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LTC and the Hospital

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?

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LTC and the Hospital

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  1. LTC and the Hospital Jeffrey P Schaefer, MD slide update available at dr.schaeferville.com

  2. Disclosure No conflicts of interests

  3. 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?

  4. Why are LTC patients admitted to hospital? … not much published data

  5. 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

  6. 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

  7. fairly flat over time

  8. 25 – 35 % prevalence of each

  9. community based controls

  10. 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

  11. Criteria for Transfer?

  12. Criteria for Transfer to Hospital? • JAMA.2006; 295: 2503-2510.

  13. Pneumonia is the best studied… • I found no publications for other conditions… • some are self evidence (hip#) • for others  expectations drive actions

  14. Randomly allocate Ontario Nursing homes to a Clinical Pathway versus Usual Care • 20 LTC facilities were enrolled

  15. 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

  16. Appropriateness of Transfer? Study: - retrospective - lacked criteria - but makes headlines - grain of truth

  17. 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

  18. Let me Decide (diamonds); Control (light squares) Bed days / Nursing Home Bed (control and intervention)

  19. Let me Decide (diamonds); Control (light squares) Mortality / 100 NH beds (control and intervention)

  20. Hazards of Hospitalization Ann Int Med 1993:118:219.

  21. 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’

  22. 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

  23. 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

  24. 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!

  25. 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

  26. What challenges face the LTC physician at discharge? • Tell me your stories…

  27. 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

  28. LTC  Hospital (ER Bypass) Admit to Acute Care Unit GIM / FamMed Attending Consultations as needed Psycho-Soc Intensive Symptom – Sign – Lab Result Protocol Driven Responses Day Unit Assessment & Re-assessments (e.g. RGH Day Med) LTC Physician Assessment telephone Manage at LTC (+/- external support) Acute Care Unit for LTC Consulting Physician

  29. Thank you! • Contact: jpschaef@ucalgary.ca dr.schaeferville.com

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