Vol. XXXIV,No. 3 Printed in U.S.A.

JOURNAL OF T H E AMERICAN GERIATRICS SOCIETY Copyright 0 1976 by the American Geriatrics Society

Errors and Omissions in Diagnostic Records on Admission of Patients to a Nursing Home* MICHAEL B. MILLER, MD, FACO** and DIAN F. ELLIOTTt

Nursing Home and Extended Care Facility of White Plains, White Plains, N Y ABSTRACT: The primary and secondary diagnoses for 100 geriatric patients consecutively admitted to a nursing home were reviewed for accuracy and omissions. Primary diagnoses were identified as the direct basis for nursing home admission. Other physical, biochemical or behavioral disorders requiring continued therapeutic care were identified as secondary diagnoses. A comparison was made of the diagnosis offered by the referring physician and the diagnosis a s determined by the medical staff of the nursing home immediately after admission. In 64 percent of these 100 patients, the primary admitting diagnosis was inaccurate. In 84 percent, the secondary diagnoses were either lacking or inaccurate. The extraordinarily inadequate medical performance with respect to identifying the primary clinical and therapeutic problems of the chronically ill aged was remarkably consistent, regardless of the source of the patient’s referral, whether from a general or psychiatric hospital, a private home, or another nursing home. The results of this study revealed a significant degree of unpreparedness and malaise in some members of the medical profession concerning the care of the chronically ill aged, particularly when such patients demonstrate behavioral disorders superimposed upon physical disease. Failure to identify the patient’s needs through diagnosis must result in poor, inadequate or inappropriate treatment programs. warrants major attention from the medical profession rather than continuation of the concept that acute disease takes precedence over chronic disease. The need for restructuring medical education in this country with respect to improving the delivery of medical services to the ill aged has previously been described (1). Quality care for the chronically ill aged is related to proper identification of disability and transmissal by the physician of such information. Thus reliable and appropriate nursing care programs can be instituted on the basis of the available medical, psychiatric and social information. Effective, sustained management of the chronically ill aged is reflective of the quality of medical leadership provided. Nursing care programs and other supportive medical services such as social work, physical and occupational therapy, speech

When national political leaders are compelled to highlight the failure of medical performance in long-term care of the ill aged, the time for the community of physicians to provide leadership in this field must be overdue. Frank recognition by physicians that the quality of medical care provided to the ill aged is something less than exemplary should constitute a n initial step along the road to correcting a wrong. In the United States there are greater numbers of beds in nursing homes than in all general hospitals combined (1.3 million versus 1 million). Thus the importance of long-term care to public health and social welfare in this country *Presented a t the 32nd Annual Meeting of the American Geriatrics Society, Eden Roc Hotel, Miami Beach, FL, April 16-18, 1975. **Medical Director. Address for correspondence: 220 West Post Road, White Plains, NY 10606. t Assistant to the Medical Director.

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therapy and recreational therapy, mirror the . creativity of available medical direction. In the absence of definitive and accurate transfer of medical information to the auxiliary treatment personnel and the institutional administrator, the welfare and future of the disabled patient is placed at high risk. Because of the multidimensional nature of the disabilities of the chronically ill aged (2), individual and appropriate care of the patient “within the resources available depends on assessment of the patient’s needs based on the patient’s status at the time of assessment.” Inappropriate assessment of disabilities culminates in inappropriate treatment and an adverse outcome (2). Senator Moss, Chairman of the Subcommittee on Long Term Care, United States Senate, has stated, “Long term care for older Americans stands today as the most troubled and troublesome component of our entire health care system” (3). The harsh contention of Senator Moss is, unfortunately, supported on clinical grounds by our findings. In order to identify the quality of medical care received by patients in the nursing home and to estimate the accuracy of the diagnoses provided by the referring physician or hospital, the following study was undertaken.

MATERIAL AND METHODS

Patients One hundred consecutive patients, newly admitted to two nursing; homes in suburban WestChester County, New York, were examined. Patients admitted to the skilled nursing home came from a variety of sources: a) general hospitals, b) psychiatric hospitals, c) private homes, d) other nursing homes, and e) a rehabilitation hospital. The study period extended from July 1973 through September 1974 in one facility and from June 1974 through February 1975 in the other. A general outline of the population of the nursing homes has been given in a previous article (4). The average age of the patients was 82 years; 95 percent were over 65 and 70 percent were over 70. Only 10 percent were married. The average duration of nursing home stay before death or discharge was three years. Nursing home placement usually was permanent, until death. Each patient had a t least 4 chronic disabilities.

Criteria for diagnostic status Shortly after admission (usually within 48 hours), the referring physician’s diagnosis (including enumeration of disabilities) was compared with that made by the Medical Director of the nursing home. Identification of the nursing-home primary diagnosis was based on that disability, somatic or behavioral, which in the opinion of the Medical Director and the Director of Nursing constituted a management problem requiring primary nursing care. Diagnoses and disabilities not requiring a detailed construct for a nursing care program were designated as secondary even though they required continuing medical and nursing care. For example, in a patient presenting with marked confusion, agitation, paranoia, hyperkinetic behavior and incontinence of urine and feces, associated with controlled diabetes, essential hypertension, hearing deficits, stabilized residuals of hemiplegia and vertebral osteoporosis, the overt behavioral disorder was identified as the primary diagnosis so far as the nursing home was concerned; all other diagnoses were considered secondary. An important observation was the frequency of decubitus ulcers among the newly admitted patients (see Table 5), since bedsores constitute a major threat to the physical integrity of the ill aged patient. However, “decubitus ulcer” was considered a secondary diagnosis; the primary diagnosis was likely to be coma due to recent stroke, advanced organic brain syndrome (OBS) associated with recent surgical repair of a fracture, or other severe disorder.

Criteria for diagnostic accuracy These criteria were: 1) Admission diagnoses were considered correct when the medical-nursing management problem for the nursing home was compatible with that posed by the diagnosis of the referring physician or health agency. 2) Secondary diagnoses were those for which the patient did not require a major degree of management, though requiring continuing therapeutic care. 3) When multiple diagnoses were offered without stating the primary one, the primary diagnosis was considered to be the first one listed. 4) Inadequate diagnoses - e.g., “cerebral arteriosclerosis” was considered inadequate for the

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identification of advanced organic brain syndrome (OBS) or other neuromuscular disability. 5) Omission errors - e.g., an accurate diagnosis of arteriosclerotic heart disease (ASHD) might be linked with omission of the diagnosis of other significant disease such as advanced metastatic cancer. 6) Omission errors - e.g., accurate identification of somatic disorders such as heart disease or diabetes might be associated with failure to identify major nursing-care problems relating to coexisting behavioral dysfunction. 7) Commission errors - e.g., a diagnosis of “cerebral arteriosclerosis,” inadequately indicative of psychiatric disability, might be associated with failure to identify chronic schizophrenia or other functional psychiatric disorders.

TABLE 2 Status of Admission Diagnoses for 100 Patients-Gross All Sources

Inaccurate Primary diagnosis

64

Inaccurate secondary diagnosis

80

Accurate primary diagnosis

36

Accurate secondary diagnosis

20

TABLE 3 Analysis of Inaccurate Diagnoses and Sources of Referral*

Source General hospital: No. of patients admitted % of hospital admissions % of all admissions Patient’s home: No of patients admitted O/o of home admissions % of all admissions Nursing home: No of patients admitted % of nursing home admissions % of all admissions Psychiatric hospital: No. of patients admitted O/o of psychiatric hospital admissions %of all admissions

Inaccurate Inaccurate AdPrimary Secondary missions Diagnoses Diagnoses 70

46

58

65.7

82.9

70

46

58

16

11

9

100

100

68.75

56.25

16

11

9

4

4

4

100

100

100

4

4

4

9

2

8

22.2

88.9

2

8

100

9

* The one patient admitted from a rehabilitation hospital was not included in this analysis.

TABLE 1 Referral Sources for the ZOO Patients

No. and D of Referral Source

No. and % of Patients

Status of Diagnosis

RESULTS Table 1 shows the distribution of referral sources for the 100 newly admitted patients. The admissions were preponderantly (70 percent) from general hospitals. For the 100 patients, the primary admission diagnosis was accurate in 36 percent, and the multiple secondary diagnoses in 20 percent (Table 2 ) . For 64 percent of the patients admitted, the primary diagnosis was inaccurate, and for 80 percent the secondary diagnoses were inaccurate either by omission or commission. The extraordinarily inadequate medical performance with respect to identifying the prime clinical and therapeutic management problems of the chronically ill aged was remarkably consistent, whatever the source of referral. Table 3 shows that the medical information obtained from hospital-associated physicians a t the time of admission contained 65.7 percent inaccurate primary diagnoses and 82.9 percent inaccurate secondary diagnoses, whether by omis-

Totals,

Patients

General hospital

70

Patient’s home

16

Psychiatric hospital

9

Nursing home

4

Rehabilitation hospital

1

sion or commission. For patients admitted from private homes, the incidence of inaccurate primary diagnoses was 68.8 percent, and of secondary diagnoses 56.2 percent. Only 4 of the 100 patients were admitted from other nursing homes. The medical information in each of these cases was uniformly deficient. The primary management problem (primary diagnosis) for patients admitted to nursing homes from psychiatric hospitals related to disability

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based on a psychiatric disorder. Thus, primary diagnoses provided by these institutions were correct in 78 percent of cases and incorrect in 22 percent. Identification of associated somatic disorders in the psychiatrically ill from various psychiatric hospitals showed 88.9 percent inaccuracy of secondary diagnoses, either by omission or commission (Table 3). The development of effective nursing care programs and the synthesis of a creative therapeutic community for the chronically ill aged is faced with an inequitable and perhaps insurmountable burden when the admission medical information is either misleading or not provided. Table 4 shows the types of physicians’ diagnostic errors with respect to the ill aged patient a t the time of nursing home placement. ILLUSTRATIVE CASES IN THE VARIOUS CATEGORIES Chronic functional psychiatric disorders

The most common type of medical misinformation on admission of a patient to the nursing home involved the physician’s inability to identify chronic functional psychiatric illness (e.g., schizophrenia, psychotic depression, chronic reactive depression, manic depressive illness), whether alone or in combination with organic brain syndrome (OBS). Analysis

of

TABLE 4 Errors in Primary Diagnoses % of Primary

No. of Cases

Diagnostic Errors

Chronic functional psychiatric disorder

20

31.2

20

Severe disability due to org. brain syndrome (OBS)

11

17.2

11

OBS as consequence of focal stroke episode

10

15.6

10

Somatic disease other than neurologic

10

15.6

10

9

14.1

9

4

6.3

4

64

100.0%

64%

Type of Primary Diagnostic Error

OBS superimposed

% of Total Admissions

upon functional psychiatric disorder Neurologic disease Totals

In this category were 31.2 percent of all primary diagnostic errors, applicable to 20 percent of all admissions (Table 4). These cases often are erroneously labeled “cerebral arteriosclerosis” or “senility” or remain unidentified, because the physician relates more easily to diagnoses of somatic disorders such as heart disease, diabetes or stroke. Physicians appear to be unaware that although the patient may present with a conventionally recognized physical disease a t the time of admission to a general hospital, the major management problem in a nursing home will relate to chronic behavioral disorders. Thus admission medical information given to the nursing staff is often misleading. Patient 1. An 82-year-old woman was admitted with diagnoses of fracture of the left shoulder, arteriosclerotic heart disease (ASHD), left bundle-branch block, Stokes-Adams syndrome. After admission the diagnoses were: chronic reactive depression; diabetes mellitus; severe visual deficits; ASHD; left bundle-branch block. The pre-admission diagnoses reflected only information pertinent at the time of admission to the general hospital. This information was misleading with respect to care on the nursing home premises. Patient 2. An 86-year-old man was admitted with diagnoses of chronic OBS. possible rheumatic heart disease, cogwheel rigidity of the upper extremities as in parkinsonism, and recent bacterial pneumonia. After admission the diagnoses were: chronic psychotic depression with severe paranoia but little evidence of OBS; residual chronic congestive heart failure (CHF) with dyspnea on moderate exertion and pedal edema; rheumatic heart disease; aortic stenosis and mitral insufficiency; parkinsonism. On admission, there was no mention of psychotic depression with chronic paranoia (a significant social problem in a nursing home). The presence of active CHF also had not been identified. Patient 3. A 79-year-old woman was admitted with diagnoses of acute thrombophlebitis, generalized arteriosclerosis, organic mental syndrome, diabetes mellitus. After admission the diagnoses were: severe reactive depression with a 10-year history of psychiatric hospitalization and repeated electroshock treatments; venous insufficiency with recurrent thrombophlebitis; recurrent bleeding secondary to hypoprothrombinemia and anticoagulation therapy; ASHD; left bundlebranch block; residual CHF; diabetes mellitus; total blindness. The many errors of omission and commission constituted misleading information which placed inequitable responsibility on the nursing home administration and all professionals who had to continue treatment. Patient 4 . A 78-year-old woman was admitted with diagnoses of ASHD, recent fracture of the right femur, osteoporosis. After admission the diagnoses were: chronic schizophrenia with a history of many years spent in various psychiatric hospitals; hypertension and ASHD with CHF; recent fracture of the femur treated by surgical reduction and fixation; osteoporosis with disabling multiple compression fractures of the vertebrae.

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MILLER AND ELLIOTT The admission diagnosis was not applicable to the immediate nursing problems, which related to behavioral dysfunction. Active congestive heart failure responded promptly to appropriate treatment, but it had not been identified before admission.

Severe disability due to organic brain syndrome (OBS) As shown in Table 4, 17.2 percent of all primary diagnostic errors concerned severe disability associated with OBS. Physicians often fail to identify this common disabling syndrome as a prime medical and nursing problem. Patient 5. An 83-year-old woman was admitted with diagnoses of laceration of the forehead, healed contusions, ASHD, CHF, auricular fibrillation. After admission the diagnoses were: total disability including complete inability to perform the activities of daily living (ADL), associated with advanced OBS as manifested by loss of meaningful memory, severe cognitive deficits, disorientation for time and place, confusion, agitation, incontinence of urine and feces; recurrent CHF; auricular fibrillation with secondary cerebral ischemia contributing to the OBS. The referred medical information related only to the conventional somatic problems. There was either unawareness or indifference to the basic needs for nursing care. Patient 6 . An 84-year-old woman was admitted with diagnoses of aphasia secondary to multiple cerebral emboli associated with auricular fibrillation, hypertensive cardiovascular disease (HCVD). After admission the diagnoses were: advanced disabling OBS with total loss of volitional ADL; HCVD with chronic auricular fibrillation, enlarged heart and myocardial changes; probable cerebral emboli with aphasia; no motor deficits. OBS was the chief management problem, previously unidentified by the referring physician. Patient 7. A 78-year-old man was admitted with diagnoses of genitourinary-tract (CU) infection, urinary retention. After admission the diagnoses were: advanced OBS due to primary neuronal degeneration, severe memory and cognitive deficits, total disorientation for time and place, marked confusion, incontinence of urine and feces; total disability in all aspects of ADL; chronic GU-tract infection; diabetes mellitus; ASHD; malnutrition; secondary anemia; chronic obstructive pulmonary disease. The admission medical information, although partially appropriate at the time, involved significant errors of commission in the primary diagnosis and of omission in the secondary diagnosis.

Organic brain syndrome as a result of focal stroke episodes Of all primary diagnostic errors, 15.6 percent concerned the physician’s failure to identify advanced OBS associated with focal stroke episodes as the primary functional disorder. Patient 8 . A 75-year-old man was admitted with diagnoses of recent resolution of intestinal obstruction due to sigmoid

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volvolus, arteriosclerotic vascular disease, OBS, glaucoma. After admission the diagnoses were: multiple bilateral cerebral arterial thromboses and associated spastic quadriparesis; advanced OBS with severe motor and perceptive aphasia, marked dysarthria, dysphagia requiring nasogastric tube feeding, incontinence of urine and feces; recurrent GU-tract infections with hemorrhagic cystitis; disabling parkinsonism; glaucoma. On admission the intestinal obstruction was no longer a disabling disorder. The physician failed to state that the patient had had a t least three focal stroke episodes involving the right and left extremities, and had advanced OBS with dysphagia. Physicians often do not identify hemiplegia associated with stroke, and even less often, do not identify quadriplegia, aphasia and dysphagia. Dysphagia may be a life-threatening disability, leading to frequent episodes of aspiration pneumonia. Patient 9. An 82-year-old woman was admitted with diagnoses of cerebral arteriosclerosis, osteoarthritis, contusion of the scalp, hypertension. After admission the diagnoses were: recent right cerebral arterial thrombosis with left hemiparesis; advanced OBS; a recent fall associated with the acute stroke phenomena; active residual CHF; thrombophlebitis of the left leg; chronic hypochondriasis, psychoneurosis and depression. The admission diagnosis failed to identify the focal neurologic disorder and the associated OBS manifested by severe agitation, hyperkinetic behavior, severe memory and cognitive deficits, confusion and disorientation for time and place. Omitted were the diagnoses of CHF, thrombophlebitis, and the chronic anxiety state, all of which required medical and nursing attention. Patient 10. An 84-year-old man was admitted with diagnoses of Alzheimer’s disease, duodenal ulcer, confusion. After admission the diagnoses were: focal left cerebral arterial thrombosis with severe perceptive and expressive aphasia and perseveration in words and songs; parkinsonism; depression and anxiety state; ASHD; benign prostatic hypertrophy with recurrent GU-tract infections; history of duodenal ulcer. In view of the characteristic aphasia and other focal neurologic signs, with onset of the disease late in the 70-80 age decade, a diagnosis of Alzheimer’s disease was untenable.

Somatic disease other than neurologic Patient 21. A 67-year-old woman was admitted with diagnoses of diabetes mellitus, peripheral vascular insufficiency, recent bilateral below-knee amputations, lumbar sympathectomy. After admission the diagnoses were: lobar pneumonia with consolidation in the right lower lobe, bronchial breath sounds, dullness on percussion, sustained high fever; advanced CHF with anasarca; diabetes mellitus with massive retinal hemorrhages and virtual blindness; diabetic nephropathy; bilateral below-knee amputations; severe GU-tract infection. With appropriate antibiotic management and aggressive diuretic and digitalis therapy the pneumonia subsided, as documented by clinical and roentgenographic evaluation. The anasarca receded and the dyspnea and cyanosis diminished. Truly noteworthy was the degree of error in identifying the multiple somatic, acute and chronic disabling disorders. Patient 12. An 81-year-old woman was admitted with diagnoses of CVA 8.5 years previously, cardiac asthma, sigmoidal diverticulitis, ASHD and CHF. After admission the diagnoses were: fungating annular carcinoma of the rectum, palpable within an inch of the anus and associated with

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ERRORS AND OMISSIONS IN ADMISSION DIAGNOSIS

tenesmus, rectal bleeding and a foul discharge; chronic obstructive pulmonary disease; ASHD; recurrent CHF; reactive depression. On further inquiry the physician and family admitted having been aware of the presence of the rectal tumor for a t least 18 months. After intervention by the nursing home staff, biopsy and resection of the recto-sigmoid with colostomy confirmed the diagnosis. Was lack of mention of an obvious carcinoma of the rectum a n error of omission or commission? Patient 13. An 85-year-old man was admitted with diagnoses of senile dementia, depression, parkinsonism. After admission the diagnoses were: active severe CHF with dyspnea, tachycardia, cyanosis, distended neck veins and 3-4+ edema of the legs extending to the presacral area; diabetes mellitus; anemia; total deafness; chronic phobic personality with paranoid ideation. Probably the deafness and paranoia were factors leading to the physician’s diagnosis of senile dementia, a disorder conspicuous by its absence in this patient. It is difficult to account for the lack of identification of overt somatic disabling disease.

Patient 16. An 86-year-old man was admitted with diagnoses of OBS, possible rheumatic heart disease, cogwheel rigidity of the upper extremities (parkinsonism), recent bacterial pneumonia. After admission the diagnoses were: minimal OBS superimposed upon psychotic depression with paranoia and intermittent combative behavior of 30-40 years’ duration; rheumatic heart disease with aortic stenosis, mitral insufficiency and CHF; parkinsonism. The paranoia was a significant factor in the antisocial behavior, which was the chief management problem. Treatment of the CHF required conventional medical and nursing procedures.

Organic brain syndrome superimposed upon a functional psychiatric disorder

Patient 17. A 78-year-old man was admitted with the diagnosis of CVA right hemiplegia with aphasia. After admission the diagnoses were: residuals of multiple bilateral stroke episodes with quadriparesis and dysphagia requiring nasogastric tube feeding to prevent aspiration pneumonia, homonymous hemianopeia, total global aphasia and incontinence of urine and feces; benign prostatic hypertrophy with recurrent GU-tract infections, hemorrhagic cystitis and episodes of urinary retention; ASHD; advanced OBS. Patient 18. An 82-year-old man was admitted with diagnoses of epidemic bronchopneumonia, ASHD with chronic auricular fibrillation, cystitis, OBS, benign prostatic hypertrophy. After admission the diagnoses were: residuals of multiple bilateral strokes with spastic quadriparesis, dysphagia, aphasia, dysarthria and the neurogenic bladder and bowel syndrome; ASHD with auricular fibrillation; active CHF; probable multiple cerebral emboli; unresolved bronchopneumonia, confirmed immediately after admission by clinical and roentgenographic evaluation. Patient 19. A 78-year-old man was admitted with diagnoses of Alzheimer’s disease, chronic obstructive pulmonary disease, polycythemia, ASHD and CHF, uncompensated. After admission the diagnoses were: residuals of multiple bilateral CVA with quadriparesis, motor and receptive aphasia, and the neurogenic bladder and bowel syndrome; advanced OBS; recurrent GU-tract infections; chronic obstructive pulmonary disease; secondary polycythemia; chronic cor pulmonale with recurrent right-sided failure. The aphasia and additional multifocal neurologic lesions, combined with advanced age, nullified the diagnosis of Alzheimer’s disease. The focal nature of the neurologic disorders was not identified by the referring physician.

Of all primary diagnostic errors, 14.1 percent involved OBS superimposed upon a primary chronic functional psychiatric disorder, unrecognized by the physician (Table 4). Confirmation of functional psychiatric disorders in all categories was achieved by current psychiatric consultation, evidence of prior psychiatric treatment, a history of electroshock therapy (obtained through the family), and evidence of prolonged or intermittent psychiatric hospitalization in the patient’s youth or middle age. Patient 14. A 78-year-old woman was admitted with a diagnosis of cataracts. She had undergone a n operation for cataract in the right eye. After admission the diagnoses were: chronic reactive depression (supported by a history of several psychiatric hospitalizations and electroshock therapy); cataract extraction; osteoporosis with multiple compression fractures of the vertebral bodies; intermittent systolic hypertension; OBS characterized by mild memory deficits, impaired cognitive functions and periodic confusion, although the patient could maintain a coherent conversation. The psychiatric disorders constituted the chief problem in nursing home management, rather than the ophthalmic disease identified in the pre-admission diagnosis. Patient 15. An 80-year-old woman was admitted with diagnoses of postmastectomy state (carcinoma of the right breast), and chronic brain syndrome. After admission the diagnoses were: manic-depressive psychosis with advanced OBS. The patient was hyperkinetic, hypervoluble, agitated, confused and disoriented. She was in the manic phase of her illness on admission. There was a documented history of repeated episodes of psychiatric treatment and electroshock therapy during her middle years. Additional diagnoses were: status post-mastectomy for carcinoma of the breast; venous insufficiency; status post-cataract removal; hypertensive vascular disease (BP 210/110); ASHD with hypertension; left ventricular hypertrophy and LV strain; probable “small stroke” episodes.

Unidentified neurologic disease Of all primary diagnostic errors, 6.3 percent involved errors in identification of neurologic disease as the primary diagnostic disorder requiring major medical and nursing care (Table 4).

General comment An attempt has been made to illustrate the types of errors in admission diagnoses according to the foregoing 6 general diagnostic categories. Only the fourth category (Table 4) relates to errors in diagnosis of non-neurologic somatic disease; here, behavioral disorders were not of significance. As a corrollary, 84.4 percent of all primary misdiagnoses concerned the common failure to

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identify disabling neurologic disease or disabling psychiatric illness or combinations thereof. The importance of aberrant behavior a s a significant or prime nursing care problem, alone or in combination with somatic problems, seems to elude the attention of most physicians as they pursue their time-honored preoccupation with identification of somatic disease. Table 5 is a sample of significant errors in primary and secondary diagnoses of somatic disease. Several errors also involved diabetes mellitus and its sequelae. In 4 percent of all newly admitted patients, the admission diagnosis did not mention the presence of untreated life-threatening cancer. Table 5 shows that in 16 percent of all patients admitted to the nursing home, active congestive heart failure was unidentified as either a primary or a secondary diagnosis. Th e identification of acute or chronic CHF in the aged and often mentally disturbed nursing home patient was made on clinical grounds in accordance with Friedberg’s tenets (5). Reversal of signs and symptoms with appropriate therapy (marked diuresis and weight loss) was considered confirmatory of the diagnosis. In a nursing home population, severe behavioral aberrations are common; anticipated symptoms often are noteworthy by their absence. The brain-damaged patient does not complain of respiratory discomfort, anginal pain or exhaustion. Cough is depressed. No orthopnea is observed. In effect, the physician must rely upon the exquisite skills of physical diagnosis and the objectively determined effects of therapy. In 4 percent of patients with severe heart failure, the condition was not identified as the TABLE 5 Examples of Significant Diagnostic Errors in Somatic Disease Type of Error Cardiac disease with active congestive heart failure CVA (stroke) Decubitus ulcers* Totals

No. of Patients 16

20

lo** 46

Error in Primary Diagnosis 4 (4%)

10(10%)

0 14 (14%)

Error in Secondary % All Diagnosis Patients 12(12%)

16%

10(10%)

20%

10 (10%)

10%

32 (32%)

46%

* 11 patients with decubitus ulcers were admitted, but only 1 case has been documented by either the hospital or attending physician. ** 9 patients were admitted from hospitals and 1from home.

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primary diagnosis, nor in 12 percent as secondary diagnoses. In these instances, behavioral disorders superseded heart failure a s the primary management problem. It is noteworthy th a t the aged in a nursing home population endure chronic congestive heart failure with little or no discomfort. Thus the diagnosis is often overlooked. Of the 100 study patients, 20 percent had sustained previously undocumented cerebral arterial thromboses even when classic hemiparesis was present (Table 5). Quadriparesis due to bilateral multi-infarct disease was almost uniformly overlooked. Eleven of the 100 patients had decubitus ulcers on admission. Usually these ulcers were severe and penetrated to the bone. Only in 1 patient had the physician appropriately identified a decubitus ulcer; the other 10 cases were unidentified a t the time of‘ admission to the nursing home; 1 patient of this group was admitted from a private home but the remaining 9 were admitted directly from general hospitals. DISCUSSION AND CONCLUSIONS The startling findings of this study reveal a general lack of preparedness among many members of the medical profession for the care of the chronically ill aged, particularly when the aged are not only physically but psychiatrically ill. The broad-based nature of the problem is emphasized by the fact th a t not less than 50 referring physicians were involved, in various geographic areas. Also involved were referrals of patients from several general voluntary hospitals, university hospitals and psychiatric hospitals. Medical information often was brought by patients and families from their private homes. Failure to identify the needs of the patient by diagnosis results in inadequate or inappropriate treatment programs. Lack of appropriate identification of the patient’s disability inevitably evokes poor medical leadership in sustaining the complex treatment programs involved in care of the chronically ill. In this era of developing medical audits for determination of the quality of care, the evolving system of audits must also fall into disrepute as a reliable indicator of the quality of care whenever the identifications of disease and disabilities are inappropriately classified a n d transmitted to the treating team. Rogers ( 6 ) of the American Hospital Association has noted: “We have difficulty in transferring those appropriate parts of the hospital-based

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medical technology to people who sleep in their own beds. The education of young physicians has been based in the hospital so much that they have not developed either the special skills or the desire to care for the aggregate of human illness outside. of acute care situations.” In a provocative statement on a personal philosophy of medical practice (7), Howard Spiro has stated: “The clinician is a morphologist and thinks most comfortably in terms of disease entities. The academician has been responsible for the training of our younger physicians and has so far abstracted himself from the patient that he rarely thinks in terms of patients as persons, but more often as repositories of disordered molecules or functions that he will study. In clinical practice the physician deduces changes in structure from signs and symptoms and thinks less often of change in function.” Spiro (7) defined “disease” as a structural change in the body, and “disorder” as a functional change. The chronically ill aged manifest a variety of significant “disease” entities, many nonreversible. Therefore attention to “disorders,” many of which are reversible, must be the everlasting target for the astute physician who wishes to make constructive contributions to the care of the ill aged, regardless of specific structural diseases. Spiro adds: “We clinicians should not be practicing 1975 medicine using 1675 concepts. We have to think in terms of disorder and not disease. Disease is a process, not an entity” (7). The diagnostic proficiency of the physician in the general hospital, which is his familiar environment, is assumed to be distinctly higher than that applicable to nursing homes. The basis for the high frequency of misdiagnoses on admission of patients to nursing homes is multifaceted, partly speculative, partly factual. However, with appropriate physician orientation, the situation is remediable. Factors in misdiagnoses include: 1) Unawareness by the physician that the primary diagnosis a t the time of admission to a general hospital may not be appropriate at the time of admission to a nursing home, because the disease causing hospitalization has subsided. 2) Inability to relinquish traditional orientation toward disease in favor of orientation toward disorders that affect the therapeutic management of the patient’s functional capacity and needs on a sustained basis. 3) Unpreparedness of the physician because of traditional training in medical school fortified by preoccupation with acute disease in the general

hospital. The physician lacks the professional technology to cope with the complexity of the treatment modalities required by the aged patients commonly found in nursing homes. The physician is untrained in coordinating physical therapy, occupational therapy, recreational therapy, social work services and speech therapy. Even with respect to nursing care programs, the indispensable therapeutic modality, the physician appears more comfortable offering criticism than providing leadership. Thus he represents a vacuum of professional guidance to the supporting professionals. 4) Lack of professional dignity, professional status and personal pride when dealing with patients in nursing homes. The current absence of fulfillment of professional ambitions in the nursing home that is detached from a hospital and university center provides little incentive for creative medical practice in working with the nonhospital-based nursing home patient. 5) An attitude toward the aged that reflects the prevailing social system of values. “They are old, terribly ill and can’t get better. What’s the use! They are better off dead. What’s the purpose of’ living that way? If I were senile I’d prefer to be dead.” There are also a host of other self-defeating attitudes which possibly reflect personal immaturity and personalized concepts of agedness, factual or otherwise. 6) An attitude toward the aged patient that often is conditioned by the personal relationships between the physician and his own parents or grandparents. Sometimes (consciously or otherwise) the physician’s long sublimated feelings of hostility, rejection or guilt toward his parents or siblings may be reflected in the form of a “premature-death” attitude toward the nursing home patient. The report of the U. S. Senate Subcommittee on Long Term Care (8) provides support for these hypotheses. In the Report, Dr. Clark stated: “To many patients with chronic disease that are not going to get better, the nursing home can be a depressing place. When you see these people you think, ‘this is going to happen to me’.’’ Dr. Kassel added: “I hate to go to a nursing home. It has not been unusual for me to sit down on a chair that is covered with urine. You just don’t want to sit down. You’re afraid to touch things. Taking care of many of the patients in nursing homes is a difficult job and you have to be very dedicated.” Selections from the same Report (8) reveal that: 1) 33 percent of the patients being treated for diabetes had no such diagnosis on their charts,

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10 percent of those receiving insulin were not given diabetes diets, and often a determination of the fasting blood sugar level had not been made in more than a year; 2) only 6 percent of the patients had had a physical examination in the preceding year; 3) 8 percent had bedsores; 4) 39 percent were inappropriately classified and placed; 5) less than 1 of 5 patients had recorded admission examinations; 6) less than 1 of 6 had undergone a mental status examination; 7) less than 1 of 4 had an admission diagnosis to provide enough information for the nursing staff so that appropriate treatment could be provided; 8) barely one-fifth of the patients had admission records that were signed by doctors; 9) more than 1 of 6 patients had doctor’s orders that were invalid or unclear; 10) hospitals were failing to send any data concerning the patient’s condition for about 40 percent of those transferred to nursing homes; 11) physicians in nursing homes provided inadequate information on the patients’ charts. Dr. Ewald Busse, in his testimony before the U. S. Senate Committee on Aging (8) stated: “There are few physicians who are capable of dealing with the large numbers of chronically ill persons with sustained enthusiasm. The physician’s evaluation of himself as an individual capable of eliminating pain and restoring function is apt to suffer when he cannot see clearly the patient’s improvement as a result of his efforts.” Thus the present study provides clinical evidence for the sad situation involving the aged in our community, and for the lack of definitive medical support, which obviously is widespread.

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The accuracy and reliability of technical medical performance with respect to the ill aged in nursing homes is far from salutary. Physicians do, however, have the technical competency to improve the lot of the ill aged. The present situation is remediable and perhaps the current revamping of medical school curricula, as expressed in the views of Pellegrino (9), will inspire the next generation. Pellegrino, as a medical educator, hopes to see the production of the competent clinical craftsman - the humane, compassionate and educated practitioner in the broadest sense. These qualities in the physician would certainly improve the status of the ill aged in our society. REFERENCES 1. Miller MB: Restructuring medical education for manage-

ment of the chronically ill aged, J Am Geriatrics SOC22: 501, 1974. 2. Jones EW: Patient classification for long term care. User’s Manual. DHEW Publication #HRA 75-3107, November 1974, p 14. 3. Subcommittee on Long Term Care, Special Committee on Aging, U S . Senate: Nursing Home Care in the United States: Failure in Public Policy. U.S. Gov’t Printing Office, Washington, DC, 42-711, February 1975, p 3. 4. Miller MB: The physiological basis of nursing problems of the chronically ill aged, J Am Geriatrics Soc 14: 244, 1966. 5. Friedberg CK: Disease of the Heart. Philadelphia, W. B. Saunders Co, 1957, p 85. 6. Rogers DE: A conversation with David E. Rogers (Am Hosp Assoc), Trustee (March) 1975, p. 30. 7. Spiro HM: Visceral viewpoints: some comments on disease and disorder, New England J Med 292: 577, 1975. 8. Subcommittee on Long Term Care, Special Committee on Aging, U.S. Senate: Nursing Home Care in the United States: Failure in Public Policy. U.S. Gov’t Printing Office, Washington, DC, 42-711, February 1975, p p 330-333. 9. Pellegrino ED; Educating the humanist physician, JAMA 227: 1288, 1974.

Errors and omissions in diagnostic records on admission of patients to a nursing home.

The primary and secondary diagnoses for 100 geriatric patients consecutively admitted to a nursing home were reviewed for accuracy and omissions. Prim...
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