged polypharmacy may result in dementia through increased PIM (potentially inappropriate medication) administration 2

Alternatives to ED Transfer

Telemedicine-Based Emergency Care

SNF-based emergency physician telemedicine services significantly reduce hospital admissions 4:

• Only 27% of telemedicine-managed patients required ED transfer versus 71% admission rate for traditional ED transfers 4
• Odds ratio for admission = 0.15 (95% CI: 0.13-0.17) favoring telemedicine approach 4
• Reduces risks of hospitalization including cognitive decline, nosocomial infections, and falls 4

Potentially Avoidable ED Visits

One-third of SNF patients are sent to the ED within 30 days of hospital discharge 5:

• Most common reasons for potentially avoidable visits: mechanical falls (17.3%), postoperative problems (16.8%), cardiac/pulmonary complaints (11.4%) 5
• Prevention strategies: Ensure timely access to outpatient lab/imaging services and postoperative follow-ups at the SNF level 5

Care Transition Management

Essential Documentation Requirements

Successful transitions require validated information transfer 1:

• Use standardized transfer forms covering essential patient information 1
• Include current medication list with recent changes clearly documented 1
• Specify diabetes management goals, recent glucose trends, and hypoglycemia risk 1
• Document advance care planning and goals of care, particularly for end-stage conditions 1

Admission Decision Framework

The geriatric ED must distinguish patients requiring inpatient resources from those suitable for outpatient management 1:

• Recognize that acute inpatient events often cause functional decline, increased dependency, and increased morbidity 1
• Coordinate immediate post-ED discharge care using nurse practitioners, nurses, social workers, and physicians 1
• Implement expedient outpatient arrangements to avoid unnecessary hospitalizations 1

Common Pitfalls to Avoid

• Do not skip medication reconciliation regardless of presenting complaint—adverse medication events are a major cause of ED visits and admissions 1
• Avoid using inpatient codes for observation patients—use outpatient E/M codes (99201-99215) for proper reimbursement 6
• Do not overlook occult injuries in fall-related presentations—high-risk injuries like blunt head trauma, spinal fractures, and hip fractures require heightened suspicion 1
• Prevent catheter-associated complications through daily assessment of indwelling catheter necessity 1

Performance Improvement Measures

Track and trend the following metrics 1:

• Adverse drug response admissions
• Pharmacist interventions for polypharmacy patients
• High-risk medication usage patterns (review annually)
• 30-day readmission rates
• ED revisit rates within specified timeframes