July 20, 2025
McKnight's Long-Term Care News
Nearly 1 in 3 hospitalizations of severely impaired or terminally ill nursing home residents are potentially avoidable. Better diagnostic practices can significantly reduce that number, as well as the associated risks and costs.
That’s according to a new analysis by a team from Florida Atlantic University that also found 70% to 80% of emergency department visits for the terminally ill or severely impaired cohort also are potentially avoidable.
“Understanding the specific diagnoses associated with these potentially avoidable events can help target educational and quality improvement efforts to reduce their frequency, risk of hospital-acquired complications, morbidity and costs,” wrote the study authors in the July issue of the journal JAMDA.
They conducted a secondary analysis of a randomized controlled trial of acute-care transfers of 6,011 severely impaired residents and 5,810 terminally ill residents from 264 US nursing homes. The study found:
- In the severely impaired group, 34% had one or more all-cause hospitalizations, of which one-third were potentially avoidable, and 18% had at least one ED visit without hospitalization, of which 70% were potentially avoidable.
- Among residents identified as terminally ill, 14% had at least one all-cause hospitalization, of which 31% were potentially avoidable, and 8% had at least one ED visit, of which 80% were potentially avoidable.
- The most common diagnoses associated with potentially avoidable hospitalizations were pneumonia and other infections, shortness of breath/respiratory failure, and altered mental status.
- In the severely impaired group, problems with feeding tubes were the most common diagnoses associated with potentially avoidable ED visits, and in the terminally ill group, it was fall-related trauma.
Some of the most common causes of potentially avoidable hospitalizations and emergency room visits in the two groups were not surprising. Urinary tract infections were identified as a common diagnosis for potentially avoidable hospitalizations and ED visits in both groups.
“UTIs are well known to be overdiagnosed in the nursing home setting, and assessment tools, care paths and guidelines now recommend not evaluating and treating a UTI unless there are specific symptoms referring to the lower urinary tract,” the authors wrote.
Pneumonia and other respiratory symptoms were also commonly associated with hospitalizations and ED visits of nursing home residents.
“Like UTIs, care paths for managing respiratory infections, preventive measures for aspiration and careful monitoring of residents with heart failure can be helpful in avoiding some hospital transfers,” report authors wrote.
Replacing feeding tubes of severely impaired residents, including those with advanced dementia, is a common cause of hospitalizations and ED visits, but the researchers found that problems with gastrostomy tubes do not always require an ED visit or hospitalization in these cases.
Educating and training nursing home staff on how to quickly replace gastrostomy tubes so that residents can remain hydrated for a few hours until a gastroenterologist or radiologist can handle the issue the next day “could prevent thousands of ED transfers annually,” according to the researchers.
Transfers related to trauma — largely from falls, including head trauma and fractures — were common among terminally ill residents. And in many cases, deemed preventable.
“Nursing homes must implement more robust fall management programs to reduce the number of injuries that result in ED visits and hospitalizations,” the authors wrote.
The researchers say these and other strategies to improve diagnoses to reduce unnecessary hospital transfers and ED visits require improving the capabilities of nursing home interprofessional staff and increasing the involvement of well-prepared medical directors and nursing home clinicians.
“Support from federal and state governments and nursing homes themselves, as well as from nursing home provider organizations, are essential to achieving these goals,” the authors wrote. “Policy changes, including minimum nursing staffing standards, creating specialized post-acute facilities that have the staff, clinicians and resources to manage sicker individuals, and creating long-stay facilities that focus on and are appropriately reimbursed for high quality care for the most impaired and terminally ill, may also help improve care and reduce costs.”
