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LTC and the Hospital
Jeffrey P Schaefer, MD
slide update available at
dr.schaeferville.com
Disclosure
No conflicts of interests
Eight Questions…
• How often & why are LTC patients admitted to hospital?
• Do criteria for transfer to acute care exist?• Has ‘appropriateness of transfer’ been studied?• Are there local alternatives to hospital transfer?• What has been tried elsewhere?• What challenges face the acute care providers?• What challenges face the LTC provider post-d/c• Can we do better?
Why are LTC patients admitted to hospital?
… not much published data
How often & why are LTC patients admitted to hospital?
• Hip fracture• Pneumonia• Stroke• Chest pain• Heart Failure• Anemia
Tidsskr Nor Laegeforen. 2005 Jun 30;125(13):1844-7
American J Public Health 1994:84:1615
• Retrospective cohort of 2,120 nursing home patients that were initially admitted to their facility in 1982 and followed.
• Munroe County, New York State
• fairly flat over time
25 – 35 % prevalence
of each
• community based controls
Predictors of Hospitalization
• Bedbound (11%) vs ambulant (26%)
• On-site Physician (21%) vs none (28%)
• Male (29%) vs female (25%)
• Co-morbidity not statistically sig
Criteria for Transfer?
Criteria for Transfer to Hospital?
– JAMA.2006; 295: 2503-2510.
• Pneumonia is the best studied…
• I found no publications for other conditions… – some are self evidence (hip#)
– for others expectations drive actions
• Randomly allocate Ontario Nursing homes to a Clinical Pathway versus Usual Care
• 20 LTC facilities were enrolled
Results
Pathway Usual
Hospitalizations 8% 20% sig
Hosp days / res 0.79 1.74 sig
ER, not admit 1.2% 1.6% nd
Death 3.1% 6.0% nd
Falls 11% 10% nd
T to N of v/s 2.5 2.7 nd
Appropriateness of Transfer?
Study:
- retrospective
- lacked criteria
- but makes headlines
- grain of truth
• What is the effect of: ‘Let me Decide’ on hospitalization of LTC residents (Australia)
• “Let me decide”– education: family, patients, care providers– advanced care planning create a Directive
• Setting provided IV abx & transfusions
Bed days / Nursing Home Bed (control and intervention)
Let me Decide (diamonds); Control (light squares)
Mortality / 100 NH beds (control and intervention)
Let me Decide (diamonds); Control (light squares)
Hazards of Hospitalization Ann Int Med 1993:118:219.
Local Alternatives
• JP Schaefer – Survey of Local Providers– HPTP Clinic – some MD’s accept– Wound Care Clinic – at least one does– IM Urgent Assessment Clinic - No– Day Medicine – some MD’s accept– Individual Specialists – few do ‘housecalls’
What has been tried elsewhere?
• What is the effect of direct admission to a focused unit in comparison to transfer to Emergency Department
• Retrospective – quasi-experimental design
Protocol
• 24 bed acute care geriatric unit
• multidisciplinary
• within a 210 bed geriatric facility
• primary care MD’s telephone in
• receiving MD’s admit according to protocol– no surgery– no ICU
Results
• 80 direct admits compared to 46 ER admits
• Deaths: 3 (all from ER) nd
• LOS: 12.5 day direct, 11.7 day ER nd
• Functional Status: nd
• 80 ER admits avoided!
What challenges face the acute care providers?
• Communication Issues– Level of Care and Expectations– Family Spokesperson (Spokespeople)– Usual Physician or Care Provider
• Medical Issues at Presentation– History of new Problem– What is the baseline level of functioning?– Medical Problem List
• Medical Issues after Presentation– Avoidance of Iatrogenesis– Medication Reconciliation– Post-discharge Care
What challenges face the LTC physician at discharge?
• Tell me your stories…
Opportunities…
• 58 new beds at RGH April 2008
• 50+ new beds at PLC 2008-9
• ?? beds at FMC (renovations needed)
• 2010 365 beds South Campus
LTC Hospital (ER Bypass) Symptom – Sign – Lab Result
Protocol DrivenResponses
LTC Physician Assessment
Acute Care Unit for LTC Consulting Physician
telephone
Manage at LTC(+/- external support)
Day Unit Assessment& Re-assessments(e.g. RGH Day Med)
Admit to Acute Care UnitGIM / FamMed AttendingConsultations as needed
Psycho-Soc Intensive
