after acute care (inc. ED)?

Transcription

1 How to prevent early & unplanned hospital admission after acute care (inc. ED)? Luis Consultant Geriatrician Forest Assessment Unit - Older People s Services Whipps Cross University Hospital Honorary Clinical Senior Lecturer MRC Unit for Lifelong Health and Ageing University College of London 21.September.2017

2 CONFLICT OF INTEREST DISCLOSURE I have no potential conflict of interest to report

3 Leppin et al., JAMA Int Med 2014;174(7): How to prevent early & unplanned hospital admission? Is the question relevant?

4 Learning objectives To acknowledge the need for new models of care To explore admission alternatives rather than solutions for a poor outcome

5 Outline 1. The need 2. The model 3. Barriers to implementation 4. THM

6 UK 65+ Population Office for National Statistics 2015

7 Multimorbidity Barnett K et al., Lancet 2012;380:37-43

8 Multiple chronic Polypharmacy conditions Appropriate medication: Disease progression Exacerbations Function Risk of drug-drug interaction Risk of drug-disease interaction Risk of over- and under-prescribing Risk of ineffective prescribing Page et al., Maturitas 2016;91:115-34

9 Wittenberg et al., Centre for Health Service Economics and Organisation 2014

10 Wittenberg et al., Centre for Health Service Economics and Organisation 2014

11 Wittenberg et al., Centre for Health Service Economics and Organisation 2014

12 Wittenberg et al., Centre for Health Service Economics and Organisation 2014

13 THM1 the need 1. Population is ageing 2. Demand for emergency services is increasing 3. Primary care and community resources are scarce 4. Older patients forced to use EDs for minor events

14 Comprehensive Geriatric Assessment Ellis et al., BMJ 2011;343:d6553 Comprehensive Geriatric Assessment

15 Comprehensive Geriatric Assessment Ellis et al., BMJ 2011;343:d6553

16 L. Mieiro

17 L. Mieiro

18 Linear process ED initial assessment Decision to admit Ward CGA Discharge

19 L. Mieiro 2017 Community Patient ED Primary Care Mental Health Relatives Carers Short stay units SALT Doctors SHARED GOALS Dietician Nurses Rapid Access Clinics Social Worker OT/PT Rapid Response Pharmacist

20 L. Mieiro 2017 Primary care ED CGA Clinic Admissions Avoidance Team Frailty Unit 7 beds Community

21 L. Mieiro 2016 Ambulance How does it work? Emergency assessment AAT GP Community matrons Fall + pain Pelvis X-ray Chest pain/dizziness/sob POCT Cough Chest X-ray + VBG + ECG Other pathway more suitable? ACS/Stroke/NOF# Majors 65+ Clinical Frailty Scale 4-7 At least 1 Geriatric Syndrome NEWS<3 AAT OT/PT ax FAU D/C CGA clinic

22 L. Mieiro 2016 Respite 1.0% Forest Assessment Unit Patient flow 3 months A&E 65+ Clinical Frailty Scale 4-7 At least 1 Geriatric Syndrome NEWS<3 Frailty Unit (n=383) CGA D % (n=193) D7 70.9% (n=234) Home 61.4% IPT Rehab 1.8% Ward 35.8% Admissions avoided predicted observed 44.4%

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24 A controlled evaluation of CGA in ED Conroy et al., Age Ageing 2014;43:

25 Is the acute care of frail elderly patients in a comprehensive geriatric assessment unit superior to conventional acute medical care? Ekerstad et al., Clin Interv Aging 2017;12:1-9

26 THM2 the model (i.e., providing CGA closer to the front door) 1. Improves patient flow 2. Identifies alternatives to admission (preventing hospital-acquired functional decline) 3. Contributes to reduction in early readmission

27 Gladman et al., Age and Ageing 2016;45(2): Embedding CGA: the know-do gap Patients Interactions Resources Professionals Guidelines Barriers to implementation Change capacity Network

28 Patient context: the cumulative complexity model Leppin et al., JAMA Int Med 2014;174(7):

29 Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials Leppin et al., JAMA Int Med 2014;174(7):

30 Hospital readmission risk Krumholz et al., NEJM 2017;377(11):

31 Take Home Messages 1. We need integrated models of care a. Ageing population b. Less severe conditions more common in the acute setting 2. Communication (professionals patients carers/relatives) 3. Embed CGA in front door services (education, education, education, ) 4. Quality improvement +++

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33 Wittenberg et al., Centre for Health Service Economics and Organisation 2014