BGS Spring The Dementia and Delirium CQUIN

Transcription

1 The Dementia and Delirium CQUIN Dr Louise Allan Clinical Senior Lecturer in Geriatric Medicine Institute of Neuroscience Newcastle University

2 Outline Why should it have happened? Why did it happen? How did it happen? What did we do? What have we learned? Where are we going? What is the role of the Geriatrician?

3 Why should it have happened? Cognitive disorders are common in acute hospitals They are often missed They are associated with poor outcomes There is research evidence that delirium can be prevented and treated Person centred care is important for people with dementia (Counting the Cost report)

4 Primary reasons Why did it happen? Recorded dementia prevalence rates Secondary reasons National audit of dementia NICE quality standards in dementia

5 Less than half of people with dementia receive a diagnosis

6 2012 The Prime Minister s Challenge 1. Driving improvements in health and social care Recorded prevalence rate placeholder in NHS OF 2. Creating dementia friendly communities that understand how to help 3. Better research

7 The prevalence rate

8 How did it happen? An idea born of the single question in delirium Has (name) been more confused lately? Single validation paper in palliative care This became the single question in dementia Has (the person) been more forgetful in the last 12 months to the extent that it has significantly affected their life? No papers

9 The first draft 1. % of all patients aged 75 and over who have been screened following admission to hospital, using the dementia screening question 2. % of all patients aged 75 and over, who have been screened as at risk of dementia, who have had a dementia risk assessment within 72 hours of admission to hospital, using the hospital dementia risk assessment tool 3. % of all patients aged 75 and over, identified as at risk of having dementia who are referred for specialist diagnosis

10 1 Improving care for people with dementia in hospital: Risk Assessment and Antipsychotic Review All patients No known diagnosis of dementia If aged over 75 Known diagnosis of dementia Has the person been more forgetful in the last 12 months to the extent that it has significantly affected their life? Diagnostic review, if indicated Yes No Steps 1,2,3 and 4 2 Dementia Care pathway Reasonable Adjustments 3 Positive Dementia Risk assessment Negative Care as usual Inconclusive 4 Dementia present Antipsychotic review Feedback to GP Dementia absent

11 Dementia CQUIN: FAIR (Find, Assess and Investigate, Refer) 1 Has the person been more forgetful in the last 12 months to the extent that it has significantly affected their daily life? All emergency admissions aged over 75 No known dementia yes no Clinical Diagnosis of delirium no yes Diagnostic assessment 2 Care as usual Find Assess and Investigate Refer Known dementia Diagnostic review, if indicated Positive Inconclusive Negative 3 Referral Dementia pathway Feedback to GP

12 Dementia CQUIN: FAIR (Find, Assess and Investigate, Refer) 1 Has the person been more forgetful in the last 12 months to the extent that it has significantly affected their daily life? All emergency admissions aged over 75 No known dementia yes no Clinical Diagnosis of delirium no yes Diagnostic assessment 2 Care as usual Find Assess and Investigate Refer Known dementia Diagnostic review, if indicated Positive Inconclusive Negative 3 Referral Dementia pathway Feedback to GP

13 Dementia CQUIN: FAIR (Find, Assess and Investigate, Refer) 1 Has the person been more forgetful in the last 12 months to the extent that it has significantly affected their daily life? All emergency admissions aged over 75 No known dementia yes no Clinical Diagnosis of delirium no yes Diagnostic assessment 2 Care as usual Find Assess and Investigate Refer Known dementia Diagnostic review, if indicated Positive Inconclusive Negative 3 Referral Dementia pathway Feedback to GP

14 Dementia CQUIN: FAIR (Find, Assess and Investigate, Refer) 1 Has the person been more forgetful in the last 12 months to the extent that it has significantly affected their daily life? All emergency admissions aged over 75 No known dementia yes no Clinical Diagnosis of delirium no yes Diagnostic assessment 2 Care as usual Find Assess and Investigate Refer Known dementia Diagnostic review, if indicated Positive Inconclusive Negative 3 Referral Dementia pathway Feedback to GP

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16 Inherent problems Its purpose is to drive dementia diagnosis rates and not improve management of cognitive disorders in hospital The evidence base is for prevention and treatment of delirium Delirium in those with dementia or exclusion factors not considered No reward for prevention or treatment Screening question unvalidated with lack of clarity as to whether patient or carer is asked and timescale of significant change Presence of delirium should lead to deferral of dementia diagnosis

17 What did we do? Comprehensive engagement with stakeholders Clinical Governance Department GPs Old Age Psychiatrists Acute care physicians Senior nursing staff IT Consulted other trusts

18 Differences across trusts Doctor or nurse led? Who does step 1? How was delirium diagnosed? Who asks question 3? Who does step 2? Are positive screens referred back to GP or directly to specialist?

19 Differences across trusts Doctor or nurse led? Doctor does, nurses chase Who does step 1? Doctor How was delirium diagnosed? Short CAM Who asks question 3? Doctor Who does step 2? Doctor but in reality seconded nurse Are positive screens referred back to GP or directly to specialist? GP, but after risk assessment

20 How was it implemented? Paper tool, subsequent electronic tool Dementia snapshot tool Weekly steering meetings Dementia specialist nurse on secondment from LOAP 2 full time staff in CGARD E learning package First brief intro to the paper tool Second linked to further training on cognition Induction session for medical directorate Drop down box in discharge letter

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23 A positive screen requires Duration of the problem is > 6 months The problem is progressive Other cognitive problems are present besides memory loss They have an abnormal cognitive test There is a clear effect upon activities of daily living (these must declined from their previous level)

24 The screen may be inconclusive if There seems to be a significant problem but it hasn t yet been present for 6 months The patient may have incompletely resolved delirium and you are not sure whether the symptoms preceded the delirium There are no other cognitive problems besides memory loss The patient is depressed The patient is still functioning at a high level but is clearly concerned that this is a change for them The patient has a normal cognitive test but previously functioned at a high level You have recently stopped anticholinergic drugs and need to see whether the symptoms will improve

25 REFER The majority should go back to the GP Other destinations: Refer Old Age Psychiatry (outpatient) Refer Melville Day Unit (medical memory clinic) Refer Liaison Old Age Psychiatry (inpatient) Transfer to Psychiatry (very urgent cases)

26 7.46% with delirium

27 Step 3 outcomes Step 3 Outcome No known dementia at step 1 Delirium present No known dementia at step 1 No delirium present Positive response to Q3 Step 2 procedure applied despite negative step 1 screen Total N % N % N % N % Negative Inconclusive Positive non urgent Positive urgent Very urgent Open to specialist service Missing Total % of step 2 cases % of step 2 cases % of step 2 cases 721 Number per week 5.1% of admissions 3.1% of admissions 2.9% of admissions % of admissions

28 Delirium focussed audit: Aims 1. Is the diagnosis of delirium being documented in discharge letters and hospital coding data? 2. Are people with delirium seen again after discharge? 3. Are we communicating effectively with GPs?

29 Methods 6446 patients screened Jan-Dec screened positive for delirium (7%) In these 481 patients: Discharge letter reviewed looking for: Diagnosis of delirium Details of follow up Coding data reviewed

30 Results 1. Is the diagnosis of delirium being documented in discharge letters and hospital coding data?

31 171 Was the diagnosis of delirium documented in the discharge letter? (36%) Died No Yes No letter on diadem No discharge date documented

32 Was the diagnosis of delirium documented in hospital coding? 112 of 481 (23%) had delirium documented in hospital coding

33 Results 2. Are people with delirium seen again after discharge?

34 Number of patients screening positive for delirium according to the CQUIN who were followed up after discharge Psychiatry referral Yes No Died No discharge letter found GP review requested

35 Results: 3. Are we communicating effectively with GPs? 202 patients had a CQUIN outcome for step 3 suggesting GP review communicated in 43 of their discharge letters

36 What happened to those referred back to the GP? 23 responses from GPs 14 were followed up 1 died 10 referred 2 had improved, not referred 1 had several further admissions 5 not seen 4 moved practice

37 What have we learned?

38 Positives Raised profile of dementia Made cognitive assessment compulsory for over 75s Did allow a mechanism to detect delirium to be included in admission Helped to drive our other plans in this area From the outset. FMN, focus chart, dementia nurse Negatives No evidence for the case finding question It s about money not patient care Delirium given lower priority than dementia Not linked to the NICE guidance on delirium

39 What have we learned? Acceptability to clinicians requires a strong link to the evidence base Ethical issues need to be considered Screening for dementia is not recommendedis this screening? CQUIN can be used to drive improvements in dementia care Some hospitals were able to turn the purpose around substantially, we only did this partially

40 Lessons learned Identification of people with known dementia and/or delirium is proving helpful Delirium and dementia coding are rising The CQUIN illustrated the need for a dementia nurse Detection is only the first step Liaison with IT is key to success Review and refinement are essential

41 Difficult cases Patients told they have dementia or led to believe they have dementia when they didn t Patients who do go on to have dementia not given diagnosis at right time for them, or with appropriate support Lack of attention to delirium meaning that known dementia is thought severe with no plan for review Discharge planning based on diagnosis rather than need

42 Where are we going? Regional task and finish group New proposal for CQUIN based on NICE Quality standards in delirium But- New national CQUIN released, issues with eligibility for some hospitals

43 1. Case finding Proposed CQUIN a. Apply to over 65s and hip fracture b. Identify known dementia c. Screen for delirium using tool based on attention d. Deliver a care package based on NICE guidance e. Include scheme such as Forgetmenot, This is me f. Record diagnoses in discharge letter g. Record follow up advice in discharge letter

44 2. Training a. Focus on delirium Proposed CQUIN b. Mandatory delivery over 3 years 3. Carer support a) Based on interviews with carers b) Specific action plan

45 What is the role of the Geriatrician? Memory services often ask GPs to defer referral for 6 months after a delirium Patients have unmet needs during this time Geriatricians need to step into this space, both clinically and in providing research base Optimisation of comorbidities and medications Multidisciplinary team

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47 Questions?