Challenges in improving the quality of care we deliver to older people

Transcription

1 Challenges in improving the quality of care we deliver to older people DR DIARMUID O SHEA CONSULTANT GERIATRICIAN SEPTEMBER 7 TH, 2016 The aging aren t only the old; the aging are all of us Alexandra Robbin 1) Some ramblings, background and HALT! 2) Recognising frailty and what it means 3) A Case 4) Why we should have that conversation 5) Outcomes for people in nursing homes Regulation of residential care in Ireland Residential care settings for older people Required to register with HIQA Inspected according to 32 national quality standards (2009) June 2013: 570 facilities, with 34,581 beds registered (Source: HIQA) 1

2 Population Projections The Planning Imperative Total Population > 65 yrs > 85 yrs In LTC 5% % Irish HALT participants Key Results Number of participating LTCF State ownership Private ownership Voluntary ownership Median LTCF size 47 beds (range = ) 50 beds (range=10 226) 46 beds (range = 5 203) Median proportion of single rooms 17% (range = 0 87) 21% (range = 0 100) 34%* Median bed occupancy 93% 95% 94% Number of eligible residents 4,170 5,922 9,318 Total Number of Nursing Home beds registered in 570 facilities Single room availability: state owned (21%), voluntary (50%), private (76%) Defining HCAI Onset day three onwards following LTCF admission Standardised HCAI definitions: compare like with like 2010 & 2011: McGeer criteria for defining HCAI in LTCF residents 2013: SHEA/CDC revised HCAI surveillance definitions for LTCF McGeer A, Campbell B, Emori TG et al. Am J Infect Control 1991;19(1):1 7. Stone ND, Ashraf MS, Calder J et al. Infect Control Hosp Epidemiol 2012;33:

3 How common are infections in Irish LTCF? Updated CDC/SHEA HCAI surveillance definitions used in 2013: We can t directly compare HCAI prevalence between 2011 & 2013 What were the most prevalent infection types in 2013? 3

4 Seasonal influenza vaccination Recommended for LTCF residents Recommended for healthcare workers influenza season 63 influenza outbreaks, majority in LTCF, affecting elderly with reported deaths HALT survey doesn t collect data on staff vaccination HALT Residents routinely 72% 75% 94% offered vaccine Nursing Home Resident 86 year old male Resident for 1 year Background: Mixed Dementia, Parkinson s Disease, Hypertension, Hyperlipidaemia, atrial fibrillation, type 2 diabetes mellitus Complaining of - worsening shortness of breath and productive cough x 5/7 Treated with co-amoxiclav 2 days ago but no response Treated for three respiratory chest infections the last 6 months Key Concepts of Comprehensive Geriatric Assessment (CGA) Multidimensional Interdisciplinary Diagnostic Process Holistic view, not sufficient to focus simply on one domain Flattened hierarchy empowering all members of the team Coordinated & Integrated Plan of Treatment Frail Older People Follow Up Respect for each of the individual roles Targeting those who will benefit the most Current tools alone are insufficient to identify the group of interest Targeting criteria could include age, comorbid illnesses, geriatric syndromes, impaired functional issues, social issues This requires time and staffing resource 4

5 Some general facts nursing home residents that you know already! Background multiple medical problems Nursing care needs Psychological needs Allied Health Professional Acute medical episodes Acute surgical episodes Follow up needs Medical care plan End of Life Care Specialist need/opinion Acute hospital? Nursing home Some general facts about nursing home residents that you may not know already! 4.6% of the older population in Ireland live in long term care facilities EU averages between 5-6% from a low of 2% in Spain, Greece & Portugal to a high of 10% in the Netherlands 2 in every 3 residents in LTC within the Leinster area >80 years of age The care is delivered in the private and public sector The majority of admissions to LTC are precipitated by the consequences of an acute event Among the challenges are Health Care Associated Infections, Delirium Polypharmacy, End of Life Care Older persons by numbers NEED >85 yrs population (Source: CSO) +29% >75 female >65 yrs population LIFE EXPECTANCY (Source; Eurostat 2014) +60% +100% +39% >75 male INPATIENT DISCHARGES >75 yrs will increase +28% (Source: HIPE) ACCESS ADMISSION RATE >75 yrs 48% >95 yrs 64% (Source: SDU 2016) PET TIMES PET times increase with age % of all 24 Hr breaches are >75yrs (BIU 2014). DEMENTIA IN IRELAND 50k with dementia 4k new cases every year 1.69billion per year 100k cases by 2026 (Source : ICGP 2014) RESOURCE Home Care and Transitional Care 15,000 HCP 130 ihcp 5,255 beds NHSS million TRANSITIONAL CARE BEDS accessed by 313 beds 17 acute hospitals LONG STAY PUBLIC BEDS (Source: SCD Operational Plan 2016) 5

6 Need for Health Services for Older People World Wide it is Becoming Increasingly Obvious that Conventional Approaches to Health and Social Care Delivery are Unsustainable People are Living Longer Population is Increasing & Ageing Methods of Delivering Care are Changing Expectations & Demands are Changing Costs are Rising Important to get a Balance & Collaboration Between Public & Private Services Are we Listening to the Opinions that Count? Some of the Challenges when Growing Old? As We Age Our Life Expectancy Decreases Increase Risk of Co-Morbidities Increasing Risk of Cognitive, Physical Decline, Falls & Delirium Increased risk of frailty Increasing risk of polypharmacy & alterations in how we handle drugs Often not included in trials so limited evidence base for what we do If Admitted to Hospital this is the Opposite to What Good Care Is? More Likely to Move Wards More Likely to Experience a Longer Stay More Likely to Experience a Delayed Discharge More Likely to Suffer an Adverse Outcome STEP-BY-STEP INTEGRATED CARE FRAMEWORK FOR OLDER PERSONS 2 UNDERTAKE POPULATION PLANNING FOR OLDER PERSONS 1 ESTABLISH GOVERNANCE STRUCTURES 3 PROMOTE SUPPORT FOR OLDER PERSONS TO LIVE WELL IN THE COMMUNITY Information & Community Advice Transport Support carers Harness Technology MAP LOCAL CARE RESOURCES 8 SUPPORTS TO LIVE WELL Social Activities 4 5 DEVELOP SERVICES AND CARE PATHWAYS REHABILITATION AMBULATORY SERVICES e.g. DAY HOSPITAL ACUTE CARE NURSING HOMES DEMENTIA FALLS ETC.. DEVELOP NEW WAYS OF WORKING NEW ROLES INCLUDING CASE MANAGEMENT APPROACH FOR LONG TERM COMPLEX NEEDS IN-REACH AND OUTREACH 10 Shopping MONITOR AND EVALUATE TRACK SERVICE DEVELOPMENTS MEASURE OUTCOMES STAFF AND SERVICE USER EXPERIENCE 7 Medication Management Home modifications & handy person PERSON CENTRED CARE PLANNING AND SERVICE DELIVERY 9 6 DEVELOP MULTI- DISCIPLINARY TEAMWORK AND CREATE CLINICAL NETWORK HUB CO-ORDINATION BETWEEN CARE PROVIDERS ENABLERS DEVELOP WORKFORCE ALIGN FINANCE INFORMATION SYSTEMS 6

7 2 UNDERTAKE POPULATION PLANNING FOR OLDER PERSONS Nature of morbidity Potential Intervention Planning for Trends in Population Very High Risk 1% Patients 10% Cost High risk 4% Patients 17% Cost At risk 15% Patients 25% Cost Minimal risk 80% Patients 48% Cost Mr O T 86 years old Nursing Home resident On 7+ medications 3+ falls in last year 3 LRTIs in past 6/12 2 hospital admissions in last 12 months Mr Collins 68 years old Recently lost wife Peripheral neuropathy 1 hospital admission in last 12 months Mrs Kelly Recently diagnosed with Type 2 diabetes Cognitive impairment: Alzheimer s 2 medications Mr Byrne Low risk Morbidity due to time limiting or acute illness rather than chronic conditions. May be at risk of developing chronic conditions Case management Care coordination Condition management Health coaching Lifestyle management Health education Health promotion & prevention strategies Lifestyle change programme Complexity Nursing Home Resident 86 year old male Resident for 1 year Background: Mixed Dementia, Parkinson s Disease, Hypertension, Hyperlipidaemia, atrial fibrillation, type 2 diabetes mellitus Complaining of - worsening shortness of breath and productive cough x 5/7 Treated with co-amoxiclav 2 days ago but no response Treated for three respiratory chest infections in the last 6 months The Big 5! Dementia / Delirium Immobility / Falls Disabilty/Frailty Polypharmacy Incontinence End of Life Care Silver Book, BGS,

8 Nursing Home Resident 86 year old male Resident for 1 year Background: Mixed Dementia, Parkinson s Disease, Hypertension, Hyperlipidaemia, atrial fibrillation, type 2 diabetes mellitus Complaining of - worsening shortness of breath and productive cough x 5/7 Treated with co-amoxiclav 2 days ago but no response Treated for three respiratory chest infections the last 6 months Medication Warfarin Gabapentin 100mg bd Sinimet 150 mg tds Omeprazole 20mg Domepridone 10mg tds Ibuprofen 200mg tds Amlodipine 10mg od Frusemide 40mg od Donepezil 10mg od Inhalers od and BD Detrusitol SR 4 mg Quetiapine 25mg nocte Capturing his Disability and Frailty Generally declining cognitively and functionally over the past 6 months Premorbid Status: Barthel index 7/20 (had been 13/20 1 yr ago), MMSE 13/30, Rockwood frailty Score 7 Function and Frailty Scores 8

9 0 No symptoms at all Modified Rankin Scale 1 No significant disability; despite symptoms able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 Moderate disability requiring some help, but able to walk without assistance 4 Moderate severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 Severe disability; bedridden, incontinent, and requiring constant nursing care and attention CSHA Clinical Frailty Scale Canadian Study of Health and Aging (CSHA) The frailty phenotype 9

10 Frailty phenotype and falls Journal of Frailty and Aging, 2013 (Fried and Walston, 2000 Vulnerability of frail older person to change in health status after minor illness 10

11 Nothing new?? Mortality in the Nursing Home Sector 2008 Total nursing home sector Private nursing home sector Residents 20,869 64% (13,313) 1 year mortality rate 23% (4735) 21% (2,822) Dependency Low Medium High Maximum 10% 22% 31% 37% 11% 24% 32% 33% 2008 Longstay data, Information unit DoH&C Mortality in Nursing Home Residents during and after unsheduled admission to Hospital n = 1015 over 18 months Mean age 83 yrs, 66% F Mortality Single admission 702 ( 69%) 2 admissions 313 (31%) P value for difference(z test) Inpatient 9.8% 21.1% < Nursing Home 28.1% 16.0% < Over-all Mortality 37.9% 37.1% 0.81 IAGG

12 Survival after the First Episode of Pneumonia, the First Febrile Episode, and the Development of an Eating Problem Panel A Pneumonia N = 323 All curves are presented for the median age (86 years), Panel B Febrile Episode median duration of dementia (6 years) and distribution according to sex (85.4% women). Panel C Eating Problems The Clinical Course of Advanced Dementia. Mitchell, Susan; Teno, Joan; Kiely, Dan; Shaffer, Michele; Jones, Richard; Prigerson, Holly; Volicer, Ladislav; Givens, Jane; Hamel, Mary New England Journal of Medicine. 361(16): , October 15, Vulnerability of frail older person to change in health status after minor illness 36 Opportunities for having that conversation Self-initiated Unscheduled care episode Chronic Disease specialist Nursing Home Staff Medical Officer/GP 12

13 Nursing Home Resident Case 1 86 year old male Resident for 1 year Background: Mixed Dementia, Parkinson s Disease, Hypertension, Hyperlipidaemia, atrial fibrillation, type 2 diabetes mellitus Complaining of - worsening shortness of breath, productive cough x 5/7 Treated with co-amoxiclav 2 days ago but no response Treated for three respiratory chest infections by GP in the last 6 months Patient Complexity and Needs Comorbidities ADL dependency Complex care Monitoring Medical intervention Frailty / Syndromes Monitoring Multidisciplinary care Monitoring Prevention Health promotion/prevention Screening Acute care On Examination AMTS 4/10, agitated, (pulling out lines) Dehydrated Temp: 38.5 c, RR 28, O2 sats 95% on 2litres, HR 105, BP 125/79 Resp: Bronchial breathing right base. Bloods: WCC 15, Neutro 11, CRP 173, NA 150, creat 160, urea 16 ECG: AF 110 bpm, QTC 480ms CXR: Right basal consolidation 13

14 Aspiration Pneumonia Right basal pneumonia,?aspiration Acute Kidney Injury Hyperactive delirium on the background mixed dementia Treatment: Management IV antibiotics and fluids SALT: Grade 2/Texture B diet Medication Review: Stopped thiazide diuretic, ace inhibitor, donepezil, statin, metformin, Advanced care planning instituted: DNR signed New Baseline function and cognition (Barthel 5/20, MMSE 10/30) Discharged back to Nursing Home and medical follow up Followed up CNS phone call to NH 4/52 Subsequent Consultant geriatrician review in NH 6/52 What is his likely longterm outcome? Mortality in Nursing Home Residents during and after unsheduled admission to Hospital n = 1015 over 18 months Mean age 83 yrs, 66% F Mortality Single admission 702 ( 69%) 2 admissions 313 (31%) P value for difference(z test) Inpatient 9.8% 21.1% < Nursing Home 28.1% 16.0% < Over-all Mortality 37.9% 37.1% 0.81 IAGG

15 Incidence and Mortality of CAP is increased in older and nursing-home patients Incidence rates and mortality rates of overall CAP increase significantly by age group By gender 2 higher in males than in females Age groups Incidence Mortality yrs 9.9/1000/y 7.2% yrs 16.9/1000/y 13.5% >85 yrs 29.4/1000/y 23.5% BMC Public Health 2008; 8:222 Mortality after Community Acquired Pneumonia Variable CAP Controls p value Sample 158, ,333 Hospital mortality 11% 5.5% < yr mortality hospital d/c 34% 25% < yr mortality 41% 29% <0.001 Kaplan V, et al. Arch Intern Med 2003;163: Opportunities for having that conversation Self-initiated Unscheduled care episode Chronic Disease specialist Nursing Home Staff Medical Officer/GP 15

16 The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location. 31/08/2016 Conclusions Large number of frail older people are living in the nursing home community on average 2.5 acute episodes per resident per year The majority of medical episodes dealt with in NH Expect 30 transfers from NH to acute hospital EDs per 100 beds per year Planning the transfer to and from nursing home is important Issues like DNR, Hospital Transfer take time to discuss where should this happen Ethical problems are common in caring for older people, including those with end stage dementia Need for Greater public debate about benefits & limits of medical care, ceilings of care Ongoing consideration of ethical issues by professional bodies Educational Activities, Liaision, Support or Outreach services can support us in continuing to improve the quality of care we deliver 85 We thread the needles eyes, and all we do All must do together What is Delirium? 16

17 What is Delirium? An acute confusional state Acute change in cognition or perception Clouding of consciousness Fluctuating symptoms Occurs in the setting of illness, injury, substance intoxication or withdrawal Population Prevalence Adult hospital inpatients ~20% Older inpatients ~50% ICU patients ~80% Palliative Care patients Up to 88% Long-term care patients Up to 70% Paediatric ICU Up to 25% Surgical patients (depends on type of 3-62% surgery) Hip fracture patients Up to 62% Stroke patients Up to 28% Delirium is a medical emergency Dementia patients Up to 89% Community sample (>55)?0.4% How Significant is Delirium? Increased hospital stay (an extra ~10 days) Independent of the underlying illness, delirium leads to Increased mortality (25% die within onemonth) Increased healthcare costs (costs doubled) Cognitive decline (Increased risk of dementia x 8.7) Increased need for nursing home (risk >doubled) Delirium in Long Term Care Up to 70% prevalence Swiss study (n=11745): 45% had either full-blown delirium or subsyndromal delirium on admission to NH In post-acute settings, delirium increases mortality and cognitive decline (48% mortality in one study) Delirium duration tends to be longer than in acute setting Poor detection rates (one study 13% recognised) 1. De Lange et al, 2013; 2. Von Gunten and Mosimann, 2010; 3. Arinzon et al, 2011, 4.Cole et al, Voyer et al,

18 Differential Diagnosis Depression Dementia Delirium Onset Weeks - months Months - years Hours - days Altered No No Yes Consciousness Inattention Mild Mild Significant Disorganised thinking Unusual unless severe Unusual unless severe Common Is this delirium? Step 1: Is the patient confused? AMT-4 1. What year are we in? 2. What do we call this place we are in? 3. How old are you? 4. What is your date of birth? Any error is abnormal and requires further assessment Appropriately assess delirium: Attention tests Attention tests WORLD backwards Serial 7s Months of the year backwards Links DeliriumED-AMAUAlgorithm.pdf 18