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COVID-19: The Nursing Home Tragedy

By ANISH KOKA, MD

Our strategy with nursing homes in the midst of the current pandemic is bad.  Nursing homes and other long term care facilities house some of our sickest patients in and it is apparent we have no cogent strategy to protect them. 

I attempted to reassure an anxious nursing home resident a few weeks ago. I told him that it appeared for now that the community level transmission in Philadelphia was low, and that I was optimistic we could keep residents safe with simple maneuvers like better hand hygiene, restricting visitors, as well as stricter policies with regards to keeping caregivers with symptoms home.  I was worried too, but optimistic.

I figured the larger medical community would be on the same page if someone did get COVID.  It made sense to me to be aggressive about testing staff and residents and quickly getting COVID-positive patients out of the nursing home.  So when I heard of the first patient that was positive in the nursing home, my heart sank, but it fell even further when I found out the COVID-positive patient was sent back from the hospital because they weren’t “sick enough” to be admitted.

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An “F” for Quality

Huge numbers of older persons transition from hospitals to the nursing home.  Often, an older hospitalized patient needs skilled nursing care before they are ready to return home.  In other cases, a nursing home patient who needed hospitalization is returning to the nursing home.  Older patients and their families certainly hope that great communication between the hospital and nursing home would assure a seamless transition in care.

But a rather stunning study in the Journal of the American Geriatrics Society suggests the quality of communication between the hospital and the nursing home is horrendous.  The study was led by researchers from the University of Wisconsin, including nurse researcher, Dr. Barbara King and Geriatrician Dr. Amy Kind.

The authors conducted interviews and focus groups with 27 front line nurses in skilled nursing facilities.  These nurses noted that very difficult transitions were the norm.  Sadly, when asked to give the details of a good transition, none of the nurses were able to think of an example.

Most of the nurses felt that they were left clueless about what happened to the their patient in the hospital.  They lacked essential details about their patient’s clinical status.  The problem was not the lack of paper work that accompanied the patient.  In fact, nurses often received reams of paper work, often over 80 pages.  The problem is that the paper work was generally full of meaningless gibberish such as surgical flow sheets that told little about what was actually going on.

Often the transfer information had errors, conflicted with what the facility was told before the transfer, and lacked accurate information about medications.

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Outrage is Easy. Solutions are Hard.

The inspector general of HHS reported this week that nearly half of the anti-psychotic drugs fed to the demented elderly in nursing homes are inappropriately prescribed. That’s about one in fourteen nursing home residents.

Forget about cost, which is over a quarter billion dollars a year. “Government, taxpayers, nursing home residents as well as their families and caregivers should be outraged and seek solutions,” wrote Daniel R. Levinson, the HHS I.G. wrote in his letter to Senators Charles Grassley (R-Ia.) and Herb Kohl (D-Wis.), who asked for the report.

Why is this happening? First, the medication patterns of the frail elderly are not monitored by the Centers for Medicare and Medicaid Services, which is afraid of a backlash from Capitol Hill where doctors and nursing home operators fiercely lobby to protect the hallowed doctor-patient relationship. The drug industry has also, in some cases, paid kickbacks to the pharmacy operators in nursing homes.

But at the root of the issue are the doctors who are faced with caring for these patients. Even though clinical trials have shown the drugs are likely to result in earlier deaths for some of these elderly patients, doctors prescribe them to reduce agitation, as Daniel Carlat, a practicing psychiatrist and purveyor of non-industry-funded continuing medical education, told the New York Times. “Doctors want to maximize quality of life by treating the patient’s agitation even if that means the patient will die a bit sooner,” he said.

As someone who watched his father’s decline with dementia over a ten year period (usually from a distance), I can attest that shortening one’s lifespan is not the crucial issue, especially in the last few years when the personality in the shell of the human being that has survived the loss of cognition has largely disappeared. The first question is whether the anti-psychotics are effective in reducing the outbursts associated with severe dementia, and whether those benefits outweigh the side effects (catatonia?). The second question is whether families have been adequately informed about the risks and benefits of this approach. That the drug companies deploy their marketing arms to stoke sales in this situation is outrageous. But even eliminating their right to do so wouldn’t solve the underlying problem.

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