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Assessment tools could reduce end-of-life hospital stays for older adults

Tuesday, January 8, 2019

Person holding hands with someone in a hospital bed

Better use of standard assessment tools could help long-term care homes identify which new residents are at risk of hospitalization or death in the first 90 days of admission.

A study from the University of Waterloo and Schlegel-UW Research Institute for Aging has found that newly admitted residents’ history of heart failure, as well as their score on the interRAI Changes to Health, End-Stage disease, Signs and Symptoms (CHESS) scale, can accurately determine which residents are most at risk.

“Being able to identify at-risk residents early can help long-term care homes ensure they have the necessary care and management strategies in place,” said George Heckman, a professor in the School of Public Health and Health Systems at Waterloo and Schlegel Research Chair in Geriatric Medicine. “These assessments can also help health providers determine which conditions require a trip to the hospital or which would be better managed as a hospice-type condition within the homes themselves.”

He added, “It is not always advisable to take someone who is closing in on the end of life out of their home and put them into a hospital setting. These residents are very complex and frail, and not only might they not benefit from the hospital visit, the transition itself can lead to harms such as delirium and further disability.”

The study examined data collected from 143,067 residents aged 65 years or older, admitted to long-term care homes in Ontario, Alberta and British Columbia, between 2010 and 2016.

It found that more than 15 percent of residents had a history of heart failure. Residents with heart failure were more likely to be hospitalized than those without (18.9 percent versus 11.7 percent). Residents with a history of heart failure were also twice as likely to have higher mortality rates than those without, 14.4 per cent versus 7.6 per cent. At the one-year mark, residents with a history of heart failure had a mortality rate of more than 10 per cent higher, at 28.3 percent compared to 17.3 percent.

The CHESS scale identifies frailty and health instability, and is embedded within the MDS, an interRAI instrument mandated in almost all long-term care homes across Canada. Higher health instability, identified through higher CHESS scores, were associated with a greater risk of hospitalization and death at three months. Most notably, residents with high CHESS scores were more likely to die even when sent to hospital, regardless of whether they had heart failure or not. Mortality rates for the highest CHESS scores were 80 percent; most of these residents died in hospital.

“Together, these two factors independently identified this increased risk,” Heckman said. “By making clinical assessments early, advance care planning discussions can take place. Furthermore, by ensuring that the entire long-term care home care team, including personal support workers, understand these risks, they can help monitor resident health and optimize their quality of life in the long-term care home.”

The study, Predicting Future Health Transitions Among Newly Admitted Nursing Home Residents with Heart Failure, appears in the Journal of the American Medical Directors Association. It was authored by Heckman, John Hirdes, Paul Hébert, Anne Morinville, Andre Amaral, Andrew Costa and Robert McKelvie, and was funded by the Canadian Frailty Network.

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