Hospitals as hotels

[mr friendly guy]

This is a particular rant I have, however it is something I think its worthy of discussion in the wider scope of socialised healthcare so I bring it up.

Having worked in Australia public hospitals for a few years, I have observed certain patients and their relatives tend to think of the hospital as like a hotel, where they can come in and stay while nurses tend to their needs, they get free food (not exactly great food, but it may very well be better than what they get at home) and then go home.

Some of these patients are admited with the diagnosis "acopia", or "dyscopia" or the even more blatant "social admission". One foreign doctor joked to me he thought his medical knowledge was inadequate when he saw patients being admitted with "acopia" and wondering what type of disease is this. Hint acopia means they aren't coping at home.

Another class of patients, come in with a disease but discharge is delayed because of social issues. This is really irking me as patients take up a hospital bed when they don't need one.

The first class of patients who are admitted for acopia usually are old decrepitated who need to be in a nursing home, or if they are not so bad they need a hostel, or social services to come give them a hand. Some of these people cannot walk without being a falls risk (this has been deteriorating for a long time). If that is the case, the admitting medical team has no choice but to take them. They will be assessed by geriatrics and eventually wait listed for a hostel / nursing home. Note a lot of the time these patients are fiercely protective of their independence, and don't want to go to a nursing home, its their family which are concerned.

What bugs me is that we could avoid this, if these patients were assessed in the community by the geriatricians. If this was a problem for such a long time, why the hell do the family wait until the patient needs to come into hospital before they get the ball rolling so to speak. Haven't they heard of a general practitioner?

The second class of patients tend to have medical problems which only require hospitalisation for a few days. Unfortunately "social issues" tend to delay the discharge.

To give recent examples I have seen

a) woman who vomitted up blood, scoped and turned out to have a gastric ulcer and placed on the appropriate medication and told to avoid anti-inflammatories. Instead of being discharged after 1-2 days of admission it ended up almost 2 weeks because the family was concern about her forgetfulness and hence her ability to cope living by herself. Besides the obvious that she was doing quite well before coming in with haematemesis, (never mind that she wanted to go home) can she not have geriatrics assess her in the community?

b) A man developed a blood clot in his lung (his main symptom was chest pain rather than shortness of breath). Now to facilitate discharge the public health system have programs such as HITH (hospital in the home) and RITH (rehab in the home). Once the diagnosis is made HITH can administer the anticoagulants (both clexane which is injected and warfarin which is orally ingested, and they can also measure the INR to check warfarin's effect to boot).

It actually is cheaper for the government to provide services such as HITH rather than keep these people in hospital. Now instead of discharging him on the second or even third day, this process is being dragged out (its now double the time I expected to get him out).

Why you ask? Well he has chest pain. You don't say, he has a clot in his lungs which is being treated (the pain itself will go away relatively early even if the clot still needs to be treated). We do send him home on pain killers which he himself admits helps. Given that he is quite capable of swallowing the tablets himself, I don't see why it would suddenly be difficult at home.

But, the family is afraid that he won't cope at home. There goes that phrase again. You would think this is strange given that he was coping before hospitalisation and if a nurse will do all the medical stuff and all he needs to do is take pain medication when he is pain, what is the difficulty?

What happens is we give an inch and say, ok one more day for the pain to go away. Then the family are asking for several more days until its apparent its not the pain thats the problem. Now if there is an underlying problem which you are worried about, come out and say it, don't give me this its pain argument.

c) paraplegic man with a kidney infection. Ok we treat him with intravenous antibiotics for 3 days. He has no complaints and its time to discharge him on oral antibiotics. Suddenly he is worried about his bowels not opening (not an unreasonable request in a paraplegic), however why the hell do you need to stay in hospital for that? Admitted to hospital for a one day history of constipation. What? This is despite the fact that his bowels eventually did open with asperiants.

He wants maybe to stay in hospital over the weekend which will lead to 3 days longer stay while we do nothing medically for him. On further questioning I get weird answers. He wants to be let out when he "feels right" and he can tell when something isn't working.

Me : What do you mean by feel right?
Him : I just know when I am going to have a problem
Me : So what symptoms do you have to tell you there is going to be a problem
Him : its hard to explain, but I just know.

Note - to facilitate more efficiency, doctors can now leave a note instructing nursing stuff under what criteria patients should be discharged without requiring a doctor's review. Someone I don't think writing "when patient feels right" is acceptable.

Geez, besides the obvious dodgy subjective criteria, after further questioning it comes out that his main worry is that his primary carer (mother) will have to give up her plans to take care of him as they cannot find another carer over the weekend. I can sympathise however that does not justify you taking up a hospital bed when we are no longer doing any medical care for you. This "can't find a carer over the weekend" conundrum obviously a problem even when you aren't unwell, so why should this problem suddenly stop you? Answer it shouldn't.

d) A woman who is such a vague historian (but seems to compalin of shortness of breath) who is a "handback" ie presented on another medical team's "on take" day but admitted under our team because we previously took care of her. This woman has a reputation as a "frequent flyer" ie she presents repeatedly to be seen some of which is dodgy.

The admitted doctor admitted her for a mild heart attack with only mildly elevated cardiac enzymes (presenting complain was some chest pain and some increase breathlessness compared to her "normally" poor breathing). Presumably she may have had a small heart attack a few days ago and by the time she presented to hospital the enzyme levels had dropped.

Ok, I accept her, treat her. We find she gets frequent blood noses and we get the ENT doctors to see her and treat that. She is somewhat breathless but her chest sounds clear and her heart has been pretty crap at least since 2005 which can account for that.

Of course after that there is not much reason to keep her here but her son and want her to stay, because you know, staying in hospital for a few more days where we do nothing magically makes someone better.

The conversation in bits and pieces went something like this.

Them : I don’t want mum to have to come back in a few weeks with some other problem

Me : she has chronic illnesses. Its unfortunate but not unexpected that this may happen and we will treat her when that happens.

Them : But what about the fluid in her lungs. I heard its because her heart is crap.

Me : She is on tablets for that. Her chest sounds clear and her heart hasn’t been good since at least 2005 (when an echocardiogram was performed). There is nothing much more we can do about it.

Them : What about a blood transfusion. It might make her feel better. I heard two doctors want it.

Me : Her blood count is slightly low (she is on iron tablets). However when we rechecked the blood her Haemoglobin is higher. The lower limit for a woman is 115. Your mother is 101. That doesn’t warrant a blood transfusion.

Repeat and fixate on blood transfusion forcing me to explain 3 fucking times why we no longer need a blood transfusion and that her chronic breathlessness is because her heart has poor function.

Them : Can’t we just keep her in the hospital a few more days, do some observations and run some more tests.

Me : What tests do you exactly expect me to run. I wasn’t planning on ordering any and my boss certainly hasn’t asked for more. What exactly are you expecting us to look for?

Me : you were willing to go home only yesterday. We only delayed so ENT can get a look at you. Whats changed.

Them : That was because she had enough of where she was at

This line is particularly damning because they pretty much admitted the only reason he wants his mum to stay is because now that they are in a nice ward as opposed to the emergency department where its difficult to sleep because lights are always on and its noisy.

After a while when it was obvious I wasn’t going to budge they just wanted one more night. The cynical part of me also thinks because of a free meal, but maybe I am just too jaded.

Them : But my place in hostel requires me to walk up 2 flights of ramps (not stairs, ramps). I can’t make it.

Me : You are willing to go tomorrow. Won’t you have to face the same problem?

Them : But my son can’t help me because he is busy and has his own life (geez and the hospital isn’t).

At this point the son takes his pants off (no I kid you not) to show me some injuries after being assaulted, and tells a sob story about how he is in pain, yada yada and the Emergency department doctors are teh evil and won’t see him and he can’t find a GP to see him “soon” despite you know a GP practice right next to the hospital because they are booked out and lets ignore the other GP practices around Fremantle.

Me : can’t the hostel stuff help you.

Them : But they have to look after sicker people

Me : If “sicker” (no such word) people can stay there why can’t you?

Them : you are just “twisting” our words.
Because pointing out logical flaws in arguments is now twisting the words apparently.

Needless to say I manage to get them out. I expect to have a complaint against me, but given that they didn’t bother to learn my name or bother to ask for it maybe I will get lucky.

The really insulting thing about talking to these people is that they assume we have an ulterior motive for sending them home - ie we need the extra bed, requiring me to explain thats not the reason. Sorry, the bed state is secondary. The true reason is that for one reason or another you don't need to be in hospital. No one, and I repeat no medical team is going to send you out just because we "need the bed".

The problem is, with a lot of these patients there is the tendency to practice "defensive medicine" ie to prevent ourselves being sued by keeping the family happy. In the perfect world decisions should be made mainly on clinical grounds, however the world isn't perfect.

Now I think socialised healthcare is much better than the systems certain right wing nutjobs on this board praise, however I think this may be a limitation of the system.

Besides the obvious and better education so that people so that they are aware people can be assessed by geriatricians in the community for nursing home / hostel placement, I am not sure what more we can do against this type of attitude where the hospital is treated like a hotel. A lot of doctors have complained that people will not take this attitude if they have to pay for it. Presumably the cost will have to be not insignificant for it to affect people, then again I have seen people who can’t afford $2 for heavily subsidised medicine who ask the hospital to supply it for FREE, so maybe we don’t need it that high. I am personally reluctant to go down that route as it defeats the purpose of providing “free” or heavily subsidised health care for everyone.

Thoughts?

[Tsyroc]

I think we end up with some of the problems you mentioned. Mostly the ones where the physician or the hospital has to cover it's ass type of thing. We are usually short on beds so anyone who can safely go somewhere else is going to get the boot in most cases. Sometimes there can be a little too much of a rush to get people out and they'll end up back in the hospital in a few days for legit reasons.

The closest we probably get to the hotel type visits are probably homeless people getting admitted to detox off of alcohol or something. We had a bit of a cold snap in January and that led to a huge increase of people admitted for alcohol detox. The police or someone finds them drunk or passed out someplace and they get brought in through the ER. It gets them someplace warm for a couple of days, plus some food without having to put up with the crap from the various shelters in town.

Nursing homes tend to dump patients on us on weekends, especially holiday weekends, when they are short staffed. Usually these patients do need a bit more care than the majority of the other nursing home patients but it's usually nursing home staffing issues more than a drastic change in the persons medical status that gets them a weekend stay with us.

I think everyone in healthcare deals with the people who start getting paranoid about various parts of their health. Based on the med orders I see I think that getting enough sleep and being able to take a crap must be the two most important things. I mean, STAT sleeper meds for someone in a hospital? WTF? Do they have somewhere important to be tomorrow and have to well rested? Will it really be a problem if they have to sleep in or take a bunch of naps during the day?

Really, I think a lot of people get put on sleepers and anti-anxiety meds at night just so they'll konk out and leave everyone alone.

[PainRack]

This is a particular rant I have, however it is something I think its worthy of discussion in the wider scope of socialised healthcare so I bring it up.

Having worked in Australia public hospitals for a few years, I have observed certain patients and their relatives tend to think of the hospital as like a hotel, where they can come in and stay while nurses tend to their needs, they get free food (not exactly great food, but it may very well be better than what they get at home) and then go home.

Would you mind clarifying what is it you are disturbed by?

If it is overstaying, you know..... this is probably one of the reasons why I think that hospitals, even if utterly socialised should charge their patients for length of stay. I mean, the really expensive stuff like drugs, diagnostic tests and other medical procedures are absorbed by the state, paying charges on simple items like laundry, food and general stay would place a cost analysis on people.

Depending on the scope of charges, it should easily meet healthcare policy on reducing length of stay, reducing consumption of scarce health resources and forcing a analysis of hospital stay while making secondary healthcare accessible and affordable for people.

Of course after that there is not much reason to keep her here but her son and want her to stay, because you know, staying in hospital for a few more days where we do nothing magically makes someone better.

The conversation in bits and pieces went something like this.

Them : I don’t want mum to have to come back in a few weeks with some other problem

Me : she has chronic illnesses. Its unfortunate but not unexpected that this may happen and we will treat her when that happens.

Them : But what about the fluid in her lungs. I heard its because her heart is crap.

Me : She is on tablets for that. Her chest sounds clear and her heart hasn’t been good since at least 2005 (when an echocardiogram was performed). There is nothing much more we can do about it.

Them : What about a blood transfusion. It might make her feel better. I heard two doctors want it.

Me : Her blood count is slightly low (she is on iron tablets). However when we rechecked the blood her Haemoglobin is higher. The lower limit for a woman is 115. Your mother is 101. That doesn’t warrant a blood transfusion.

Repeat and fixate on blood transfusion forcing me to explain 3 fucking times why we no longer need a blood transfusion and that her chronic breathlessness is because her heart has poor function.

Them : Can’t we just keep her in the hospital a few more days, do some observations and run some more tests.

Me : What tests do you exactly expect me to run. I wasn’t planning on ordering any and my boss certainly hasn’t asked for more. What exactly are you expecting us to look for?

LOL: This sounds exactly like something that happened here.
Relative: What if my father gets sick again after he leaves the hospital? It would be better if he stays just for a few more days to ensure nothing else will happen.

Nurse: Well, it would be better for him to leave anyway. He can get his wound dressed at a polyclinic and if he stays here, he may just get sick anyway from all the sick patients here.

Relative: If you go by that logic, why aren't you sick?

The problem is, with a lot of these patients there is the tendency to practice "defensive medicine" ie to prevent ourselves being sued by keeping the family happy. In the perfect world decisions should be made mainly on clinical grounds, however the world isn't perfect.

Now I think socialised healthcare is much better than the systems certain right wing nutjobs on this board praise, however I think this may be a limitation of the system.

Won't this be a limitation of any system? The sole difference is that in an utterly socialised system, more people can afford to abuse this.

A lot of doctors have complained that people will not take this attitude if they have to pay for it.

Doesn't work here. I seen too many anecdotes here where our co-payment scheme doesn't prevent people from overstaying if they want to.

After all, if they just simply ignore the bill, the government will have no choice but to simply deduct it from their social security.

[Turin]

The problem is, with a lot of these patients there is the tendency to practice "defensive medicine" ie to prevent ourselves being sued by keeping the family happy. In the perfect world decisions should be made mainly on clinical grounds, however the world isn't perfect.

Now I think socialised healthcare is much better than the systems certain right wing nutjobs on this board praise, however I think this may be a limitation of the system.

Won't this be a limitation of any system? The sole difference is that in an utterly socialised system, more people can afford to abuse this.

You're going to have the same problem with patients in any system, true. But in socialized medicine, at least it comes down to the medical professionals deciding whether or not the patient really has a problem, rather than the insurance actuaries. Unfortunately for mr friendly guy, the doctors are going to inevitably bear the brunt of patient problems. "Defensive medicine" is still going to be an issue, although I'm curious how the malpractice issue works in a social medicine system -- doctors in the US pay a hefty premium for medical malpractice insurance.

I'm somewhat amused by the description of hospitals as a hotel, by the way. The architectural firm I work at does a lot of healthcare work, and one of the trends in patient suites these days (at least in the US) is to make the space seem more like a hotel! Apparently, this is in order to improve patient comfort (which is thought to improve healing). Little did we know we were aggravating the doctors!

[Darth Wong]

Businesses and governments have the same problem when it comes to "customers"; the most unreasonable customers always get themselves free stuff, by virtue of being so goddamned whiny and insufferable that it's easier to give in than to fight. It happens to every kind of industry, and the medical industry is no exception.

[General Zod]

If it is overstaying, you know..... this is probably one of the reasons why I think that hospitals, even if utterly socialised should charge their patients for length of stay. I mean, the really expensive stuff like drugs, diagnostic tests and other medical procedures are absorbed by the state, paying charges on simple items like laundry, food and general stay would place a cost analysis on people.

Depending on the hospitals, a bed can cost anywhere from a few dozen bucks per night to well over a thousand per night for intensive care. So it's not exactly like length of stay is cheap either.

[Edi]

Businesses and governments have the same problem when it comes to "customers"; the most unreasonable customers always get themselves free stuff, by virtue of being so goddamned whiny and insufferable that it's easier to give in than to fight. It happens to every kind of industry, and the medical industry is no exception.

They don't much put up with that crap here. If somebody makes too much of a fuss with the hospital services for no reason, they will get tossed out and they can then take it up with the appropriate oversight authority which will investigate and then roundly tell them to go fuck themselves.

I wish I could take the Bastard Operator from Hell approach to some of the fucks who I have to deal with as an ISP tech support person, but most of our customers are remarkbaly docile, understanding and patient as long as you treat them with a firm and polite attitude. The assholes get dealt with in a placating manner and then their complaints are treated just the same as everyone else's and too fucking bad, read the goddamn Terms of Service. Don't like it, go ahead and switch operators, they will do the exact same thing to you.

Edi

[mr friendly guy]

The closest we probably get to the hotel type visits are probably homeless people getting admitted to detox off of alcohol or something. We had a bit of a cold snap in January and that led to a huge increase of people admitted for alcohol detox. The police or someone finds them drunk or passed out someplace and they get brought in through the ER. It gets them someplace warm for a couple of days, plus some food without having to put up with the crap from the various shelters in town.

Over here, most people who are drunk come in for like a day and usually don't make it past the emergency department. Once they can walk and are sober enough they get out. Chronic alcoholics will need to stay in for a few days usually with thiamine and other vitamin replacements. Funny you should mention it, I recently presented a case of an alcoholic whose electrolytes were all out of whack, and its a good case on what alcohol does and how it does it. Needless to say he discharged himself before the social worker could see him about his alcoholism.

Nursing homes tend to dump patients on us on weekends, especially holiday weekends, when they are short staffed. Usually these patients do need a bit more care than the majority of the other nursing home patients but it's usually nursing home staffing issues more than a drastic change in the persons medical status that gets them a weekend stay with us.

The funny thing is, once you say there is nothing ACUTELY medically wrong, the nursing home will find an excuse not to take them in right now.

I think everyone in healthcare deals with the people who start getting paranoid about various parts of their health. Based on the med orders I see I think that getting enough sleep and being able to take a crap must be the two most important things. I mean, STAT sleeper meds for someone in a hospital? WTF? Do they have somewhere important to be tomorrow and have to well rested? Will it really be a problem if they have to sleep in or take a bunch of naps during the day?

I am not unsympathetic to people who can't sleep. Public hospitals are noisy, with nurses coming in constantly to do observations, so I guess short term dose of benzos on a prn basis is acceptable.

[mr friendly guy]

Would you mind clarifying what is it you are disturbed by?

If it is overstaying, you know..... this is probably one of the reasons why I think that hospitals, even if utterly socialised should charge their patients for length of stay. I mean, the really expensive stuff like drugs, diagnostic tests and other medical procedures are absorbed by the state, paying charges on simple items like laundry, food and general stay would place a cost analysis on people.

Mainly the overstaying. The other thing is people seem to have a misconception of what the hospital is for. Not all illnesses need hospitalisation. To use an analogy, you are sick and you see the GP. They prescribe you meds and say you will get better in a few weeks. During those few weeks did you need to stay in the GP practice, or can you take the meds at home. So why can they not extend this line of thinking to the hospital.

Depending on the scope of charges, it should easily meet healthcare policy on reducing length of stay, reducing consumption of scarce health resources and forcing a analysis of hospital stay while making secondary healthcare accessible and affordable for people.

These days we have several nurses whose job title is the discharge coordinator and transfer coordinators. They help facilitate discharges. They can sort of arrange transfer to other hospitals, re : private hospitals (who are more than happy to accept because they get paid for it), or rural hospitals (if the patient is from the country area).

They even offer free taxi vouchers if the patient cannot arrange their own transport. Unfortunately it doesn't always work, and we still have patients wanting to stay "just in case something happens".

Won't this be a limitation of any system? The sole difference is that in an utterly socialised system, more people can afford to abuse this.

That was my point. Patients who want to stay even though they don't need to, will find it much easier if the Government picks up the tab.

A lot of doctors have complained that people will not take this attitude if they have to pay for it.

Doesn't work here. I seen too many anecdotes here where our co-payment scheme doesn't prevent people from overstaying if they want to.

After all, if they just simply ignore the bill, the government will have no choice but to simply deduct it from their social security.

Hmm. I wonder if it will work if the government simply adds it on to the tax bill. So when people pay for things like electricity and water they also get a bill for hospitalisation.

[Johonebesus]

As someone on the other end of it, the primary caregiver for my eighty year old grandmother with COPD and Alzheimer's, I might be able to shed some light on their motives.

First of all, from your descriptions, most of these patients are not really healthy in genreal. It can be difficult for family to come to terms with the fact, or even really comprehend, that grandma is chronically ill, that her health is irreparably damaged and that it is all downhill from here. This is especially true if the patients live alone. The family likely assumes that if the patient is still sick he still needs care, and it doesn't seem right to send someone home who can barely walk. Even after two years it is difficult at times to tell when my grandmother really needs the hospital and when she is just having a bad day.

Eventually an elderly patient will get to a point where near constant care is required to keep him alive, and to the layman the best place for such care would seem to be a hospital. In fact, from a purely medical point of view, it likely is. I don't know the situation in Australia, but in the U.S. nursing homes are basically places you send someone to wait for death, when living alone would guarantee a quick, cruel end. Without constant vigilance on the part of family, the patient in a home will likely have his medical and even basic physical needs neglected to one degree or another. Even decent nursing homes aren't really equipped or staffed to properly deal with dozens or hundreds of sick people.

Then there is the selfish motive. It might seem callous, but caring for a chronically sick person 24/7 is exhausting, and my fear and concern when she does go to the hospital is always mixed with a bit of guilty relief that I will get a couple of nights of uninterrupted sleep. Now, I have never pressed doctors to keep her beyond what they think is needed, but she is never really "healthy" when she leaves, and I can't say I really look forward to emptying her pot and listening to the monitor all day and night again.

I can understand why families might honestly feel that their loved ones would be better off kept in the hospital a bit longer, and patients themselves probably don't want to give up quality care. I doubt it's often about free meals, but rather about not having to cook for themselves. When you are chronically ill, even simple tasks can be quite taxing. Suffering a chronic illness is a terrible burden, and the hospital is probably very refreshing for both patients and caregivers. It might seem selfish and unreasonable to you, but consider how miserable they probably are at home, that being cooped up in a hospital bed and fed institutional fare is more attractive.

[PainRack]

Depending on the hospitals, a bed can cost anywhere from a few dozen bucks per night to well over a thousand per night for intensive care. So it's not exactly like length of stay is cheap either.

Obviously, charges will have to be revised based on what services you consume. However, by charging them for stay, we can still achieve the twin goals of making healthcare affordable while limiting overconsumption.

These days we have several nurses whose job title is the discharge coordinator and transfer coordinators. They help facilitate discharges. They can sort of arrange transfer to other hospitals, re : private hospitals (who are more than happy to accept because they get paid for it), or rural hospitals (if the patient is from the country area).

They even offer free taxi vouchers if the patient cannot arrange their own transport. Unfortunately it doesn't always work, and we still have patients wanting to stay "just in case something happens".

Ouch. Here, the staff nurses have to do that, via referral to the various nursing homes and social medical workers.

Eventually an elderly patient will get to a point where near constant care is required to keep him alive, and to the layman the best place for such care would seem to be a hospital. In fact, from a purely medical point of view, it likely is. I don't know the situation in Australia, but in the U.S. nursing homes are basically places you send someone to wait for death, when living alone would guarantee a quick, cruel end. Without constant vigilance on the part of family, the patient in a home will likely have his medical and even basic physical needs neglected to one degree or another. Even decent nursing homes aren't really equipped or staffed to properly deal with dozens or hundreds of sick people.

That sounds more like a hospice than a nursing home. While nursing homes aren't really prepared to deal with medical emergencies, they should be, well, in an ideal world, more than adequately staffed to care for the critically ill.

Then there is the selfish motive. It might seem callous, but caring for a chronically sick person 24/7 is exhausting, and my fear and concern when she does go to the hospital is always mixed with a bit of guilty relief that I will get a couple of nights of uninterrupted sleep.

Is there respite care facillities available?

[mr friendly guy]

I have to say sometimes doctors bring patients in purely for respite. Ok, maybe not completely as they will usually have a few other medical issues in, but they end up staying much longer because we are aiming for respite.

For example, during my last job we booked in a patient with multiple sclerosis. The idea is this may save money in the long term if these brief periods of respite delay the patient being placed in a nursing home, but unfortunately hospital isn't the best place for it, but sometimes its the only place available (we don't always have adequate respite facilities in the community).

I can understand that respite will certainly help carers, however I think people have to realise hospitals aren't the appropriate place for it. Unfortunately there may not necessarily be much in the way of respite for your particular disease.

Onto another point, I am not sure about the US, but over in Australia people aren't sent to nursing homes to die, thats hospice. And once in a hospice they don't need to be sent to the hospital, because they are not for resuscitation and just kept comfortable with things like morphine / clonazepam infusions with some hyoscine.

The purpose of a hostel / nursing home is basically for someone who can no longer take care of themselves or relatives can't do it in the community even with social workers arranging people to come in weekly to help out. The difference is just in the level of care the staff need to provide the residents (hostel is low level care, while nursing home is high level care).

Nursing homes are supposed to provide some degree of care, usually there will by a doctor coming around regularly to check up on patients, and staff can administer medications.

It might sound a bit callous, but if you cannot provide the 24/7 care your relative needs, perhaps you should consider a nursing home (although NH in the US may very well be different to in Australia). The trick is finding one which isn't dodgy.

[Johonebesus]

When I said that folks go to nursing homes to die, I meant that the level of care is usually extremely poor. No-one is sent to a nursing home for the overt purpose of dieing comfortably, but neglect and abuse is so rampant that it's little more than a warehouse for folks who have lived too long. There are nurses and physicians, but they are usually understaffed and employ lots of untrained, underpaid highschool drop outs as aids and caregivers. Nursing homes are almost always for-profit establishments, so the owners cut as many corners as possible. Not all of them are really horrible, but even the best ones can’t really provide a high level of care. If the family isn't able to visit daily to check up on the patient, or hire a sitter, the patient is usually given just enough care to maintain life, barely. Of course, as with anything, there are good facilities for those with lots of extra money, though I've heard lots of horror stories even from those.

There are hospices for people who are very near death, at least around big cities, but around here there is only "home hospice," where nurses and aides come to the home several times a week. When the patient gets to a critical stage, he is almost always going to spend his last days in a hospital.

Your "hostels" are probably what we would call "assisted living facilities." Supposedly, patients who still have their wits and aren't very sick but are too weak to really care for themselves can move into little apartments. Employees will help the patient with bathing, cleaning, laundry, etc. However, these facilities are not covered by Medicare, and are quite expensive and rarely have good service.

And of course, the U.S. is huge with great disparities in wealth. Some places are like third world countries, while others would put the richest districts of Europe to shame. I live somewhere in between, probably a bit towards the poorer end, so the situation might be different for folks living in Connecticut or the West Coast or some such place.

It might sound a bit callous, but if you cannot provide the 24/7 care your relative needs, perhaps you should consider a nursing home (although NH in the US may very well be different to in Australia). The trick is finding one which isn't dodgy.

That's the rub. Around big cities there may be lots of different types of facilities, but even today most folks don't live near big cities. There are no hospice or "respite" facilities anywhere nearby. It's a nursing home (which would take all of her pensions and income, and possibly even her properties) or the hospital. The home hospice people said that they have a respite system where the patient can be checked into the hospital for a short time to give us a rest, but we haven't really needed it. I didn't mean to imply that we aren't capable of caring for her. I am certain that if she had gone into a nursing home two years ago she would be dead by now. It's a taxing occupation, but not crippling, and I don’t begrudge it at all. I'm not alone, so we take it in shifts, and it's not too bad, and actually sort of rewarding. Eventually, if her heart or lungs don’t give out, she will have to go to nursing home, but we're not there yet.

[Larz]

Well, now that I wrote and deleted all I wrote because it was simply a rant I should get down to writing something useful. It really is a problem, and especially so with psychiatric patients.

A lot of what I've been seeing mentioned regards geriatic patient care, which their over long hospitalization really is a problem. Where I work almost all of our geriatric patients and DD patients are dumps from family, res care, or nursing homes who don't want to deal with a difficult/volitle/odd acting patient any more. I think at the moment more than half of our current geriatric inpatients have some sort of organic diagnosis (organic or simply old age dementia, alzihemers, etc.) which no psychotherapy, psychotropic drugs, or any of that is ever going to cure or help. Whats really sad is that it takes threats of legal action most of the time to finally get a nursing home or such to take a patient.

A really good example of this was a patient that we had on our ward for nearly 2 months before we discharged her to NM's long term psychiatric hospital. She tended to strip, curse like a sailor, and pose like captian morgan before peeing all because she had mestastisized brain cancer. What she needed was hospice care but instead her nursing home dumped her with us.

More of my thoughts on this later if the thread doesn't die, gotta get to work, to work, to work.

[Winston Blake]

Them : Can’t we just keep her in the hospital a few more days, do some observations and run some more tests.

Me : What tests do you exactly expect me to run. I wasn’t planning on ordering any and my boss certainly hasn’t asked for more. What exactly are you expecting us to look for?

Firstly, I have no healthcare experience. Anyway, one possibility might be that people watch medical dramas on TV and assume it's like real life since they don't know any better. Dramatically, there must be complications and unexpected twists to keep the plot moving, with conflicts between doctors' opinions (good guys and bad guys) and either a heartbreaking ending or a fulfilling ending where everyone is happy and healthy.

So when they're thrust into the TV situation, people might subconsciously 'know' that there is 'something we/they missed' or that the carer who is refusing them is the villain of the story, who'll get their comeuppance in the denouement. If you've ever seen middle-aged women spit stilted phrases at each other that seem lifted straight out of a cheesy soap opera, that's the sort of influence I'm imagining.

[Larz]

Them : Can’t we just keep her in the hospital a few more days, do some observations and run some more tests.

Me : What tests do you exactly expect me to run. I wasn’t planning on ordering any and my boss certainly hasn’t asked for more. What exactly are you expecting us to look for?

Firstly, I have no healthcare experience. Anyway, one possibility might be that people watch medical dramas on TV and assume it's like real life since they don't know any better. Dramatically, there must be complications and unexpected twists to keep the plot moving, with conflicts between doctors' opinions (good guys and bad guys) and either a heartbreaking ending or a fulfilling ending where everyone is happy and healthy.

So when they're thrust into the TV situation, people might subconsciously 'know' that there is 'something we/they missed' or that the carer who is refusing them is the villain of the story, who'll get their comeuppance in the denouement. If you've ever seen middle-aged women spit stilted phrases at each other that seem lifted straight out of a cheesy soap opera, that's the sort of influence I'm imagining.

Doubtful in such a situation. There are people that grasp at straws when faced with a painful decision regarding treatment, diagnosis, so on but the situation being described by Mr Friendly Guy is not such a situation. Its where a patient is medically clear and no longer requires the level of care a hospital offers. As you will note the next part of that monologue was:

Me : you were willing to go home only yesterday. We only delayed so ENT can get a look at you. Whats changed.

Them : That was because she had enough of where she was at

More often than not when you hear the such above it people trying to foist the family member, spouse, etc off onto the hospital. They are grasping at straws, but moreso in the hopes the doctor will find something just enough out the ordinary to keep them hospitalized longer. Granted, some people are just paranoid and looking for an invisible killer thats not there, but I think thats the exception not the rule.

On another point, I'm a bit interested in whether other healthcare workers have ever run into patients whom themselves wish to hospitalised and look for any reason to stay such? I'm not just talking about the over paranoid and OCD folks who think everything under the sun is wrong with them but as well the over dependent, learned helpless, or simply just enjoy the environment and setting of the hospital. I am curious as almost all of our 'regular' patients in the psychiatric hospital tend to be of the later kind (with the rest of the regulars being volitile, psychotic, substance abusers, or typically all three.)

[Tsyroc]

Over here, most people who are drunk come in for like a day and usually don't make it past the emergency department. Once they can walk and are sober enough they get out. Chronic alcoholics will need to stay in for a few days usually with thiamine and other vitamin replacements. Funny you should mention it, I recently presented a case of an alcoholic whose electrolytes were all out of whack, and its a good case on what alcohol does and how it does it. Needless to say he discharged himself before the social worker could see him about his alcoholism.

We usually give thiamine, folic acid and a multivitamin orally or IV on a daily basis. I think they can give the thiamine and folic acid IM if need be. The MVI is too much volume to do that.

They also usually get a standard tappering scale of either diazepam, lorazepam, or chlordiazepoxide. That, if I recall correctly, ends after the second day.

The funny thing is, once you say there is nothing ACUTELY medically wrong, the nursing home will find an excuse not to take them in right now.

The more I hear about the local nursing homes and long term care facilities the more and more horrible I think they are.

I am not unsympathetic to people who can't sleep. Public hospitals are noisy, with nurses coming in constantly to do observations, so I guess short term dose of benzos on a prn basis is acceptable.

I can't really say that I mind all the sleeper drug orders. Personally, if I'm ever admitted I want them to put me on a midazolam drip and keep me on it until I'm discharged. I don't want to remember whatever my co-workers have been doing when taking care of me.

I just resent the avalanche of phone calls and crying for STAT ambien, temazepam etc... in the middle of the night for a new admit. ASAP I can usually deal with, but STAT should be reserved for emergencies and using a sleeper to get slightly annoying or anxious patient to leave the nurse alone doesn't qualify.

The legality is also a little on the fringe when used that way. We have a lot of restrictions on things that can be considered chemical restraints. If something is used on a PRN basis to help someone sleep then that's okay, but change the same order withthe same schedule but it says for anxiety or agitation and then it becomes a problem. The problem being that the patient's anxiety or agitation level is being determined by the nurse's judgement and not by any specific criteria.

It's basically an offshoot of some laws meant to protect people in long term care facilities. The goverment is looking to protect the quality of life of patients. The idea being that they didn't want nursing homes full of people who were sedated solely for the convenience of the staff.

[Broomstick]

For example, during my last job we booked in a patient with multiple sclerosis. The idea is this may save money in the long term if these brief periods of respite delay the patient being placed in a nursing home, but unfortunately hospital isn't the best place for it, but sometimes its the only place available (we don't always have adequate respite facilities in the community).

The US has respite care in large urban areas, but it can be extremely expensive and is often not covered by insurance. Thus, for the poor the only respite left is to put the person in the hospital. If the alternative is the caregiver having a breakdown (or if the caregive him/herself is ill or injured) the hospital may be the least worst alternative.

A few charities offer some respite, but there's not nearly enough.

Onto another point, I am not sure about the US, but over in Australia people aren't sent to nursing homes to die, thats hospice. And once in a hospice they don't need to be sent to the hospital, because they are not for resuscitation and just kept comfortable with things like morphine / clonazepam infusions with some hyoscine.

The US has hospice, but it's underutilized so in effect a lot of people are sent to nursing homes when they should go to hospice. In the US, hospice is supposed to be the last 6 months of life. The average hospice patient dies within 2 weeks. Obviously, part of the under-utilization is not using it soon enough - this from a combination of factors ranging from culture to fear of malpractice suits.

Hospice units may or may not be located in the same medical complex as a hospital, or might even be in the same building. This would also facilitate some pallitive procedures that involve surgery or require intensive nursing care for comfort. Most such units also have home hospice, though, so at least there the choice can often be made by the patient.

The purpose of a hostel / nursing home is basically for someone who can no longer take care of themselves or relatives can't do it in the community even with social workers arranging people to come in weekly to help out. The difference is just in the level of care the staff need to provide the residents (hostel is low level care, while nursing home is high level care).

In the US, I think what you call "hostel" is what we call "assisted living", which may or may not be in the person's home, in an "assisted living community", or perhaps in a building that functions as a group home and may not be much different than a nursing home. They range from very good to hellish.

It might sound a bit callous, but if you cannot provide the 24/7 care your relative needs, perhaps you should consider a nursing home (although NH in the US may very well be different to in Australia). The trick is finding one which isn't dodgy.

Yes - non-dodgy nursing homes can be hard to get into.

They can also cost enormous amounts of money for the private ones. The public ones are all too often cesspits, though there are some exceptions. What happens when the family (which may be down to an elderly, frail spouse) can't afford a nursing home and also can't continue to care for the invalid?

More in tune with the OP - the US also has people that seem hard to get out of the hospital, "frequent flyers" who show up far more often than they should, as so on. Any system of this sort will have some abuse, it's inevitable (something the public and the politicians do not want to hear) and it's a matter of keeping it minimal without blocking access to care.

In the US, it's often the homeless and the mentally ill, who have no good place to go, who wind up sitting in a bed far longer than they should. The law says everyone showing up at the ER with a complaint must be seen to, but outside of that there is some mechanism for eviction - which, of course, must be done carefully to avoid lawsuits. Sometimes, if for example there is no one home to help someone with bandage changes (as an example) or to assist someone unsteady in moving about that patient might be kept a little longer, but the preference is to have some sort of social services help out.

Of course, the gap between theory and practice can be huge. No question, things don't always work as well as we'd like.