Professor Brian Draper

Transcription

1 Understanding what s different for patients with dementia in acute care hospitals coalface implications Psychiatry Professor Brian Draper UNSW & Prince of Wales Hospital, Randwick

2 Background Previous analyses and publications from the HDS project have demonstrated: People with dementia are high users of acute hospitals approx 25% of persons with dementia in NSW hospitalised in 2006/7 Outcomes of people with dementia are worse than those without dementia - longer LOS; increased Mortality, increased potentially preventable complications, increased risk of transfer to residential care Services for people with dementia vary across hospitals with most being associated with hospital-based geriatric services & few being located outside of major cities (Draper et al, 2011; Karmel & Anderson, 2012; Bail et al, 2013; Draper et al, 2013; Bail et al, in press)

3 Predictors of LOS and Placement into Residential care In our initial analyses we were able to demonstrate that numerous factors contributed to these outcomes 1. Patient characteristics e.g. age, comorbidities, mental health issues, fractures 2. Hospital characteristics e.g. hospital location, presence of geriatricians, provision of subacute care 3. Regional level service provision e.g. availability of community care packages, onsite residential care beds

4 What does the Multi-Level Modelling add to our understanding? Hospitals are complex organisations with varying resources Hospitals interact with other hospitals and the local community and these interfaces contribute to admission & discharge policies and performances Dementia adds complexity to the assessment & management of many medical & surgical conditions MLM with principal components analysis describes how factors might interact helps to describe the types of hospitals with different outcomes

5 Is a Shorter LOS a Proxy for Good Dementia Care in Acute Hospitals? YES Earlier diagnosis and treatment Better quality care with less preventable complications More efficient hospital Better hospital/community interface MAYBE/NO Premature discharge High transfer rates to another hospital High transfer rates to RACF

6 Relative risk of preventable complications in hospitalised people age 50+ Preventable complication Relative risk (RR) people with dementia compared to people without dementia Medical Patients Surgical Patients Urinary tract infection 1.79** 2.88** ( ) ( ) Pressure Ulcer 1.61** 1.84** ( ) ( ) Pneumonia 1.37** 1.66** ( ) ( Sepsis 1.34* 1.25 ( ) ( ) Delirium 2.83** 3.10** ( ) ( ) Phys / metabolic derangement ** ( ) * P Value <0.05 ** P Value < CI Confidence Intervals at 95% Bail et al, BMJ Open, 2013

7 When Might a Longer LOS represent Good Dementia Care? 1. Appropriate use of subacute care to enable rehabilitation e.g. post fall, recovering from severe infection 2. Awaiting community services to be in place to reduce risk of readmission 3. Awaiting transfer to RACF rather than discharge home to a risky environment to await placement

8 Do hospitals with comprehensive geriatric medical services have better outcomes? Yes! Large urban hospitals with specialised aged care staff & geriatricians on site, Emergency Departments with dedicated aged care staff & general assessment clinics have shorter LOS for people with & without dementia and lower rates of transfer to Residential Aged Care Facilities (but only for people without dementia)

9 Comprehensive Hospital-based Geriatric Services 1. Geriatricians on site each day (not just VMO) 2. Multidisciplinary teams with nursing & allied health 3. Specialist Aged Care Wards for acute and/or subacute care 4. Assessment clinics 5. Emergency Departments have dedicated specialist aged care staff

10 Meta-Analysis of RCTs Comprehensive Geriatric Assessment Comprehensive geriatric assessment increases patients likelihood of being alive and in their own homes after an emergency admission to hospital. More likely to improve cognition Having a geriatric ward works better than just working as a team Ellis et al, BMJ

11 However... Outside of the large urban hospitals, shorter LOS in people with dementia is found in two types of hospitals Type 1 unlikely to have hospital-based specialist geriatric services Type 2 likely to have hospital-based geriatric services Neither type had any other distinguishing features from the data we collected.

12 Types of hospitals with Longer LOS that MIGHT represent lower quality dementia care Several principal components identified hospitals that were characterised by some or all of following: 1. Lack of specialist aged care staff in Emergency Departments 2. Small to Medium sized 3. Often inner regional location 4. Geriatricians, if present, tend to be visiting rather than on site 5. High levels of transfers 6. Very few short admissions 7. Longer LOS not found in people without dementia

13 The Issue of Resources To what extent are hospital outcomes for people with dementia related to the types of resources available: multidisciplinary specialist aged care staff with geriatricians available on site, specialist aged care wards, specialist input to all other parts of the hospital including ED?

14 Lower access to specialist staff in Rural areas Per cent 60 Hospitals with geriatricians visiting for physical health problems Major Cities of Australia Inner Regional Australia Remoteness Outer Regional Australia Remote and Very Remote Australia

15 Lower access to specialist staff Solutions being tried Telemedicine was highly valued. Valued use of Dementia CNC for education and training. ASET advising staff on the wards managing BPSD. Developing capacity in other staff through online education, Dementia Champions, and dementia-specific KPIs in the CEO s contract.

16 Are outcomes worse in rural vs urban hospitals? In general, LOS in rural hospitals is longer for people with & without dementia This should not be interpreted as being equivalent to a worse outcome it may also reflect challenges related to waiting for tests to be done, doctors to visit, community services to be arranged etc Transfers to Nursing Homes are more likely to happen in rural settings but only in people WITHOUT dementia

17 The Front End of the Hospital is Very Important How, when and why a person is admitted to hospital plays a key role in determining the outcome of care For example, for people with dementia: Admission on a weekend is associated with a shorter LOS are these potentially avoidable admissions? Having specialist aged care staff in ED tends to reduce LOS perhaps because the correct initial management is instituted earlier

18 Aged Care Services in Emergency (ASET) Based in ED Focus on older patients Assess functioning, cognition, social circumstances, care needs and services Refer to wards, discharge planners, allied health, AARCS, community service providers, ACAT, Compacks Provide advice about discharge safety Improve relationships between hospitals and non-acute sector including aged care facilities Advocate for older people within hospital and RAC settings Different health professionals at different sites Size of ASET team varies ASETs generally valued by ED specialists Nature of role varies depending on what other services and professionals are available 18

19 Emergency Wards (N = 139) People with dementia are more likely to be emergency admissions than people without dementia (Natalwala et al, 2008). Confirmed by key informants during HDS field visits. 20% had dedicated aged care staff with dementia expertise 29% had access to aged care staff with dementia expertise 51% Emergency Wards had neither In NSW, dedicated ED staff with dementia expertise are in ASET positions 19

20 ED dementia expertise: how many hours? 70% 60% 50% 40% 30% 20% Dedicated staff Access to staff 10% 0% 20 hours or less hours hours 61 hours or more 20

21 Transfer to Residential Aged Care Characteristics of the hospital system that we were able to measure have a greater impact on risk of transfer to a Residential Aged Care Facility for people WITHOUT dementia Some small hospitals with mainly subacute care have both higher & lower rates of RACF transfer for people with dementia

22 Interpretation of the Multi-Level Modelling We have shown a clear, significant hospital level effect on both transfer to residential care and patient LoS The MLM demonstrates that hospital size, location and service configuration are strong drivers However the MLM also hints at some of the unobserved hospital-level drivers. These could include: - individual clinician practices & culture (hospitals with similar characteristics can still have vastly different LoS and placement outcomes for similar patients) - hospital networks

23 Data from site visits to 20 hospitals Hospital culture includes language and attitudes towards PWD, and openness to shifts in practice. Staff leadership - combination of specialist skills, knowledge & management. Skilled Staff - Specialty knowledge in dementia, delirium and aged care was important in determining trajectories of care. Hospital environment the presence of dementia friendly environments such as secure wards & outdoor areas, calm & pleasantly distracting spaces, colour coding 23

24 Site Visit Assessments of Hospitals Leadership Skilled Staff Environment Culture Type A High High High High Type B High High Low Medium Type C High Low Low Medium Type D Low High High Medium Type E Low Low Medium High Type F Low Low Low Low

25 Staff leadership Combination of specialist skills, knowledge & management. Understand system and key players, have effective strategic impact on financial distribution. Enables other staff to lead dementia care and enables resources Blowing the budget, but making decisions that are right for the person at the end of the line. A focus on building capacity for the region. Bringing about the change and the implementation took being a doer, getting in there, getting the right thing to happen for the patient no matter if it was hard

26 Skilled staff availability Specialty knowledge in dementia, delirium and aged care was important in determining trajectories of care. Differed from unit to unit and was dependent on other areas In areas where the RACF or community don t have the staff and resources and supports, patients get admitted Not enough senior staff to provide supervision for students Paediatric Nurse recently employed to be CNC of Aged Care Need for ED staff education in relation to establishing baseline cognitive ability in confused patients and in terms of excluding delirium

27 Well designed ward environment Secure aged care ward, co-located with rehab Areas of interest carpeted couch nooks, dining areas, gym (share by both wards), garden Secure unit within the ward environment own outdoor courtyard, bus stop etc Whole ward very calm and quietly active

28 Hospital Culture Includes language and attitudes towards people with dementia and openness to shifts in practice the demented ones who act up bed blockers nurse nightmares

29 Conclusions There is system-wide evidence that the outcomes of hospital care for people with dementia vary from hospital to hospital Factors that influence those outcomes include 1. Having a skilled specialist hospital-based geriatric medical services in larger hospitals 2. Ensuring there are specialist aged care staff in ED 3. In all hospitals, staff training, leadership, positive attitudes and attention to the hospital environment

30 Thank you. Any questions? Contact us: Web: Brian Draper: Diane Gibson: