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Addressing needs of long-term care facility residents during acute hospitalization.

Staying in a long-term care facility (LTCF) or skilled nursing facility (SNF) serves as a vital bridge between acute hospitalization and a return to regular lives for many patients. According to the Centers for Disease Control and Prevention (CDC), a daily average of 1,383,700 people resided in LTCFs in 2013 (Harris-Kojetin, Sengupta, Park-Lee, & Valverde, 2013). These residents often had multiple comorbid conditions that could lead to acute care admission with exacerbation. They also have special care considerations that offer more challenges than the average hospitalized patient. Residents could benefit if hospitals formed partnerships with LTCFs to improve care transitions, reduce readmission rates, and improve the quality of life.


In June 2013, over 15,600 LTCFs were licensed in the United States (American Health Care Association, 2013). Their management is complicated and varies from state to state, with no direct oversight from the federal government. Additionally, residents are not classified easily. While many of them stay for a relatively short time, a minority of residents require long-term care. Wysocki and co-authors (2014) found most persons are discharged from a LTCF within approximately 90 days of admission. Patients who stay longer often spend several months or even years in LTCFs.

Reasons for Hospital Admission

Residents of LTCFs are transferred to the hospital for varied reasons. A study by Grunier and colleagues (2010) examined the frequency and pattern of resident transfers to hospital and found the three most common reasons for transfer to be heart failure (15.9%), urinary tract infection (UTI) (20.3%), and pneumonia (30.1%). Additional factors contributing to hospital transfers identified by Berkowitz, Schreiber, and Paasche-Orlow (2012) were lack of rapid laboratory testing, intravenous fluid and medications, and medical personnel; inadequate assessments; poor communication; and no advanced directives.


According to the Infectious Disease Society of America (IDSA) (High et al., 2009), residents of LTCFs are at great risk for infection because many of them are older adults with multiple comorbid health conditions. To compound this care challenge, many LTCFs have fewer staff and lack the tools to diagnose infections found commonly in hospitals. Additionally, fever as the most common symptom of infection may not be present in up to half of residents with a serious infection.

The first signs used to diagnose any infection are alterations in functional ability (High et al, 2009). These alterations can manifest in many ways, including new or increased incontinence, confusion, or falls, as well as decreased mobility, appetite, or cooperation with staff. Fever, the second sign of infection, is defined by the IDSA as a single oral temperature greater than 100[degrees] F (37.8[degrees] C) (High et al., 2009). Fever also can be diagnosed with two consecutive oral temperatures greater than 99[degrees] F (37.2[degrees] C), rectal temperature of 99.5[degrees] F (37.5[degrees] C), or an increase in baseline temperature greater than 2[degrees] F (1.1[degrees] C). Nurses should investigate these changes.

The IDSA recommended LTCFs have the basic ability to diagnose and treat residents' infections (High et al., 2009). This includes access to basic laboratory testing as well as advanced practice nurses, physician assistants, or physicians on staff to evaluate patients. If UTI is suspected, the next low-cost method to confirm diagnosis is a urinalysis and urine culture. If pneumonia is suspected, pulse oximetry should be preformed to assess for hypoxia. If the resident's respiratory rate is high and/or the oxygen saturation is below 90%, transfer to a hospital is warranted. In both cases, a complete blood count with differential is the next step in diagnosis. Careful evaluation is needed if the white blood cell (WBC) count is elevated (>14,000 cell/[mm.sup.3]) or a shift to the left is seen (percentage of band neutrophils or metamyocytes >6% of WBC count; or total band neutrophil count is [greater than or equal to]1,500 cell/mm3). Transfer to a hospital may be necessary, especially if suspected pneumonia causes the resident to be tachypneic or hypoxic.

Heart Failure

Heart failure is a complex disease resulting from structural or functional impairment of ventricular filling or ejection of blood. Heart failure has an absolute mortality rate of 50% within 5 years of diagnosis and accounts for more than one million hospital admissions annually (American Heart Association [AHA], 2013). According to the CDC, approximately 5.1 million people in the United States have heart failure; costs of direct medical care and missed work days reach $32 billion annually (Harris-Kojetin et al., 2013).

Heart failure is a chronic, progressive disease marked by the heart's inability to pump enough blood to address the body's demand for oxygen. To compensate, the heart initially becomes enlarged and then blood vessels constrict to help maintain adequate blood pressure. Subjective findings for heart failure include fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachycardia, edema, nocturia, dusky, diaphoresis, behavioral changes, and chest pain (AHA, 2013).

Because no cure exists, treatment of heart failure focuses on alleviating symptoms. Generally, a combination of beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics are used (AHA, 2013). For nurses in LTCFs, astute physical examination and early intervention to prevent exacerbation is the best way to keep a resident from needing transfer to a hospital.

Conservatorship/ Guardianship

Many residents of LTCFs have their medical care guided by a conservatorship. The terms conservatorship and guardianship generally are synonymous as related to medical decision making. However, guardianship is associated more closely with the care of minors. Medical conservatorship refers to the process in which a third party is able to make decisions for an adult who is unable to make decisions. Although conservatorship laws vary from state to state, generally anyone with an interest in the well-being of a resident (family members, friends, clinicians, or social workers) may become a conservator. In addition, many states have public conservator programs for persons without available friends or family, or resources to pay for their care (Guzman-Clark, Reinhardt, Schantz-Wilkins, & Castle, 2012).

Creation of a conservatorship begins when an interested party files a petition with the court to allow him or her to take control of a resident's care. The court then investigates the case, reviews medical records, and interviews all interested parties (including clinicians and the person to be conserved). A hearing is held to determine if a conservatorship will be granted (Guzman-Clark et al., 2012).

This process can be time consuming and expensive, and can have marked impact on the life of the person being conserved. A conservatorship severely limits a resident's freedoms as he or she will no longer be able to make decisions concerning where to live and what medical treatments to receive. Also, depending on a person's condition, determining the necessity of a conservatorship may be very difficult. For example, a person diagnosed in the early stages of Alzheimer's disease can appear able to manage personal affairs when in fact he or she could benefit from a conservatorship. Advanced planning on the part of the patient could negate the need for a conservatorship later in life. Legally binding documents such as a living will or advanced directives can be created when the patient possesses full mental capacity. These documents then can be used to guide medical care if the patient becomes unable to make decisions (Guzman-Clark et al., 2012).

Do Not Resuscitate Orders

Another tool to ensure residents of LTCFs receive the care they desire is the use of do not resuscitate (DNR) orders. Mukamel, Ladd, and TemkinGreener (2013) found approximately 50% of persons admitted to a LTCF did not have a DNR order in place. Of these, 40% had an order after 5 years. Reasons given for this substantial change were multiple hospital admissions and nursing home transfers.

A similar study found the majority of residents of LTCFs in Japan also did not have DNR orders (Asai, Ohkuni, Ashworth, & Kaneko, 2014). Authors indicated DNR orders are seldom seen in Japanese society for cultural reasons. However, when asked, 94% of residents or their medical decision makers did not want mechanical ventilation used to prolong life.

Because the topic of advanced directives can be emotionally charged for everyone involved, tools are available to help nurses discuss the desired level of treatment with residents (Molloy, Russo, Stiller, & O'Donnell, 2000). Nurses need education concerning advanced directives while residents and families need time to determine the desired level of care. After decisions are made, they also will need support in carrying out the decisions (Molloy et al., 2000).

Abuse Screening

As mandated reporters of abuse, nurses need to conduct a detailed abuse screening when residents of LTCFs are admitted to the hospital. Because no federal law for preventing elder abuse exists and because criteria for elder abuse vary from state to state, a clear definition of what constitutes elder abuse is difficult to ascertain. However, Stark (2012) defined elder abuse as any action by a caregiver or trusted person that causes harm or the high risk of harm to a dependent elder. In addition, any inaction on the part of the caregiver or other trusted person that causes harm or failure to provide for the elder's needs constitutes abuse. Physical, psychological, sexual, or financial abuse of elders is possible. Because of their dependence on the staff at LTCFs, residents also should be screened regularly for abuse by LTCF staff as well as any family members or other individuals involved in their care.

Signs and symptoms of abuse can be difficult to discern in older adults. Bone loss, overmedication, somnolence, weight loss, and non-adherence to a medication regimen leading to exacerbation of chronic conditions may be associated with aging and may not reflect abuse (Stark, 2012). Physical abuse should be suspected when the elder has multiple wounds in various stages of healing or when results of tests or physical examination do not coincide with the patient's statements. Sexual abuse should be suspected if nurses identify unexplained ecchymosis of the breasts or genitalia, or vaginal or rectal bleeding, or the patient has a preoccupation with sexually transmitted infections. Psychological abuse should be suspected if the patient appears exceedingly withdrawn, agitated, confused, or fearful. Finally, financial abuse should be suspected if signatures on documents do not match or if the resident has unpaid bills, suddenly depleted bank accounts, a new or recently changed will, or excessive payments for care or reimbursements for groceries or other personal items (Stark, 2012).

Many tools can help nurses perform an expedient and accurate abuse assessment. Fulmer, Guadagno, Dyer, and Connolly (2004) found several tools of great value to the clinician evaluating elder abuse. In particular, the Elder Assessment Instrument (Fulmer, 2003) uses a general assessment by the clinician in conjunction with a Likert scale to evaluate the elder's general condition, level of independence, and medical conditions to determine any risk for abuse or neglect. This tool, developed with the help of emergency room nurses, is designed to be completed quickly and without special training, making it an ideal choice for use in busy hospital settings. It also can be used effectively in nonhospital settings.

Another effective tool for quickly assessing an elder's abuse risk is the Brief Abuse Screening for the Elderly. This five-question test takes only 1 minute to complete. However, training is required for accurate administration, perhaps making implementation and maintenance in a busy hospital setting difficult (Fulmer et al., 2004).

Reducing Hospital Readmissions

The Centers for Medicare & Medicaid Services (CMS) (2013) examines readmission rates for patients with myocardial infarction, heart failure, or pneumonia at hospitals that accept Medicare payments. Hospitals that perform poorly on these 30-day readmission rates are penalized 1% of their reimbursements and ultimately 3% of reimbursements if they do not improve by the third year of the program. The AHA estimates 25% of patients admitted to the hospital for heart failure will be readmitted for it within 30 days. Of 1.8 million persons admitted to LTCFs in 2009, Berkowitz and colleagues (2012) found 23.5% were readmitted within 30 days at a cost of $4.3 billion.

Team Improvement and Patient Safety Conferences

Berkowitz and co-authors (2012) used team improvement and patient safety conferences conducted every 2 weeks for 1 year to identify ways to reduce hospital admissions at one SNF. Members of the care team as well as administrators and social workers examined the reason for hospital transfer by any residents in the LTCF. They developed new protocols and procedures to decrease the hospital transfer rate, including a discharge checklist; revised medication reconciliation protocol that included nurses, residents, family members, and pharmacists to reduce the number of medication errors; new protocols for calls to residents' family members; protocols for dealing with difficult or disruptive family members; and a universal transfer form. These changes reduced the hospital transfer rate by 20% while reinforcing the importance of resident safety to staff.

Improving Care

According to Gillick (2014), providing care to the oldest, sickest, and most frail members of society is a formidable challenge. Because of the nature of their illnesses, many residents in LTCFs experience exacerbations that may require hospitalization. While hospitalized, these persons are at great risk for adverse events, such as a falls, delirium, and medication reactions. Finding safe alternatives to hospitalization should be a priority.

One of the most promising alternatives to traditional hospitalization has been developed by Johns Hopkins University (Hospital at Home[R] [HAH], 2014). The HAH program provides safe, hospital-level care to patients in the comfort of their own homes. Potential patients are identified in the emergency department or outpatient center and representatives of the HAH program are notified. An HAH program physician examines the patient to determine appropriateness for the program. Appropriate candidates are transported home by ambulance. If a patient is not a good candidate, he or she is admitted to a traditional hospital setting.

Once at home, the program participant receives extended nursing care during the initial phase of treatment. With improvement, the participant receives regular nursing visits at least once a day. Additionally, physicians will visit the patient at least once a day to direct the care. Many treatments (e.g., administration of intravenous medications) can be performed at home. Any necessary treatments that cannot be completed at home, such as computed tomography scans, can be scheduled on an outpatient basis. Doctors and nurses, available via phone around the clock, can evaluate the patient if his or her condition changes. After recovery, the patient is discharged to the care of the primary care physician (HAH, 2014).

A study by Leff and colleagues (2008) found patients receiving care through the HAH program were less likely to suffer delirium, be prescribed sedatives, or need restraints. Additionally, patients and their families rated their care as superior to the care they received in a traditional hospital. Finally, family members reported feeling less stress with the HAH program compared to traditional hospitalization. Due to the lack of research on ways to improve care of patients in LTCF, additional thorough study of this topic is needed.


Avoiding all hospitalizations for residents in LTCFs is virtually impossible to achieve. However, minimizing the need for hospitalization, maximizing the coordination of care, finding ways to incorporate the wishes of patients into the care they receive, and reducing stress on loved ones should be the goal of everyone involved in resident care. These actions will provide many alternatives to hospitalization, reduce costs, and improve quality of life for residents (Gillick, 2014). CEZ1


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Title Annotation:Clinical Practice
Author:Bowman, Brian; Forbes, Alison
Publication:MedSurg Nursing
Article Type:Report
Date:Nov 1, 2015
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