Download Will This Admission Help?

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
A Study
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.
Another Study
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?
Thank you