Management of Acute Changes in Condition in Skilled Nursing Facilities

Abstract

OBJECTIVES To describe the presentation and management of acute changes in condition in skilled nursing facilities (SNFs) during implementation of a program designed to reduce unnecessary emergency department visits and hospitalizations. DESIGN Secondary analysis of data from a randomized controlled trial involving 264 SNFs. PARTICIPANTS One hundred thirty‐three of the 264 participating SNFs that provided data on acute changes in condition: 55 in the intervention group, 78 in the control group. INTERVENTIONS During a 12‐month period, intervention SNFs received training and support for implementation of the Interventions to Reduce Acute Care Transfers program. Control SNFs were offered training and implementation support after the end of the 12‐month trial. MEASURES Project champions used a structured online tool to describe acute changes in condition that did not result in a hospital transfer within 72 hours of the change. RESULTS Most of the 7,689 episodes of acute change in condition reported involved multiple changes that were not disease specific. Ten percent resulted in hospital transfer between 72 hours and 7 days after the change. Five acute changes had odds ratios for transfer greater than 2 (mental status change, abnormal vital signs, bleeding, shortness of breath, and unresponsiveness). Most transfers were for reasons other than the initial change in condition. CONCLUSIONS A wide variety of acute changes in condition can be managed in SNFs without hospital transfer. Most of these changes are nonspecific and multiple, and when they are associated with hospital transfer, the reasons for the transfer are most often different from the initial acute change in condition. These data highlight the multifactorial nature of acute changes in condition in the SNF population and suggest that disease‐specific protocols and assessment tools may not be the most appropriate approach to managing acute changes in condition in the SNF setting. J Am Geriatr Soc 66:2259–2266, 2018.

Evaluation of a Multicomponent Care Transitions Program for High‐Risk Hospitalized Older Adults

“…Disease-specific programs may not, however, be optimal in the SNF setting because of the multiple and nonspecific nature of acute changes in condition that result in hospital transfers. 45 Finally, there is a possibility that our focus on discharge home whenever safe and feasible and the educational and follow-up components of the STAR program may have led to a higher rate of hospital returns than we anticipated. Medicare patients discharged home have higher rates of hospital readmissions, but lower overall costs than those discharged to an SNF.…”

“…Thus, for some conditions, condition‐specific programs may be more effective than a program targeted to a broader group of hospitalized high‐risk geriatric patients. Disease‐specific programs may not, however, be optimal in the SNF setting because of the multiple and nonspecific nature of acute changes in condition that result in hospital transfers …”

Strategies to reduce potentially avoidable hospitalisations among long-term care facility residents

“…In a large-scale trial in which nursing homes were selected based on the availability of adequate resources, there was no evidence that INTERACT implementation had a negative impact on self-reported measures of quality and patient safety such as falls, dehydration and unexpected death 29. Nursing homes in this trial were able to manage a wide variety of acute changes in condition without hospital transfer in the 7 days after the initial change in condition in close to 90% of the cases they reported on 31. A second example of an unintended consequence in efforts to manage sicker residents in the LTCF is unnecessary antimicrobial use, adverse effects of these agents including diarrhoea and related complications, and the development and spread of resistant organisms within the facility and to affiliated hospitals.…”

To Tailor Solutions, You Must Understand the Problems: Nursing Facility Resident Changes of Condition

“…In this issue of the Journal of the American Geriatrics Society , Ouslander and colleagues describe results from an analysis of thousands of short‐term changes in status that occurred in nursing facilities that participated in a randomized controlled trial testing the INTERACT program (Interventions to Reduce Acute Care Transfers) . Both intervention group facilities (n = 55) and control group facilities (n = 78) submitted descriptions of changes in condition using a structured tool, with a range of 1 to 322 changes in condition reported by facilities.…”

“…I n this issue of the Journal of the American Geriatrics Society, Ouslander and colleagues describe results from an analysis of thousands of short-term changes in status that occurred in nursing facilities that participated in a randomized controlled trial testing the INTERACT program (Interventions to Reduce Acute Care Transfers). 1 Both intervention group facilities (n = 55) and control group facilities (n = 78) submitted descriptions of changes in condition using a structured tool, with a range of 1 to 322 changes in condition reported by facilities. To provide insight into how changes in condition are treated in the nursing facility, facilities in the study were asked to report on a sample of episodes of changes (1) for which a nurse completed an INTERACT SBAR tool (Situation-Background-Assessment/ Appearance Request/Review) and (2) that did not result in a hospital transfer in the first 72 hours after the change.…”