Time to Resolution of Infection in COVID-19 Patients: the Experience of a Tertiary Medical Center in Israel.

With the spread of coronavirus disease, reports have indicated that young patients are usually asymptomatic with a short convalescence period. The current study compared the time to resolution of infection in symptomatic and asymptomatic patients. Seventy-six patients aged 44.4 ± 23.3 years were admitted to the coronavirus disease 2019 (COVID-19) unit during the study period. Data were collected from patient records. Throat and nasal swabs for COVID-19 were collected for reverse transcriptase-polymerase chain reaction (RT-PCR). Time to resolution of infection was defined as the number of days from the date of the first COVID-19 positive outcome to the second consecutive negative PCR results. Most patients showed COVID-19 signs and symptoms (71.1%) between 1 and 6 days, and the rest were asymptomatic. No association was found between the time to resolution of infection and the presence of COVID-19 signs and symptoms (symptomatic: median [Md] 10.0, 95% confidence interval [CI] 8.4-11.6; asymptomatic: Md 15.0, 95% CI 10.5-15.5; P = 0.54). Age was not correlated with the number of COVID-19 signs and symptoms (r = 0.13, P = 0.37) or with the time to resolution of infection (r = 0.06, P = 0.58). In patients with mild to moderate symptoms, the time to resolution of infection from COVID-19 is not different from that in asymptomatic patients.

The impact of intensive staff education on rate of Clostridium difficile-associated disease in hospitalized geriatric patients.

BACKGROUND: Toxin-producing Clostridium difficile is the most common cause of nosocomial diarrhea in geriatric units. AIM: The purpose of study was to check the impact of intensive staff education on rate of Clostridium difficile-associated disease in hospitalized geriatric patients. METHODS: The sampling frame was all patients suffering from diarrhea checked for Clostridium difficile toxin during the years 2017-2018. Clostridium difficile-positive patients were compared to a similar number of Clostridium difficile toxin-negative patients. The data were compared to our previous study, followed by medical staff's educational program for Clostridium difficile control and prevention. RESULTS: Among 217 patients with diarrhea, 60 (27.6%) were positive for Clostridium difficile toxin. The study group tended to be of older age (p = 0.06), and showed higher rate of functional impairment (p < 0.001) and mortality (p < 0.001) than Clostridium difficile toxin negative patients. The rate of Clostridium difficile toxin-positive patients did not significantly differ between the previous and current studies (20.0% and 27.6%, respectively). CONCLUSIONS AND DISCUSSION: In spite of findings, that patients tended to be older, with high rate of mortality, the rate of Clostridium difficile did not change from the previous study.

To check or not to check. Rectal ESBL colonization in hospitalized elderly patients.

BACKGROUND: The worldwide spread of extended-spectrum-beta-lactamase (ESBL) producing bacteria has affected health care. ESBL confers resistance to the majority of beta-lactam antibiotics. MATERIALS AND METHODS: We intended to quantify the rates of rectal ESBL-positive and negative patients that eventually developed fever and urinary tract infection (UTI). All rectal ESBL-positive patients were to be initially treated with the conventional antibiotics that have anti-ESBL activity (amikacin or ertapenem), while ESBL-negative patients were given ceftriaxone. RESULTS: Most patients were rectal ESBL-positive (60.7%). Fever was in 51% patients; 67.8% of them developed signs and symptoms of UTI. Most patients with UTI were urinary ESBL-positive (79%), most rectal ESBL-negative patients were urinary ESBL-negative (75%), (χ2 = 18.5, df = 1, P < .001). Overall mortality was higher in the febrile group (39, 34.8%) versus the afebrile (1, 0.9%) (χ2 = 42, df = 1, P < .001). The mortality rate in the febrile group was significantly higher in the rectal ESBL-positive patients (χ2 = 7.5, df = 1, P = .006). DISCUSSION: The direct correlation of rectal ESBL-positive and negative and respectively urinary ESBL-positive and negative patients' advocate for the use of antibiotics with anti-ESBL activity as an empiric treatment of rectal ESBL-positive patients with suspected UTI. CONCLUSION: In our opinion, it is worthwhile to identify rectal ESBL-positivity on hospital admission.

Action Observation of Motor Skills Followed by Immediate Sleep Enhances the Motor Rehabilitation of Older Adults With Stroke.

BACKGROUND AND PURPOSE: Motor rehabilitation following stroke is a demanding challenge in search for new strategies to improve outcome. Rehabilitation through action observation has been reported beneficial for older adults recovering from stroke. Early sleep session following motor learning enhanced the performance of the acquired motor skills. The purpose of this study was to examine whether an early sleep session following action observation has benefit over action observation alone in the rehabilitation of older adults after stroke. METHODS: Twenty patients with paresis of dominant upper limb in first ischemic stroke were assigned to 2 study groups (10 subjects each). The participants were presented a 5-minute video film of phone operation. Participants of the intervention group had a sleep session of 90 to 120 minutes immediately following the film while control participants did not sleep. Identical procedure was repeated for 4 consecutive sessions (4 weeks). A single item of the Chedoke Arm and Hand Activity Inventory was used as rehabilitation's outcome measure. RESULTS: During the 4 weeks of the study, the performances of both groups improved but the intervention group had higher Chedoke Arm and Hand Activity Inventory scores, as indicated by a significant session by group interaction (P < .001). CONCLUSIONS: An early sleep session added to action observation therapy may significantly improve motor performances of patients with stroke. Further studies are required to support this method for inclusion in rehabilitation arsenal.

Clostridium difficile-associated disease: A primary clinical evaluation of elderly patients in a geriatric hospital.

The purpose of this study was to screen all cases of Clostridium difficile-associated disease during a 2-year period in a geriatric hospital to determine the incidence and clinical characteristics related to this risk. Twenty percent of suspected cases were diagnosed as positive and analyzed. The C difficile disease-associated clinical factors were ischemic heart disease and chronic obstructive pulmonary disease. Use of acetylsalicylic acid, other nonsteroidal anti-inflammatory drugs, and steroids were more frequently found in the non-C difficile group. There were fewer cases in men than in women and more in patients residing in skilled nursing wards.

QT Interval Length in Elderly Prostatic Cancer Patients on Anti-Testosterone Treatment.

UNLABELLED: Background: QT segment prolongation is a high risk factor for fatal arrhythmias. Several studies have indicated a possible relation between low testosterone levels and QT interval prolongation. OBJECTIVES: To compare the QT interval length in elderly patients with prostate carcinoma who were on anti-testosterone treatment and those who were not. METHODS: We screened the electrocardiograms (ECGs) of 100 prostate cancer patients divided into two groups: 50 patients on anti-testosterone drug treatment and 50 patients not. QT interval length was measured according to the accepted methods. RESULTS: The mean QTc 12 leads in the entire group was 0.45 ± 0.04 sec, which is close to the upper limit. Mean QTc was actually longer in the control group and there was no QTc difference between the groups after adjustment for possible confounders. Prolonged QTc 12-lead ECG (48% in treated and 54% in non-treated) and lead L2 QT interval (50% in treated and 56% in non-treated) did not differ significantly between the groups. The analysis of QTc 12-lead ECG indicated no significant effects of anti-testosterone drug treatment. Only the use of furosemide was associated with QT prolongation. CONCLUSIONS: The results of this preliminary study do not support our initial concern of an alarmingly prolonged QT interval in the anti-testosterone treated group. However, further prospectively designed studies are needed. In the meanwhile we call for a close follow-up of the QT interval length in patients receiving anti-testosterone treatment.

Roxithromycin Pharmacokinetics in Hospitalized Geriatric Patients: Oral Administration of Whole Versus Crushed Tablets.

BACKGROUND: Drug administration as tablets to debilitated elderly patients in crushed form can modify the pharmacokinetic characteristics of the active components. Only scarce information is available on the pharmacokinetics when administered in such form. The aim of this study was to evaluate the pharmacokinetics of roxithromycin administered in crushed form and to compare it with the pharmacokinetics of a group of geriatric patients receiving it in the conventional tablet form. METHODS: Twenty patients from the acute ward of the Shmuel Harofeh Geriatric Medical Center in stable, clinical, and hemodynamic condition were studied. Patients in group 1 (n = 10) received medications orally in tablet form. Group 2 (n = 10) included age- and disease-matched patients from the same department, who received oral roxithromycin in crushed tablet form. The mean daily dose was the same in both groups: 300 mg (150 mg twice daily). The patients received the drug for 3 days before the initiation of the study. Blood samples for determination of the roxithromycin concentration were taken at the baseline, 1 hour before the drug administration, and at 1, 3, 4, 6, 8, and 10 hours after drug administration. Roxithromycin concentration was measured by a liquid chromatography-tandem mass spectrometry method. RESULTS: Pharmacokinetic parameters of roxithromycin were significantly different between the 2 groups: the Cmin and Cmax were significantly higher, the tmax significantly longer, AUC0-10 larger, and CL/F smaller in group 2. CONCLUSIONS: Roxithromycin pharmacokinetic parameters were significantly different between the 2 patient groups resulting in higher drug serum concentrations in the crushed tablets group. The impact of the increased drug exposure is unclear.

On-spot rheumatology consultations in a multilevel geriatric hospital.

BACKGROUND: Musculoskeletal and joint disorders are extremely common in the elderly. They directly affect mobility, gait stability, quality of life, and independence. OBJECTIVES: To assess the nature of joint problems encountered in a geriatric inpatient population and evaluate the contribution of a rheumatologist. METHODS: We reviewed the rheumatology consultation records that were conducted in a geriatric medical center over a 10 year period. RESULTS: A total of 474 consultations were held; most of these patients (86%) were hospitalized in the acute geriatric departments, 10% in the rehabilitation ward and 4% in the long-term care wards. Some patients were seen more than once. A rheumatologic joint problem was the main reason for hospitalization in 53% of these patients. Monoarthritis was the most frequent complaint (50%), followed by pauciarticular arthritis (two to five joints) in 30% of patients. Arthrocentesis, diagnostic and therapeutic, was performed in 225 patients, most of them in knee joints (81%). The most frequent diagnosis was osteoarthritis with acute exacerbation (28%), followed by gout (18%), pseudo-gout (9%) and rheumatoid arthritis (9%). In 86 cases (18%) the diagnosis was a non-specific rheumatologic problem: arthralgia, nonspecific generalized pain, or fibromyalgia. CONCLUSIONS: Prompt and appropriate evaluation, as well as arthrocentesis and treatment initiation, including local injections, were made possible by the presence of an in-house rheumatologist.

Evaluation of an intra-institutional diabetes disease management program for the glycemic control of elderly long-term care diabetic patients.

AIM: Increasing numbers of nursing home elderly patients suffer from diabetes requiring individually optimized glycemic control. This is a complicated challenge because of their high comorbidity level, and heterogeneous and changing eating status varying from independent to dysphagia and enteral feeding. In order to cope with these complex needs, we developed and implemented a diabetes disease management program. The purpose of the present study was to evaluate this program. METHODS: We used the point prevalence approach by checking for fasting blood glucose, glycated hemoglobin and other routine biochemical tests. Eating status was evaluated by the Functional Outcome Swallowing Scale. Details about the diabetes disease management program are given in the text. RESULTS: A total of 86 (36%) of the 234 patients on the study day were diabetics. Of these, 80 were eligible for the study. Their mean fasting blood glucose was 143.1 ± 60.6 mg/dL. The mean glycated hemoglobin level was 7.23 ± 1.39%. CONCLUSION: No case of hypoglycemia was detected on the examination day, or during the preceding 3 weeks. No significant difference was found among the different Functional Outcome Swallowing Scale categories. These results are within satisfactory range for this category of patients suggesting that our diabetes disease management program contributes to a better glycemic control.

Pharmacokinetics of ciprofloxacin in hospitalized geriatric patients: comparison between nasogastric tube and oral administration.

OBJECTIVES: Drug administration to debilitated elderly patients on enteral feeding through a nasogastric tube (NGT) can modify the pharmacokinetic characteristics of the drug and influence its therapeutic blood concentration. The aim of this study was to evaluate the pharmacokinetics of ciprofloxacin administered through an NGT and to compare it with those of a group of patients receiving the drug orally. METHODS: Twenty patients in stable clinical and hemodynamic condition from the long-term care ward of a geriatric multilevel hospital were studied. Patients in group 1 (n = 10) had oropharyngeal dysphagia and received food and medications, including ciprofloxacin, by NGT. Group 2 (n = 10) included age- and disease-matched orally fed patients from the same department receiving ciprofloxacin orally. Blood samples for ciprofloxacin concentration were taken at steady state, before drug administration, time 0, and at 1, 2, 3, 4, 6, 8, and 10 hours after drug administration. Ciprofloxacin was measured using liquid chromatography with tandem mass spectrometric detection. The mean daily dose was the same in both the groups: 1000 mg (500 mg twice daily). RESULTS: Pharmacokinetic parameters of ciprofloxacin were not significantly different between the 2 groups: trough concentrations were 1.24 ± 0.95 µg/mL (0.25-3.67 µg/mL) versus 1.30 ± 0.61 µg/mL (0.21-2.36 µg/mL) (P = 0.76); Cmax 3.30 ± 2.16 µg/mL (1.54-8.62 µg/mL) versus 4.24 ± 1.99 µg/mL (2.24-9.02 µg/mL) (P = 0.356); tmax 2.8 ± 1.5 versus 3.1 ± 2.8 hours (P = 0.799); and AUC0-10 20.2 ± 12.1 µg·h·mL (9-51.07 µg·h·mL) versus 24.4 ± 13.0 µg·h·mL (5.57-52.48 µg·h·mL) (P = 0.493), in the oral fed versus NGT, respectively. CONCLUSIONS: Ciprofloxacin pharmacokinetic parameters are not significantly different between patients receiving the drug through NGT compared with those who received it orally, and therefore, in frail elderly patients, this route of administration can be considered.

The effect of a pain management program on the rehabilitation of elderly patients following hip fracture surgery.

BACKGROUND: Pain following hip fracture and internal fixation is a major factor during the treatment of elderly patients on rehabilitation programs. A proactive pain management program was instituted in our geriatric rehabilitation ward in 2005. OBJECTIVES: To compare retrospectively two groups of patients, one before and one after implementation of the proactive pain management program. METHODS: The study group comprised 67 patients and the control group 77 patients. Pain in the study group was evaluated daily by the visual analogue scale (VAS) and the outcome of the rehabilitation process by the Functional Independence Measure (FIM). During the study period (2003-2006) no changes were made in the rehabilitation team, methods or facilities other than introduction of the pain control program. We compared the FIM scores between admission and discharge in both groups. RESULTS: Improvement in FIM scores between admission and discharge was significantly higher in the study group than in the control group (11.07 +/- 7.9 vs. 8.4 +/- 7.3, P < 0.03). There was no significant difference between the average lengths of stay. CONCLUSIONS: These data support the view that the proactive monitoring of pain in surgical hip fracture patients is associated with a better outcome of the rehabilitation process.

QT interval disturbances in elderly residents of long-term care facilities.

BACKGROUND: The QT interval reflects the total duration of ventricular myocardial repolarization. Disturbed QT--either prolonged or shortened--is associated with arrhythmia and is life-threatening. OBJECTIVES: To investigate an elderly population for disturbed QT interval. METHODS: We conducted a cross-sectional study on residents of long-term care wards in a geriatric hospital. Excluded were those with pacemaker, atrial fibrillation or bundle branch block. The standard 12 lead and lead 2 electrocardiograms in the patients' files were used for the evaluation of QT interval. RESULTS: We screened the ECGs of 178 residents. QTc prolongation based on the mean 12 ECG leads was detected in 48 (28%), while 45 (25%) had prolonged QTc based on lead L2. Factors associated with QT prolongation were male gender, chronic renal failure and diabetes mellitus. Short QT was found in 7 residents (4%) and was not related to any parameter. CONCLUSIONS: About one-third of the elderly long-term care residents in our study had QT disturbances. Such a considerable number warrants close QT interval follow-up in predisposed patients.

Bacteremia in a multilevel geriatric hospital.

BACKGROUND: Bloodstream infection (BSI) is a major cause of morbidity and mortality in hospitals. Bacteremia in the elderly remains a diagnostic as well as a therapeutic challenge to the clinician. METHODS: We investigate the clinical features, microbiological characteristics, and outcome of bacteremic episodes in a mixed LTC elderly population in a multilevel geriatric hospital. Data of patients with the diagnosis of BSI (during 2 years) was collected retrospectively from the records of the bacteriology laboratory of a 400-bed multilevel geriatric hospital. RESULTS: During the 2 years of the study period, 3453 blood cultures have been performed; 368 positive blood cultures (10%) were detected in 309 patients. The total mortality rate at 2 weeks was 42%. One quarter of the deaths occurred in the first 3 days of the septic event (rapidly fatal period). Escherichia coli was the most common isolate (detected in 31% of cases). The second most common isolates were Staphylococcus aureus (19%; 63% of them MRSA) with a mortality of 39% and Proteus mirabilis (18%) with a 51% mortality rate. Urinary tract infection was the leading cause (70%), followed by decubitus ulcers (25%) and respiratory tract infections (12%). CONCLUSIONS: the number of elderly skilled patients with severe and complex conditions in LTC facilities is increasing and more infections complicated by bacteremia are expected, requiring high clinical suspicion, close surveillance, and adequate reporting.

Community physicians' knowledge on basic health care for elderly persons in Israel: comparing findings from 2006 to 1996.

Community physicians should be knowledgeable of basic geriatrics to cope with the challenges posed by the growing number of older patients and their complex needs. A survey of knowledge in basic health care for elderly persons, carried out by our team in 1996, revealed that it was insufficient. The authors repeated this survey in 2006, by using the same methodology, namely, a mailed questionnaire sent to 500 randomly sampled community physicians. No significant changes were found after this 10-year period. Likewise, no difference was evidenced between physicians that participated in geriatric training of any kind and those who did not. This lack of change requires health system leaders to coordinate their efforts and develop efficient teaching programs to prevent similar findings 10 years from now.

[The screen for caregiver burden of demented patients].

Most elderly individuals with dementia live in the community with the assistance of their caregivers, usually their family members. Their strength is essential for continuing home care and avoiding or postponing institutionalization. The screen for caregiver burden (SCB) is a 25 item scale, in use for the evaluation of caregivers of demented persons in the USA. A recent study in the USA showed that answers to 7 of those 25 questions, rapid screen for caregiver burden (RSCB), are sufficiently indicative and may replace and simplify the application of this questionnaire. In this study, the authors translated the SCB into Hebrew and tested it on 94 caregivers of demented elderly patients. The study results suggest that the shortened cluster of 7 items could also be used in Israel and is adequately indicative for the evaluation of the caregiver's burden.

Metabolic alkalosis in skilled nursing patients.

Renal failure is common among the long-term care (LTC) elderly. Little is known about the acid/base status of these patients. The aim of this study is to evaluate the relationship between the acid base status and renal function in a representative group of skilled nursing patients and relate it to their feeding status. LTC elderly patients, in stable clinical condition, 50 on naso-gastric tube (NGT) feeding, 40 orally fed (OF), were recruited to this study. As controls, we studied a group of 30 elderly independent, ambulatory patients admitted to the acute geriatric departments of the hospital for different causes which were not related to their acid-base status. Venous blood was taken for the routine tests and blood gases. In the LTC study groups a 24-h urine collection was examined for biochemical parameters and calculations of all clearances. Glomerular filtration rate (GFR) was estimated by the Cockroft and Goult and MDRD formulas. Renal function was similar in the two main study groups. Daily secretion of sodium and chloride were 50% lower in the NGT fed patients (p<0.001). The LTC elderly patients had significantly higher venous pH values, with no differences in pCO(2) or HCO(3). An alkalotic state (pH>7.45) was found in 13.6% of them (18% in the NGT and 6.5% in the OF) while none of the independent elderly had such values (p<0.05). Similarly, HCO(3)>34 was found in 12% of the LTC elderly versus none in the independents (p=0.06). Values of pO(2) and O(2) saturation were significantly higher in the nursing elderly and mainly those fed by NGT. Hemoglobin levels had a significantly negative correlation with the pH (r=-0.3, p<0.002). In conclusion, unexpected metabolic alkalosis was found in a group of skilled nursing patients, more prominent in those fed by NGT. This finding warrants the inclusion of routine pH determination in patients whenever pharmacokinetic considerations are essential.

Mortality of patients hospitalized for active tuberculosis in Israel.

BACKGROUND: Pulmonary tuberculosis continues to cause of mortality, particularly in developing countries. Despite modern anti-TB treatment, the elderly and immigrants from TB-endemic countries are at risk. Multidrug resistance has yet to be resolved.. OBJECTIVES: To determine the mortality rate and predictors of mortality among patients hospitalized with TB in Israel. METHODS: We evaluated the medical records of 461 patients with active pulmonary TB who were hospitalized in the respiratory care department during the 5 year period 2000-2004. Data included demographic, clinical, laboratory and radiological findings, drug resistance as well as adverse reactions to anti-TB treatment. RESULTS: Three main ethno-geographic groups were observed: 253 patients from the former USSR, 130 from Ethiopia, and 54 of Israeli origin (as well as 24 residents of other countries). Of the 461 patients 65 (13%) died in hospital. The factors that were best predictors of mortality were older age, ischemic heart disease, cachexia, prior corticosteroid treatment, hypoalbuminemia and pleural effusion (P < 0.005 for all). The ethno-geographic factor and the presence of multidrug-resistant bacteria had no significant effect on mortality in our study group. CONCLUSIONS: The mortality rate in our study was relatively low, and there was no significant difference between the three ethno-geographic groups.

Postprandial hypotension in long-term care elderly patients on enteral feeding.

OBJECTIVES: To examine the prevalence and nature of postprandial hypotension (PPH) in orally fed (OF), nasogastric tube (NGT)-fed, and percutaneous endoscopic gastrostomy (PEG)-fed older people. DESIGN: Prospective comparative study. SETTING: Nursing and skilled nursing wards of three geriatrics hospitals. PARTICIPANTS: Three groups (OF, PEG, NGT) of long-term care patients (50 in each cohort) were enrolled. MEASUREMENTS: Blood pressure (BP) and heart rate measurements were obtained just before lunch and at 15-minute intervals for 90 minutes after the completion of the meal. The meals were similar in caloric content and composition. RESULTS: PPH was evidenced in 64 (43%) patients. No significant intergroup (OF, PEG, NGT) differences were present. In 68% of PPH patients, the systolic BP (SBP) drop appeared within 30 minutes, and 70% reached their systolic nadir at 60 minutes. In 31%, the SBP drop was registered on only one measurement, whereas in 25%, the drop was detected on five to six measurements. All parameters were without notable intergroup differences. CONCLUSION: In enterally fed elderly patients (NGT or PEG), the rate and pattern of PPH are similar and not significantly different from that observed in OF patients.

Progressing stroke with neurological deterioration in a group of Israeli elderly.

Progressing stroke with neurological deterioration (PSND), i.e., neurological deterioration of patients during the first days following a stroke, although not an infrequent event, has hitherto been addressed only by few studies. This is the first investigation conducted in Israel with the aim to determine its prevalence and characteristics. Data regarding 140 patients with first ever stroke were collected prospectively between May 1999 and October 2000. All patients underwent a thorough daily neurological examination over the first 7 days, using the Canadian Neurological Scale. Most (90%), patients had hemiparesis, with dysarthria, aphasia and dysphagia being the most frequent associated neurological deficits. Thirty percent of the patients were on anti-aggregant therapy prior to the stroke. The prevalence of PSND was 23%. The 1-month in-hospital death rate of these PSND patients was 31%. Univariate analysis showed that previous anti-aggregant therapy, Parkinson's disease (PD), obesity, hyperlipidemia, and presence of aphasia were significantly more frequent in the PSND group. In addition, these patients arrived earlier to the emergency room. However, logistic regression analysis showed that only PD and obesity could possibly be considered as predictors for development of PSND. The prevalence as well as the death rate of PSND in this group of Israeli elderly is within the range reported in the literature. However, prior anti-aggregant treatment and PD, are here reported for the first time as associated conditions. Future research will possibly clarify the links between these entities and PSND.

Management of adverse clinical events by duty physicians in a nursing home.

BACKGROUND AND AIMS: The nature of adverse clinical events (ACE) during duty hours (16:00-08:00 and holidays), as well as the way they are addressed by duty physicians (DP) in a nursing home (NH) are the subject of this study. METHODS: Data, including medical details concerning ACEs and the resultant referrals to hospital, were collected prospectively during 183 consecutive days in a 90-bed NH. RESULTS: Ninety-six residents experienced 370 ACEs, representing an average of one for every 44.5 patient days. The highest rate of events was during evening hours (18:00-21:00). The most prevalent ACE was fever (32%). Most cases (53%) were treated by the DPs on site. No intervention was needed in 19% of cases, whereas 28% of ACEs (104 cases) were referred to the Emergency Room (ER) of a general hospital. Sixty-six percent of these were actually admitted. The rate of ER referral of residents was one for every 158 patient days. About 40% of the referred patients had been discharged from hospital the previous week. High fever was the commonest cause for referral: 47%. During the working hours of the study period, the rate of referral by the staff physician was only 1 for every 915 patient days. Only 17% of these had high fever. CONCLUSIONS: Evening rounds by staff physicians, strengthening of working relations with hospital physicians, as well as fostering intravenous treatment in NHs, are suggested as means for reducing hospital transfers. A standardized method for the reporting of ACEs and referrals to hospitals should be adopted in order to facilitate comparisons between NHs and to evaluate its use as a quality indicator.