SURVEY AND REGULATORY UPDATE

January 2023

Assisted Living: Calling Emergency Medical Services

Assisted living facilities are required to develop and implement policies directing staff on the process of responding to medical emergencies. It stands to reason that these policies include contacting emergency medical services (EMS) for times when a resident’s condition requires urgent medical attention. Staff must be trained on these policies and have access to them at all times.

Over the past few years, WHCA has been approached by various EMS departments across the state requesting assistance in educating assisted living staff on the proper use of EMS services. With the pandemic’s impact on staffing across the healthcare spectrum, and limited resources available at EMS and hospital settings, the use of EMS services must be carefully considered again with a close eye.

Department of Social and Health Services (DSHS) licensing agency (RCS) has historically expected assisted living facility providers ensure they have proper equipment and staffing to care for the residents they choose to admit and retain. An updated Dear Provider Letter dated May 27, 2022, highlighted when staff should call 911:

• When a resident:
• Has an acute, serious, or life-threatening medical condition or complaint. Examples include but are not limited to chest pain, stroke, new onset or worsening seizures, or fall with a broken bone.
• Is medically unstable. Examples include but are not limited to significant difficulties breathing or sudden unconsciousness/unresponsiveness.
• Has an immediate health risk. Examples include but are not limited to sudden swelling of the tongue/throat, unstoppable bleeding, severe abdominal pain, or sudden vision change.

The Dear Provider Letter also referenced times when calling 911 is unnecessary such as when the resident is medically stable, or the health status is non-acute or not serious. Some examples of times when 911 has been called and the resident’s health condition did not warrant transport to the hospital include (but are not limited to):

• The onset of a urinary tract infection
• A urinary catheter that had come dislodged
• A resident who had fallen and possibly hit his head (without change in alertness, level of confusion, headache, or vomiting)
• A resident who had fallen, was uninjured, and could not get up without hands-on assistance
• Increased leg swelling
• Positive COVID test

At times residents or their family members may want 911 called when the resident’s health issue could better be managed in-house through coordination with the resident’s health care provider, a visiting ARNP/MD, or via an urgent care visit. For those facilities situated in the greater Puget Sound or Spokane areas, Dispatch Health offers visiting urgent care visits to minimize the need to send a resident to the hospital for conditions best treated in the assisted living setting. Educating residents and families on the various options to ensure the resident’s health condition is treated in the best possible location can help alleviate non-emergency calls to EMS.

This article is not meant to underscore the need for EMS services; there are certainly times when a resident’s urgent medical condition warrants a call to EMS. In those times, it is essential the facility staff is prepared to provide necessary information to the 911 dispatcher, including:

• Name of the caller and name of the facility
• Facility address and resident apartment number
• Call-back number
• Resident information, including full name, gender, date of birth or age, specific medical complaint, and any medical treatment already tried

Someone should be available to show the EMS team where to go once they arrive onsite. A staff member knowledgeable of the resident and the situation should remain with the resident until EMS arrives; this person should be prepared to answer the EMS staff’s questions such as details of the resident’s condition, level of consciousness, vital signs, medical history, etc. EMS staff will need copies of pertinent resident information upon their arrival, including a medications list, face sheet (with resident’s name and date of birth, emergency contacts, insurance information, etc.), and any advance directives and POLST form available. A sample printable badge shared with WHCA by one EMS department may provide clarification for facility staff regarding when to call 911, and what information to have ready to share with the 911 dispatcher and the arriving EMS team.

Ideally, the facility’s policies, procedures, and training efforts include the information provided in this article.

Older and vulnerable assisted living residents tend to heal from illnesses and injuries at improved rates when they are in their own apartments. Extensive waits in the emergency department lead to worse resident outcomes, including decreased abilities to perform activities of daily living, increased pain, and worsening cognition. Non-emergency transports via EMS cause back-ups in the agency’s ability to respond to life-threatening emergencies in the greater community.

Questions about assisted living regulations? Please email Vicki McNealley or call 1-800-562-6170, ext. 107.

Hospital Readmission Rates are at an All-Time High for Sepsis | SNF

Hospital readmission rates are at an all-time high and one of the reasons is NOT COVID, it is SEPSIS. First and foremost nursing staff need to ensure that each resident receives the care/services necessary and required per F684. Also for a skilled nursing facility, it is vitally important that nurses and caregivers understand the requirements concerning antibiotic stewardship (F880 and F881) as well as the need to prevent hospital readmissions. Sepsis is a potentially life-threatening condition, and staff need to recognize and respond rapidly if a resident appears to have contracted this condition.

According to the Agency for Healthcare Research and Quality, of the ten most common principal diagnoses in 2018, septicemia was both the most frequent (2,218,800 stays) and the costliest ($41.5 billion in aggregate). Septicemia ranked as the first or second most common diagnosis among adults, both male and female. Approximately 1.7 million Americans are admitted with sepsis every year and of those, 270,000 will die.  

Our grandmothers knew about sepsis—they called it “blood poisoning.” Their descriptive term for the illness was spot on since sepsis means that an infection is in the blood stream and the chemicals released by the body to fight the infection get out of balance. This can cause changes that can damage multiple organ systems. Make no mistake, it is a life-threatening disease and requires immediate intervention which often includes an ICU admission to the hospital. If sepsis advances into septic shock, the blood pressure drops dramatically, which may lead to death. Now more than ever, with the lack of available emergency room and hospital beds in both urban and rural areas, it is especially important for SNF staff to utilize infection control practices and recognize and act quickly in response to the signs and symptoms of sepsis.

Sepsis is caused by an infection and can happen to anyone at any age. However, older adults, pregnant women, children younger than one, people with chronic conditions (diabetes, kidney or lung disease, and cancer) and people with weakened immune systems are the most common victims. Other risk factors include having wounds or injuries such as burns, invasive devices such as intravenous catheters or breathing tubes, and/or having previously received antibiotics or corticosteroids.

Signs and symptoms of sepsis include:

• Change in mental status
• A systolic blood pressure reading of less than or equal to 100 mm Hg
• Respiratory rate of 22 breaths per minute or higher
• Extreme pain or general discomfort
• Pale or discolored skin
• Anxiety—“I feel like I might die”
• Shortness of breath
• Shivering, fever, or very cold

Most often sepsis occurs in people who are hospitalized or who have recently been hospitalized. Sepsis should be treated as a medical emergency and time matters! Most hospitals have specific time-limited protocols in place for treating sepsis. As sepsis worsens, blood flow to vital organs, such as the brain, heart, and kidneys, becomes impaired. Sepsis can lead to blood clots in the organs and body parts such as the arms, legs, fingers, and toes, leading to varying degrees of organ failure and tissue death (gangrene). A staggering statistic is that 40-50% of people who progress to septic shock will die from the damage to their bodies.

What can be done to stay ahead of sepsis in your resident population? The first thing is to prevent infections. Long term care facility residents need to manage and receive care/treatment for chronic conditions and get all recommended vaccines such as pneumonia, flu, and shingles. Secondly, staff need to practice good hand hygiene. If staff or residents have breaks in the skin from cuts or abrasions, they need to stay clean and covered until they are healed. Third, staff need to know the symptoms of sepsis as addressed earlier in this article. Lastly, act fast! Sepsis is a medical emergency and time does matter!

Teach the nursing staff to recognize sepsis. The CDC has multiple educational resources on its website as well as downloadable posters and reminder cards for staff education. Here are some resources that will assist your facility in education regarding sepsis:

• Mayo Clinic – Sepsis Overview
• Centers for Disease Control – Sepsis Overview and Tools
• WebMD – Sepsis

Questions? Please email Elena Madrid or call at 1-800-562-6170, ext. 105.