Transitions of Care for the Geriatric Patient in the Emergency Department

Clinics in Geriatric Medicine

Volumn 29, Issue 1, 2013, Pages 49-69

  Kessler, Chad ^a,b   Williams, Meredith C ^c   Moustoukas, John N ^b   Pappas, Cleo ^b  

^a JESSE BROWN VA MEDICAL CENTER   (United States)

^b UNIVERSITY OF ILLINOIS AT CHICAGO   (United States)

^c UNIVERSITY OF CHICAGO   (United States)

Author keywords

Emergency department; Geriatric hand off; Patient transfer; Senior; Transfer of patients; Transitions

Indexed keywords

EMERGENCY CARE; EMERGENCY WARD; GERIATRIC CARE; GERIATRIC PATIENT; HEALTH CARE COST; HEALTH CARE PERSONNEL; HEALTH CARE PLANNING; HIGH RISK POPULATION; HOSPITAL DISCHARGE; HUMAN; MORBIDITY; NEEDS ASSESSMENT; NURSING HOME; PREVALENCE; PROCESS OPTIMIZATION; RECIDIVISM; REVIEW; RISK ASSESSMENT; RISK FACTOR;

AGED; AGED, 80 AND OVER; COMMUNICATION; CONTINUITY OF PATIENT CARE; EMERGENCY SERVICE, HOSPITAL; GERIATRIC ASSESSMENT; GERIATRICS; HEALTH SERVICES FOR THE AGED; HUMANS; NURSING HOMES; OUTCOME ASSESSMENT (HEALTH CARE); PATIENT DISCHARGE; PATIENT TRANSFER;

EID: 84870045435     PISSN: 07490690     EISSN: 18798853     Source Type: Journal    
DOI: 10.1016/j.cger.2012.10.005     Document Type: Review

References (174)

1. Kinsella K., Velkoff V.A. An aging world: 2001 (US Census Bureau, Series P95 01-1) 2001, US Government Printing Office, Washington, DC.
2. McNamara R., Rousseau E., Sanders A.B. Geriatric emergency medicine: a survey of practicing emergency physicians. Ann Emerg Med 1992, 21:796-800.
3. Eliastam M. Elderly patients in the emergency department. Ann Emerg Med 1989, 8:133-139.
4. Burt C.W., McCaig L.F. Trends in hospital emergency department utilization: United States 1992-99. Vital Health Stat 13 2002, (150):1-34.
5. Emergency department managers warned of 'catastrophic' crowding due to elderly. ED Manag 2008, 20(2):13-15.
6. Roberts D.C., McKay M.P., Shaffer A. Increasing rates of emergency department visits for elderly patients in the United States, 1993 to 2003. Ann Emerg Med 2008, 51(6):769-774.
7. Lowenstein S.R., Crescenzi C.A., Kern D.C., et al. Care of the elderly in the emergency department. Ann Emerg Med 1986, 15:528-535.
8. Dickinson E.D., Verdile V.P., Kostyun C.T., et al. Geriatric use of emergency medical services. Ann Emerg Med 1996, 27:199-203.
9. Stiell A., Forster A.J., Stiell I.G., et al. Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ 2003, 169:1023-1028.
10. Partnership for Solutions. New poll reveals Americans' concerns about living with chronic conditions and desire for elected officials to take action to improve care. Available at: Accessed October 22, 2012. http://partnershipforsolutions.org/media/press-releases.
11. Wilber S.T., Gerson L.W. A research agenda for geriatric emergency medicine. Acad Emerg Med 2003, 10:251-260.
12. Grabowski D.C., O'Malley A.J., Barhydt N.R. The costs and potential savings associated with nursing home hospitalizations. Health Aff 2007, 26:1753-1761.
13. Miller D., Lewis L., Nork M., et al. Controlled trial of a geriatric case-finding and liaison service in an emergency department. J Am Geriatr Soc 1996, 44(5):513-520.
14. Ackermann R.J., Kemle K.A., Vogel R.L., et al. Emergency department use by nursing home residents. Ann Emerg Med 1998, 31(6):749-757.
15. Strange G.R., Chen E.H., Sanders A.B. Use of emergency departments by elderly patients: projections from a multicenter database. Ann Emerg Med 1992, 21:819-824.
16. Ettinger W.H., Casani J.A., Coon P.J., et al. Patterns of use of the emergency department by elderly patients. J Gerontol 1987, 42:638-642.
17. Singal B.M., Hedges J.R., Rousseau E.W., et al. Geriatric patient emergency visits part I: comparison of visits by geriatric and younger patients. Ann Emerg Med 1992, 21:802-807.
18. Baum S.A., Rubenstein L.Z. Old people in the emergency room: age-related differences in emergency department use and care. J Am Geriatr Soc 1987, 35:398-404.
19. Aminzadeh F., Dalziel W.B. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med 2002, 39:238-247.
20. Murtaugh C.M., Litke A. Transitions through postacute and long-term care settings: patterns of use and outcomes for a national cohort of elders. Med Care 2002, 40(3):227-236.
21. Naylor M.D., Kurtzman E.T., Pauly M.V. Transitions of elders between long-term care and hospitals. Policy Polit Nurs Pract 2009, 10(3):187-194.
22. Morrison R.S., Olson E., Mertz K.R., et al. The inaccessibility of advance directives on transfer from ambulatory to acute care settings. JAMA 1995, 274:478-482.
23. Coleman E.A., Berenson R.A. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med 2004, 141:533-536.
24. Wang H.E., Shah M.N., Allman R.M., et al. Emergency department visits by nursing home residents in the United States. J Am Geriatr Soc 2011, 59:1864-1872.
25. Naylor M.D., Stephens C., Bowles K.H., et al. Cognitively impaired older adults: from hospital to home. Am J Nurs 2005, 105:52-61.
26. Meier D.E., Beresford L. Palliative care's challenge: facilitating transitions of care. J Palliat Med 2008, 11:416-421.
27. Vladeck B.C., Miller N.A., Clauser S.B. The changing face of long-term care. Health Care Financ Rev 1993, 14:5-23.
28. Coleman E.A., Smith J.D., Raha D., et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med 2005, 165:1842-1847.
29. Travers D., Kjervik D., Katz L. Insufficient access to elderly patients' advance directives in the emergency department. Key aspects of preventing and managing chronic illness 2001, 207. Springer, New York. S.G. Funk, E.M. Tornquist, J. Leeman (Eds.).
30. Hwang U., Morrison R.S. The geriatric emergency department. J Am Geriatr Soc 2007, 55:1873-1876.
31. Terrell K.M., Brizendine E.J., Bean W.F., et al. An extended care facility-to-emergency department transfer form improves communication. Acad Emerg Med 2005, 12:114-118.
32. Terrell K.M., Miller D.K. Challenges in transitional care between nursing homes and emergency departments. J Am Med Dir Assoc 2006, 7(8):499-505.
33. Gaddis G.M. Elder care transfer forms. Acad Emerg Med 2005, 12:160-161.
34. Currie C.T., Lawson P.M., Robertson C.E., et al. Elderly patients discharged from accident and emergency departments-their dependency and support. Arch Emerg Med 1984, 1:205-213.
35. Hedges J.R., Singal B.M., Rousseau E.W., et al. Geriatric patient emergency visits part II: perceptions of visits by geriatric and younger patients. Ann Emerg Med 1992, 21:808-813.
36. Brookoff D., Minniti-Hill M. Emergency department-based home care. Ann Emerg Med 1994, 23:1101-1106.
37. McCusker J., Ardman O., Bellavance F., et al. Use of community services by seniors before and after an emergency visit. Can J Aging 2001, 20:193-209.
38. Gerson L.W., Rousseau E.W., Hogna T.M., et al. Multicenter study of case finding in elderly emergency department patients. Acad Emerg Med 1995, 2(8):729-734.
39. Brown-Williams H., Neuhauser L., Ivey S., et al. From hospital to home: improving transitional care for older adults 2006, University of California, Health Research for Action, Berkeley (CA), p. 1-34. Available at:, Accessed October 22, 2012. http://www.healthresearchforaction.org/hospital-home-improving-transitional-care-older-adults.
40. Coleman E.A., Parry C., Chalmers S., et al. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med 2006, 166:1822-1828.
41. Boockvar K., Fishman E., Kyriacou C.K., et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med 2004, 164(5):545-550.
42. American Medical Director's Association. Improving care transitions from the nursing facility to a community based setting. Columbia (MD): 2010. Available at: Accessed October 22, 2012. http://www.amda.com/governance/whitepapers/transitions_of_care.cfm.
43. Foster A.J., Murff H.J., Peterson J.F., et al. The incidence and severity of adverse drug events affecting patients after discharge from the hospital. Ann Intern Med 2003, 138(3):161-167.
44. Page R.L., Ruscin J.M. The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use. Am J Geriatr Pharmacother 2006, 4:297-305.
45. Clarfield A., Bergman H., Kane R. Fragmentation of care for frail older people-an international problem. Experience from three countries: Israel, Canada, and the United States. J Am Geriatr Soc 2001, 49:1714-1721.
46. McCloskey R. The 'mindless' relationship between nursing homes and emergency departments: what do Bourdieu and Freire have to offer?. Nurs Inq 2011, 18:154-164.
47. Dalawari P., Duggan J., Vangimalla V., et al. Patient transfer forms enhance key information between nursing homes and emergency department. Geriatr Nurs 2011, 32(4):270-275.
48. Belfrage M.K., Chiminello C., Cooper D., et al. Pushing the envelope: clinical handover from the aged-care home to the emergency department. Med J Aust 2009, 190(Suppl 11):S117-S120.
49. Jones A.L., Dwyer L.L., Bercovitz A.R., et al. National Center for Health Statistics. The National Nursing Home survey: 2004 overview. Vital Health Stat 13 2009, 13(167):1-155. Available at:, Accessed October 22, 2012. http://www.cdc.gov/nchs/nnhs/nnhs_products.htm.
50. Bergman H., Clarfield A.M. Appropriateness of patient transfer from a nursing home to an acute-care hospital: a study of emergency room visits and hospital admissions. J Am Geriatr Soc 1991, 39(12):1164-1168.
51. Nawar E.W., Niska R.W., Xu J. National hospital ambulatory medical care survey: 2005 emergency department summary. Adv Data 2007, 386:1-32.
52. Jagsi R., Kitch B.T., Weinstein D.F., et al. Residents report on adverse events and their causes. Arch Intern Med 2005, 165:2607-2613.
53. Singh H., Thomas E.J., Petersen L.A., et al. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med 2007, 167:2030-2036.
54. Kripalani S., LeFevre F., Phillips C.O., et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007, 297:831-841.
55. LaMantia M.A., Scheunemann L.P., Viera A.J., et al. Interventions to improve transitional care between nursing homes and hospitals: a systematic review. J Am Geriatr Soc 2010, 58:777-782.
56. Ahmad S., O'Mahony M.S. Where older people die: a retrospective population based study. QJM 2005, 98:865-870.
57. Jakobsson E., Johnsson T., Persson L.O., et al. End-of-life in a Swedish population: demographics, social conditions and characteristics of places of death. Scand J Caring Sci 2006, 20:10-17.
58. Klinkenberg M., Visser G., Broese van Groenou M.I., et al. The last 3 months of life: care, transitions and the place of death of older people. Health Soc Care Community 2005, 13:420-430.
59. Van den Block L., Deschepper R., Bilsen J., et al. Transitions between care settings at the end of life in Belgium. JAMA 2007, 298:1638-1639.
60. Wilson D.M., Northcott H.C., Truman C.D., et al. Location of death in Canada. Eval Health Prof 2001, 24:385-403.
61. Gabrel C.S., Jones A. The National Nursing Home Survey: 1997 Summary. Vital Health Stat 13 2000, 147:1-121.
62. Young M.P., Gooder V.J., McBride K., et al. Inpatient transfers to the intensive care unit: delays are associated with increased mortality and morbidity. J Gen Intern Med 2003, 2:77-83.
63. Chalfin D.B., Trzeciak S., Likourezos A., et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007, 35(6):1477-1483.
64. Yurkova I., Wolf L. Under-triage as a significant factor affecting transfer time between the emergency department and the intensive care unit. J Emerg Nurs 2011, 37(5):491-496.
65. Arora V., Johnson J., Lovinger D., et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care 2005, 14:401-407.
66. Horwitz L.I., Krumholz H.M., Green M.L., et al. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med 2006, 166:1173-1177.
67. Beach C., Croskerry P., Shapiro M. Profiles in patient safety: emergency care transitions. Acad Emerg Med 2003, 10:364-367.
68. Sinha M., Shriki J., Salness R., et al. Need for standardized signout in the emergency department: a survey of emergency medicine residency and pediatric emergency medicine fellowship program directors. Acad Emerg Med 2007, 14:192-196.
69. Behara R., Wears R.L., Perry S.J., et al. A conceptual framework for studying the safety of transitions in emergency care. Advances in patient safety: from research to implementation 2005, vol. 2:309-321. Agency for Healthcare Research and Quality, Rockville (MD). K. Henriksen, J.B. Battles, E.S. Marks (Eds.).
70. Eisenberg E.M., Murphy A.G., Sutcliffe K.M., et al. Communication in emergency medicine: implications for patient safety. Comm Monogr 2005, 72:390-413.
71. Apker J., Mallak L.A., Gibson S.C. Communicating in the "gray zone": perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med 2007, 14:884-894.
72. Beach C. Lost in transition. AHRQ WebM&M [serial online]. Available at: Accessed October 22, 2012. http://webmm.ahrq.gov/case.aspx%3FcaseID116.
73. Burke C.S., Salas E., Wilson-Donnelly K., et al. How to turn a team of experts into an expert medical team: guidance from the aviation and military communities. Qual Saf Health Care 2004, 13(Suppl 1):i96-i104.
74. Bunderson J.S., Sutcliffe K.M. Comparing alternative conceptualizations of functional diversity in management teams: process and performance effects. Acad Manage J 2002, 45:875-893.
75. Horwitz L.I., Meredith T., Schuur J.D., et al. Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med 2009, 53(6):701-710.
76. Coiera E.W., Jayasuriya R.A., Hardy J., et al. Communication loads on clinical staff in the emergency department. Med J Aust 2002, 176:415-418.
77. Tversky A., Kahneman D. Judgment under uncertainty: heuristics and biases. Science 1974, 185:1124-1131.
78. Kelly R. Goings-on in a CCU: an ethnomethodological account of things that go on in a routine hand-over. Nurs Crit Care 1999, 4:85-91.
79. Kerr M.P. A qualitative study of shift handover practice and function from a socio-technical perspective. J Adv Nurs 2002, 37:125-134.
80. Lally S. An investigation into the functions of nurses' communication at the inter-shift handover. J Nurs Manag 1999, 7:29-36.
81. Sherlock C. The patient handover: a study of its form, function and efficiency. Nurs Stand 1995, 9:33-36.
82. Agency for Healthcare Research and Quality HCUPnet. Outcomes by patient and hospital characteristics for all discharges. 1999. Available at: Accessed October 22, 2012. http://hcup.ahrq.gov/HCUPnet.asp.
83. Barker W.H., Zimmer J.G., Hall W.J., et al. Rates, patterns, causes, and costs of hospitalization of nursing home residents: a population-based study. Am J Public Health 1994, 84:1615-1620.
84. Beers M., Sliwkowski J., Brooks J. Compliance with medication orders among the elderly after hospital discharge. Hosp Formul 1992, 27:720-724.
85. Williams S., Moore C., Wisnevesky J., et al. Assessing medical errors related to the continuity of care from an inpatient to an outpatient setting. J Gen Intern Med 2002, 17(Suppl 1):218. [abstract].
86. Kravitz R., Reuben D., Davis J.W., et al. Geriatric home assessment after hospital discharge. J Am Geriatr Soc 1994, 42:1229-1234.
87. Meredith S., Feldman P.H., Frey D., et al. Possible medication errors in home healthcare patients. J Am Geriatr Soc 2002, 49:719-724.
88. Guttman A., Afilafo M., Guttman R., et al. An emergency department-based nurse discharge coordinator for elder patients: does it make a difference?. Acad Emerg Med 2004, 11(12):1318-1327.
89. McCusker J., Dendukuri N., Tousignant P., et al. Rapid two-stage emergency department intervention for seniors: impact on continuity of care. Acad Emerg Med 2003, 10(3):233-243.
90. Ouslander J.G., Lamb G., Perloe M. Potentially avoidable hospitalizations of nursing home residents: frequency, causes, and costs. J Am Geriatr Soc 2010, 58(4):627-635.
91. Parker S.G., Fadayevatan R., Lee S.D. Acute hospital care for frail older people. Age Ageing 2006, 35(6):551-552.
92. National Transitions of Care Coalition. Improving transitions of care: the vision of the national transitions of care coalition. Little Rock (AR); 2008. Available at: Accessed October 22, 2012. http://www.ntocc.org/Portals/0/PolicyPaper.pdf.
93. Coleman E.A., Boult C., The American Geriatrics Society Health Care Systems Committee Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc 2003, 51:556-557.
94. Hastings N., Schmader K., Sloan R., et al. Adverse health outcomes after discharge from the emergency department-incidence and risk factors in a veteran population. J Gen Intern Med 2007, 22(11):1527-1531.
95. Kramer A., Eilertsen T., Lin M., et al. Effects of nurse staffing on hospital transfer quality measures for new admissions. Appropriateness of minimum nurse staffing ratios for nursing homes 2000, 9.1-9.22. Health Care Financing Administration, Baltimore (MD). Health Care Financing Administration (Ed.).
96. Caplan G., Williams A., Daly B., et al. A randomized controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of the elderly from the emergency department-the DEED II study. J Am Geriatr Soc 2004, 52(9):1417-1423.
97. Ballabio C., Bergamaschini L., Mauri S., et al. A comprehensive evaluation of elderly people discharged from an emergency department. Intern Emerg Med 2008, 3(3):245-249.
98. Saliba D., Kington R., Buchanan J., et al. Appropriateness of the decision to transfer nursing facility residents to the hospital. J Am Geriatr Soc 2000, 48(2):154-163.
99. Ouslander J.G., Lamb G., Tappen R., et al. Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project. J Am Geriatr Soc 2011, 59(4):745-753.
100. NCHS Data Brief Number 33, April 2010. Potentially preventable emergency department visits by nursing home residents: United States, 2004. Available at: Accessed November 2, 2012. http://www.cdc.gov/nchs/data/databriefs/db33.pdf.
101. Intrator O., Zinn J., Mor V. Nursing home characteristics and potentially preventable hospitalizations of long-stay residents. J Am Geriatr Soc 2004, 52:1730-1736.
102. Kane R.L., Keckhafer G., Flood S., et al. The effect of Evercare on hospital use. J Am Geriatr Soc 2003, 51:1427-1434.
103. Bodenheimer T. Long-term care for frail elderly people-the On Lok model. N Engl J Med 1999, 341:1324-1328.
104. Tresch D.D., Simpson W.M., Burton J.R. Relationship of long-term and acute-care facilities: the problem of patient transfer and continuity of care. J Am Geriatr Soc 1985, 33:819-826.
105. Coleman E.A. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc 2003, 51(4):549-555.
106. Gittell J.H., Fairfield K.M., Bierbaum B., et al. Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay. Med Care 2000, 38:807-819.
107. Levine C. Rough crossings: family caregivers' odysseys through the healthcare system 1998, United Hospital Fund of New York, New York.
108. Coleman E., Smith J.D., Frank J., et al. Development and testing of a measure designed to assess the quality of care transitions. Int J Integrated Care 2002, 2. Available at:, Accessed October 22, 2012. http://www.ijic.org/.
109. Weaver F.M., Perloff L., Waters T. Patients' and caregivers' transition from hospital to home. Needs and recommendations. Home Health Care Serv Q 1998, 17:27-48.
110. Jones J.S., Dwyer P.R., White L.J., et al. Patient transfer from nursing home to emergency department. Outcomes and policy implications. Acad Emerg Med 2002, 4:908-915.
111. Ghusn H.F., Teasdale T.A., Jordan D. Continuity of do-not-resuscitate orders between hospital and nursing home settings. J Am Geriatr Soc 2002, 445:465-469.
112. Grief C.L. Patterns of ED use and perceptions of the elderly regarding their emergency care: a synthesis of recent research. J Emerg Nurs 2003, 29(2):122-126.
113. Jones J.S., Rousseau E.W., Schropp M.A., et al. Geriatric training in emergency medicine residency programs. Ann Emerg Med 1992, 21:825-829.
114. Jones J.S. Geriatric emergency care: an annotated bibliography. Ann Emerg Med 1992, 21:835-841.
115. Sanders A.B. Care of the elderly in emergency departments: conclusions and recommendations. Ann Emerg Med 1992, 21:830-834.
116. Sanders A.B. Care of the elderly in emergency departments: where do we stand?. Ann Emerg Med 1992, 21:792-795.
117. Sanders A.B., Morley J.E. The older person and the emergency department. J Am Geriatr Soc 1993, 41:880-882.
118. Schwartz G.R. Geriatric emergency medicine. Principles and practice of emergency medicine 1992, 2559-2598. Lea & Febiger, Philadelphia. 3rd edition. G.R. Schwartz, C.G. Cayten, M.A. Mangelsen (Eds.).
119. Institute of Medicine Crossing the quality chasm: a new health system of the 21st century 2001, National Academy Press, Washington, DC.
120. Through the patient's eyes. Understanding and promoting patient-centered care 1993, Jossey-Bass, San Francisco (CA). M. Gerteis, S. Edgman-Levitan, J. Daley (Eds.).
121. vom Eigen K.A., Walker J.D., Edgman-Levitan S., et al. Care partner experiences with hospital care. Med Care 1999, 37:33-38.
122. Anderson M., Helms L. Communication between continuing care organizations. Res Nurs Health 1995, 18:49-57.
123. Terrell K., Hustey F., Gerson L., et al. Quality indicators for geriatric emergency care. Acad Emerg Med 2009, 16(5):441-449.
124. Horwitz L.I., Moin T., Krumholz H.M., et al. Consequences of inadequate sign-out for patient care. Arch Intern Med 2008, 168(16):1755-1760.
125. Pronovost P., Needham D., Berenholtz S., et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006, 355:2725-2732.
126. Patterson E.S. Structuring flexibility: the potential good, bad and ugly in standardization of handovers. Qual Saf Health Care 2008, 17:4-5.
127. Horwitz L.I., Moin T., Green M.L. Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med 2007, 22:1470-1474.
128. Lee L.H., Levine J.A., Schultz H.J. Utility of a standardized sign-out card for new medical interns. J Gen Intern Med 1996, 11:753-755.
129. Petersen L.A., Orav E.J., Teich J.M., et al. Using a computerized signout program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv 1998, 24:77-87.
130. Van Eaton E.G., Horvath K.D., Lober W.B., et al. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg 2005, 200:538-545.
131. Vidyarthi A.R., Arora V., Schnipper J.L., et al. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med 2006, 1:257-266.
132. Aydin C.E., Rice R.E. Bringing social worlds together: computers as catalysts for new interactions in health care organizations. J Health Soc Behav 1992, 33:168-185.
133. Milliken F.J., Martins L.L. Searching for common threads: understanding the multiple effects of diversity in organizational groups. Acad Manag Rev 1996, 21:402-433.
134. Davenport D.L., Henderson W.G., Mosca C.L., et al. Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am Coll Surg 2007, 205:778-784.
135. Rex J.H., Turnbull J.E., Allen S.J., et al. Systematic root cause analysis of adverse drug events in a tertiary referral hospital. Jt Comm J Qual Improv 2000, 26:563-575.
136. Ursprung R., Gray J.E., Edwards W.H., et al. Real time patient safety audits: improving safety every day. Qual Saf Health Care 2005, 14:284-289.
137. Lardner R. Effective shift handover, etc., prepared for the United Kingdom, Health and Safety Executive, Offshore Safety Division. Available at: Accessed October 22, 2012. http://www.hse.gov.uk/research/otopdf/1996/%20oto96003.
138. Patterson E.S., Roth E.M., Woods D.D., et al. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care 2004, 16:125-132.
139. Kuperman G.J., Boyle D., Jha A., et al. How promptly are inpatients treated for critical laboratory results?. J Am Med Inform Assoc 1998, 5:112-119.
140. Yen K., Gorelick M.H. Strategies to improve flow in the pediatric emergency department. Pediatr Emerg Care 2007, 23:745-749.
141. Smith P.C., Araya-Guerra R., Bublitz C., et al. Missing clinical information during primary care visits. JAMA 2005, 293:565-571.
142. Oakes S.L., Gillespie S.M., Ye Y., et al. Transitional care of the long-term care patient. Clin Geriatr Med 2011, 27:2-32.
143. National Quality Forum. National voluntary consensus standards for hospital care: Additional priority areas-2005-2006. Available at: Accessed October 22, 2012. http://www.qualityforum.org.
144. Boockvar K.S., Carlson LaCorte H., Giambanco V., et al. Medication reconciliation for reducing drug-discrepancy adverse events. Am J Geriatr Pharmacother 2006, 4:236-243.
145. Spaite D.W., Bartholomeaux F., Guisto J., et al. Rapid process redesign in a university-based emergency department: decreasing waiting time intervals and improving patient satisfaction. Ann Emerg Med 2002, 39:168-177.
146. Moore C., Wisnivesky J., Williams S., et al. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 2003, 18:646-651.
147. Kim C.S., Spahlinger D.A., Kin J.M., et al. Lean health care: what can hospitals learn from a world-class automaker?. J Hosp Med 2006, 1:191-199.
148. Crotty M., Rowett D., Spurling L., et al. Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. Am J Geriatr Pharmacother 2004, 2:257-264.
149. Tolle S.W., Tilden V.P., Nelson C.A., et al. A prospective study of the efficacy of the physician order form for life-sustaining treatment. J Am Geriatr Soc 1998, 46:1097-1102.
150. Madden C., Garrett J., Busby-Whitehead J. The interface between nursing homes and emergency departments: a community effort to improve transfer of information. Acad Emerg Med 1998, 5:1123-1126.
151. Katon W., Von Korf M., Lin E., et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 1995, 273:1026-1031.
152. McCusker J., Bellavance F., Cardin S., et al. Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc 1999, 47:1229-1237.
153. McCusker J., Bellavance F., Cardin S., et al. Screening for geriatric problems in the emergency department: reliability and validity. Acad Emerg Med 1998, 5:883-893.
154. McCusker J., Bellavance F., Cardin S., et al. Prediction of hospital utilization among elderly patients during the 6 months after an emergency department visit. Acad Emerg Med 2000, 36:438-445.
155. McCusker J., Cardin S., Bellavance F., et al. Return to the emergency department among elders: patterns and predictors. Acad Emerg Med 2000, 7:249-259.
156. McCusker J., Healey E., Bellavance F., et al. Predictors of repeat emergency department visits by elders. Acad Emerg Med 1997, 4:581-588.
157. Meldon S.W., Mion L.C., Palmer R.M., et al. Implementation of a two-stage geriatric screen in the ED. Acad Emerg Med 1999, 6:530-531.
158. Rubenstein L.Z. The emergency department: a useful site for CGA?. J Am Geriatr Soc 1996, 44:601-602.
159. Naylor M., Brooten D., Campbell R., et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA 1999, 281:613-620.
160. Rich M., Beckham V., Wittenberg C., et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995, 333:1190-1195.
161. Stewart S., Pearson S., Horowitz J. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. Arch Intern Med 2000, 158:1067-1072.
162. Zuckerman J., Sakales S., Fabian D., et al. Hip fractures in geriatric patients. Results of an interdisciplinary hospital care program. Clin Orthop 1992, 274:213-225.
163. Ogilvie-Harris D., Botsford D., Hawker R. Elderly patients with hip fractures. Improved outcome with the use of care maps with high-quality medical and nursing protocols. J Orthop Trauma 1993, 7:428-437. 170.
164. Ethans K., MacKnight C. Hip fracture in the elderly: an interdisciplinary team approach to rehabilitation. Postgrad Med 1998, 103:157-158.
165. Coleman E., Besdine R. Integrating quality assurance across sites of geriatric care. New ways to care for older people 1998, 185-195. Springer, New York. E. Calkins, E. Wagner, C. Boult (Eds.).
166. National Chronic Care Consortium Self-assessment for system integration tool 1998, SASI, Bloomington (MN).
167. Joint Commission on Accreditation of Healthcare Organizations Hospital accreditation standards 2002, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace (IL).
168. Wenger N.S., Young R.T. Quality indicators for continuity and coordination of care in vulnerable elders. J Am Geriatr Soc 2007, 55:S285-S292.
169. Naylor M., Brooten D., Campbell R., et al. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA 1999, 281:613-620.
170. Rich M., Beckham V., Wittenberg C., et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995, 333:1190-1195.
171. Stewart S., Pearson S., Horowitz J. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. Arch Intern Med 2000, 158:1067-1072.
172. Zuckerman J., Sakales S., Fabian D., et al. Hip fractures in geriatric patients. Results of an interdisciplinary hospital care program. Clin Orthop 1992, 274:213-225.
173. Ogilvie-Harris D., Botsford D., Hawker R. Elderly patients with hip fractures. Improved outcome with the use of care maps with high-quality medical and nursing protocols. J Orthop Trauma 1993, 7:428-437.
174. Ethans K., MacKnight C. Hip fracture in the elderly: An interdisciplinary team approach to rehabilitation. Postgrad Med 1998, 103:157-158.