Improves care and results in fewer readmissions to the ED.
Nursing homes should not send patients to emergency departments for issues that can be managed in the nursing home setting. Good communication goes a long way.
John, a nursing home patient with bipolar disorder, has been increasingly manic for the past two weeks. Normally mild-mannered and pleasant, he now has pressured speech and intrusive thoughts and is irritable. He cycles from angry outbursts to weeping and threatens to assault others. Increasing John’s antipsychotic medication and mood stabilizer has not been effective, so the psychiatrist sends him to the emergency department of the local hospital to be seen by a member of the crisis team. John’s brother, who serves as his healthcare proxy, is also there.
Because his brother is present, John manages to keep it together for the short 20-minute interview. Concluding that John doesn’t require inpatient admission and disregarding the psychiatrist’s assessment of symptoms on the referral form, the crisis team clinician sends John back to the nursing home with no changes in medication. The next day, he hits a nurse and is sent back to the ED.
With the court’s permission
Joan, a patient with paranoid schizophrenia, is consistently psychotic and refuses all medication. While on the inpatient psychiatric unit, a “Rogers” is obtained, and she is put on Invega Sustenna (paliperidone palmitate), a long-acting, injected antipsychotic that is given once a month. (A Rogers is permission from the court, based on a substituted judgment by a surrogate, to give medication against a person’s will.) Joan rapidly improves and is admitted to a local nursing home for care.
Joan does well for several weeks but refuses her next injection when the nurse prepares to administer it. Although a Rogers grants permission to forcibly administer a medication, the nursing home staff is unwilling to do so. (In reality, forcibly giving this medication rarely happens outside of a psychiatric unit or emergency department.) In a few days, Joan is again actively psychotic and refusing all medications, including those needed for medical conditions. Soon she will need another inpatient admission.
Jenna is a patient with dementia who is aggressive and combative in the nursing home. Admitted to the hospital psychiatric unit after several unsuccessful medication trials, she is put on a low-dose antipsychotic with good results. Because the drug has a black box warning, her healthcare proxy is notified of its risks and benefits and agrees to continue authorizing it. Jenna returns to the nursing home and is doing well until the pharmacy consultant notices that she is being given antipsychotic medication. Following CMS guidelines restricting use of psychotropic medications in patients with dementia, the consultant recommends it be discontinued, the attending physician complies, and Jenna’s combative behavior returns.
In a similar situation, a combative patient is put on an antipsychotic in the psychiatric unit with good results and sent back to the nursing home. When it is discovered that the patient has a guardian but no Rogers, the medication is discontinued until a Rogers is obtained. This interrupts treatment and is like starting over again.
Why these disconnects? Why, in John’s case, did the crisis team clinician discount or not consider the evaluation of the nursing home psychiatrist, who has known John for years? Nursing home staff members hear nothing from the ED until a clinician calls to say John will be sent back to their facility.
This is not uncommon. Patients who cannot be managed safely in a nursing home are often sent to a hospital emergency department, where the patient holds it together long enough for the crisis team to determine that the nursing home can manage the patient’s care—or because no inpatient psychiatric bed is available.
Is it an emergency?
Many nursing home patients are sent to the ED unnecessarily. Brief altercations or outbursts that are relatively minor, suicidal statements not accompanied by a plan, or refusals to eat or take medication are not sufficient. To warrant a trip to the emergency department, the patient must be a clear danger to self or others. In John’s case, given the nature of his decline, the ED was perhaps not the best choice. Because he had already been evaluated by his treatment psychiatrist during his medication trials, John could have been referred to a psychiatric unit for direct admission. The crisis evaluation was probably not warranted.
Many hospital psychiatric units are unaware of nursing home constraints and regulatory requirements. Psych units can use restraints, injectable medications, and classes of drugs that are closely regulated in nursing homes. A common example of this is off-label use of Seroquel (quetiapine fumarate) for sleep. When a patient comes into a nursing home on Seroquel, use of that medication for sleep is not acceptable, so it is usually discontinued—or the patient is switched to another medication, such as trazadone. The change may affect the new patient’s sleep patterns.
Although hospitals also have regulations, they can and will give a Rogers patient an injection against his or her will, if needed. It seems like a good choice for a noncompliant patient. Hospital personnel may not realize that forced injections won’t be done in a nursing home setting. Administering a rapidly disintegrating p.o. medication, such as Risperdal M-Tab or Abilify Discmelt, might be a better way to stabilize a patient before returning him or her to a nursing home.
Communication is key
The key to avoiding such disconnects is good communication between nursing home and hospital staff members. Nursing homes should not send patients to emergency departments for issues that can be managed in the nursing home setting. When patients are sent to the ED, the nursing home should clearly describe, verbally and in writing, what the behavior is, why he or she can’t be managed in the long-term care setting, and the expected treatment.
Crisis team members, on the other hand, should contact the referring team, especially if there is a discrepancy between what is being observed in the emergency department and what was happening in the nursing home. During the patient’s hospital stay, the facility’s personnel should communicate with nursing home staff so that when the patient returns to the nursing home, treatment can be effectively continued or adjusted as needed.
Educating inpatient psychiatric staff about regulatory and legal aspects of nursing home treatment can help ensure that planning is carried over with success. Staying in contact helps avoid mistakes, such as placing patients on medications not approved by a Rogers or in forms not acceptable in the long-term care setting. Better communication between nursing home and hospital staff will improve care and result in fewer patient returns to the emergency department or inpatient admissions. RNL
Michael C. LaFerney, PhD, RN, PMHCNS-BC, is a psychiatric clinical nurse specialist at Arbour SeniorCare in Haverhill, Massachusetts, USA.