Do‐Not‐Hospitalize Orders in Nursing Homes: “Call the Family Instead of Calling the Ambulance”

Cohen, Andrew; Knobf, RN M. Tish; Fried, Terri R.

doi:10.1111/jgs.14879

Cited by 26 publications

(28 citation statements)

References 26 publications

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“…ACP helps support informed, values‐based decision making that is essential to decision quality and improving end‐of‐life care . In the absence of recorded preferences for treatment, staff and providers act on system defaults and provide all available interventions …”

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confidence: 99%

“…4 In the absence of recorded preferences for treatment, staff and providers act on system defaults and provide all available interventions. 5 A primary goal of ACP is to ensure that care provided is concordant with patient goals. 6 In nursing facilities, residents and family members of incapacitated residents frequently elect to focus on comfort and avoid hospital transfers.…”

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Systematic Advance Care Planning and Potentially Avoidable Hospitalizations of Nursing Facility Residents

Hickman

Unroe

Ersek

et al. 2019

J American Geriatrics Society

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BACKGROUND/OBJECTIVES The Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project is a successful, multicomponent demonstration project to reduce potentially avoidable hospitalizations of long‐stay nursing facility residents. Systematic advance care planning (ACP) is a core component of the intervention, based on research suggesting ACP is associated with decreased hospitalizations of nursing facility residents. The purpose of this study was to describe associations between ACP documentation resulting from the OPTIMISTIC intervention and hospitalizations. DESIGN Specially trained project nurses were embedded in 19 nursing facilities and systematically engaged in ACP as part of a larger demonstration project. PARTICIPANTS Residents (n = 1482) enrolled in the demonstration project for a minimum of 30 days between January 1, 2015, and June 30, 2016. MEASUREMENTS ACP status: (1) Physician Orders for Scope of Treatment (POST) comfort measures or do not hospitalize (DNH) orders; (2) ACP orders with no hospitalization limit (eg, code status only); and (3) no ACP (potentially avoidable and all‐cause hospitalizations per 1000 resident days). RESULTS Residents with POST comfort measures/DNH orders (33.2% or n = 493) were less likely than residents with no ACP (14.7% or n = 218) to experience a potentially avoidable hospitalization (P = .001) or all‐cause hospitalization (P = .001). These differences became statistically nonsignificant after adjusting for age, functional status, and cognitive functioning. CONCLUSION In this successful multicomponent demonstration project to reduce potentially avoidable hospitalizations, ACP outcomes were not associated with hospitalization rates of nursing facility residents after adjusting for resident characteristics. These findings highlight the challenge of measuring the contributions of individual components of complex, multicomponent interventions. Associations between lower hospitalization rates and ACP completion may be influenced by contextual factors, such as clinical expertise and resources to manage acute conditions leading to hospitalization, in addition to interventions to increase ACP. J Am Geriatr Soc 67:1649–1655, 2019

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confidence: 99%

Systematic Advance Care Planning and Potentially Avoidable Hospitalizations of Nursing Facility Residents

Hickman

Unroe

Ersek

et al. 2019

J American Geriatrics Society

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“…75% agreement, resp.). Nevertheless, only a minority of residents is estimated to have a personal AD [64] and problems in their use such as the often insufficient specificity are known [40,64,65]. Advance care planning (ACP) aims to discuss and record patient preferences concerning goals of care in the case of physical or mental deterioration [66] and a German study showed that its implementation leads to a better adoption of ADs in NHs [67].…”

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confidence: 99%

Perspectives of general practitioners and nursing staff on acute hospital transfers of nursing home residents in Germany: results of two cross-sectional studies

et al. 2020

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Background: Visits in emergency departments and hospital admissions are common among nursing home (NH) residents and they are associated with significant complications. Many of these transfers are considered inappropriate. This study aimed to compare the perceptions of general practitioners (GPs) and NH staff on hospital transfers among residents and to illustrate measures for improvement. Methods: Two cross-sectional studies were conducted as surveys among 1121 GPs in the German federal states Bremen and Lower Saxony and staff from 1069 NHs (preferably nursing staff managers) from all over Germany, each randomly selected. Questionnaires were sent in August 2018 and January 2019, respectively. The answers were compared between GPs and NH staff using descriptive statistics, Mann-Whitney U tests and χ2-tests. Results: We received 375 GP questionnaires (response: 34%) and 486 NH questionnaires (response: 45%). GPs estimated the proportion of inappropriate transfers higher than NH staff (hospital admissions: 35.0% vs. 25.6%, p < 0.0001; emergency department visits: 39.9% vs. 20.9%, p < 0.0001). The majority of NH staff and nearly half of the GPs agreed that NH residents do often not benefit from hospital admissions (NHs: 61.4% vs. GPs: 48.8%; p = 0.0009). Both groups rated almost all potential measures for improvement differently (p < 0.0001), however, GPs and NH staff considered most areas to reduce hospital transfers importantly. The two most important measures for GPs were more nursing staff (91.6%) and better communication between nursing staff and GP (90.9%). NH staff considered better care / availability of GP (82.8%) and medical specialists (81.3%) as most important. Both groups rated similarly the importance of explicit advance directives (GPs: 77.2%, NHs: 72.4%; p = 0.1492). Conclusions: A substantial proportion of hospital transfers from NHs were considered inappropriate. Partly, the ratings of possible areas for improvement differed between GPs and NH staff indicating that both groups seem to pass the responsibility to each other. These findings, however, support the need for interprofessional collaboration.

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“…75% agreement, resp.). Nevertheless, only a minority of residents is estimated to have a personal AD [63] and problems in their use such as the often insufficient specificity are known [40,63,64]. Advance care planning (ACP) aims to discuss and record patient preferences concerning goals of care in the case of physical or mental deterioration [65] and a German study showed that its implementation leads to a better adoption of ADs in NHs [66].…”

Section: Harrison Et Al [39] Used a Series Of Vignettes Based On Commentioning

confidence: 99%

Perspectives of General Practitioners and Nursing Staff on Acute Hospital Transfers of Nursing Home Residents in Germany: Results of two cross-sectional Studies

Fassmer

Pulst

Spreckelsen

et al. 2020

Preprint

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Background: Visits in emergency departments and hospital admissions are common among nursing home (NH) residents and they are associated with significant complications. Many of these transfers are considered inappropriate. This study aimed to compare the perceptions of general practitioners (GPs) and NH staff on hospital transfers among residents and to illustrate measures for improvement.Methods: Two cross-sectional studies were conducted as surveys among 1,121 GPs in the German federal states Bremen and Lower Saxony and staff from 1,069 NHs (preferably nursing staff managers) from all over Germany, each randomly selected. Questionnaires were sent in August 2018 and January 2019, respectively. The answers were compared between GPs and NH staff using descriptive statistics, Mann-Whitney U tests and χ2-tests.Results : We received 375 GP questionnaires (response: 34%) and 486 NH questionnaires (response: 45%). GPs estimated the proportion of inappropriate transfers higher than NH staff (hospital admissions: 35.0% vs. 25.6%, p<0.0001; emergency department visits: 39.9% vs. 20.9%, p<0.0001). The majority of NH staff and nearly half of the GPs agreed that NH residents do often not benefit from hospital admissions (NHs: 61.4% vs. GPs: 48.8%; p=0.0009). Both groups rated almost all potential measures for improvement differently (p<0.0001), however, GPs and NH staff considered most areas to reduce hospital transfers importantly. The two most important measures for GPs were more nursing staff (91.6%) and better communication between nursing staff and GP (90.9%). NH staff considered better care / availability of GP (82.8%) and medical specialists (81.3%) as most important. Both groups rated similarly the importance of explicit advance directives (GPs: 77.2%, NHs: 72.4%; p=0.1492).Conclusions : A substantial proportion of hospital transfers from NHs were considered inappropriate. Partly, the ratings of possible areas for improvement differed between GPs and NH staff indicating that both groups seem to pass the responsibility to each other. These findings, however, support the need for interprofessional collaboration.

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Do‐Not‐Hospitalize Orders in Nursing Homes: “Call the Family Instead of Calling the Ambulance”

Cited by 26 publications

References 26 publications

Systematic Advance Care Planning and Potentially Avoidable Hospitalizations of Nursing Facility Residents

Systematic Advance Care Planning and Potentially Avoidable Hospitalizations of Nursing Facility Residents

Perspectives of general practitioners and nursing staff on acute hospital transfers of nursing home residents in Germany: results of two cross-sectional studies

Perspectives of General Practitioners and Nursing Staff on Acute Hospital Transfers of Nursing Home Residents in Germany: Results of two cross-sectional Studies

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