Best Practices for Custodial Care in the Acute Care Setting

On rare occasion, a patient presents to the emergency department without the acute care needs that would warrant hospital admission or observation services. Unfortunately, the patient cannot safely return to their prior disposition. This presents a challenge for the patient and the hospital. The temptation is to “admit” the patient to the inpatient ward or even keep the patient for a three-midnight stay to then transfer to a skilled nursing facility (SNF). Both of these practices violate CMS guidance and federal regulations and would not withstand an audit. Since these patients tend to be frail elders, bringing them to an inpatient setting further exposes them to the risks of inpatient hospitalization which can lead to prolonged stays that might be detrimental to the patient. Each institution should evaluate options and develop a plan to best manage these patients in the safest and most compliant fashion. The following are suggested best practices to consider.

Early identification of the patients at risk

Emergency department (ED) staff and ED case management resources need to work vigilantly to identify these patients as promptly as possible. Social services should be engaged immediately, and information should be promptly obtained regarding the patient and their social supports while contacts or family members are still available. One should perform an immediate assessment of the patient’s options while the patient is in the ED.

Validation of lack of acute care needs

At times, patients are erroneously labeled as custodial when they actually have acute care conditions. Appropriate consultation in the emergency department and a thorough and careful assessment of the patient by more than one provider can often yield important information. Because these patients might not be able to provide a good history, obtaining a history from the patient’s caregiver or contact is crucial. Acute conditions are often missed. Critical questions to ask might include:

• How was the patient managing previously? Are there changes in behavior, gait, fluency, or movements?
• What changed today, this week, or this month where the patient cannot return to their prior site of care?
• Did the patient have any medication changes, or are any medications at risk of causing an encephalopathy? Is the patient being undertreated?
• Have a conversation with the patient’s outside providers. Are they surprised that the patient is as described? Are they aware of any recent changes to the patient or their medications? Are they aware of any other individuals involved with the patient?

Early escalation

Consult with your physician advisor or advisory service provider. There should be a prompt escalation to the administrator on call (or appropriate person) while the patient is in the ED to ensure that appropriate resources are deployed. Individuals caring for this patient might need to be released from other duties or have their workload adjusted.

Early family (guardian) meeting

An early family meeting is critical to educate family members regarding the hospital’s role and its ability to care for patients. Many patients or their families still believe that the route to a skilled nursing facility is through the hospital. Review and discuss goals of care and feelings regarding intrusive life-sustaining treatments. Patient in this situation may deteriorate cognitively rapidly, and having a documented understanding of the patient’s wishes can be critical to future conversations.

Create a long-term plan beyond the ED doors and transition to outside professionals

Immediately exploring local resources is critical. Many of these patients will require a care setting for which there might be a long waiting period. Often patients leave the ED only to return a few weeks or months later in a worse state unable to leave the ED. Relying on family or other contacts to follow through with plans has a high probability of failure. Family members might require more support to navigate the system and options. Catalog potential resources already available to the patient to support them in the community:

• Home health
• Relatives
• Volunteer services
• Family friends

If all reasonable alternative options have been exhausted, choose the least restrictive setting

If it is deemed that the patient cannot safely leave the ED and all alternative options have been exhausted, the patient should be brought into the least restrictive setting that would allow for their safe care. A single person or role should be responsible for deciding that this step is appropriate.

• These patients should be brought in as an outpatient in a bed, or bedded outpatient. They cannot be brought in under observation or inpatient status for a three-midnight stay.
• Include the patient on the list right away for careful review and assessment of their plan if there are complex care or excess length-of-stay rounds.
• It should be determined early in the course if the patient will require guardianship. If guardianship is required, steps should be taken to pursue this as promptly as possible.

Choose the safest care

• Care should be taken to choose a setting where the patient is not at risk of sundowning (if clinically relevant).
• Remind staff that the patient still will require assessments and procedures as outlined by the hospital and regulatory standards. These patients are at risk of being forgotten amidst the needs of more acutely ill patients.
• A review of the patient’s medications and orders should be performed to ensure appropriateness.
• To detect changes and to have a clear owner of clinical information, it is best to have a single provider (or at most 2-3 providers) caring for the patient. The patient should still “count” on the provider’s census as they may require meetings or paperwork.
• If you have a volunteer service, scheduling visits can be helpful to patients who otherwise do not have social contacts or are alone.
• Be judicious with care and testing. When we see patients in an acute care facility, it is natural to treat them as acutely ill. Carefully consider ab testing, vital signs measurements, DVT prophylaxis measures, and consultations for appropriateness before ordering.

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