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