Preventing Hospital Acquired Debility

Transcription

1 Preventing Hospital Acquired Debility IATROGENIC DISABILITY PARTIALLY AVOIDABLE PHYSICAL DEPENDENCE MEDICAL DECONDITIONING HOSPITAL ACQUIRED DECONDITIONING POST HOSPITAL SYNDROME Objectives 1. Identify common reasons for hospital acquired debility. 2. Describe ways staff can alter their workflow or processes to prevent hospital acquired debility. What is Hospital Acquired Debility? Sudden loss of ability to complete basic ADLs needed to live independently 8 Functional reserve: capacity for older adults to handle additional stressors or illnesses without loss of independence 10 1

2 Hospital Acquired Debility Defined Change in functional status is a clinical vital sign and the most important manifestation of illness in older adults across admitting diagnoses. 8 powerful prognostic tools: Mortality Institutionalism Readmission within in 30 days Adverse health outcomes during and after hospitalization Rarely a single cause Accumulate impairments over multiple domains Functional status should guide care Frailty Defined 3 of the 5 symptoms define frailty Muscle weakness slow movement speed self reported exhaustion decreased physical activity unintentional weight loss Frailty is anindependent risk factor for increased mortality, institutionalism, and disability 10 Frailty or Hospital Acquired Debility? Frailty Hospital Acquired Debility gradual accumulation of impairments 8 Fast accumulation of impairments (2-3 days) 8 2

3 Frailty plus Hospital Acquired Debility When an already frail older patient is admitted to the hospital and doesn t get mobilized often: accelerated decline in function and even increased rates of institutionalism and mortality 11 Risk Factors for Hospital Acquired Debility Increased age Poor mobility prior to admit use of assistive devices Need assist with ADL or IADL before admit Prior history of falls or incontinence Poor cognitive function Poor social factors Depression Illness itself After hospitalization risk factors for readmission: Environmental factors, resources, poverty, lack of community support, quality of discharge plan 8 Statistics Adults over 65 years old account for 60% hospital admissions % pts considered able to ambulate, did not ambulate at all while hospitalized 3 83% patient time spent in bed 3 Hospital older patients are 61 times more likely to develop disability in ADL s than those not hospitalized % pts over 70 years old, and hospitalized with medical illness, are discharged with an ADL disability they didn t have before 8 More than 50% older adults over 85yo leave hospital with major new ADL disability 8 3

4 Why should these statistics alarm us? 1 yr after discharge less than ½ older adults are at their premorbid level 10 29% remained disabled at 1 year 8 30% returned to PLOF 8 Death and NH placement are increased 1 year after hospitalization 10 41% died with in 1 year 8 Diagnosis of deconditioning = poorer trajectory of functional recovery than a clearer medical diagnosis 10 Older adults with HAD have higher than average rates of readmission and lower rates of community discharge poor physical function = 3x more likely to be re-hospitalized with in 30 days compared to older adults with medically complex conditions and increased physical function. 10 I just want to rest What happens? Decreased outcomes/health 5 Multiple body systems affected: 6 Cardiovascular Impaired stamina7 Respiratory Pneumonia 3 Gastro-intestinal Decreased appetite 3 Integument Musculoskeletal Impaired coordination 7 Decreased muscle mass and strength 8, 4, 7 Renal Endocrine Nervous New onset delirium 3 Increased pain 5 What happens with hospital Rest Decreased Outcomes Decreased ADL, IADL independence 3 New (or worsening) walking dependence 2 days of bed rest % hospitalized older patients Remains persistent with 67% of patients failing to improve by D/C. 27% still dependent in ambulation 3 months after discharge Physical functional decline and ADL decline are predictive of hospital readmission, institutionalism, and mortality 10 Falls 7 Decreased ability to follow post D/c instructions 7 Reserves depleted 7 Body can t defend against health threats 4

5 What happens with hospital rest? Decreased quality 5 ⅕patients discharged (2.6 million seniors) readmit with in 30 days Original admit for heart failure, pneumonia, COPD These patients were only readmitted for these reasons 37%, 29% and 36% of the time.7 Increase risk adverse health events 3 Increased cost Increased LOS 5 Delayed discharge 5 NH placement is a substantial public expense: Prolonged hospital stay with HAD 8 Barriers to Mobilizing Older Patients Patient Factors Illness severity 13 Co-morbid conditions (COPD, Depression, dementia, etc.) 13 Symptoms (pain weakness, etc.) 13 Cognitive issues 3 and Delirium 13 Fall concerns 5, 13 Weakness 4, 3 Pain 3 Fatigue 4, 3 Barriers - Institutional Factors Staffing Nursing to pt ratio -staffing patterns 13, 3 Staff illness, unfilled position 5 Unexpected increase in work demands (deteriorating health of patient, many admits/discharges, high census, etc. 5 Unit Expectations Expectations visible to colleagues, supervisors (white boards, CQI, end of shift report) increases accountability 3 Manager and physician support increases accountability 3 Unit activity level -increased activity, increased admissions, D/C, codes = decreased ambulation 3 5

6 Barriers Institutional Factors Inadequate orientation 5 Handoff problems from floor to floor 5 Environmental factors bed most comfortable to watch TV. 5 Lack of chairs Ineffective delegation 5 Failure of RN to obtain buy in from nurse assistant Lack of financial support 2 Barriers Institutional Factors RN training and critical thinking/planning treatment 3 Risk Potential for injury patient or RN = increased risk = lower level of mobility Prevention -DVT, pneumonia, pressure ulcer, THEN functional decline. RN knows ambulation is ideal, but not necessary as there are other options that are almost as effective spirometry, rolling, SCD s, dangling, chair Completing tasks Mobility is used primarily as a means to another end not as an end in itself 3 Roll to look at rash, chair for lunch, walk to bathroom, not to walk because it is good for patient. Available resources of staff, equip, 13, 5, 3 If not enough support, mobility moves to next lower level (instead of ambulation go to chair, instead of chair, sit up in bed) Nurse characteristics: personal strength, size, experience, self-confidence prior injury large patients = higher risk, less likely to ambulate Smaller patient, lower risk = ambulate more Barriers Institutional Factors Attitudinal factors of staff Attitudes toward mobility during hospitalization 13 Labeling patients: Nursing home patient perceived non ambulatory = won t mobilize them Community ambulators, RN pushed them more ***Perception could be changed by family, NP, Physician telling us their PLOF, complaining, or being persistent 3 The fact that missed nursing care was more prevalent in areas where the impact was not immediately apparent is noteworthy. (lack of ambulation not evident till d/c, eating) 5 6

7 Barriers Institutional Factors Not my job syndrome 5 Once delegated to PCA, no longer RN responsibility PT s job ( the nursing staff reported that they believed all ambulation was PT s job. ) nurses still stated pts didn t ambulate enough 5 Habit -skip something one day, don t get caught, easier to skip the next day 5 Denial -RN s don t want to know if NA s don't do something. Makes them feel bad 5 RN s may not begin mobilizing patients until they are ready for discharge 3 Barriers Treatment Related Bed rest 2, 13 Some required, others not necessary Ambiguous orders 3 Restraining devices 5, 3, 13 lines/tubes, restraints Catheter = 1 point restraint Medicine Time required for intervention = Increased time = less likely to do 5(tilt table) Ambulation pt education Hygiene emotional support Solutions Hospital Wide Form a Lift Team 12 Goal to increase mobility, decrease adverse outcomes, LOS and injury, focus on older patients, obese, patients Transport staff were trained by PT/OT in 4 hour sessions Used lift equipment Positive outcomes in decreasing falls and staff injury Caution: Only wanted male staff Mobility Program 10 Assisted ambulation BID Maintained their pre-hospital function up to 1 month after discharge -used recreation therapists, volunteers, mobility aids Hospital Wide Walking Program Specially trained transporters (nights and weekends because patients busy in the day) walks/patient 13 7

8 Add therapy staff costs Most frequently mentioned solution: PT. That is why we try to encourage the Doctors to order physical therapy, because we don t have time to ambulate patients in the hallway like the doctor expects. This article also stated the PT s have the equipment.13 Add nursing staff -costs Due to their consistent presence at the patient s bedside, nurses have been identified in the literature as health care providers who can affect the incidence of new walking dependence in hospitalized older adults. 3 Outcomes: Nurse driven mob program: 6 Total steps -low or negative from 1st to 2nd day = increased LOS Quantity ambulation more than 5 m on 1st day and amount of time upright predicted LOS Ambulation outside room at least 1x/day = 1.5 shorter LOS (even adjusted for pre-admission mobility levels) Improve our assessments and ACT on them 2 2 week pre-hospital function (questionnaire), admit function 2, 3, and daily assessments 8 ADL, Mobility and Cognitive 8 AMPAC 6 click Could use as scorecard for the patient to help plan discharge Sedation, agitation, delirium status (CAM)2 BMAT mobility assessment decide how to mobilize patient - CoxHealth Financial support Form team 2 ID champions across disciplines, include all players ID and address barriers Ed, communicate, coordinate create business plan demonstrating cost savings, improved outcomes 1 if no money = prioritize, work as team 1 Solutions Sleep Nourishment Pain control Provide schedules Sedate appropriately Incorporate prevention 7 8

9 Ace Unit: Acute Care of Elders -strongest evidence, best outcomes 8 Interdisciplinary care includes geriatrician Cost savings may be greater than added costs of unit More discharges to home Decreased LOS Increased satisfaction of patients, RN s, physician s (just having these pieces not in a unified unit doesn't help as much as a dedicated unit with a geriatrician NO DISCHARGE planning Plan to go home Solutions - Hospital Wide Environmental changes in ACU Unit -8 Carpeted floors decrease falls and noise, orientation aids (large calendars) Cultural changes in ACE Unit Decrease restricted mobility get rid bed rest, enable safe mobility, avoid tethers and restraints Rehab protocols and prevention Encourage ADL s without assist Dress in street clothes Daily pharmacy reviews Decrease psychoactive drugs and anticholinergics Decrease NPO Avoid strict diets Provide snacks If no ACE Unit, many elements can be incorporated, but it isn t as successful 8 Communication with Dr., social worker, PT, OT, RN, daily rounds WALK in HALLS 3-4x/day, exercises, to chair at least for meals Decrease tethers EAT - common dining areas socialization, access to snacks Family to stay overnight Earphones, large clocks, calendars, low bed with rails down 9

10 GEM Unit -Geriatric Evaluation and Management Unit 8 Admit after acute issues stabilized Increase focus rehab, not prevention Selective - patients who would benefit from rehab Multidisciplinary and geriatric assessments HAH -hospital at home -modest reduction in disability 8 HELP -Hospital Elder Life Program 8 Targets delirium Decreased hospital costs 10 Institutionalism lower Decreased LOS Solutions Therapy Return patients to PLOF 10 Add prevention DON T under dose strength 10 No general conditioning 11 Need to use overload principal DO high resistance training 11 Older adults have decreased muscle protein synthesis Their response to protein intake is dependent more heavily on exercise to maintain balance between muscle protein breakdown and synthesis High Intensity strength training = 70-80% 1 RM 11 OK even for patients with osteoporosis 11 No need for 1 RM max, no special equip Encourage enough resistance to cause muscle fatigue to the point of failure at 8-12 reps with form deterioration over last two reps Borg PRE = on 6-20 scale Muscle soreness ok Increased ADL performance, increased lower body strength and gait speed No risk increased serious adverse events 10

11 Solutions - Therapy Task specific ADL training -increase muscle strength and motor learning 11 Balance also recommended by ASCM multi-component training Improves Berg score and decreases fall rates. 11 Motor control based gait training with high level taskorientated activities Greater gains in gait speed and self reported function than traditional endurance based programs. 11 General conditioning is typically what we do, but is NOT skilled therapy. Need intensity, frequency, duration and specificity to be skilled 11 References 1. Denehy, L., et al. A Physical Function Test for Use in the Intensive Care Unit: Validity, Responsiveness, and Predictive Utility of the Physical Function ICU Test (Scored). Physical Therapy, vol. 93, no. 12, 2013, pp , doi: /ptj Parry, Selina M., et al. Implementing Early Physical Rehabilitation and Mobilisation in the ICU: Institutional, Clinician, and Patient Considerations. Intensive Care Medicine, 2017, doi: /s Doherty-King, B., and B. Bowers. How Nurses Decide to Ambulate Hospitalized Older Adults: Development of a Conceptual Model. The Gerontologist, vol. 51, no. 6, 2011, pp , doi: /geront/gnr Brown, Cynthia J., et al. The Underrecognized Epidemic of Low Mobility During Hospitalization of Older Adults. Journal of the American Geriatrics Society, vol. 57, no. 9, 2009, pp , doi: /j x. 5. Kalisch, Beatrice J. Missed Nursing Care. Journal of Nursing Care Quality, vol. 21, no. 4, 2006, pp , doi: / Kalisch, Beatrice J, et al. Outcomes of Inpatient Mobilization: a Literature Review. Journal of Clinical Nursing, vol. 23, no , 2013, pp , doi: /jocn Krumholz, Harlan M. Post-Hospital Syndrome â An Acquired, Transient Condition of Generalized Risk. New England Journal of Medicine, vol. 368, no. 2, 2013, pp , doi: /nejmp References 8. Covinsky, Kenneth E., et al. Hospitalization-Associated Disability. Jama, vol. 306, no. 16, 2011, doi: /jama Fortinsky, R. H., et al. Effects of Functional Status Changes Before and During Hospitalization on Nursing Home Admission of Older Adults. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, vol. 54, no. 10, 1999, doi: /gerona/54.10.m Growdon, Matthew E., et al. The Tension Between Promoting Mobility and Preventing Falls in the Hospital. JAMA Internal Medicine, vol. 177, no. 6, 2017, p. 759., doi: /jamainternmed Falvey, J. R., et al. Rethinking Hospital-Associated Deconditioning: Proposed Paradigm Shift. Physical Therapy, vol. 95, no. 9, 2015, pp , doi: /ptj Danos, Todd S. Early Mobility: Good for the Patient, Good for the Facility. Rehab.pub.com, 29 Aug. 2013, Brown, Cynthia J., et al. Barriers to Mobility during Hospitalization from the Perspectives of Older Patients and Their Nurses and Physicians. Journal of Hospital Medicine, vol. 2, no. 5, 2007, pp , doi: /jhm