Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

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Reducing Unnecessary Hospitalizations of Nursing Home Residents

Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

Today in the New England Journal of Medicine there is a perspective piece on something near, and dear, to all of our hearts – unnecessary hospital admissions from nursing homes.

A lot of nursing home patients could be treated on site, without calling an ambulance to take them to the ED (Emergency Department) to produce large bill, but maybe not any better care.

More than 1.6 million Americans live in nursing homes. Hospitalizations are common in this population; in 2006, 23.5% of the people admitted to a post-acute-care skilled-nursing facility were rehospitalized within 30 days.1 Several studies suggest that many of these hospitalizations are inappropriate, avoidable, or related to conditions that could be treated outside the hospital setting — and they cost more than $4 billion per year.1-3 Avoidable hospitalizations are also common among long-stay residents of nursing homes (see graphs Unavoidable and Potentially Avoidable Hospitalizations of Nursing Home Residents Eligible for Both Medicare and Medicaid, 2005.).2-4[1]

Click on the image to make it larger.

In addition, nursing homes have a financial incentive to hospitalize residents who have Medicaid coverage, because after a 3-day inpatient stay, the resident may qualify for Medicare Part A payment for post-acute care in the nursing home at three to four times the daily rate paid by Medicaid.4[1]

I knew it.

I knew it.

I knew it.

I knew it.

I . . . .

Two caveats are critical. First, not all hospitalizations for conditions that can theoretically be managed outside an acute care hospital are preventable. Second, given fiscal constraints and the dearth of health care professionals trained in geriatrics and long-term care, not all nursing homes have the capacity to safely evaluate and manage changes in the condition of the clinically complex nursing home population.[1]

Inother words, the patient may be a stable transport to the hospital for a stay of a couple of days, but if the nursing home is not prepared to provide the necessary care, the patient could be unstable by the time an ambulance is called.

Unstable means that we will want to see a valid prehospital DNR (Do Not Resuscitate) order in Pennsylvania. Anything that is not a prehospital DNR and we are supposed to call medical command to receive permission to obey the patient’s wishes clearly documented on a valid legal document. Of course, this is presuming that the nursing home is able to provide any documentation at all.

A note, from the nursing home doctor on a prescription pad pretending to be a DNR order, should result in malpractice charges against the doctor. Not that I have any opinion on the matter, but we should expect more responsible behavior from Dr. Conrad Murray.

You’ve never seen a prescription written in crayon? OK, I haven’t either, but a DNR on a prescription pad is no less valid in crayon than in ink, or even in invisible ink. This is a non-DNR. What does the patient not want done? Who authorized this? Based on what consultation with the patient or family or court appointed representative? The incoherent rambling of dementia are no less valid.

Interventions designed to reduce preventable hospitalizations should therefore be directed at facilities that have the infrastructure, leadership commitment, and culture of quality and safety necessary to undertake more acute care.[1]

I have been impressed lately by some of the nursing home nurses. In different facilities, I have been told, The patient needs IV antibiotics. We can do that here. I don’t know why the doctor is sending the patient to the hospital for something we can provide here.

Maybe the nurses are getting a bit rogue and are not feeling that they are providing good care to their patients by just transferring a patient to the hospital every time the patient has a fever that lasts more than a few hours.

If you were the patient, would you prefer to be placed in an ambulance, on a thin mattress, bounced along just over the rear axle in this ambulance truck, to go to the ED. At the ED, the doctor does not know you, generally does not have all of the documentation he would want (DNR, living will, . . . ) to understand how aggressive to be in treatment. Then you may be admitted for a few days to build up strength for the return ambulance ride.

In many areas of the United States, realistic concerns about legal liability, as well as satisfaction on the part of nursing home residents and their families, affect hospitalization patterns. Thus, tort reform that limits liability for poor outcomes unrelated to the quality of care, and education of residents and families about realistic goals for care and advance care planning that considers the risks as well as benefits of hospitalization, can be key to reducing preventable hospitalizations.[1]

Imagine having the patient, the family, the nursing home staff, and the doctor all communicating about what is best for the patient,


[1] Reducing Unnecessary Hospitalizations of Nursing Home Residents
Joseph G. Ouslander, M.D., and Robert A. Berenson, M.D.
N Engl J Med 2011; 365:1165-1167September 29, 2011
Free Full Text from NEJM

Joseph G. Ouslander, M.D., and Robert A. Berenson, M.D. (2011). Reducing Unnecessary Hospitalizations of Nursing Home Residents N Engl J Med , 365 (September 29, 2011), 1165-1167