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Transitions of Care from Hospital to Post-Acute Care · The SHEA Podcast

• 0:09
  SPEAKER_02: Welcome to the Shays Podcast, Transitions of Care from Hospital to Post Acute Care.
• 0:16
  SPEAKER_02: We are excited to be joined by the Post Acute and Long-Term Care Medical Association, Hulk Med, formerly AMDA, the Medical Specialty Society representing the community of medical directors, physicians, nurse practitioners, physician assistants, and other practitioners working in various post-acute and long-term care settings.
• 0:39
  SPEAKER_02: And the ASCP, a professional association of pharmacists and long-term care pharmacies that manage medications of older people and medically complex to talk about an important topic that doesn't always get the attention it deserves.
• 0:57
  SPEAKER_02: Transitions of care from hospital to post-acute care.
• 1:01
  SPEAKER_02: I am today's moderator, Dr.
• 1:03
  SPEAKER_02: Lauren Gleason.
• 1:04
  SPEAKER_02: I am a geriatrician and associate professor of medicine at the University of Chicago Medicine, and the medical director of the post-acute care continuum at U Chicago Medicine.
• 1:15
  SPEAKER_02: We have the privilege of being joined by some leading experts that will really allow us to hear the practicalities associated with this topic.
• 1:25
  SPEAKER_02: Our experts include Dr.
• 1:27
  SPEAKER_02: Susan Wong, Professor of Infectious Diseases at University of California Irvine and Medical Director of Infection Prevention at UCI Health.
• 1:39
  SPEAKER_02: She has worked extensively in hospitals and nursing homes to address infection.
• 1:56
  SPEAKER_02: And Dr.
• 1:56
  SPEAKER_02: Swadi Carr, a senior medical director for post-acute care services at Northeast Georgia Health System.
• 2:05
  SPEAKER_02: She was the chair of the Infection Advisory Committee, a member of the COVID-19 task force with the Pulp Med during the COVID-19 pandemic.
• 2:14
  SPEAKER_02: She is a member on Georgia's Antimicrobial Stewardship Committee.
• 2:20
  SPEAKER_02: So we'll first start off with some questions.
• 2:23
  SPEAKER_02: Why are transitions of care, especially hospital to nursing home, such a critical point in a patient's treatment journey?
• 2:31
  SPEAKER_03: This is Susan.
• 2:32
  SPEAKER_03: Coordination of care is a delicate balance.
• 2:35
  SPEAKER_03: Discharge timing is often unpredictable.
• 2:37
  SPEAKER_03: And yet medications have a schedule for their next dose.
• 2:41
  SPEAKER_03: The coordination for transfer often has different drivers on the hospital side versus the nursing home side.
• 2:46
  SPEAKER_03: And this can lead to suboptimal transitions.
• 2:50
  SPEAKER_02: Thank you, Susan.
• 2:50
  SPEAKER_02: Let's take the example of antibiotics.
• 2:53
  SPEAKER_02: What are some of the biggest challenges you see with antibiotic management during this transition?
• 2:59
  SPEAKER_03: Well, it's common for patients to be transferred to a nursing home specifically to complete IV antibiotic therapy for serious infections.
• 3:07
  SPEAKER_03: And success of antibiotic therapy requires transferring orders that have the correct dose and drug and frequency of dosing.
• 3:15
  SPEAKER_03: And we've previously identified that 30% of transfers to nursing homes experience some sort of unwanted deviation in therapy.
• 3:23
  SPEAKER_03: The most common transition errors involve early or late dosing and missed safety labs.
• 3:30
  SPEAKER_01: Oftentimes, as a nursing home physician, I noticed that when the gap between notification to the nursing home about transfer of that particular patient and the patient arriving is too small, the nursing homes are unable to get that particular dose at a certain time that they were scheduled at.
• 3:54
  SPEAKER_01: So we often get questions on is it okay to miss a dose?
• 3:59
  SPEAKER_01: Susan, what should be our answer in those cases?
• 4:04
  SPEAKER_03: In an ideal world, of course, the answer is no.
• 4:08
  SPEAKER_03: But practically it depends on the severity of the infection and the timing when the dose is missed, whether it's early or late in the treatment course.
• 4:17
  SPEAKER_03: A lot of times in the transition from a hospital, the patient has just become well enough to transfer out.
• 4:23
  SPEAKER_03: And so in that case, we would try really hard not to delay a dose by more than a handful of hours.
• 4:29
  SPEAKER_03: But given the complexity of logistics, transferring clinicians need to be clear if it's really, really critical that a dose is provided exactly on time.
• 4:38
  SPEAKER_00: Yeah, this is Chad.
• 4:40
  SPEAKER_00: One major barrier can be that pharmacies, long-term care pharmacies, are not located in nursing homes.
• 4:46
  SPEAKER_00: So a little different than the hospital and out in the clinic settings is that there's just not a pharmacy inside the nursing home.
• 4:54
  SPEAKER_00: So evening, night orders sometimes could be delayed to the next day, especially if they're uncommon or expensive.
• 5:02
  SPEAKER_00: There are some factors that influence delay and how quickly the admission orders are sent by the facility.
• 5:08
  SPEAKER_00: And in the case of an antibiotic, it's common medication might be available in the emergency supply at the nursing home, but if it's less common or it requires some level of preparation, preparation like an IV antibiotic, it's not going to be at the nursing home and it has to be delivered from the long-term care pharmacy to the home.
• 5:27
  SPEAKER_02: That's a great point.
• 5:28
  SPEAKER_02: So let's talk about what should be done if a dose is missed.
• 5:32
  SPEAKER_02: Swati, do you have any thoughts on that?
• 5:36
  SPEAKER_01: Yes, thank you, Lauren.
• 5:38
  SPEAKER_01: The clinician should be notified immediately if there is a dose missed.
• 5:43
  SPEAKER_01: And if a dose is missed, um uh they should commonly they should be discussing with their pharmacy counterparts.
• 5:52
  SPEAKER_01: Um, the reason why doses could be potentially missed is um because of the medpass issue, where you know the nursing um uh ratios to patient ratios are different compared to the hospital, and um uh sometimes the timing of doses are modified to common nursing home med passes.
• 6:17
  SPEAKER_01: Um if a full dose was missed, generally the ID physicians would recommend that the duration of therapy may be extended by a day.
• 6:27
  SPEAKER_01: That to say that preempting decisions when the nursing home is deciding to accept patients is really a best practice where they can see if they are able to dose um at these IV antibiotics correctly.
• 6:45
  SPEAKER_00: Yeah, on that note, I think it's also important when those transfer orders come to clearly identify the start date of the antibiotic.
• 6:54
  SPEAKER_00: A lot of this is about communication.
• 6:56
  SPEAKER_00: Um, so sometimes orders come and they just show the original duration of the antibiotic course.
• 7:02
  SPEAKER_00: Um, but it's not uncommon for nursing homes to receive an order for a 14-day course.
• 7:07
  SPEAKER_00: You know, it's not clear if the patient has already received some of that course before transfer.
• 7:12
  SPEAKER_00: So it's really important that we specify.
• 7:14
  SPEAKER_00: Um, you know, a patient could be receiving a 14-day course when, in truth, they already got seven days at the hospital and therefore only need another week.
• 7:22
  SPEAKER_00: So that communication is important.
• 7:25
  SPEAKER_02: That's a great point, Chad.
• 7:27
  SPEAKER_02: And Chad, can you also comment from a pharmacy's perspective?
• 7:30
  SPEAKER_02: Why can't the nursing home just order the drug in advance before they transfer to the hospital?
• 7:35
  SPEAKER_02: Why can't they, you know, take that needed dose, for example, and just tape it to the transfer grooney or put it in the patient's pocket when they're transferring the patient?
• 7:44
  SPEAKER_00: Yeah, I think as clinicians, we we feel like we always have some sort of solutions to some of these problems that are really the result of a very complex healthcare system.
• 7:53
  SPEAKER_00: Um but the first thing we have to remember is the setting has changed.
• 7:57
  SPEAKER_00: Um, if you're familiar with how hospitals are reimbursed and nursing homes are reimbursed, a lot of it is around cost.
• 8:03
  SPEAKER_00: So the hospital doesn't really want to send an extra dose that they've paid for or prepared.
• 8:09
  SPEAKER_00: Um, and the nursing home wants to get that order and have it reviewed by their physician so that they take responsibility for it.
• 8:17
  SPEAKER_00: Um the other piece of that is just that responsibility factor.
• 8:21
  SPEAKER_00: Um that's why when admission orders come from a hospital setting, the first step is to have them reviewed by the attending physician at the nursing home because they're now under that physician's care.
• 8:32
  SPEAKER_00: Um so that doesn't need to slow things to slow things down.
• 8:35
  SPEAKER_00: In fact, you know, it might be an opportunity for that physician or the pharmacist that's reviewing those admission orders to change the orders to something that's better accessible.
• 8:44
  SPEAKER_00: Maybe it is in the emergency supply of the nursing facility to kind of ensure that we don't miss doses.
• 8:50
  SPEAKER_00: Um as related to ordering in advance, um, there are enough cancellations and delays and transfers that nursing homes don't want to get that antibiotic until the resident is already on premises and they've had that initial review, particularly the ones that require preparations or compounding like IV medications.
• 9:09
  SPEAKER_00: Otherwise, that cost is ultimately lost and uh the burden of the nursing home at that point.
• 9:15
  SPEAKER_00: With regard to any dose taped to the patient or gurney, um I think that's a great sort of visual.
• 9:22
  SPEAKER_00: There is a concern of chain of custody.
• 9:24
  SPEAKER_00: Was it stored properly?
• 9:25
  SPEAKER_00: Um, it's moving from a hospital, you mean maybe to an ambulance to a nursing facility.
• 9:31
  SPEAKER_00: Um, it's highly unlikely that a hospital would want to assume that cost of that medication, as I mentioned earlier.
• 9:37
  SPEAKER_00: Um, the cost of that medication goes against their reimbursement.
• 9:41
  SPEAKER_00: So, helpful takeaway is for hospital clinicians to be really attentive to patients whose infection will not tolerate a delay in antibiotic dose and to success to selectively ensure they transfer with sufficient time to get that next dose.
• 9:55
  SPEAKER_00: And that time includes the review and ordering of those antibiotics as well as uh the preparation of those antibiotics and the delivery from the pharmacy that is providing for that nursing home.
• 10:05
  SPEAKER_00: Um so prioritizing those medications and those admissions by the physician uh is important so that the medications can be delivered on time.
• 10:14
  SPEAKER_02: Thank you.
• 10:15
  SPEAKER_02: That's really helpful to hear that information.
• 10:18
  SPEAKER_02: So, what I'm really hearing from all of you is that there are key pieces of information to convey when there's an on-time receipt of the next dose of antibiotic and the dose, you know, if it's critical to a safe transfer.
• 10:31
  SPEAKER_02: Other than timing, are there any considerations for the type of antibiotic and the dose of the antibiotic that should be given?
• 10:40
  SPEAKER_02: I'll ask Susan to tackle that first.
• 10:43
  SPEAKER_03: I think just like Swati and um and Chad said, a cost is a really big issue.
• 10:48
  SPEAKER_03: Nursing homes are low resource settings.
• 10:50
  SPEAKER_03: They receive a per diem for post-acute care, and antibiotic costs are deducted from that amount.
• 10:57
  SPEAKER_03: So if there are lower-priced antibiotics that are deemed equivalent, many nursing homes will want to switch to the lower-priced option.
• 11:04
  SPEAKER_03: So I think it would be really helpful if the transferring hospital clinician considers two things on transfer.
• 11:11
  SPEAKER_03: Um, first, is there an equivalent lower-priced option?
• 11:15
  SPEAKER_03: And if that option is available to the nursing home, stating that could be really helpful.
• 11:21
  SPEAKER_03: Um, second, if there is a reason why a patient should not be switched to a common alternative agent, then specifying the reason so that there's a clinician to clinician exchange in the transfer documents would be really helpful.
• 11:35
  SPEAKER_00: Yeah, I agree.
• 11:36
  SPEAKER_00: Um, you know, for example, if a patient is on daptamycin for a staph Areas infection, a transferring note that specifies the daptamycin dose, but also states that vancomycin would be an acceptable alternative can be helpful um in that admission process and moving, you know, particular a particular antibiotic to one that is uh less expensive for the nursing facility and still maintains the efficacy for the patient.
• 12:02
  SPEAKER_00: While more and more nursing homes are able to get lower prices on things like daptomycin, it's still a uniformly more expensive drug.
• 12:09
  SPEAKER_00: Alternatively, if a patient requires ceftroline and dapamycin for a complex staph infection, confirming the reason and the critical need for that regimen is also important to ensure that they don't make a switch.
• 12:22
  SPEAKER_00: So, for all those reasons, ensuring both the microbiology laboratory results and the associated antibiotic sensitivities is important for the receiving nursing home clinician and pharmacist.
• 12:33
  SPEAKER_00: If the transferring ID physician has reasons to favor a regimen, that information should be conveyed so that it can be considered in the cost context of the cost constraints.
• 12:44
  SPEAKER_03: And such a great example, communication is so critical.
• 12:48
  SPEAKER_03: Nursing homes often don't have ready access to an infectious diseases physician.
• 12:53
  SPEAKER_03: And even more so, they don't necessarily have a way to directly contact the infectious diseases physician who was consulting during a hospital stay.
• 13:02
  SPEAKER_03: One example that we've seen is having a patient admitted to our hospital for a relapse of a serious MRSA infection because the transferring facility dropped cepterylene and only continued deptomycin, meaning they were not specifically instructed about the need for both of those things.
• 13:19
  SPEAKER_03: And the microbiology results could have said it's susceptible to deptomycin, vagomycin, cepteraline, and they might have thought that only one of them was necessary.
• 13:28
  SPEAKER_03: So I think especially ID physicians need to be careful that complex things where most clinicians may not know why double dosings or double drugs are given really do have to be carefully communicated.
• 13:42
  SPEAKER_02: Communication is just so key.
• 13:44
  SPEAKER_02: What other considerations should clinicians really be aware of when planning to discharge to nursing homes?
• 13:53
  SPEAKER_02: Thinking about the hospital side here.
• 13:56
  SPEAKER_00: Yeah, I I think it it stems from that whole conversation around communications.
• 14:01
  SPEAKER_00: The people taking care of the person on the other side in the nursing home is gonna need access to the same types of information that the ID physicians and the hospital clinicians were making when they made the decision about what antibiotic to use.
• 14:15
  SPEAKER_00: So labs are an important element of that.
• 14:18
  SPEAKER_00: That's important for safe care.
• 14:20
  SPEAKER_00: We know that older adults have issues, especially with respect to renal function.
• 14:25
  SPEAKER_00: And sometimes it's hard to hunt down the labs that you that you need to calculate the right dose and make sure that you're providing um the right interval for some of the medications that we're giving people.
• 14:38
  SPEAKER_03: Yes, I couldn't agree more.
• 14:40
  SPEAKER_03: Um we found that 20% of errors um occur due to missed safety labs.
• 14:44
  SPEAKER_03: And I'm still curious what Swatji thinks about this.
• 14:47
  SPEAKER_03: You know, since patients in nursing homes are generally older and require several weeks of therapy, monitoring for these adverse events is pretty important and should be carefully specified in transfer documents from hospitals.
• 14:59
  SPEAKER_01: Yeah, that's a great point.
• 15:01
  SPEAKER_01: Um there are important logistics to consider related to safety labs.
• 15:07
  SPEAKER_01: Some nursing homes have difficulty obtaining weekly labs, and nursing home clinicians will have to make the clinical judgment on how to implement the safe the safety lab testing.
• 15:20
  SPEAKER_01: For example, it's going to be incredibly helpful if transfer documents from the hospital included prior lab data, since we do need something to compare to.
• 15:32
  SPEAKER_01: And also, if there were any concerns that were already noted in the hospital, for example, elevation and creatinine or LFDs that are off, melirban, CPK increases, especially with daptamycin, even if they are transient, it is really important for the nursing home physician to know.
• 15:53
  SPEAKER_01: And then, you know, really to know what to do with these weekly labs, since we do safety labs, and then we do, you know, sometimes get those labs for monitoring the response to treatment.
• 16:07
  SPEAKER_01: And how do you create partnerships in monitoring those labs with the ID physicians?
• 16:15
  SPEAKER_02: That's great.
• 16:16
  SPEAKER_02: That's such a great point, Safi.
• 16:18
  SPEAKER_02: Related to safety, Chad, I know you briefly touched upon this, but let's talk about the considerations of the dose of the antibiotic in nursing home residents.
• 16:28
  SPEAKER_02: You know, you did say a lot of them might be older adults.
• 16:31
  SPEAKER_02: Any thoughts on that with why dosing antibiotics might be different in the older adult population?
• 16:38
  SPEAKER_00: Yeah, I mean, I think familiar with older adults and older adult medicine, we know that you know, body systems begin to break down or deteriorate over time.
• 16:46
  SPEAKER_00: Older adults are definitely more susceptible to both organ injury as well as slower clearance, kidney clearance, uh, metabolism through their liver.
• 16:56
  SPEAKER_00: And the average doesn't often apply.
• 16:58
  SPEAKER_00: You have to be prepared for the unexpected.
• 17:00
  SPEAKER_00: Even if the patient was doing well in the hospital, renal injury can still happen after discharge.
• 17:06
  SPEAKER_01: Yes, beyond adverse effects that safety labs can detect, you know, we at nursing home, uh as clinicians, as geriatricians, also do need to be attentive to common and often weight side effects in older adults related to medication doses.
• 17:25
  SPEAKER_01: Higher is not always better.
• 17:27
  SPEAKER_01: For example, fluoroquinolones do have side effects that we are now more and more aware of.
• 17:36
  SPEAKER_01: And these side effects are really more prominent and more devastating in older adults than many younger adults.
• 17:43
  SPEAKER_01: So we have to keep that consideration in mind.
• 17:46
  SPEAKER_01: Um, you know, those side effects can be neurological side effects like mental cloudiness, confusion, delirium in older adults.
• 17:55
  SPEAKER_01: Um, for that reason, and due to that uh point that Chad just noted about renal clearances, um, a lower dose of, for example, levofloxicin should be given to older adults if that drug was actually necessary.
• 18:14
  SPEAKER_01: Um similarly, in nursing homes, for most uh infections that we deal with tend to use a lower dose of um ciftriaxone at a one million one gram dose rather than a two-gram dose, which is what we would consider if the person was about to go into you know sepsis or we had um worry about that.
• 18:41
  SPEAKER_01: Um so those are the doses considerations in uh generally for older adults that we need to be aware of.
• 18:50
  SPEAKER_02: This has really been a terrific discussion on how to ensure the safe and effective transfer of antibiotics from that hospital to the nursing home.
• 19:00
  SPEAKER_02: And really wrapping up this summary, can each of you give a pearl or two on how hospitals and nursing homes can better collaborate to improve patient safety during transitions of care from the hospital to nursing homes?
• 19:13
  SPEAKER_02: Susan, I'd like you to start with this from the hospital vantage point.
• 19:18
  SPEAKER_03: Yeah, from the ID physician on the hospital side, I'd say that more thoughtful communication and documentation is key.
• 19:24
  SPEAKER_03: It'd be really wise for ID physicians to include three pieces of advice in someone who's likely to go to a nursing home.
• 19:32
  SPEAKER_03: You know, one, can a less costly regimen, say vancomycin versus deptomycin, be considered by the nursing home, even if, for example, deptomycin is the preferred drug in the hospital.
• 19:43
  SPEAKER_03: So thinking about not what we want to do in the hospital, but what is available to the nursing home on transfer.
• 19:50
  SPEAKER_03: Number two, I'd say whether there are clinical milestones that could shorten the course of antibiotics, or whether or not the six-week course of medication for osteomyelitis must be completed.
• 20:02
  SPEAKER_03: So if it's a pneumonia, a lot of times it can be shortened if the person shows improvement.
• 20:06
  SPEAKER_03: Having some sort of guidance, especially when the course should not be shortened when symptoms get better, would be really helpful.
• 20:14
  SPEAKER_03: And the third thing I'd say is specific direction to the hospitalist team to send the final ID note so that the nursing home can actually read it.
• 20:24
  SPEAKER_03: It's important to remember that hospital transfers usually occur without the involvement of the ID consultants.
• 20:30
  SPEAKER_03: They've often signed off and they're not even aware of what exactly is packaged together to go to the nursing home.
• 20:37
  SPEAKER_03: So a specific recommendation to the team to make sure that a specific note goes can be really valuable.
• 20:50
  SPEAKER_01: Absolutely.
• 20:51
  SPEAKER_01: Thanks, Susan.
• 20:52
  SPEAKER_01: I think you know these um curls are super helpful for us as uh long-term care physicians.
• 20:59
  SPEAKER_01: And one thing that I really um liked about what you just said was um being very specific as ID physicians to not substitute.
• 21:11
  SPEAKER_01: That um came up in your earlier discussion with Chad as well, where you were talking about the sensitivities may look a certain way, but there is a reason why you're using a certain medication.
• 21:22
  SPEAKER_01: And I think us knowing that is so critically important.
• 21:26
  SPEAKER_01: So just, you know, putting a big um uh um in big letters saying do not substitute, similar to that concept of brand name only, is super helpful when the um when the residents come to the nursing home and we are having to make that decision.
• 21:46
  SPEAKER_01: So really appreciate that.
• 21:48
  SPEAKER_01: So, from nursing home vantage point, what I would say is that when we are accepting a resident, the dose, the duration, especially the stop date, as Chad had talked about.
• 22:00
  SPEAKER_01: you know the the the medication may have been started earlier within the hospital stay so stop date is really important and also the indication and the prescribing doctor should be a standard that should be a just a must have when accepting um uh our residence on IV antibiotics.
• 22:23
  SPEAKER_01: The second thing that I would say that is so critically important in post-acute care facilities is the route of antibiotic, the site care the date of line insertion is also critically important and that is so that we can follow the infection prevention practices that are needed to be followed.
• 22:45
  SPEAKER_01: And when we are having these residents with IV lines, especially the central line and the bigger veins, it is really important for us to have a running list of people who are there with those lines inserted to assure that we are not creating issues like CLAB C.
• 23:09
  SPEAKER_01: And also should be discussed in your quality assurance and process improvement meetings to see the number of people that residents who we have with these lines as they do need special infection prevention practices that are outlined by CDC, you know, including the enhanced barrier precautions.
• 23:31
  SPEAKER_01: And finally agreeing with Susan if antibiotics are prescribed by an ID physician in the hospital we should have not only the note but also the contact information on the chart to communicate some of these critical informations about the resident in a timely fashion.
• 23:50
  SPEAKER_02: Chad do you want to wrap it up and give the last little bit of tips here from the pharmacy vantage point?
• 23:56
  SPEAKER_00: Yeah absolutely I think um both Susan and Swati did a great job really laying out what's important in transitions as it relates to antibiotics and treating infections and communication is the ultimate answer.
• 24:10
  SPEAKER_00: Good processes for high risk medications, particularly antibiotics are critical to transitions of care, especially when working to avoid any delays or missdoses.
• 24:21
  SPEAKER_00: Pharmacies are equipped to get those medications to people as fast as possible.
• 24:26
  SPEAKER_00: So the earlier they're in the loop as to what the medication is, does it need to be prepared?
• 24:31
  SPEAKER_00: Is it an IV medication or something that's available in the emergency supply is critical.
• 24:36
  SPEAKER_00: They have processes to stat medications out.
• 24:39
  SPEAKER_00: They have processes to store medications on site that are commonly used.
• 24:44
  SPEAKER_00: And as long as we're keeping the pharmacy in that communication loop and being complete with what med, what dose and then what ancillary information is needed with respect to labs and things like that, we can deliver good care to patients through transitions and not run into to risks associated with missing doses or extending antibiotics beyond what the original ID physician was looking for.
• 25:14
  SPEAKER_02: That's great.
• 25:16
  SPEAKER_02: Thank you all very much I'd like to thank our speakers Dr.
• 25:19
  SPEAKER_02: Zwang and Gar as well as Chad Wers, our pharmacist here and for really sharing your perspectives and experiences.
• 25:27
  SPEAKER_02: This is really a terrific discussion.
• 25:30
  SPEAKER_02: That concludes this episode of the Shay podcast and thank you so much for tuning in