Aging Research Day March 8, 2012

Transcription

1 Aging Research Day March 8, 2012 Heidi R. Wierman, MD Mane Medical Center Division Director, Geriatrics Assistant Professor, Tufts School of Medicine

2 Overview 1.Brief Delirium Review 2.Describe HELP function 3.Review of publications regarding HELP benefits 4.Other benefits of HELP

3 Case Presentation 78 yo man admitted from home, lives alone CC: Short of Breath PMH: CHF, h/o a fall, osteoarthritis of the knee In ED: Still SOB, O2 requirments despite diuretics Admitted for diuretics, CHF teaching Anticipated LOS 48 hours Transferred to medical floor at 10pm - foley in place due to difficulty getting to bathroom

4 Case... Foley kept in place Benadryl ordered prn and given for poor sleep at 11pm 2 am confusion develops foley pulled out oxygen removed 3 am hypoxic & more confused IV pulled out, patient falls 5 am patient more restless, hasn t voided and bladder scan shows 700 cc urine foley placed with large amounts of bloody urine & clots

5 Case... (con t) Urology consult - urinary retention & bleeding/clots, foley needed for irrigation Delirium continues and patient must be restrained to keep foley in place, oxygen on. UTI develops hospital day 3 Hospital day 8, patient finally clearer - family states patient still not himself. Physically decompensated d/c to rehab for 2 week stay before finally to home.

6 Consequences of Delirium Prolonged hospitalization falls Functional decline Increased risk for institutionalization Cognitive impairment may persist for months or never resolve completely Increased mortality

7 Maldoncido Crit Care Clinic 24(2008)

8 Confusion Assessment Method for Diagnosis of Delirium* Acute Onset Cognitive Change & Fluctuating change in mental status & Inattention & Altered level of consciousness or Disorganized thinking * Inouye Ann Intern Med 1990;Dec 15,

9 Delirium Prevention Think HELP (Hospital Elder Life Program)

10 Goals of HELP Provision of safe, patient centered care during hospitalization through the utilization of an interdisciplinary team that includes volunteers, with a goal to: Maintain physical and cognitive functioning despite hospitalization Maximize independence at discharge Prevent unplanned readmissions Assist with transition to home

11 How does HELP work? Can have hospital wide or unit based focus, but geriatric unit is not required Skilled staff and volunteers carry out interventions (as opposed to consulting and only making recommendations) Interventions are directed to appropriate patients, targeting known risk factors for cognitive and functional decline Outcomes monitored to assure quality

12 How does HELP work (con t)? HELP staff includes: Geriatrician (ideally) Elder Life Nurse Specialist Elder Life Specialist Volunteers Interdisciplinary team may include PT/OT, Pharmacy, Chaplain, Nutrition, Staff Nurses, etc.and, of course, the Patient

13 Risk factors identified for enrollment (and targeted with volunteer interventions) Cognitive dysfunction Mobility dysfunction Dehydration Sensory Impairment Sleep Deprivation Polypharmacy/Hi risk medication use

14 Other factors identified History of delirium with hospitalization Living situation Nutrition Spiritual Needs Areas of interest

15 What the patients see Assessment with a focus on function, life outside the hospital Volunteers 2-3 times/day All patients have friendly visit (orientation, therapeutic activities) and mobility Other aspects target risk factors.

16 New HELP Dissemination Model No centralized dissemination or support staff* Materials available (open access, free of charge) on line after accepting terms and disclaimer (materials are copyrighted) Mentorship/assistance through Centers of Excellence

17 HELP Studies Sustainability and Scalability of HELP at a Community Hospital Rubin FH et al JAGS 2011;59: Measure impact of HELP on delirium, LOS, cost in over 27,000 patients in 7 years Delirium assessed by proxy Estimated savings of over $7 million/year via delirium prevention (cost savings + more patient/bed=revenue), shorter LOS when delirium occurred (more patient/bed)

18 HELP Studies 2011(con t) Sustaining Programs During Difficult Economic Times SteelFisher G, et al JAGS 59: in depth interviews with 19 HELP sites Successful programs: Meaningful interaction with Decision-Makers, maintaining visibility Documenting Successes the data admin wants used to show impact on outcomes, cost, patient satisfaction Support from Staff relationship with ancillary staff, nurses and physicians is important Future what about sites that do not succeed?

19 HELP Studies 2011 (con t) Modified Hospital Elder Life Program: Effects on Abdominal Surgery Patients Chen et al, J Am Coll Surg 213(2): Tawain, 65+yo, 36 bed unit for elective abdominal surgery with LOS expected >6 days. 189 enrolled, pre-post intervention Intervention = usual care + HELP nurse to provide early mobilization, nutritional assist, therapeutic/ cognitive activities Results: HELP decreased delirium, functional decline at d/c with modified 3 protocols intervention.

20 HELP: Prevent Cognitive Decline & Loss of Physical Function Inouye SK et al JAGS 2000; 48: HELP vs Control less cognitive decline (8% vs 26%, P<0.05), less physical decline (14% vs 33%, P<0.05) at discharge Inouye SK et al NEJM 1999;340: Reduced incident delirium with HELP (OR=0.60, P=0.02)

21 HELP is Cost Effective Rizzo JA,et al Medical Care;2001;39: Hospitalized Intermediate risk patients with lower overall cost by $831/patient ($415-$1689 range) Savings across every cost category (nursing, room, diagnostic procedures, ICU) Leslie DL,et al JAGS; 2005; 53: year f/u of Delirium prevention trial patients No affect on likelihood of nursing home placement Patients who were placed in nursing home had Lower total cost ($50,881 vs $60,327, p=0.01) Shorter LOS (241 vs 280, p<0.05) Lower cost per survival day ($148 vs $175, 0<0.02)

22 HELP can be replicated successfully Caplan GA et al Int Med J 2007;37: Australia, before/after study in a different health care system Lower delirium incidence (6% vs 38%) Decreased use of nursing assistants ($121K US $ cost savings) Rubin FH et al JAGS 2006;54: QI study over 3 years (4763 patients) Delirium decreased by 14.4% (35.3% RRR, P=0.002) Decreased: LOS 0.3 days/patient, Cost $1.25 mil in one year Hi nursing and patient/family satisfaction

23 HELP Reduces Falls Inouye SK et al NEJM 2009;360: hospitals with HELP, 95% of staff members report fall rate reduction Data from 3 sites: 11.4 to 3.8 per 1000 patient days 4.7 to 1.2 per 1000 patient days 4.2% to 2.4% in 4000 patients/1 year

24 Other HELP Benefits Program is a great training opportunity for all disciplines Nursing Students, NP Students, Medical Student, Residents Benefits of assessment/interventions may be applied to other patients (sleep protocol, management of delirium) Patients/families LOVE it write notes to hospital administration, donations.

25 Our case: Attention to delirium prevention Think about the geriatric issues: Foley/tethers Sleep impairment Fall risk/gait instability Multiple medications A better outcome...

26 Case revisited Foley kept in to facilitate sleep due to diuretic given at 9 pm Patient to bed, head slightly elevated for breathing, room quiet foley out in morning Urinal available for frequent urination due to diuretic PT evaluation Ambulation encouraged Oxygen weaned to 1 liter CHF education about diet, daily weights IV diuretic time changed from 9 pm to 5 pm to interfere less with sleep HD #2 - oxygen weaned to off in morning, po diuretic started Patient discharge to home on HD#2

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