Causes of acute change of condition in a resident residing in a skilled nursing facility can be categorized into either reasons that relate primarily to the resident’s current status or condition or reasons less directly related to the resident’s current condition or status.  Understanding these reasons and the common conditions that can result in a hospital readmission for a resident are a key component to any quality improvement initiative aimed at preventing hospital readmissions as well as to management of a resident’s care including identification of and minimization of key risk factors that a resident may have for hospital readmission.  Reasons related primarily to the resident’s current status or conditions include:

  • Availability of in-house diagnostic support services
  • Level of care to which resident is assigned on admission to long-term care facility
  • Resident’s level of dependency in performing activities of daily living
  • Resident’s underlying medical complexity or comorbid condition
  • Premature discharge from acute-care facility to long-term care facility
  • Presence or absence of advance care planning instructions about management of acute medical illness
  • Severity of illness or degree of medical instability

Reasons less directly related to the resident’s current condition or statuses include:

  • Inability of staff at long-term care facility to obtain medical supervision of acute change of condition
  • Inadequate practitioner-nurse communication
  • Inadequate reimbursement for provision of acute care in the long-term care facility
  • Pressure from family, nursing staff, or physician to hospitalize the resident
  • Time of day or week when the acute change of condition occurs

Resident’s in skilled nursing facilities often are admitted for a short-stay that involves therapy services following an event such as a hip or knee replacement with the intent of returning back to their home.   These residents more often than not, however, come to us with underlying comorbidities that place them into the high risk category for acute change of condition.   These conditions that may predispose a resident to an acute change of condition include the following:

  • Cardiopulmonary
    • Congestive Heart Failure
    • Hypertension
    • Functional
      • Acute impairment of one or more activities of daily living
      • Impaired mobility
      • Recurrent falls during the past 3 months
      • Prolonged bedrest
      • Urinary retention
      • Metabolic
        • Diabetes mellitus
        • Malnutrition
        • Weight loss
      • Musculoskeletal
        • Muscle weakness secondary to old stroke
        • Osteoporosis
      • Neuropsychiatric
        • Confusion
        • Depression
        • Dizziness, impaired balance
        • Mild/moderate dementia
        • Sensory
        • Vision/hearing impairment
      • Systemic/General
        • Postoperative status
        • Pain
        • Pressure ulcers
        • Use of multiple medications
      • Other
        • Cancer
        • Cerebrovascular disease
        • Endocrine disease
        • Gastrointestinal disease
        • Infectious disease

Understanding these causes of acute change of condition can lead to a self-analysis to determine what capabilities a facility needs to have to ensure management of residents with these issues and conditions.  Capabilities that support testing and treatment of acute change of condition in a long-term care facility include:

  • Appropriate reporting mechanisms to ensure that changes in condition are reported to appropriate personnel in a timely fashion
  • Ability to initiate treatment within several hours—
    • Antibiotics
    • Respiratory therapy
    • Pain medication
    • Ability to initiate IV therapy for rehydration within 2 hours of initial order
    • Sufficient direct RN supervision to oversee effective resident management and monitoring over a 24-hour period
    • Sufficient RN staffing
      • Daily RN assessment of any resident until acute condition change stabilizes
      • Recognition and reporting possible complications of the illness or treatment within a day of identification
      • Sufficient practitioner availability to respond to calls from nursing and discuss resident condition and diagnostic results

If a facility lacks any of these capabilities decisions must be made related to the feasibility of adding resources necessary to provide the capabilities or whether certain residents may need referred to a different setting that has these capabilities.   These decisions are often difficult to make and require a review of resources and current marketing strategy including communication to the acute care hospitals that are referral sources.

Finally, staff should be trained to recognize that all hospital admissions are not avoidable and should have a key understanding to conditions that lead to appropriate transfer and readmission to the acute care hospital.   These include but are not limited to:

  • Acute abdominal pain of moderate to severe intensity accompanied by intractable vomiting
  • Chest pain that cannot readily be attributed to non-cardiac causes and that is not readily relieved by antacids or nitroglycerin
  • Fall with pain and other clinical features consistent with a fracture
  • Hypertensive crises associated with a systolic blood pressure of 230 mm Hg. that cannot be readily reduced or that is accompanied by significant cardiac or neurological symptoms
  • Active upper gastrointestinal bleeding accompanied by postural hypotension and tachycardia
  • Respiratory distress that does not respond to oxygen, nebulizers, suctioning, etc.
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Comments (1)
  • Massive bleeding from the GI tract can be dangerous. However, even very small amounts of bleeding that occur over a long period of time can lead to problems such as anemia or low blood counts.Once a bleeding site is found, many therapies are available to stop the bleeding or treat the cause…”*;

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