David Oliver: Keeping care home residents out of hospitalBMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i458 (Published 26 January 2016) Cite this as: BMJ 2016;352:i458
Few doctors working in acute medicine get through an on-take shift without seeing patients brought by ambulance from care homes. If it’s distressing for us to witness, it’s much more so for them. Sometimes a short hospital visit may be in a care home resident’s interests, but often it’s not. A recent systematic review showed common avoidable harms associated with residents’ hospitalisation.1 A deeper analysis of hospital admissions in Ireland2 showed little added value for many residents.
The United Kingdom has about 20 000 nursing and residential homes (or “aged care facilities”) and 430 000 residents, almost all of whom have age related disability, frailty, multimorbidity, or cognitive impairment.3 4 Median life expectancy in nursing homes is 15 months, one in four residents dying within the first year, so planning and support for end of life care should be the norm.4 5
One third of residents admitted acutely to hospital die during that admission,1 and it’s often apparent when they first arrive that they are close to the end of life—so why not support them to die in the place they live? Many more, on arrival at hospital, receive only very short term treatment with fluids, oxygen or antibiotics, or x rays to exclude injury, but they then risk being marooned in hospital, waiting to return.6
Yet care home residents aged over 75 are three times more likely to be admitted as emergencies than over 75s in the general population.7
Professional consensus7 and NICE guidelines8 have both emphasised that care homes need proactive care planning and equitable access to medical and other healthcare inputs. These should include palliative care and support for dementia and other mental health problems: with 24 hour care available, such residences should allow for rapid “hospital at home”-style interventions in a crisis, or collaboration with ambulance staff and emergency GPs to make conveyance a last resort. Specialist clinicians such as geriatricians or specialist nurse practitioners can work with care homes to support them.9
It’s not all about external input from the health services. Care home staff—already undervalued and scarce—need to feel trained, supported, and empowered (by regulators, managers, and primary care teams) to do the right thing for residents rather than feel obliged to use acute admission as the default option.10 11 And residents’ families need honest conversations about the nature of frailty, end stage dementia, and “progressive dwindling.”
Done well and systematically, these things can achieve drastic reductions in ambulance conveyance or hospital admission, as recent cases in Ashford12 and Walsall13 have shown. NHS England is now supporting “vanguard” sites for care home medicine. It’s surely time such approaches were mainstream.
Cite this as: BMJ 2016;352:i458
Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.