End-of-life care programme in nursing homes reduces AED attendance, hospital admissions
An end-of-life (EOL) care programme in residential care homes for the elderly (RCHEs) is shown to markedly reduce rates of accident and emergency department (AED) attendance and hospital admissions, with substantial cost savings.
“The Enhanced Community Geriatrics Assessment Team Service for EOL Care in RCHEs [ECEOL] programme was started in October 2015 in the Hong Kong West Cluster following a pilot programme rolled out in September 2009,” said Dr James Luk of the Fung Yiu King Hospital. “The programme, with shared care provided by trained RCHE staff and healthcare professionals, is associated with significant reductions in AED attendance and acute or convalescent hospital admissions in our recent study.”
“Among 223 patients recruited between October 2015 and December 2017, a 40 percent reduction in AED attendance, 43 percent reduction in acute hospital admission, and 24.5 percent reduction in convalescence admission [all p<0.001] were seen at 6 months after vs 6 months before implementation of the programme,” he reported.
Among 115 patients who died, 60 percent of deaths occurred at a designated geriatric convalescence ward, and 66.1 percent of the patients were under geriatric care when death occurred. Most patients died of chest infection (60.8 percent).
In these 115 patients, a 31 percent reduction in AED attendance (p=0.001) and 33.6 percent reduction in acute hospital admission (p<0.001) were seen at 6 months post-ECEOL vs 6 months pre-ECEOL. However, there was no reduction in convalescence admission.
“Larger reductions in health service utilization were seen among patients who remained alive [n=108], with a 50 percent reduction in AED attendance [p=0.001], 55 percent reduction in acute hospital admission [p<0.001], and 50 percent reduction in convalescence admission [p<0.001],” said Luk.
“The ECEOL programme was associated with a possible annual cost saving of HKD 6.52 million in the 223 patients, or HKD 29,000 per patient per year,” he added.
A majority of patients (96 percent) in the study had advance care planning (ACP) established, most commonly in RCHEs (97 percent). Surrogates for ACP were most commonly the patient’s daughter (46 percent), followed by the patient’s son (36 percent).
While 37.4 percent of patients were already on nasogastric tube feeding at the time of ACP establishment, 36.4 percent preferred not to use nasogastric tube feeding. “There may be a case for increased use of comfort feeding and careful hand feeding in the future,” remarked Luk.
“Surprisingly, 69.1 percent of the patients preferred intravenous [IV] or subcutaneous hydration and 71 percent accepted the use of IV antibiotics at EOL,” he continued. “About 53 percent did not accept the use of nasal intermittent positive pressure ventilation [NIPPV]. Only eight patients had advance directives established because most patients had cognitive impairment.”
“Our results also showed excellent compliance with ACP and DNACPR [do not attempt cardiopulmonary resuscitation] forms,” he said. “Compliance rate for DNACPR was 96 percent. Compliance rates for ACP on the use of nasogastric tube, IV drip, antibiotics and NIPPV were 95 percent, 91.5 percent, 95.2 percent and 99 percent, respectively.”“Based on these results, expansion of the ECEOL programme is recommended,” Luk concluded.