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Taken to Hospital by Ambulance: Nobody Wanted to Take Responsibility

A study of the University of Bremen led by the University of Oldenburg indicates that nursing home residents are very often unnecessarily admitted to emergency rooms and hospitals. In Germany, the number of hospitalization of nursing home residents seems to be much higher than in other countries.

Nursing home residents are often treated at emergency departments and hospitals. “Too often”, says Dr. Guido Schmiemann. The physician and healthcare researcher is involved in the HOMERN study. The abbreviation stands for “Hospitalisierung und Notaufnahmebesuche von Pflegeheimbewohnern” (Hospitalization and Emergency Admissions by Nursing Home Residents). The aim is to find out how often and why patients are admitted to hospitals. In addition, the study wants to identify healthcare deficits and propose measures for improvement.  

Adverse Effects for Persons Affected

After three years of research, concrete figures and information are now available. In Germany, about 800,000 people are currently living in nursing homes. This number continues to grow. Nursing home residents often suffer from chronic illnesses, have to take several different medications, and have physical or cognitive impairments. For this reason, they are often treated in hospital. "In Germany, this happens much more frequently than in other countries," warns Dr. Guido Schmiemann. Hospital stays can have undesirable consequences for those affected: risk of infection or increased mental confusion. Schmiemann himself is a general practitioner (GP) and some of his patients are also nursing home residents. He works as a researcher at the Department of Healthcare Research at the Institute of Public Health and Nursing Research (IPP) of the University of Bremen and is responsible for one component of the HOMERN study.

Who Made the Decision?

In order to find out who is responsible for hospital admissions and which mechanism is behind it, Schiemann and his research assistant, Alexandra Pulst, included 14 nursing homes in and around Bremen in their study. Of the 802 residents recorded, half of them suffered from dementia and a quarter was over 90 years old. The records show 627 hospital stays. "However," says Dr. Schmiemann, "these are not the number of persons, but the actual number of emergency admissions and hospital stays. It includes nursing home residents who had to be transported to a hospital several times in the course of a year.
"Statistically, the average is 0.78 events of this type per resident per year". The research teams from Bremen and Oldenburg were looking at the nursing homes for a period of twelve months and recorded the events with questionnaires. Why was the patient taken to the hospital? What was the diagnosis? Who made it? Who made the decision? How long was the stay in hospital? Was there a benefit for the patient?

Emergency Services as Safety Net

So, what are the results? Male residents and those with a higher need for care are more at risk of spontaneous hospital transfers. In addition, fears of legal consequences influence the decision to admit someone to hospital. One example the researcher gives is that "nurses often made the decision without involving the GPs". The main reasons for calling the emergency services were falls, accidents, a deterioration of the residents’ general condition, and neurological abnormalities. "It’s a structural problem," sums up Guido Schmiemann. "The nursing staff call 112. The medical emergency dispatcher who receives the call is personally responsible for their decision, so if in doubt they are more likely to alert an ambulance. The ambulance driver is not being paid for empty trips in most regions, so in cases of doubt they take the nursing home resident to the hospital. This is an automated process. We’ll have to find ways to get out of it."

Insufficient Reconciliation with GPs

The second main problem is a lack of communication. Nursing home and GPs seldom work together in a structured way. In half of the cases, the GP's office was not even informed that a patient was unwell. "It would be helpful if the GP’s practice and the nursing home were on the same page. The same file, the same medication plan," says the healthcare researcher.

Medical Staff Confirm Study Results

The HOMERN Group recently published its research results at a symposium in Bremen. The 70 participants were all experts: GPs, nursing staff and paramedics confirmed the reality of the research. It was not by chance that the symposium was entitled: "Hospital stays of nursing home residents: Just because nobody wanted to take responsibility?” Dr. Guido Schmiemann summarizes: "Empowering nursing staff, improving structural conditions, and improving communication and cooperation between the actors involved could reduce the number of avoidable hospital transfers from nursing homes".

About the HOMERN Project:

Falk Hoffmann, professor at the Department of Health Services Research at the School of Medicine and Health Sciences at the University of Oldenburg, is leading the project. The Institute of Public Health and Nursing Research at the University of Bremen has taken over a subproject. Data from nursing home residents who are insured with the AOK Bremen/Bremerhaven were evaluated and interviews were conducted with GPs, nurses and paramedics in order to provide a comprehensive view of the problem. In addition, the researchers systematically analyzed and recorded hospital transports from 14 nursing homes in the Northwest Metropolitan Region over a period of 12 months. The Federal Joint Committee, the highest decision-making body of the joint self-government of physicians, dentists, psychotherapists, hospitals, and health insurance funds in Germany, is funding the research project with 500,000 euros. The funds come from the Innovation Fund for Health Services Research.

Further information:

innovationsfonds.g-ba.de/projekte/versorgungsforschung/homern-hospitalisierung-und-notaufnahmebesuche-von-pflegeheimbewohnern-haeufigkeit-ursachen-und-entwicklung-einer-intervention-zur-verbesserung-der-versorgung.54 (in German only)

https://www.public-health.uni-bremen.de/staff/guido-schmiemann/projects/en/?proj=729&page=1

Contact:

Dr. Guido Schmiemann
Adjunct lecturer
Institute of Public Health and Nursing Research
Department of Healthcare Research
University of Bremen
Phone: +49 421 218 68815
Email: schmiemann@uni-bremen.de

 

Ambulance on the way
When compared internationally, nursing home residents in Germany are taken to hospital too often.