How Was The Hospital Born Before Subacute Care?
Hospitals cater to the acutely unwell. They do not cater to the subacute care needs we see today. We conceived the idea of acute hospitals in a very different time. It was a time when children died of childhood illnesses. Men came home from wars with unspeakable injuries. Middle-aged adults suffered from single diseases. Workplace injuries were far more common than we see today. We hatched an ingenious plan to collocate all our greats in one powerhouse. Great doctors. Great nurses. Great state-of-the art technology. Great research minds. It was the invention of the acute hospital.
And The Results Were Simply Spectacular
As a result of cohabiting our brilliance in one place, we saw epic advances. Technological advances and incredible treatment protocols have culminated in an incredibly advanced life expectancy. Brilliant research saw vaccines eradicate many of the diseases the world had come to accept. New surgical specialties were born. The entire specialty of plastic and reconstructive surgery has it roots in devising innovative ways of dealing with war torn injuries.
Today, we can expect to live until we are well into our 80’s.
Surely It’s A Great Plan Forever, Then
The nature of disease is changing. We have done a grand job to cure disease, but in its wake is left chronic disease. The need for acute management is fast being surpassed by the needs of the chronically ill, frail patient. And that need is largely subacute care.
Disability and disease increase with age. 76% of people over 75 years have a disability, chronic condition or long term condition. In 2007, the Australian Institute of Health & Wellness found that those aged over 75 years constituted 6% of the population but were responsible for 25% of the burden of disease.
Slowly, but surely, our shining beacons of clinical excellence are populated less and less by the 42 year old fit, well man with appendicitis and more and more with the octogenarian with a fractured hip. The fractured hip, in itself, is not so much a problem. It’s the gaggle of syndromes that she brings with her that sets her on a trajectory that is maligned with the acute care hospital. Enter the demon we know as subacute care.
How Does It All Go So Wrong?
Our octogenarian’s fracture is well managed by her orthopaedic surgeon. He comes from a well-founded and indoctrinated training protocol that produces experts in organ- and disease-specific prowess. He deals with that fracture with proficiency and finesse. His journey navigating her post-operative confusion, atrial fibrillation on Day 5 and a urinary tract infection secondary to her incontinence on Day 10, however, is more challenging to him.
However, three weeks later – a far cry from the but-the-care-plan-says-7-day admission – the orthopaedic surgeon is happy that her hip is ready for discharge home. Where she lives alone. Her mobility is poor – she is at least six months off being returned to her pre-injury function. Her evening confusion worsens. Her nutrition declines. Her incontinence exacerbates. Her children are sick with worry about how she will cope. Desperate, they present to an emergency department. She is re-admitted, with a primary diagnosis that we see for this group far too commonly: Acopia, the most frequently used. Social admission, another common one. Failure to thrive, features prominently. Ultimately, a posse of euphemisms for “Subacute Care”.
The hospital executives squirm under the pressure of the high nursing care costs of her dependency and her long length of stay under a funding model that rewards handsomely the single-diagnoses and heavily punitive on the complexities that accompany the frail. Consequently, she is moved from one institution of high-tech clinical intervention, that can offer her chronic complexity nothing, to another. Premature admission to a nursing home: a probable end.
The tsunami of chronic disease and needs of the frail leaves the system exposed. Our first baby-boomers have just turned 65 years old. In ten years, their health care demands will take a sharp incline. Those “Subacute Care” catch-all categories we see so commonly materialises on our spreadsheets as a staggering prediction of 285% increase in demand. Other clinical subsets that are related to the aged are also on the staggering side: respiratory medicine with in increase in 227% in demand. In fact, all specialties that correlate with AIHW’s 9 health priority areas are representative of disproportionate growth in demand.
How Can My Little Corner Of The Clinical World Help That?
Being unable to do everything is a poor excuse for doing less than we should. Oliver, D (2012)
- Purge Ageism. The NHS has got it right: their 2010 Equality Act dictates that there is no place for aged-based discrimination in our society, let alone our health system. The very principles of who we are as nurses – Patient Advocates – mandates that this falls squarely in our laps. We provide the best care and advocate for the best outcomes for our patients through compassion and dignity. No greater subset needs nurses more than the vulnerable frail.
- Embrace Wellness. Yep, being a wellness warrior isn’t just for the Paleo devotees. There isn’t a more important time to think about how powerful health promotion can be for this group. Reversing disability risk factors by decreasing physical inactivity, increasing nutritional status, teaching chronic disease self-management can be facilitated in any health service from the community, to the GP’s rooms, even the emergency room. But short-circuiting their spiral through a streak of “subacute care” admissions to an untimely nursing home admission is critical.
- Re-engineer Pathways. Our clinical pathways are inherently embedded in “single-disease-thinking” methodology. Yes, predictably, our 42 year old appendicectomy had an entirely uneventful 2 day post-operative recovery and discharged with nothing untoward occurring. The chances of our octagenarian achieving the same is nigh-on-impossible. But that’s not a variance. In fact, it was entirely predictable. Her journey being event-free would have been the variance! We can’t change the funding models that are in complete contrast to our everyday experience, but there is plenty we can do while we wait for common sense to reign. Good assessment at the beginning. Rock solid planning to follow. Protocols for the predictable events in the oldest old’s post-operative journey will make the immeasurable difference.
- Build Connections. Acute care and community care have to be one fabulous animal, not two separate species which is sometimes how we feel. It’s a tough gig, currently, as our system is imminently moving into Consumer Directed Care – new for us all. How it will operationalise is truly yet to be understood by all of us. But a change like this is an opportunity to rethink how hospitals and community services partner together and the role of discharge planning. Changing the way our hospitals operate is a little like turning a battleship: it’s really quite heavy and takes quite a while to turn it. But we will head in the right direction after everyone on board does their bit to turn it!
Nicole’s career coaching blog can be found at http://www.nursemanagerhq.com