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Post-Hospital Discharge Adverse Events in the Nursing Home Setting

HSS Investigators: Alok Kapoor, Terry Field, Kimberly Fisher, Sybil Crawford, Ning Zhang, Jerry Gurwitz
Funding Agency: Agency for Healthcare Research and Quality (AHRQ)
Status: Complete

Project Overview: In this project, we studied adverse events occurring among long-term care residents who transitioned from the nursing home setting to an acute care setting, and were then discharged back to the same facility.  The setting was a representative sample of 32 nursing homes drawn from across the six New England states. The specific aims of the study were to characterize the rates, types, severity, and preventability of adverse events that occur in the 45-day period post-hospital discharge among long-stay nursing home residents (long-stay = >100 days) who were hospitalized and returned to the same facility; to identify demographic, clinical, and functional resident characteristics associated with the occurrence of adverse events; to identify facility-level characteristics associated with the occurrence of adverse events; and to examine the impact of level of facility participation in the New England regional National Nursing Home Quality Care Collaborative on the occurrence of adverse events. Nurse abstractors collected data from resident charts at the 32 homes on a quarterly basis and four physician adjudicators evaluated the adverse events reported by the nurse abstractors.

Main Findings: 555 unique nursing home residents contributed data on 762 hospital discharges with return to the same facility.  Nearly 66% were female, and the mean age was 82.2 years. There were 379 adverse events identified.  Of those 379 events, 197(52.0%) were related to resident care, with pressure ulcers, skin tears, and falls with injury representing the most common types of events in this category.  Health care–acquired infections (108 [28.5%]) and adverse drug events (64 [16.9%]) were the next most common.  In terms of preventability, 267 (70.4%) adverse events were deemed preventable or ameliorable. Adverse events developed in nearly 4 of 10 of discharges from hospital back to LTC. Most were preventable or ameliorable. Standardized reporting of events and better coordination and information transfer across settings are potential ways to prevent adverse events in LTC residents. Read more about our findings here.

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