Nursing Home Adverse Events: Further Insight into Highest Risk Periods Malcolm Doupe, PhD, Marni Brownell, PhD, Phillip St. John, MD, MPH, FRCPC, David G. Strang, MD, FRCPC, Dan Chateau, PhD, and Natalia Dik, MSc Introduction: Adverse events (AEs) occur frequently in nursing homes (NHs). Although the literature iden- tifies several AE risk factors, the effect of resident transition on AE risk is less well defined. This article is the first to describe how AE risk varies across several NH transition periods and to define the most vulnera- ble junctures of an NH stay. Methods: This research was conducted on the popula- tion of NH residents in Manitoba, Canada, from April 1, 1999, to March 31, 2004. AEs were captured using physician-based diagnostic claims for hip fractures, other fractures, hospitalized falls, skin ulcers, and re- spiratory infections. AE rates were compared across several transition periods (eg, following first NH ad- mission from hospital versus elsewhere, after NH transfer, and preceding resident death), before and after adjustment for several resident demographic, clinical, and facility-level factors. Results: Although residents (n 5 22,846) spent only 6.6% of all NH days in transition, between 15.3% (skin ulcers) and 27.8% (respiratory infections) of AEs occurred during these times. Except following NH transfers, adjusted AE rates were consistently higher during all transition versus nontransition pe- riods. Among transition periods, adjusted hip frac- tures, hospitalized falls, and respiratory infections were most strongly associated with resident death. Adjusted skin ulcer and non–hip fracture rates were equally highest during ‘‘pre-death’’ and fornew resi- dents admitted from hospital. Conclusions: This article is the first to identify the most vulnerable times of a NH stay. For newly admit- ted residents, our results also show that previous ex- posure to a hospital environment, and not simply resident illness, at least partially contributes to in- creased AE risk. This and additional evidence can help clinicians and administrators to better identify periods of high risk for NH residents, and also to de- velop more targeted care improvement strategies. More robust and frequently obtained measures of resident illness are required to further examine these issues in more detail. (J Am Med Dir Assoc 2011; 12: 467–474) Keywords: Nursing home; adverse events; high-risk periods Nursing homes (NHs) in Canada provide long-term per- sonal and health services to people with chronic illnesses and disabilities. 1 These environments have become increas- ingly complex as residents today have more extensive func- tional disabilities, medical comorbidities, and cognitive impairment. 2,3 Lengths of NH stay in Canada have also decreased 2 so that residents now spend more of their time in transitional periods, such as following admission and when approaching death. Several researchers have investigated the determinants of NH adverse events (AEs), 4,5 showing how AE risk is influ- enced by clinical measures, 6–8 NH ownership type, 7,9 and fa- cility staff volume and/or turnover. 10–13 With some exceptions, 14–16 this literature does not identify especially high-risk periods of NH stay. Further identification of these high-risk junctures enables clinicians and administrators to develop more targeted NH care strategies. This article is the first to describe variation in AE risk across multiple transition periods. Specifically, our objectives Faculty of Medicine, Department of Community Health Sciences, Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Canada (M.D.); Faculty of Medicine, Manitoba Centre for Health Policy, University of Mani- toba, Winnipeg, Canada (M.B.); Department of Internal Medicine, University of Manitoba, Winnipeg, Canada (P.S.J.); Department of Medicine, University of Manitoba and Deer Lodge Centre, Winnipeg, Canada (D.G.S.); Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Canada (D.C., N.D.). The authors acknowledge the Manitoba Centre for Health Policy for use of data contained in the Population Health Research Data Repository under project #(2004/2005-02). The results and conclusions are those of the authors and no official endorsement by the Manitoba Centre for Health Policy, Man- itoba Health, or other data providers is intended or implied. The authors have declared no conflicts of interest. Address correspondence to Malcolm Doupe, PhD, Faculty of Medicine, De- partment of Community Health Sciences, Manitoba Centre for Health Policy, University of Manitoba, 408–727 McDermot Avenue, Winnipeg, MB, Canada R3E 3P5. E-mail: Malcolm_Doupe@cpe.umanitoba.ca Copyright Ó2011 American Medical Directors Association DOI:10.1016/j.jamda.2011.02.002 ORIGINAL STUDIES Doupe et al 467