Advance care planning and use of hospital resources among COVID-19 nursing home patients in an integrated care programme for the elderly

Abstract

Introduction Older adults with advanced chronic diseases require an integrated model of care that includes an adaptation of the therapeutic effort. The objective of this work was to estimate compliance with a standardized process of identification and registry of advance care planning (ACP) of patients in chronic home care (CHC) with palliative needs living in nursing homes and referred to the Hospital for COVID19. Theory/Methods Prospective cohort of patients in nursing home chronic care, >64 years, affiliated to the Health Maintenance Organization Hospital Italiano de Buenos Aires, with a diagnosis of COVID19 infection (3/15/2020 to 9/15/2020). The standardized care process uses the identification of patients with palliative needs based on the Necpal tool and registry of the advanced care planning in a central place in the electronic health record (EHR). Results 30% (1032) of CHC patients live in nursing homes. 65% (374/568) of suspected cases for COVID-19 were confirmed as positive. Among COVID-19 cases: 88% were women, median age was 88 yo., 92% were admitted to the Hospital, 0.3% used invasive ventilation, 80% (295) were stratified and identified in the EHR as patients with palliative needs, 68% (199) had the ACP registered in the EHR. 32.6% of hospitalized patients met severity criteria. 1% of patients with advanced chronic diseases with severity criteria were admitted to the intensive care unit. Mortality was 25% (94/374). Of those who died, 74.4% had severity criteria (p <0.001) and 90% were advanced chronic patients (p <0.001). Patients stratified as advanced had mortality OR of 10.89 (95% CI 3.34 to 35.47, p <0.001). After adjusting for severity criteria, the adjusted OR was 6.21 (95% CI 1.82 to 21.14, p 0.003). Discussions Carrying out a care process based on the stratification and identification of patients with palliative needs, and limitation of therapeutic effort according to the ACP, could improve the quality and safety of care and optimize resources in health emergency situations. Conclusions (comprising key findings): We evidenced a high rate of patient identification as chronic palliative with advanced diseases and registry of the ACP. Most covid critically ill patients had their ACP registered preventing them to be admitted to intensive care units.//Lessons learned Teamwork, including families, is essential when assisting advanced palliative care patients in order to generate advanced care planning. Structured and systematic registry of advanced care planning facilitates communication and care transition between different care areas and could optimize hospital resources, especially in patients with palliative needs. Limitations The pandemic context might explain part of our estimates. We could not evidence association between ACP and resources use because of the low frequency of intensive care unit admission. Suggestions for future research Each centre has to make efforts to apply standardized systems to obtain and register ACP to improve quality and safety care. [ABSTRACT FROM AUTHOR]