A Dose Of Nursing Home Reality

"Hello, Dr. Smith? This patient has a fever..."

Read this New England Journal Perspective by Drs. Ouslander and Berenson on Reducing Unnecessary Hospitalizations of Nursing Home Residents, and it's easy to conclude that the enlightened application of better documentation, quality assurance, payment reform, administrative policies, decision support, guidelines, appropriate downjobbing and delegation of responsibility will keep many sick and feverish nursing home residents away from the unnecessary expense of emergency rooms and hospitals.

Were that it was so simple.  Such is the unreality of many Journal authors inhabiting the oxygen-deprived academisphere.

When residents of nursing homes get sick, they require a significant amount of nursing attention.  Since busy, salaried (and sometimes understaffed) nursing home personnel aren't compensated for the additional work of documenting, monitoring and worrying about that sick patient down the hall, they have every incentive to transfer sick patients elsewhere.  No amount of macroeconomic policy making bells and whistles is likely to change that.

When physicians and other non-physician providers are alerted by the nursing home personnel that a patient is sick, they have been taught that the best approach is to evaluate the patient in person. That takes time and effort.  While they may be compensated for the additional work of a bedside evaluation, it's not enough to make up for the additional work of documenting, monitoring and worrying about that sick patient down the hall.  So, they also have every incentive to agree with the nurse and transfer the patient to a setting where a bedside evaluation is available.  At 2 AM, the answer is to move that bedside to the local emergency room.

Would the bells and whistles that Ouslander and Berensen be enough to keep the nursing homes and the doctors from sending most sick patients to the emergency room?  Based on the simple realities described above, the answer is no.