MDS Alert

Don't be known as the SNF that bounces residents back to the hospital.

Concern about rehospitalization rates for SNF patients is now officially more than a blip on the federal government's radar screen, thanks to the June 2007 Medicare Payment Advisory Commission report to Congress. And that means your facility could end up in surveyors' crosshair if residents show a pattern of avoidable readmissions to the hospital for conditions that clinical staff didn't detect or treat in time.

What you can do: MDS nurses and teams are in a key position to collect information before and immediately after admission not only for the MDS but also to identify a resident's clinical risks and care needs.

"The overriding issue" in preventing avoidable rehospitalization "is symptom management--identifying symptoms early and acting on them," says Sheryle Thomas, RN, the MDS coordinator for Superior Woods Healthcare, a subacute nursing facility in Ypsilanti, MI.

Triage Residents Before Admission

Look for these high-risk conditions so you can provide more frequent skilled monitoring and services to prevent, detect and treat problems:

• Congestive heart failure is the "biggie" in terms of causing rehospitalization, in part, because it tends to get better and then worse, says David Mehr, MD, MS, with the University of Missouri-Columbia. "But if you keep a close eye on the patient and perform daily weights and frequent blood pressures, you may be able to catch an exacerbation early enough to prevent rehospitalization," he says.

Keep an eye on these meds: Mehr notes that "sometimes physicians get excessively rigid about following guidelines" and put everyone with heart failure and systolic dysfunction on ACE inhibitors.

But if the medication causes the patient's creatinine "to go through the roof--or causes excessive hypotension--the person can end up back in the hospital."
Don't forget the geriatric principle for meds: "Start low and go slow and watch for side effects," Mehr counsels.

• Infection can start a downward spiral resulting in rehospitalization. Watch for "subtle signs and symptoms of infection in the newly admitted resident, including changes in mental status (which could vary from agitation to lethargy), falls, complaints of general weakness or malaise," advises Stephanie Mayork, RN, CIC, infection control nurse at Levindale Hebrew Geriatric Center and Hospital in Baltimore.

Tip: "If someone is in the hospital for three days, you'll typically see pneumonia or urinary tract infection within the first three days," after the SNF admission, says James Marx, RN, CIC, principal of BroadStreet Solutions in San Diego.

Clinical gem: A person can pick up an infection in the hospital "manifested only by delirium" that the hospital physician doesn't detect or attributes to dementia, says Mehr. If that's the case, the person will crash a day or two after SNF admission due to the hospital-acquired infection, he cautions.

Resident taking an antibiotic? Pay close attention to a resident taking antibiotics that "bridge into the nursing home and stop" because he has the potential to relapse right after discontinuing the medication, cautions Mehr. "The person may not have been treated adequately or he might have an abscess--or have developed antibiotic resistance."

Be on the lookout for C. difficile in residents who have been on antibiotics in the hospital, suggests Mehr. "You have to be very aware if someone stops eating or gets diarrhea. They may not have that many stools," he adds.

• A resident with an invasive device. Any resident who has an invasive device (Foley catheter, central line, G-tube, etc.) will be higher risk for infection, cautions Mayork.

Preventive tip: Don't place residents with invasive devices in rooms with other residents who have multi-drug resistant organisms or like to wander and cannot control their secretions/excretions, she advises.

• Dehydration. Sometimes patients are admitted to the facility with a low level of dehydration, which worsens if not treated, notes Mehr. Or the person may have received IV fluids in the hospital that kept him hydrated. But he doesn't have the IV in the nursing home and doesn't drink well after admission, leading to dehydration.

Do you do this? Perform intake and output on residents at high risk for dehydration at admission until you determine that the person is taking sufficient fluids.

• Fever is absolutely a danger sign, says Mehr, as older people can get very sick and not have a fever. "If someone has a fever, look for pneumonia and UTI unless there's some other obvious condition, such as a large infected pressure ulcer."

"A temperature of 99 in an elder can be a significant fever," says Clare Hendrick, ARNP, a nurse practitioner and consultant in San Clemente, CA. It depends on the person's baseline, she adds.

Falls. "Doing a good fall assessment right at admission can prevent falls that land someone right back in the hospital," says Mehr, who has had patients admitted to the nursing home and readmitted to the hospital shortly after with a hip fracture.

Stay on Top of Lab Results

You can uncover problems by looking at labs, says Mehr--for example, anemia and hyponatremia.

If a new admission hasn't had labs within the past two to three days in the hospital, consider doing a complete blood count and chemistry panel to make sure the resident doesn't have a major undiagnosed problem that's going to cause rehospitalization, Mehr advises.

Suppose the hospital physician changes a patient from a sliding-scale insulin regimen back to an oral agent for diabetes before admission to the nursing home. That can lead to problems controlling the resident's blood sugars if the nursing facility staff don't check the person's blood sugars, cautions Mehr.

For patients on warfarin (Coumadin): The facility needs systems to make sure lab values, especially INRs, don't fall through the cracks, advises Mehr.

Watch out for warfarin-drug interactions: If nursing staff contact the resident's physician or an on-call physician about a med order, make sure to let him know the resident is taking warfarin, emphasizes Mehr.