Posts Tagged admission

The 95 Year-Old Slam Dunk Admission

courtesy cc license by jonrawlinson

courtesy cc license by jonrawlinson

It’s often bragging rights to the doctor who can discharge the 90+ year-old patient to home, because they’re just so likely to have something, and it’s viewed as so risky to send them out. (Similarly for the HIV patient or the renal patient; bonus points for being able to send the 95 year-old HIV+ renal patient home.) And you’re never going to hear someone complain about it being a bogus admission, even if labs are normal. You get to a certain age where you’re just allowed to say whatever you want, and if you say it in triage, you’re coming in.

But ironically, the group with the highest odds of having something seriously wrong with them are probably also the most likely to have something go wrong with them while they’re in the hospital. Benzos in the elderly, for example, have been implicated in cognitive impairment, increased falls, and more side effects than in younger patients (PDF), probably because of changes in CNS receptors and changes in metabolism. Even without benzos, they’re more likely to experience delirium or to sundown. And when they get these side effects, they’re more likely to fall, and when they fall, they’re more likely to break a hip or get a subdural, and when they do those things, they’re less likely to have a good outcome. If you give a mouse a cookie, et cetera.

That’s why, when possible, I think a discussion with the patient and his or her family members is better than a simple “He’s coming in,” dispo, no matter how mentally satisfying an auto-disposition is. There’s the obvious cases, and the few who can obviously go home, but I think there’s probably more patients in the grey area that I don’t even consider. Last week a friend in California was telling me about a chest pain and syncopal patient duo of 90-somethings he had discharged after a conversation with the family — even with an initially elevated troponin in one of them. They didn’t want a cath, or more medications, or heart surgery even if it meant the patient was having a heart attack. I probably wouldn’t want any of those interventions at that age, either. Discharge home.

I’m one of those crazy guys who thinks dying by code in a hospital bed or sedated with tubes in every orifice in an ICU just isn’t what people want, if they have enough experience with the health care system to know what those terms mean. (90% of Americans when surveyed want to die at home, but 80% die in an institution.) I’m also crazy enough to think that often if you’ve made it to 90, you probably don’t want to spend any miniscule percentage of time in the last days, months, or years of your life in a hospital. I certainly admit the vast majority of my elderly patients, but who knows, maybe many of them wouldn’t even want what the inpatient team might be able to offer them in terms of diagnosis or treatment.

Whenever I’m discussing a treatment or procedure with a patient, or getting consent, I often talk about how I believe the benefits of it outweigh the risks; that we in medicine above all try to do no harm (ha!). But this same criteria is often glossed over when deciding to admit a patient, ignoring the potential complications of any hospital admission: falls, nosocomial infections, medication errors, etc. Why do we often minimize these? Perhaps because we don’t know the true risks of a hospital admission? Perhaps because we don’t like the cognitive dissonance that in a profession of healing, in a place of healing, we can actually cause harm. Perhaps because it’s easier not to consider the risks?

In medicine, everything — and I mean everything — comes with a risk and benefit profile. And in considering admission, we need to consider what our patient would want, when feasible and possible.

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The Social Admission Service

courtesy jamesfischer of flickr

courtesy jamesfischer of flickr

Well, as is bound to happen in the medical blogosphere, a minor kerfuffle has erupted in response to Jesse Pines’ piece about a social admission in the WSJ last week.

In one corner, the respected internist, Robert Centor (yes, of the Centor strep criteria fame) complaining about Dr. Pines admitting an uninsured woman for a cancer workup. GruntDoc, another EP blogger, fires back across the bow that Dr. Centor hates EPs, and Dr. Centor writes back, bringing up an interesting point: why are we paying so much for social admissions? Shouldn’t we have some sort of other option for the uninsured–or the social placements altogether?

I definitely don’t want to give any ammunition to the “the uninsured get all the medical care they need” crowd, (partially because it’s simply untrue) but we all certainly admit people for primarily social–not medical–reasons. (This probably would come as a surprise to the majority of the American population, who luckily aren’t reading this blog. And thank you, our tens of readers, for keeping this such a secret.)

If you look at pretty much any disease, under “Disposition” or “Indications for Admission,” there’s always that teensy tiny little caveat of “If the patient cannot care for himself/herself,” or “Expected clinical decline upon discharge.” From the teen with PID who just won’t take the meds or follow-up to the early-demented patient without help at home, you know they’re coming in. It’s kind of like any psych diagnosis: you can be as crazy as you want to be, talking about the demons in the lightbulbs, but as long as it doesn’t affect your ability to function in your life in any way, it ain’t a disorder. The social really does matter in medicine, just like it does in psychiatry.

Probably too late to tack this on to Congress’s health care financing bill, but what the hell: I hereby propose… THE SOCIAL ADMISSION SERVICE. Dr. Centor’s right; we probably shouldn’t be spending an expensive hospital bed on patients who don’t need hospital care, but GruntDoc is right too; we can’t simply turn away people who will get lost in the system or who can’t care for themselves. So we have a social admission service. Maybe it’s a doctor, some social workers, and a case worker–some sort of “comprehensive care team” that understands there may be a few simple medical issues, but the primary issue is placement, emergency Medicaid, or some simple labs tests/imaging/procedure. Quick admit, quick dispo. Maybe they only need vital signs once a day, maybe they can eat their own food. Maybe they don’t even need to stay overnight, if they’re safe going home. We save ourselves (and our country) some money, ourselves and our colleagues some valuable time, and best, of course, help our patients out of a bad situation.

Pipe dream? Maybe. Awful, terrible idea? Certainly possible. But I’d love to hear better ones, different ones, and solutions. No one’s going to deny that our health care system is in trouble–and not just because of the uninsured, or medico-legal liability, or the aging population, or any one thing in particular–and it’s going to take creative ways to fix it. Outside the box.

Today’s hospital system is based on an acute care, acute illness model, while our patients’ diseases have become almost completely chronic. Who knows? Perhaps acknowledging that “Admit/Discharge” is a bit too binary for today’s patient is the answer that we need.

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