THE PHYSICIAN DECISION-MAKING PROCESS IN TRANSFERRING NURSING-HOME PATIENTS TO THE HOSPITAL

Background: Each year more than 25% of nursing home patients are trans ferred to the emergency department or hospital for evaluation and trea tment of infection. These transfers may have an adverse impact on the quality and cost of patient care. This study examined physician assess ment and management of acute infections in the nursing home. Methods: A cross-sectional study was conducted of all acute urinary tract infec tions and lower respiratory tract infections occurring from February t hrough June 1991 in eight randomly selected urban nursing homes. The n umbers of transfers to the emergency department or hospital were recor ded along with identification of the clinical, psychosocial, and insti tutional factors that influenced the physician's decision to transfer. Results: Three hundred fifty-nine patients had 258 urinary tract infe ctions 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 st aff notification of an acute event and physician response by telephone was 5.12 hours. Independent mobility (P less than or equal to.05), a transfer to the hospital during the previous 6 months (P less than or equal to.01), and fewer nursing home laboratory tests and treatments ( P less than or equal to.01) were all associated with hospital transfer . Conclusions: In this sample of acutely ill nursing home patients, ph ysicians collected limited clinical data before the decision to transf er. Although some transfers maybe appropriate, a reduction in the tran sfer rate may reduce health care costs and limit the risk of iatrogene sis, thus improving the outcome of acute illnesses occurring in the nu rsing home.