Improving the emergency medical treatment of older nursing-home residents.

Improving the care of older residents in nursing homes during a medical crisis is an important challenge. Although the respective priorities, accountabilities and responsibilities of homes, hospitals and primary health care services differ, developing a defined and co-ordinated approach is highly desirable [1, 2]. For example, a recent Audit Commission report stated that hospitals were dependent on nursing homes to provide places for frail older people who no longer required acute care [3] and were ‘blocking’ beds [4, 5]. Similarly, older people in nursing homes are vulnerable if, for example, support from general practice is inadequate [6, 7]. Some emergency admissions from nursing homes could be prevented if some ill residents were treated in the homes themselves. This would require better preventative, rehabilitative, diagnostic and interventional facilities [8–24] in nursing homes, as well as support from primary and community care services [25–28] (perhaps equivalent to that offered by hospital-at-home schemes). Such support would enable some older residents to stay in their homes and minimize risks associated with hospital transfer. Indeed, experience from North America suggests that some frail older patients do less well if sent to hospital than if given treatment in nursing homes [12, 14, 16, 29–31]. For older residents with acute medical needs, increased co-operation between public and private sectors would result in more effective use of professional skills and time. Such co-operation would result in more efficient use ofhospital facilities, morehumane treatment and perhaps better health outcomes and could be enhanced through initiatives such as: 1. Better transfer of documentation between institutions and professionals—especially on admission, transfer or discharge [29 32–35]; 2. Better inter-disciplinary support of frail older people to prevent illness and unnecessary hospitalization [36, 37]—given its potential risks, adverse outcomes [5, 16, 22, 30–32, 38–45] and the uncertain effectiveness of emergency treatment [28]; 3. Improved recuperation facilities after illness; 4. Systematic visiting by general practitioners (GPs) to nursing homes; 5. Better access to trained practitioners with expertise in old-age medicine [8]. The aim of this review is to examine UK research and explore alternatives to current arrangements for monitoring, assessing, diagnosing and treating older nursing-home residents during acute crises. We reviewed the UK literature through keyword and author searches of Medline and BIDS from 1982 to 1997. Our UK literature search is supported by selective reference to other research findings, particularly from North America.