Changes in Nursing Staff Levels and Injury-Related Emergency Department Visits among Assisted Living Residents with Alzheimers Disease and Related Dementias

Abstract

ObjectivesTo examine the relationship between changes in nursing staff-hours per resident-day and injury-related emergency department (ED) visits among assisted living (AL) residents with Alzheimer disease and related dementias (ADRD). DesignRetrospective cohort study. Setting and ParticipantsWe leveraged a data set of AL community characteristics in Ohio linked to Medicare claims data from 2007 to 2015. MethodsWe estimated Poisson models examining the relationships of personal care aide, registered nurse (RN), licensed practical nurse (LPN), and total nursing hours with injury-related ED visits. Models were adjusted for resident characteristics (ie, age, race, sex, dual eligibility, presence and number of chronic conditions), AL community characteristics (percentage of residents on Medicaid, average resident acuity), year fixed effects, and assisted living fixed effects. We examined all injury-related ED visits and injury-related ED visits resulting in hospital admission as separate outcomes. ResultsThe sample included 122,700 person-months, representing 12,144 fee-for-service Medicare beneficiaries with ADRD within 455 different AL communities in Ohio between 2007 and 2015. Median total nursing hours increased from 1.34 in 2007 to 1.69 in 2015. In the fully adjusted model, an increase in 1 RN-hour per resident-day was associated with a decrease in the risk of any injury-related ED visit (incidence rate ratio 0.59, 95% CI 0.36-0.96), representing a 53% decrease. Changes in RN-hours were not associated with injury-related inpatient hospitalizations. Changes in total nursing, LPN, and personal care aide hours were not associated with changes in the risk of injury-related ED visits or inpatient hospitalizations. Conclusions and ImplicationsIncreases in RN staffing hours were associated with reduced injury-related ED use among AL residents with ADRD. RNs provide surveillance and care oversight that may help mitigate injury risk, and they are able to physically assess residents at the time of a fall and/or injury, which can preempt unnecessary ED transfers.