LTC and the Hospital

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LTC and the Hospital

• Jeffrey P Schaefer, MD
• slide update available at
• dr.schaeferville.com

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Disclosure

• No conflicts of interests

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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?

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Why are LTC patients admitted to hospital?

• not much published data

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How often why are LTC patients admitted to
hospital?

• Hip fracture
• Pneumonia
• Stroke
• Chest pain
• Heart Failure
• Anemia
• Tidsskr Nor Laegeforen. 2005 Jun
  30125(13)1844-7

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American J Public Health 1994841615

• Retrospective cohort of 2,120 nursing home
  patients that were initially admitted to their
  facility in 1982 and followed.
• Munroe County, New York State

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• fairly flat over time

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• 25 35
• prevalence
• of each

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• community based controls

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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

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Criteria for Transfer?
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Criteria for Transfer to Hospital?

• JAMA.2006 295 2503-2510.

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

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

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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

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Appropriateness of Transfer?

• Study
• - retrospective
• - lacked criteria
• - but makes headlines
• - grain of truth

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• 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

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Let me Decide (diamonds) Control (light squares)
Bed days / Nursing Home Bed (control and
intervention)
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Let me Decide (diamonds) Control (light squares)
Mortality / 100 NH beds (control and intervention)
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Hazards of Hospitalization Ann Int Med
1993118219.
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Local Alternatives

• JP Schaefer Survey of Local Providers
• HPTP Clinic some MDs accept
• Wound Care Clinic at least one does
• IM Urgent Assessment Clinic - No
• Day Medicine some MDs accept
• Individual Specialists few do housecalls

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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

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Protocol

• 24 bed acute care geriatric unit
• multidisciplinary
• within a 210 bed geriatric facility
• primary care MDs telephone in
• receiving MDs admit according to protocol
• no surgery
• no ICU

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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!

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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

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What challenges face the LTC physician at
discharge?

• Tell me your stories

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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

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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
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Thank you!

• Contact jpschaef_at_ucalgary.ca
• dr.schaeferville.com