Don’t Dump: Helping the ED with SNF transfers

[Woo-hoo! GeriTech is pleased to welcome its very first clinician guest post, by Graham Walker, MD]

To dump: the act of defection; to put down or abandon (something) hurriedly in order to make an escape; to abandon or desert (someone).
To dump on: to treat badly.
If you understand these definitions, you understand why we call them “nursing home dumps” in the emergency department. The dementia patient transferred for confusion. The comfort-care-only patient transferred for cough. Now please don’t misconstrue my cynicism; many nursing homes do a great job, and have an incredibly difficult set of patients to care for; I’m frequently amazed at how many days and how many interventions they’ve tried before the patients are transferred. I’m not suggesting that all nursing home transfers are “dumps,” but certainly a number of them are.
The vast majority of the time, the staff member at the nursing home who felt the patient needed to come to the ER is gone, having “just left shift,” with a transfer sheet only stating “confused,” with a pleasantly demented patient wide-eyed, staring at you in the face without any particular complaint. At my hospital, we’re frequently much luckier, with pretty good communication and notes to know how the patient ended up in the ER.
So what is an ER doctor to do? It’s 2am, you’ve called all the family members, and no one’s answered. No one that knows the patient is at the skilled nursing facility. The paperwork gives you nothing about how the patient is “confused,” or “altered.” Your exam is normal. Here’s how it usually goes:
1) Order a CT head, cath UA, basic labs, EKG.
2) Give some IV fluids.
3) Wait until morning until you can get some more information, possibly having to sedate the agitated, demented patient and complicate their mental status even more.
Could there possibly, possibly be a better way? I think so. Enter SNFTube.

SNFTube: An idea to help the ED understand a SNF resident’s baseline

What if we had a way to know a demented patient’s–or any patient’s–baseline mental status and function? What if the doctor at the bedside could see a video of the patient’s baseline, best-case-scenario mental status and cognitive function, complete with some data on their most recent MOCA, along with some video of their baseline function? Do they move all 4 of their extremities? (Frequently when someone’s problem list already includes 3 prior strokes, it’s hard to know if their left-sided weakness is new or old.) Are they bed bound? Do they typically feed themselves? Can they get themselves dressed? Are they typically this agitated and angry at night? 
This information would be incredibly helpful to any physician trying to make critical decisions about someone’s mother, father, sister, or brother, especially when no one is there to be able to provide some background for us.
We have the technology to upload millions of cat videos; why not make a service that helps us care for our aging (and growing) geriatric patient population?
“To dump” has one more definition, usually used in the digital world, and I think it’s actually quite apropos to what I’ve proposed: “a copying of stored data to a different location.” 
Anyone want to build it?
 
 
Graham Walker is an emergency physician in San Francisco, and the developer of several web-based medical tools: MDCalc, a medical calculator, and theNNT, an evidence-based medicine tool. His monthly column, Emergentology is featured in Emergency Medicine News. You can also find him on Twitter @grahamwalker.

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