will this admission help? leonard hock, d.o., cmd covenant hospice
TRANSCRIPT
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