The physician decision-making process in transferring nursing home patients to the hospital

Each year more than 25% of nursing home patients are transferred to the emergency department or hospital for evaluation and treatment of infection. These transfers may have an adverse impact on the quality and cost of patient care. This study examined physician assessment and management of acute infections in the nursing home.

A cross-sectional study was conducted of all acute urinary tract infections and lower respiratory tract infections occurring from February through June 1991 in eight randomly selected urban nursing homes. The numbers of transfers to the emergency department of hospital were recorded along with identification of the clinical, psychosocial, and institutional factors that influenced the physician's decision to transfer.

Three hundred fifty-nine patients had 258 urinary tract infections and 219 respiratory tract infections. Eighty-one (17%) of these events resulted in transfer to a hospital for evaluation (16/81) and/or admission (65/81). Less than one third (30.4%) of the events caused the patient to be examined in the nursing home by a physician before the decision to transfer to the hospital. The mean time between the staff notification of an acute event and physician response by telephone was 5.12 hours. Independent mobility (P < or = .05), a transfer to the hospital during the previous 6 months (P < or = .01), and fewer nursing home laboratory tests and treatments (P < or = .01) were all associated with hospital transfer.

In this sample of acutely ill nursing home patients, physicians collected limited clinical data before the decision to transfer. Although some transfers may be appropriate, a reduction in the transfer rate may reduce health care costs and limit the risk of iatrogenesis, thus improving the outcome of acute illnesses occurring in the nursing home.