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The Acute Care Hospital and late El(lerly: Framing the Issues Mitchell T. Rabin At least Me recent achievements have brought us to He state of penury now claimed by payers for health care. One is the advancing life expectancy, which has created a relative increase in the number of elderly. Another is advances in medical technology, which have led to increased applications of diagnostic and therapeutic modalities to dis- eases in the elderly and increased enthusiasm for hospitalizing the elderly in the face of acute disease or exacerbations of chronic illness. The third achievement, particularly during the decades from 1965 to 198S, has been the significant increase in funding for the care of the elderly Medicare and Medicaid. Only one of these Me advanceslife expectancy, medical tech- nology, and increased funding is technological; the others are clearly societal. Nevertheless, we are now confronted, as medical care expendi- tures are being trimmed, with He need to reconsider the venous compo- nents of that societal burden of rising heals care costs. The pressure is on the medical care establishment. ACUTE HOSPITAL CARE OF THE ELDERLY Probably no single component of health care costs is as large as that for the acute hospital care of the elderly. It represents about 40 percent of the inpatient revenue at Boston's Beth Israel Hospital and at many other major teaching hospitals and community hospitals; in some hospitals the figure may be even higher. Yet, we must not forget a fundamental fact: the vast bulk of these dollars is spent on a relative minority of the elderly. Most old people, during most of their advanced 80

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ACUTE CARE AND THE Fi~ERLY: ISSUES 81 years, fall within the category of "successful aging," as our former geron- tology chief, Dr. John W. Rowe, has written. Thus, we should begin with a caution. If prevention is the most effective medicine, then we had better pay attention to maintaining and extending successful aging among the population whose numbers, life span, and average age are increasing, lest the economic pressures we now feel grow to a size that strains not only our material resources but also our ethical reserves. The pressures recently applied by Medicare and other payers have had a major impact on the nature of hospitalization, particularly for me elderly. The extent of this pressure varies state by state, perhaps hospital by hospital. It vanes over time, too, as we move, for example, from regional to national rates of payment for Medicare. These pressures win probably escalate furler. The result win be a real change in who gets admitted and for how long. For many hospices, the result has already been a sharp increase in Me pace of inpatient turnover, especially if the hospital remains fun by a~nithng more and more patients, as ours does. The turnover pace seems much faster both to the caregiver and Me patient with, for example, the loss of the preoperative day; with discharge often occurring before He patient or family can grasp what has been going on; and with postdischarge arrangements made in a manner that often seems to the patient and family as last minute or, if it starts at the time of admission, inconsiderate. The patient has less time to get to know the inpatient unit, its physical geography, and its staff. The patient has less lime to form reassuring relationships and to be reassured. The anxiety spins over, not only to the patient's family, but to Me caregivers as weU. It is less satisfying to be a patient. It is also less satisfying to be a provider of care. ~ wrote several years ago about what I labeled the SAG index, an acronym for Sense of Anxiety versus Gratification all. The days when we no longer hospitalize patients are clearly the days of relative gratifica- tionthe patients feel, finally, that they are being cured; the doctors fee! that they have been able to accomplish something. The days that remain are Me days of anxiety. "Do ~ know what is going on?" asks the doctor. 'twin I live or win I die?" asks Be patient. Nowadays, the SAG index has moved up markedly. Therapeutic goals have become subverted by the utilization review process. Regardless of the vision properly held by the doctor or nurse of a reasonable therapeutic goal for the patient, the fact is that when the patient's condition is deemed no longer needing the capabilities of the

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82 MITCH T. RABKIN acute care institution, the patient is pressured to leave. The hospital, aware of the economic consequences of therapeutic chantableness, ap- plies pressure, although not always directly. When the acute illness subsides to a level which could be handed elsewhere, this approach destroys what should be the the focus in therapy in many patients. Coming to the hospital with a background of relatively stable chronic illness and level of functioning, the patient often regresses as a result of the acute illness. The acute care focus tends to deny that proper goal, the restoration of the patient's status quo after the acute illness has been handed. Given He vagaries of subsequent attention in the padent's home or the nursing home, which may be good but too often is not, the patient might or might not ever return to a functional status that might have been achieved under more favorable hospital circumstances. The relinquishing of responsibility once the acute episode has tempered also assaults the longitudinal continuity so important in care, particularly in the elderly, for whom new scenes and new relationships are often difficult to manage. Even He efficient transfer of information to the skilled nursing facility does little to maintain a flue sense of continuity. PROBLEMS OF THE ELDERLY IN THE HOSPITAL Let us look at the elderly who populate the hospital. What specific problems do most of them present as a result of age and of less, rather than more, successful aging? Aging assails many physiological protective mechanisms, such as clearing of the tracheobronchial tree; He skin is more fragile and breaks down more easily; aspiration of fluid into He lungs occurs more readily. Injury, especially falls, are more common because of decreased peripheral vision, because the elderly cannot find their glasses, because the hospital bed is a different height than their own, or because a bit of incontinence has made the floor slippery. The new and unfamiliar hospital environment creates confusion made worse by new medications or by Snag toxicity, hypotensive agents, or salt restriction. Unfamiliar foods or dishes can lead to bums. Hot packs can burn before the patient is aware. Meal schedule disruptions or He strange tastes of salt restriction may lead to anorexia. Depression is common, even for the patient who did not enter depressed. Sensory depnvation or overstimulation in a new environment and the loss of diurnal clues in the passage of days and nights, particularly in the ever- lighted intensive care unit (ICU) commonly occurs. Ordinary inconti- nence may be viewed as normal for age even though often it can be

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ACUTE CARE AND THE ELDERLY: ISSUES 83 improved. Bowel pattems, often perverted though needless laxative use at home, may create major problems. The sleep and rest cycle is disturbed. The roommate or the roommate's family may be problematic. Immobility in bed may create more Man bedsores and pulmonary problems. A marked decrease in mental functioning can result. Often the elderly bring to the hospital a damaged sense of their own identity, ability, and self-esteem. The vicissitudes of Weir life, their retirement, the loss of spouse, the restrictions of age or illness, the youth orientation of the world around them, me lack of respect for the experi- ence and insights their years have brought- these can be sources of self- consciousness, a sense of deficiency, humiliation, and depression. Acute hospitalization itself is no help, for it assaults the strongest of us as we are Trust into a more passive, regressed role. Hospitalization can be made even worse by the expectation of the health care team that the patient win comply with He speed set by these younger, acclimatized, and in-charge people. And to wrap it up, we take away their name and give them a number, we take away their clothes and give them a Johnny, and then we lose their dentures! Too often, the clinical team does not even begin to touch on issues of major concern to the patient. In part, it is the pace of life in a hospital, but sometimes the elderly patient's concems, for example, concerns about sexuality, are not even considered as being reasonable. Nor is He pa- tient's anticipation of his or her own death considered to be a reasonable concern. We would certainly want to participate in the decision for ourselves if orders are written not to resuscitate. Does age mean that the elderly do not want to? Interestingly, a Beth Israel nurse made a comment to me Hat sums up some of this. She said, `'You know, competency is never an issue when He patient says, 'Yes,' only when the patient says, ~No,.,' This litany describes He situation of patients everywhere, and ~ believe, in practical fact, that we do better at Beth Israel than at many hospitals; but the problem is universal. We must address these questions: How can we change our policies? How can we use technology to improve the care of He aged? Hospital Policy Some of the agony of the elderly that ~ have just described surely must be exacerbated by the anomie of some of our hospitals. No new policies need be formulated, but the successful implementation of exist-

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84 MITCH T. RABKIN ing policies relating to effective management of Me hospital is important. For example, hospital workers, from physicians and nurses to transporters and dietary aides, must understand the issues of the elderly and use that understanding to make Weir systems work to soften the harshness of hospitalization. It is imperative that hospital management rationalize its operations as effectively as possible. Payers' policies could be changed in relation to length of stay and the resulting pressures for discharge. ~ suspect, how- ever, Hat major relief win not be forthcoming until Be heady care proportion of the gross national product (GNP) decreases significantly, which, ~ believe, will happen only if Be denominator (GNP) grows faster than the numerator Beach care costs). Technology in the Acute Care Setting In medical care, we find that most technology does not eliminate jobs or save money. Furthermore, many tasks Squire the exercise of judgment that has not yet been synthesized into machines; the basis of professional expertise is still judgment, which is based on cI~n~cal expen- ence. ~ liked the idea Rat was previously mentioned of using bar codes. I would like to see bar codes on wristbands and on unit-dose medication packets, tied in with computer ordering, used for documentation and billing, coupled with purchasing and receiving in Be pharmacy, used with a drug incompatibility system and a least-cost drug program, and many other applications. This is no longer high technology. It is middle-level technology, but the same considerations apply to bar codes as they do win PET scanning or magnetic resonance imagery. Indeed, mistakes occur both in today's systems of administration of medication and in the absence of PET scanning; in bow instances suboptimal care and even deadly mis- takes can occur because the conect technology is not in place. Will it be worth the vast dollar cost to salvage those few lives? The question is Be same, regardless of high tech, middle tech, or low tech ~ hope that Be answer is "yes," but Be reality will always be that the size of Be purse powers the purchase. ' See Robert L Kane, "Home and Community Care of the Elderly: Framing the Issues," in this volume.

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ACU~17i CARE AND THE F~)ERLY: ISSUES 85 PRIMARY NURSING In service industries and hospital care is a service industry, me best approach to problems is not invariably technology. So, without retreating from me many ways to think about these issues, I want to propose greater adoption of a "no-technology technology"; one that has great potendal- Me way in which we use nurses in the hospital. ~ call it a technology because it is a way of empowering nurses to improve He therapeutic process. Our previous comments on me risks of hospitalization and problems, often cited in nursing literature, such as He effects of immobility, orientation, lighting and quiet, ambience, and over aspects of the hospital environment, emphasize He importance of nursing. Hospitals are nursing institutions, not doctoring ~nshtutions. Twenty- four hours a day, seven days a week, He professional nurse provides professional nurturing that sustains the patient and allows the physician to touch base periodically to create various perturbations, some for good and some perhaps not. Much of the difficulties of the elderly hospital patient can be helped markedly by better use of nurses on the inpatient unit. In most hospitals today, nursing is organized under a concept called team nursing, which organizes nursing personnel at venous skis levels, with He profes- sional nurse typically directing and supervising the work of others. This has two problems. First, nurses do specific tasks for many patientsthe beds, baths, temperatures, and so onbut no one really knows any spe- cific patient. The second problem, worse in times of a nursing shortage, is that the few professional nurses are so involved in supervising that they do not get to know the patients, even though they are the ones who give the medications and treatments that aides are not qualified to give. The idea of primary nursing arose out of dissatisfaction with this arrangement and was based on the notion that patients, rather man tasks, should be He focus of the professional nurse. The concept is that a professional nurse would be accountable for the care of relatively few patients over the entire 24-hour daydeveloping their nursing care plans; delivering He total care while on shift, with assistance from others as needed; and then delegating to associate nurses on other shifts the respon- sibilities for carrying out the plan and reporting what happened. The continuity in reporting is maintained shift by shift, and as a result He primary nurse becomes able to maintain an awareness 24 hours a day of the patient's physiology changes and psychology; an understand-

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86 MITCH T. KIN ing of how the disease is progressing; an understanding of how much the patient understands and what preparations the patient has made for con- troBing and dealing with the illness after discharge; the role of the pa- tient's family; and so on. The primary nurse's role becomes an ~m- mensely important complement to the physician's activities and aware- ness. Furthermore, it is gratifying for both nurse and patient. Beth Israel Hospital's vice president for Nursing, Joyce C. Oif- ford, instituted primary nursing a dozen years ago ~ughout the entire hospital. The impact on patient care and patient satisfaction has been tremendous. The impact on nurse satisfaction is such that, over the years, when other major Boston teaching hospices have had to close beds because of nurse vacancies, we have not needed even to float nurses from one unit to another. And our costs, whether expressed in terms of nursing hours per patient day or nursing salaries, have remained in line with those of the other major Boston teaching hospitals. If you understand primary nursing, then you can understand why having continuity of care with one responsible individual enables the primary nurse to become a knowledgeable and effective advocate for the elderly patient who, as we have seen, can be severely disadvantaged. The primary nurse acts as support for the older patient faced with difficult decisions in hospital or with discharge planning issues. Because primary nurses gives the daily care, they are able to assess the skins, the strengths, and Me deficits of each patient. While they give this care, some of which others may label as grunt work, Hey are able to taDc with the patients and learn more about Heir hopes, needs, and fears. It is an intimate relation- ship with He patient, one which is professionally fulfilling. The primary nurse decreases the patient's sense of isolation and becomes a familiar, sometimes dear, friend and the nurse's 24-hour accountability leads to a far more individualized and tailored program and, often, a greater likeli- hood of compliance. A leader in American nursing wrote, "Professional services are meanings only if they meet society's needs. Patient care in hospitals has not done this for a long time, if ever." Primary nursing offers the vehicle to accomplish this service to society. Let us hope that its promise will be realized. REFERENCE I. Rabkin, M.T. The SAG index. New England Joumal of Medicine 307:135(}1351, 1982.