Acute front door care of frail older people. Simon Conroy Professor of Geriatric Medicine

Transcription

1 Acute front door care of frail older people Simon Conroy Professor of Geriatric Medicine

2 Why is this important for physicians? Type 1 A&E attendances 11% Total Activity (Leicester) Elective admissions 7% Elective excess beddays 0% Non-elective admissions 12% Follow-up outpatient appointments 39% Non-elective excess beddays 15% First outpatient appointments 16%

3 21% of admitted patients are 75+ & frail, but: 100.0% Resource use in Leicester for older people with frailty 90.0% 80.0% 86.3% 85.4% 86.5% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Percentage of total beddays Percentage of emergency readmissions within 90 days Percentage of deaths within 90 days of admission

4 Flow of patients through the emergency care pathway 2014/15 vs. 2013/14 NHS Monitor econometric modelling: Bed-occupancy >85% = 0.4% reduction in 4HS Bed-occupancy >90% = 1.0% reduction in 4HS Bed-occupancy >95% = 1.6% reduction in 4HS

5 So what s new? No tangible response from community services No change in social care funding (for the better) Not likely to see a drop off in attendances Hospitals closing Control what you can control

6 Is there a different model required? Acute medical model does what it says on the tin very well But is it all just about medicine? Frail older people, 90 days post AMU discharge: 76% had one or more adverse outcomes 6% died 20% increased dependency 46% reduced mental well-being 49% reduced quality of life 42% had two or more individual adverse outcomes

7 We think we are doing it but are we?

8 Are we really? Some geriatric competencies in AIM curriculum, but Sufficient detail? Sufficient breadth?

9 Lots of variation in process measures

10 But also in clinical measures

11 Uncontrolled variation is the enemy of quality Can we develop a more structured response to the care of older people? There is an evidence base: Fox 2012: ACE units better than usual care Ellis 2011: wards better than teams; frail better than age-specific Baztan 2010: acute geriatric units better than conventional care Deschodt 2013: teams reduce mortality but not function or service outcomes Lessons from stroke care & orthogeriatric care CGA can be adapted for acute care: Acute Frailty Network FRAILsafe Silver Book

12 The compelling narrative 48% of people over 85 die within one year of hospital admission Imminence of death among hospital inpatients: Prevalent cohort study. David Clark, Matthew Armstrong, Ananda Allan, Fiona Graham, Andrew Carnon and Christopher Isles, published online 17 March 2014 Palliat Med 10 days in a hospital bed (acute or community) leads to the equivalent of 10 years ageing in the muscles of people over 80 Gill et al (2004). studied the association between bed rest and functional decline over 18 months. They found a relationship between the amount of time spent in bed rest and the magnitude of functional decline in instrumental activities of daily living, mobility, physical activity, and social activity. Kortebein P, Symons TB, Ferrando A, et al. Functional impact of 10 days of bed rest in healthy older adults. J Gerontol A Biol Sci Med Sci. 2008;63: If you had 1000 days left to live how many would you chose to spend in hospital? 12

13 What does good look like in urgent care? 1. Establish a mechanism for early identification of people with frailty 2. Put in place a multi-disciplinary response that initiates Comprehensive Geriatric Assessment (CGA) within the first hour 3. Set up a rapid response system for frail older people in urgent care settings 4. Adopt clinical professional standards to reduce unnecessary variation 5. Develop a measurement mind-set 6. Strengthen links with services both inside and outside hospital 7. Put in place appropriate education and training for key staff 8. Identify clinical change champions 9. Patient and public involvement 10. Identify an executive sponsor and underpin with a robust project management structure

14 A clinical case 82 years old Glaucoma blind left eye IHD (quiescent) Heart failure AF Sudden onset left sided lower limb weakness CT head SVD Recovered within hours CHADS-VaSc: 5

15 A clinical case CFS grade 4 Mean LoS 8 days IP mortality 3% 13% readmission at 30 days Medical Glaucoma blind left eye IHD (quiescent), heart failure AF & TIA; CHADS-VaSc: 5 Psychological Bright Cognate Function Ind ADLs & most IADLs Mobile 400m, but slowing up, waddling gait Social Lives alone (wife died few years ago) Environment Bungalow, some aids

16 A clinical case Medical Discussion about DOAC Vitamin D levels X-ray hips (OA) Psychological No action Functional Refer falls clinic Environment No action Social Aware of Age UK etc

17 And it works!

18 And no it is not ALL about geriatricians!

19 Identification, assessment and management underpinned by specific actions/competencies: Frailty ID (1 minute) Holistic assessment (5 domains ) - patient centred; problems>diagnoses MDT discussion (1 minute per patient ) flattened hierarchy, constructive challenge Structured assessment shared clerking document Access to case management (within or without the hospital) Environment adapted to reduce disruption Clinical Adapted pain assessments Awareness of asymptomatic bacturia Aware of risks of urinary catheterisation Comfortable differentiating delirium from dementia Adept at rationalising medication Sharp, focussed falls assessments

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21 Next round 19/9/16; 50 Trusts

22 Acute Frailty