- Email: [email protected]
Acute Care Observations: Can We Turn a Lemon Into Lemonade?
FROM THE EDITOR
Dr. Barbara Resnick
Acute Care Observations: Can We Turn a Lemon Into Lemonade? Driven out of a concern among hospitals about the financial risk of admitting Medicare beneficiaries for inpatient stays that may later be denied upon contractor review, hospitals have elected to treat beneficiaries as outpatients by providing them with observation services rather than admit them. In recent years, the number of cases of Medicare beneficiaries receiving observation services for more than 48 hours, although still small, has increased from approximately 3% in 2006 to approximately 7.5% in 2010. A major consequence for beneficiaries of not being classified as an inpatient is that their subsequent stays in a skilled nursing facility (SNF) are not covered by Medicare. In response to this opportunity for hospitals to potentially increase revenue though the use of reimbursement for short-stay observations, emergency department observation units (EDOU) were created. The origin of EDOUs actually was present back in the 1960s, but Medicare’s introduction of a single, bundled payment for an entire hospital stay called a Diagnosis-Related Group (DRG) payment in 1983 created an incentive to minimize the resources needed to care for patients. The rapid growth of EDOUs over the past 4 decades has been driven by financial incentives as well what many believe is good medical management. Emergency department physicians or advanced practice nurses have an option to “observe” patients they are concerned about without going through an admission process for a diagnosis that will likely result in a loss of revenue. In 2003, in its first recognition of the EDOU as a distinct entity, Medicare offered payments for 3 common observation diagnoses: chest pain, heart failure, and asthma. This has been expanded to include other types of diagnostic groups. Given the concerns for older adults, as our Medicare beneficiaries, losing their opportunity Geriatric Nursing, Volume 33, Number 5
for short-stay rehabilitation following “observation,” Representatives Joseph Courtney (D-CT) and Tom Latham (R-IA) and Senators John Kerry (D-MA) and Olympia Snowe (R-ME) introduced the Improving Access to Medicare Coverage Act of 2011 (H.R. 1543/S. 818) to require Medicare to include the observation time period toward eligibility for the 3-day acute care stay. The results of that bill are still pending at the time of this writing. Although I share concerns about reimbursement, my concerns about observation stays expand beyond the financial impact. In my optimistic manner, I see observation stays as a major opportunity for nursing. I recently had the fortune of experiencing an observation stay with a family member and was quite fascinated with the process. The medical management was perfectly on target, albeit done in what I would consider the most inefficient way possible. There is no “team” in these settings, and each individual comes in to ask the same questions, do the same examination, and provide the same information. Within a few hours, this type of assessment was performed by 4 nurses and 3 physicians. We would have no health care shortage if we learned to talk to each other, trust each other’s assessment and judgment, and change our health care system paperwork and policy. More important is to consider observations from the perspective of nursing care. Wow, what an opportunity to think about discharge from the minute of observation. I appreciate that the observation period is focused on the acute problemsdintravenous antibiotics, cardiac monitoring, or treatment of an exacerbation of a chronic illness such as asthma. The nurse must follow orders (although I would recommend critical thinking around those orders) and ensure that treatments are implemented. Nursing 337
knowledge and expertise should, however, consider the impact of treatment on the patient, and this should be an essential part of his or her nursing care. Bedrest is endemic in these observation environments, and in fact the environment does not allow for anything other than bedrest to occur. In some settings, there may be no appropriate chairs for the patient to sit on and no areas in which walking would be safe and acceptable behavior. What does 24 to 48 hours of bedrest and lack of skin or oral care do to an older adult? Indulge me while I remind you, and maybe you can share this with your acute-care colleagues working in these areas.
Implications of Bedrest and Inactivity Bedrest was common as a prescribed medical intervention up through the 1960s. Patients would be required to remain on bedrest after a myocardial infarction (4 weeks), hernia repair (3 weeks), cataract surgery (4 weeks), or childbirth (2 weeks).1 During World War II, clinicians began to question bedrest utility as they noted a relationship between inactivity and functional decline and found that early activity improved outcomes.2 The impact of bedrest is pervasive and can result in adverse outcomes across all systems. Psychologically, bedrest can result in feelings of anxiety, confusion, and depression. Immobilized patients also develop sleep disorders more than those who are ambulatory.3 A persistent supine position results in changes to the cardiovascular system, including a decrease in cardiac muscle mass, subsequent decrease in the force of contraction, and subsequent orthostatic intolerance, which is further exacerbated by that change in sensitivity of the body’s pressure sensors, which likewise occurs with bedrest. In addition, venous return is affected due to a decrease in the necessary muscle contraction that helps with fluid return, and thus pooling and persistent edema is noted. Overall, patients who remain in bed for an extended period have a decrease in their plasma volume, a subsequent increase in blood viscosity, and a well-known increased risk of venous thromboembolism. The musculoskeletal system is likewise negatively influenced by bedrest. There is a significant decline in muscle strength, muscle mass, and joint stiffness, all of 338
which contribute to the risk of falling. Connective tissue (tendons, ligaments, and cartilage) begin to deteriorate and contractures, particularly fixed plantar flexion, can occur. Calcium clearance in bone is 4 to 6 times greater in the first weeks of bedrest than normal and affects cortical and trabecular bone.4 Pulmonary function changes associated with bedrest include a decline in respiratory tidal volume and inspiratory/expiratory volumes, leading to airway narrowing and reduced tissue elasticity. In addition, there is mucous pooling in the lower lobes of the lungs and increased risk of pneumonia. From an immune system perspective, there is a decrease in cytokine production and reactivation of latent viruses when patients are on bedrest. Decreased cytokine production creates a proinflammatory state and can lead to cachexia and reduced circulating antibodies.5 As muscles begin to atrophy, protein synthesis decreases and nitrogen synthesis increases. Insulin sensitivity decreases, as does aldosterone production and plasma renin activity. Although the skin on our feet is well designed to bear our weight, all other skin is not, and unrelieved weight results in ischemia and necrosis, resulting in the well-known risk and occurrence of pressure ulcers. Nutrition status, generally ignored in the acute care setting, is also influenced by bedrest. There are changes in smell and taste, a decline in appetite, and a positional risk of dysphagia. The gastrointestinal tract slows, and food takes 40% longer to be digested and eliminated when a person is supine. Constipation is exacerbated. Lack of hygiene is likewise detrimental to the recovery process. In addition to how one feels and smells without bathing, without rehydrating the skin externally, there is the risk of increased dryness, cracking, flaking, and infection. Neglected oral hygiene is now a well-known risk for developing a pneumonia6 and certainly should be considered important during the acute care observation stay.
Nursing Opportunity Nurses have the opportunity to use the observation period to initiate prevention of the cascade of negative outcomes associated with bedrest by implementing a function-focused care approach. Function-focused care is a philosophy of care that evaluates patients’ underlying capability with Geriatric Nursing, Volume 33, Number 5
regard to function and physical activity and helps him or her to optimize time spent in physical activity. The purpose of function-focused care is to change care philosophies such that nurses teach, cue, position, and help patients engage in physical activity. Function-focused care contrasts with traditional approaches to patient care in hospital settings. Traditionally, nurses and other caregivers perform tasks for older patients and limit the amount of activity they need to perform (e.g., give patients urinals or bedpans vs. helping them walk to the bathroom). Moreover, in these settings, sedentary activity is encouraged with the underlying belief that this will prevent falls. Function-focused care activities are practical and individualized based on the patient’s current physical and cognitive ability. Examples of functionfocused care interactions include such things as nurses engaging patients in bed mobility during care so that the patient performs the activity with cueing versus the nurse performing the activity (e.g., the nurse pulling the patient up in bed); ambulating patients to the bathroom or in the hallway and engaging families to do likewise; and having patients sit at the edge of the bed or practice sit to stand while giving an intravenous antibiotic. Let me share a recent real-life experience. I had the opportunity to take a family member to the emergency department with a questionable deep vein thrombosis and cellulitis. Despite walking into the acute care setting, albeit with some discomfort, he was immediately stripped, placed in a bed, and tethered there to monitor vital signs, which were all within normal limits. During the multiple histories and physical assessments completed, not one provider ever asked about function or physical activity. There was not an accessible bathroom in the emergency department, and thus he was given a urinal. After 10 hours, he was moved to the “observation unit,” an environment that looked much like a postoperative recovery area for patients. Twenty-four hours later, he was still in that bed, tethered, dirty, depressed, discouraged, weak, and tired. The cellulitis was responding well to antibiotic treatment, and the goal was to discharge him as quickly as possible on oral antibiotics. Despite his nurse’s disagreement with my plan, I suggested it was time to get out of the bed and go for a walk. He tried to tell me, as many patients will, he was too sick, too tired, and couldn’t get out because of the intravenous and monitoring equipment. My response focused on the walk Geriatric Nursing, Volume 33, Number 5
being critical otherwise he quite simply would not be able to get home. We got him untethered from the intravenous, and with the nurse pointing a finger at me saying, “Don’t let him fall because there is so much paperwork I have to do,” I got him to walk at least 500 feet and then sit up for few hours. He returned to bed a happy man, encouraged, and proud. When we returned the next morning, the same nurse happily reported to me that he had been walking that morning. When it came time for discharge, the nurse informed him that she would be back in a few minutes to “get him dressed.” I proceeded to tell her, just as nicely, that there was nothing wrong with either his mind or his arms and he would get himself dressed. I pulled the privacy curtain around his bed, gave him his clothes and told him to go for it! He succeeded and was, fortunately, ready, able and willing to get home. In addition to management of the acute medical problem, nurses have the responsibility of informing families and caregivers of how to optimize function and physical activity at the time of discharge to ensure full recovery. To provide that level of guidance, assessment and implementation of a function-focused approach is necessary. Recognizing that there is much yet to be fixed around reimbursement issues with regard to emergency department observation stays, I believe nursing has an opportunity to optimize this experience and make the transition back home successful. This is particularly important because individuals who have been exposed to this observation period will not, at this time, be eligible to receive rehabilitation services that are covered by Medicare. Moreover, hospitals will be penalized for readmission of these individuals 30 days following discharge. For nurses with expertise in geriatrics and optimizing recovery of older adults, your time has come! Take the lead and implement these types of real-world approaches to care that can have an impact on your patients and the health care system.
References 1. Knight J, Nigam Y, Jones A. Effects of bedrest 1: cardiovascular, respiratory and haematological systems. Nurs Times 2009;105:16-20. 2. Asher R. The dangers of going to bed. BMJ 1947;2:967-8. 3. Fox MT, Sidani S, Brooks D. Perceptions of bed days for individuals with chronic illness in extended care facilities. Res Nurs Health 2009;32:335-44.
339
4. Chen JS, Cameron ID, Cumming RG, et al. Effect of agerelated chronic immobility on markers of bone turnover. J Bone Mineral Res 2005;21:324-31. 5. Truong AD, Fan E, Brower RG, Needham DM. Bench-tobedside review: mobilizing patients in the intensive care unitdfrom pathophysiology to clinical trials. Crit Care 2009;13:216.
340
6. Yoneyama T, Yoshida M, Ohrui T, et al. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc 2002;50:430-3. 0197-4572/$ - see front matter Ó 2012 Published by Mosby, Inc. http://dx.doi.org/10.1016/j.gerinurse.2012.07.002
Geriatric Nursing, Volume 33, Number 5
Dr. Barbara Resnick
Acute Care Observations: Can We Turn a Lemon Into Lemonade? Driven out of a concern among hospitals about the financial risk of admitting Medicare beneficiaries for inpatient stays that may later be denied upon contractor review, hospitals have elected to treat beneficiaries as outpatients by providing them with observation services rather than admit them. In recent years, the number of cases of Medicare beneficiaries receiving observation services for more than 48 hours, although still small, has increased from approximately 3% in 2006 to approximately 7.5% in 2010. A major consequence for beneficiaries of not being classified as an inpatient is that their subsequent stays in a skilled nursing facility (SNF) are not covered by Medicare. In response to this opportunity for hospitals to potentially increase revenue though the use of reimbursement for short-stay observations, emergency department observation units (EDOU) were created. The origin of EDOUs actually was present back in the 1960s, but Medicare’s introduction of a single, bundled payment for an entire hospital stay called a Diagnosis-Related Group (DRG) payment in 1983 created an incentive to minimize the resources needed to care for patients. The rapid growth of EDOUs over the past 4 decades has been driven by financial incentives as well what many believe is good medical management. Emergency department physicians or advanced practice nurses have an option to “observe” patients they are concerned about without going through an admission process for a diagnosis that will likely result in a loss of revenue. In 2003, in its first recognition of the EDOU as a distinct entity, Medicare offered payments for 3 common observation diagnoses: chest pain, heart failure, and asthma. This has been expanded to include other types of diagnostic groups. Given the concerns for older adults, as our Medicare beneficiaries, losing their opportunity Geriatric Nursing, Volume 33, Number 5
for short-stay rehabilitation following “observation,” Representatives Joseph Courtney (D-CT) and Tom Latham (R-IA) and Senators John Kerry (D-MA) and Olympia Snowe (R-ME) introduced the Improving Access to Medicare Coverage Act of 2011 (H.R. 1543/S. 818) to require Medicare to include the observation time period toward eligibility for the 3-day acute care stay. The results of that bill are still pending at the time of this writing. Although I share concerns about reimbursement, my concerns about observation stays expand beyond the financial impact. In my optimistic manner, I see observation stays as a major opportunity for nursing. I recently had the fortune of experiencing an observation stay with a family member and was quite fascinated with the process. The medical management was perfectly on target, albeit done in what I would consider the most inefficient way possible. There is no “team” in these settings, and each individual comes in to ask the same questions, do the same examination, and provide the same information. Within a few hours, this type of assessment was performed by 4 nurses and 3 physicians. We would have no health care shortage if we learned to talk to each other, trust each other’s assessment and judgment, and change our health care system paperwork and policy. More important is to consider observations from the perspective of nursing care. Wow, what an opportunity to think about discharge from the minute of observation. I appreciate that the observation period is focused on the acute problemsdintravenous antibiotics, cardiac monitoring, or treatment of an exacerbation of a chronic illness such as asthma. The nurse must follow orders (although I would recommend critical thinking around those orders) and ensure that treatments are implemented. Nursing 337
knowledge and expertise should, however, consider the impact of treatment on the patient, and this should be an essential part of his or her nursing care. Bedrest is endemic in these observation environments, and in fact the environment does not allow for anything other than bedrest to occur. In some settings, there may be no appropriate chairs for the patient to sit on and no areas in which walking would be safe and acceptable behavior. What does 24 to 48 hours of bedrest and lack of skin or oral care do to an older adult? Indulge me while I remind you, and maybe you can share this with your acute-care colleagues working in these areas.
Implications of Bedrest and Inactivity Bedrest was common as a prescribed medical intervention up through the 1960s. Patients would be required to remain on bedrest after a myocardial infarction (4 weeks), hernia repair (3 weeks), cataract surgery (4 weeks), or childbirth (2 weeks).1 During World War II, clinicians began to question bedrest utility as they noted a relationship between inactivity and functional decline and found that early activity improved outcomes.2 The impact of bedrest is pervasive and can result in adverse outcomes across all systems. Psychologically, bedrest can result in feelings of anxiety, confusion, and depression. Immobilized patients also develop sleep disorders more than those who are ambulatory.3 A persistent supine position results in changes to the cardiovascular system, including a decrease in cardiac muscle mass, subsequent decrease in the force of contraction, and subsequent orthostatic intolerance, which is further exacerbated by that change in sensitivity of the body’s pressure sensors, which likewise occurs with bedrest. In addition, venous return is affected due to a decrease in the necessary muscle contraction that helps with fluid return, and thus pooling and persistent edema is noted. Overall, patients who remain in bed for an extended period have a decrease in their plasma volume, a subsequent increase in blood viscosity, and a well-known increased risk of venous thromboembolism. The musculoskeletal system is likewise negatively influenced by bedrest. There is a significant decline in muscle strength, muscle mass, and joint stiffness, all of 338
which contribute to the risk of falling. Connective tissue (tendons, ligaments, and cartilage) begin to deteriorate and contractures, particularly fixed plantar flexion, can occur. Calcium clearance in bone is 4 to 6 times greater in the first weeks of bedrest than normal and affects cortical and trabecular bone.4 Pulmonary function changes associated with bedrest include a decline in respiratory tidal volume and inspiratory/expiratory volumes, leading to airway narrowing and reduced tissue elasticity. In addition, there is mucous pooling in the lower lobes of the lungs and increased risk of pneumonia. From an immune system perspective, there is a decrease in cytokine production and reactivation of latent viruses when patients are on bedrest. Decreased cytokine production creates a proinflammatory state and can lead to cachexia and reduced circulating antibodies.5 As muscles begin to atrophy, protein synthesis decreases and nitrogen synthesis increases. Insulin sensitivity decreases, as does aldosterone production and plasma renin activity. Although the skin on our feet is well designed to bear our weight, all other skin is not, and unrelieved weight results in ischemia and necrosis, resulting in the well-known risk and occurrence of pressure ulcers. Nutrition status, generally ignored in the acute care setting, is also influenced by bedrest. There are changes in smell and taste, a decline in appetite, and a positional risk of dysphagia. The gastrointestinal tract slows, and food takes 40% longer to be digested and eliminated when a person is supine. Constipation is exacerbated. Lack of hygiene is likewise detrimental to the recovery process. In addition to how one feels and smells without bathing, without rehydrating the skin externally, there is the risk of increased dryness, cracking, flaking, and infection. Neglected oral hygiene is now a well-known risk for developing a pneumonia6 and certainly should be considered important during the acute care observation stay.
Nursing Opportunity Nurses have the opportunity to use the observation period to initiate prevention of the cascade of negative outcomes associated with bedrest by implementing a function-focused care approach. Function-focused care is a philosophy of care that evaluates patients’ underlying capability with Geriatric Nursing, Volume 33, Number 5
regard to function and physical activity and helps him or her to optimize time spent in physical activity. The purpose of function-focused care is to change care philosophies such that nurses teach, cue, position, and help patients engage in physical activity. Function-focused care contrasts with traditional approaches to patient care in hospital settings. Traditionally, nurses and other caregivers perform tasks for older patients and limit the amount of activity they need to perform (e.g., give patients urinals or bedpans vs. helping them walk to the bathroom). Moreover, in these settings, sedentary activity is encouraged with the underlying belief that this will prevent falls. Function-focused care activities are practical and individualized based on the patient’s current physical and cognitive ability. Examples of functionfocused care interactions include such things as nurses engaging patients in bed mobility during care so that the patient performs the activity with cueing versus the nurse performing the activity (e.g., the nurse pulling the patient up in bed); ambulating patients to the bathroom or in the hallway and engaging families to do likewise; and having patients sit at the edge of the bed or practice sit to stand while giving an intravenous antibiotic. Let me share a recent real-life experience. I had the opportunity to take a family member to the emergency department with a questionable deep vein thrombosis and cellulitis. Despite walking into the acute care setting, albeit with some discomfort, he was immediately stripped, placed in a bed, and tethered there to monitor vital signs, which were all within normal limits. During the multiple histories and physical assessments completed, not one provider ever asked about function or physical activity. There was not an accessible bathroom in the emergency department, and thus he was given a urinal. After 10 hours, he was moved to the “observation unit,” an environment that looked much like a postoperative recovery area for patients. Twenty-four hours later, he was still in that bed, tethered, dirty, depressed, discouraged, weak, and tired. The cellulitis was responding well to antibiotic treatment, and the goal was to discharge him as quickly as possible on oral antibiotics. Despite his nurse’s disagreement with my plan, I suggested it was time to get out of the bed and go for a walk. He tried to tell me, as many patients will, he was too sick, too tired, and couldn’t get out because of the intravenous and monitoring equipment. My response focused on the walk Geriatric Nursing, Volume 33, Number 5
being critical otherwise he quite simply would not be able to get home. We got him untethered from the intravenous, and with the nurse pointing a finger at me saying, “Don’t let him fall because there is so much paperwork I have to do,” I got him to walk at least 500 feet and then sit up for few hours. He returned to bed a happy man, encouraged, and proud. When we returned the next morning, the same nurse happily reported to me that he had been walking that morning. When it came time for discharge, the nurse informed him that she would be back in a few minutes to “get him dressed.” I proceeded to tell her, just as nicely, that there was nothing wrong with either his mind or his arms and he would get himself dressed. I pulled the privacy curtain around his bed, gave him his clothes and told him to go for it! He succeeded and was, fortunately, ready, able and willing to get home. In addition to management of the acute medical problem, nurses have the responsibility of informing families and caregivers of how to optimize function and physical activity at the time of discharge to ensure full recovery. To provide that level of guidance, assessment and implementation of a function-focused approach is necessary. Recognizing that there is much yet to be fixed around reimbursement issues with regard to emergency department observation stays, I believe nursing has an opportunity to optimize this experience and make the transition back home successful. This is particularly important because individuals who have been exposed to this observation period will not, at this time, be eligible to receive rehabilitation services that are covered by Medicare. Moreover, hospitals will be penalized for readmission of these individuals 30 days following discharge. For nurses with expertise in geriatrics and optimizing recovery of older adults, your time has come! Take the lead and implement these types of real-world approaches to care that can have an impact on your patients and the health care system.
References 1. Knight J, Nigam Y, Jones A. Effects of bedrest 1: cardiovascular, respiratory and haematological systems. Nurs Times 2009;105:16-20. 2. Asher R. The dangers of going to bed. BMJ 1947;2:967-8. 3. Fox MT, Sidani S, Brooks D. Perceptions of bed days for individuals with chronic illness in extended care facilities. Res Nurs Health 2009;32:335-44.
339
4. Chen JS, Cameron ID, Cumming RG, et al. Effect of agerelated chronic immobility on markers of bone turnover. J Bone Mineral Res 2005;21:324-31. 5. Truong AD, Fan E, Brower RG, Needham DM. Bench-tobedside review: mobilizing patients in the intensive care unitdfrom pathophysiology to clinical trials. Crit Care 2009;13:216.
340
6. Yoneyama T, Yoshida M, Ohrui T, et al. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc 2002;50:430-3. 0197-4572/$ - see front matter Ó 2012 Published by Mosby, Inc. http://dx.doi.org/10.1016/j.gerinurse.2012.07.002
Geriatric Nursing, Volume 33, Number 5