Will This Admission Help? Leonard Hock, D.O., CMD Covenant Hospice
Chronic patients in Acute Care • Emergency rooms serve chronic patients • About 50% of hospital admissions come from the Emergency Department • ER physicians and staff often recognize patients at the door • Frequent fliers • Gomers • Exasperation and frustration with limited choices in the ER
Sick People Get Admitted • The options of care are limited in the ER • Sick people get admitted • An acute process in a chronic patient is usually seen as an acute action point. • Case management in the ER usually means “get an ICU bed right away.” • Once in the ER, living wills and advanced directives are secondary to care.
Admissions Myths • Best care for the patient. • Families expect admission. • Admissions equal census and that’s good for the hospital.
Will this admission help? • Help? • Improve the condition? • Lengthen life? • Improve quality of life? • Respect the patient’s wishes? • Be the best option of care?
Family Expectations • 80% of Americans believe every death is due to a medical failure. • Then, what they need is education about the facts. • Not the numbers, but the facts about the person they love. • What is the diagnosis, the prognosis the likely outcome for this person.
Admissions and Census • When patients can have a diagnosis, a treatment and a likely improvement they should be admitted. • When the diagnosis is terminal, treatment is futile and improvement not achievable, the admission will be frustrating, risky, long and expensive.
Are there options? • Safety first • For the patient • For the hospital • Get the facts • Previous decisions • Previous declarations • Living will, advanced directives, hospice pt.
Options • Admit. • Admit with limits and endpoints. • Return to home or nursing home with treatment and follow up. • Involve hospice as an option of care.
Evidence Based Decisions • Previous admissions with no improvement • Multiple chronic disease processes • Overwhelming multi system failure • End-stage disease that is finally end-stage • Data consistent with terminal condition • Family input consistent with end-of-life
C.A.R.I.N.G. • Cancer • Admissions • Resident • ICU • Non cancer • Guidelines • Fischer et al, Journal of Pain and Symptom Management, April ‘06
C.A.R.I.N.G. • Simple • Retrievable • No testing required • Part of basic medical history • Useful • On-the-spot decision making
Cancer • Primary Cancer diagnosis? • Active diagnosis of cancer?
Admissions • Two (2) or more admissions to the hospital for a chronic illness within the last year.
Resident of a nursing home • Being a nursing home resident identifies that there is some debility, frail state or chronic disease.
ICU • Recent ICU admission with Multiorgan Failure (MOF).
Non Cancer • Non cancer diagnosis on Hospice service.
Guidelines • Used in the Emergency Dept. prior to admission. • Identify patients with limited life expectancy. • On-the-spot decision making • To have the discussion about options of care.
Results • 49% of Medical Service admissions met one or more of the CARING criteria. • 26% of Medical Service admissions died within one year. • Age mattered.
Results • As expected, the more CARING criteria met, shorter was the length of life. • The highest valued indicator was Chronic Disease on Hospice service. • The lowest was Nursing Home resident.
ICU Palliative Care • ICU admit from a regular hospital admission (avg. 10 days). • > 80 y/o with two (2) serious co morbid diagnosis. • Active metastatic cancer. • Status post cardiac arrest. • CVA requiring mechanical ventilation. Norton et al, Proactive Palliative Care in the ICU, Critical Care Medicine, 2007
Outcomes • 26% of ICU admissions met criteria. • With palliative/hospice referral the ICU stay was one week shorter without a difference in mortality. • Quality of life and symptom control was the focus of care. • $50, 000 per patient saved.
Opportunities • Quick and easy to remember criteria. • Highly predictive of death in one year. • Helps identify futile hospital admissions. • Admissions that are often long expensive and do not add days or quality to life. • A time to start or continue the discussion about options of care.
Options of Care • Aggressive diagnosis and treatment • Regular or routine care • Palliative Care • Symptom relief • Hospice Care • Symptom relief at the end-of-life • Where and how?