Jane, June and John are long-stay nursing home residents who have recently been transferred to hospital.
Jane, 82, was admitted for a urinary tract infection and dehydration. Discharged after 4 days, she returned a week later for the same condition.
June, 91, landed in the ER for her cough. Her vital signs and oxygen saturation were normal, but questions about her chest x-ray and falsely elevated enzyme test led to admission for possible lower respiratory infection. While in hospital, she developed delirium and fell, fracturing her pubic bone.
John, 95, has end-stage Alzheimer’s. He was hospitalized for the fourth time in two months for aspiration pneumonia. During this fourth admission, his family finally consented to hospice transfer.
Which, if any, of these transfers were necessary?
The answer, according to Dr. Joe Ouslander, is none of them. In fact, they may have done more harm than good.
When risk outweighs reward
Dr. Joe, Chair of the Integrated Medical Science Department and Senior Associate Dean of Geriatric Programs in FAU’s Charles E. Schmidt College of Medicine has made many contributions to the field of geriatric medicine. INTERACT (Interventions to Reduce Acute Care Transfers) is the one he’s most proud of. INTERACT is a quality improvement program that helps long-term care facilities and programs improve care and reduce unnecessary – and often risky – hospitalizations.
“There is a high incidence of acute confusion and delirium when vulnerable older people go in hospital,” says Dr. Joe. “They get put on complicated, expensive drug regimens that make them prone to falls and injuries. And even two or three days in bed can lead to immobility and make people prone to pressure ulcers. The best way to prevent these and other complications? Don’t send them to the hospital if you can safely manage them where they are.”
Hospital transfers are common. Around 1 in 5 patients admitted to a skilled nursing facility (SNF) from a hospital are readmitted within 30 days. And for every filled nursing home bed in the US, there are around two emergency department (ED) visits – approximately 3 million each year. A little over half of those ED visits resulted in discharge, with about 63% of patients presenting with normal vital signs and close to 20% not requiring any diagnostic tests.
With his INTERACT Program, Dr. Joe aims to safely reduce unnecessary transfers to the hospital, improve quality of care, decrease morbidity and complications and decrease necessary costs. “Why are people being sent from an SNF to an ED with normal vital signs, and then they’re seen by clinicians who don’t think they need a test? We can’t keep paying for things that are not effective, potentially harmful, and costly – it just doesn’t make sense.”
Turning strategies into action
The INTERACT Program contains care paths and tools clinicians and other healthcare providers can use in their everyday practice. The tools target three key strategies to reduce potentially avoidable hospitalizations: managing selected acute conditions in the nursing home; preventing conditions from becoming severe enough to require acute hospital care; and improving advance care planning for residents for whom a palliative or comfort care plan, rather than acute hospitalization, may be appropriate.
While they can be used as paper tools, INTERACT integrates seamlessly with EHR software programs and electronic order sets. “According to a report published by the Office of the Inspector General, the chance of incurring an adverse event in the first 45 days of admission to an SNF is about 27%,” says Dr. Joe. “Of those, about 2/3 were thought to be preventable. That’s why we’re excited about electronic order sets, because they help prevent those adverse events. I’d like to see them used more around the world.”
Using INTERACT’s standardized protocol and working with an on-call nurse practitioner who visits the nursing home daily, residents can receive care in the nursing home without complications and at a much lower cost.
What does this mean at the point of care? With early detection and evaluation tools, Jane’s UTI and dehydration could have been observed, managed and documented in the nursing home; with careful monitoring and observation, June could have remained in her residence; with improved advance care planning and communication with his family, John could have been admitted to hospice initially rather than hospital for a condition that will occur over and over again.
“INTERACT is not meant to be a notebook on a shelf – it’s meant to be tools that people can use in their everyday practice. Education is important, but it’s not sufficient to change behaviour and outcomes. You need tools.”
- The Revolving Door of Rehospitalization From Skilled Nursing Facilities
- JAMDA: Identifying Potentially Preventable Emergency Department Visits by Nursing Home Residents in the United States
- Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries