H.E.L.P. ing Elder Trauma Patients Avoid Delirium and Functional Decline

Transcription

1 H.E.L.P. ing Elder Trauma Patients Avoid Delirium and Functional Decline Montreal ITC 2014 Sept. 26 Joann Creager, CNS Geriatrics, Manager, MUHC Elder Friendly Hospital

2 Presentation Overview 1. Elder patient concerns 2. Associated risks of hospitalization 1. Delirium 2. Functional decline 3. Management to minimize risks 4. What is H.E.L.P.? 5. H.E.L.P at the MUHC

3 Outcomes Important to Geriatric Trauma Patients Home or... Nursing home? Functional or... dependent? Worry about mortality but esp. function! Physical mental Disability poor Quality of Life (QOL), ++complications, possible relocation to nursing home

4 What Predicts Risk of Disability Geriatric syndromes & impaired ADLs predict risk better than standard measures based on Sx procedure or disease Syndromes : Cognitive impairment Falls Incontinence Low BMI Low vision Cigolle et al Ann Int Med 2007; 147:

5 Two Associated Risks of Hospitalization For the Elderly

6 First Associated Risk - Delirium Most common complication of hospitalization for elder pts. Highest risk hip Fx, vasc. Sx Risk if TBI also involved Young & Inouye 2007, McCusker & Marcantonio 1994, Miller 1981, Dasgupta 2006, Bickel 2008, Kat 2008

7 Why is Delirium a Concern? mortality (2x), Length of Stay Risk of : Impaired 1 & 6 mos 1 yr Young & Inouye 2007, McCusker & Marcantonio 1994, Miller 1981, Dasgupta 2006, Bickel 2008, Kat 2008

8 Associated Risks of Hospitalization: Delirium Delirium Chart Review CHUM 368 pts Population Delirium Delirium ALOS Mortality At Admission During Hosp. (days) Medical 4.5% 31% 21 vs 13 30% vs 9% Surgical 2% 28% 19 vs % vs3%

9 What is Delirium? acute, fluctuating change in mental status, with inattention & altered levels of consciousness Can be hyper- or hypo- active marked agitation or somnolence

10 Delirium Predisposing Risk Factors Age Male gender Abnormal cognitive status Memory, psych issues Sensory impairment Functional impairment Medical comorbidities Chronic use of psychoactive substances Siddiqi et al Cochrane syst review 2007, Dasgupta 2006, Inouye 1993

11 Delirium Precipitating Risk Factors Pain Metabolic abnormalities Abnormal vital signs infection Fecal impaction Tethers catheters, lines, O2 Medications esp anticholinergics, benzos Constantly changing environment Etc., etc. Siddiqi et al Cochrane syst review 2007, Dasgupta 2006, Inouye 1993

12 Best Management? PREVENTION!!! Every episode of delirium has an impact Takes time to resolve 48 hours 30 days never duration cognitive damage Pts with delirium are often immobilized Restrained Kept in bed

13 Second Associated Risk Functional Decline Due to IMMOBILIZATION (Sager, 1998) For patients day of immobilization = 3 additional days of hospitalization 1 week of immobilization = pt will require rehabilitation due to loss of muscle mass (Source: Cadre de référence Approche Adaptée à la Personne Agée, MSSS,2011)

14 Associated Risk - Functional Decline 33% of hospitalized patients over 65 will experience a decline in basic activities of daily living (ADL) compared to two weeks before admission Disability = LTC delayed discharge Source: (Creditor M.C.: Hazards of Hospitalization of the elderly, Annals of Internal Medicine 1993, 118(3):

15 Functional decline Associated with Hospitalization (Sager et al 1996) ADL Pre admission Discharge Bathing 72% 29% Dress 82% 35% Transfer 92% 45% Walking 90% 48% Toileting 89% 53% Eating 93% 72%

16 Recommended Management to Minimize Risks

17 Intervene in the Factors Provoking Delirium and Functional Decline Sleep deprivation Nutrition Hydration Falls Poly Medication Immobilization Delirium Functional Decline Pain Sensory impairment Urinary Catheters Incontinence Constipation Depression

18 Recommended Post-Op Care Assess: comorbidities (esp. cardiopulmonary) Function (mobility, cognition, vision, hearing) Medications : Review - polypharmacy? Desired level of care, expected outcomes delirium prevention and treatment, early removal of tubes, lines D/C planning Soc support, ADL dependency, nutrition, cognition, ambulation, meds McGory et al J. Am. Coll. Surg. 2005; 201:

19 Delirium Prevention & Management Adequate O2 delivery Fluid/electrolyte balance Bowel/bladder regimen Pain management Medication management (? withdrawal, new meds?) Nutrition Maintain normal sleep/wake cycle environmental stimuli (noise/lights) Improve sensory capacity Manage agitation Prevention & rapid Tx of med. complications Aspiration precautions Early mobilization Re-oprientation and normal cognitive stimulation

20 What is H.E.L.P.?

21 What Is the Hospital Elder Life Program? A comprehensive program of care for hospitalized older patients, designed to PREVENT delirium and functional decline Based upon award winning clinical trial that demonstrated clinical effectiveness Target patients = >75 year olds with LOS > 2 days

22 Yale H.E.L.P. Program Delirium Prevention Trial - Outcomes 852 patients (70+) enrolled; 50% received HELP intervention, 50% received usual hospital care. HELP interventions resulted in: 34% reduction of delirium (9.9% vs. 15% ) total number of days with delirium (105 vs. 161) total number of delirium episodes (62 vs. 90) functional decline1(4% vs. 33%)

23 Yale Delirium Prevention Trial More Outcomes hospital costs for 73% of intervention patients costs of implementing program offset by cost savings from the program. (Medical Care 2001;39: Dose-response relationship between adherence with the interventions and delirium reduction. adherence rates of delirium (Archives of Internal Medicine 2003;163: ) in use of long-term nursing home services. Intervention associated with 15.7% in long-term nursing home costs. ( Journal of the American Geriatrics Society. 2005;52: )

24 Volunteer Training Program 16 hours of training 4 key interventions Safety Shadowing New volunteer buddied with certified volunteer Competency evaluation See one do one

25 Key Volunteer Interventions of HELP Program 1. Daily visitor program 2. Therapeutic activities program 3. Early mobilization 4. Feeding and fluid assistance

26 The Daily Visitor Program Goal: Prevent or decrease confusion Activities: Orientation Protocol Teaching covers : importance of encouraging patient to wear hearing aids and eyeglasses how to introduce themselves to the patient and help patient to be oriented how to locate hospital unit, utility room, kitchenette, patient room and how to use the call bell, lights, bed controls, tray table etc.

27 Therapeutic Activities Program Goal: Stimulate and maintain cognition and sense of well being Activities: Current events (newspaper, radio) Reminiscence (card sets, story telling) Trivia games Relaxation ( music, DVD, etc) Sleep enhancement (herbal teas, tapes, etc.) Teaching will cover the following points: How to prepare the initial contact with the patient How to choose the materials needed for the activity How to establish communication with the patient How to start the activities with the patient

28 Early Mobilization Program Goal: Keep older patients physically active Activities: Help patient who is able to walk Wheelchair mobility Passive range of motion exercises Teaching covers : principles of body mechanics how to help the patients to walk how to proceed if a patient falls active range of motion exercises

29 Feeding and Fluid Assistance Program Goal: Maintain patient s nutritional status Activities: Assisting with menu Companionship and encouragement Set up tray Partial or full feeding assistance Teaching covers : how to create a mealtime environment how to provide feeding assistance (set up meal tray, companionship, partial or full feeding assistance) safety precautions ( what to do if choking occurs) Terms and special diets (NPO, Supplements, Fluid restriction..)

30 What the staff experience Non clinical needs of patient are met by volunteers Reduced interruptions and demands on floor staff Reduced rate of delirium and fewer iatrogenic complications increases quality

31 What patients experience More opportunities to mobilize More visiting, chance to socialize, reduce boredom cognitive stimulation Better eating and drinking Reduced rate of delirium and fewer iatrogenic complications increases confidence And their families perceive increased care

32 H.E.L.P. at the MUHC

33 MUHC Trauma Setting Level One trauma center Patients housed on two surgical units Unit with larger census of trauma : 20% patients = 75+ Incidence of delirium 20% H.E.L.P. already running on medical unit Resources available to extend H.E.L.P. for 1 yr on trauma unit

34 Requirements for Establishing H.E.L.P. Volunteer source Volunteer bureau screened candidates Mostly students (CEGEP & univ.) Nurse clinician coordinator and trainer Collaboration of unit team Referrals, ongoing assessments Geriatric consultation Assessments & f/u Materials, incentives

35 Train staff in use of : Confusion Assessment Method (CAM) ASK the following questions: 1: Acute Onset and Fluctuating Course 2: Inattention (distractible) 3: Disorganized thinking (illogical) 4: Altered Level of consciousness Diagnosis of Delirium = #1 and #2 = yes AND #3 yes or #4 yes

36 Manage Volunteers & Patients Run training 3-4 times per year Schedule volunteers to cover days and evenings, Q7 Allocate patient assignments and task lists f/u volunteer consistency Reporting to duty Interventions f/u pt status Revise interventions assigned Quality audits staff, pts, families, volunteers Satisfaction audits staff, pts, families, volunteers

37 Results Adherence to interventions less than 50% Excellent quality of interventions when they were done Satisfaction extremely high all groups! 95% expressed enjoyment, benefit Couldn t get clear measure of delirium episodes Often not included on D/C summary Staff inconsistent in screening However H.E.L.P. staff often signaled delirium to unit No consistent measure of patient function at admission and D/C

38 Difficulties with Adherence Patient factors 75+ pts often refused to participate in interventions suggested by volunteers aged 20+ Volunteer factors Predominantly students Academic schedules Varying commitment weak in understanding need to respect schedules or to advise of absence in advance High turnover constant need for new training Unit factors some staff uncertain about having non-professionals perform interventions Unit had a tumultuous year unusual staff turnover

39 Integration : H.E.L.P. Program with Unit Processes Nurse clinician - very devoted But efforts ran parallel with efforts of unit team Low integration low number referrals and f/u assessments of delirium Geriatric nurse consultants very involved But efforts ran parallel with efforts of unit team Low integration low number referrals and f/u assessments of delirium Staff nurses very much appreciated presence of volunteers But presence often interpreted as doing interventions that the unit had no time for

40 Yale H.E.L.P. Program Is it worth it? Yes! even though MUHC does not have resources to continue it at present Like any program would do better if implemented in a reasonably stable environment MUHC is moving to the Glen... MUHC is advancing with AAPA implementation requiring: staff competency in assessing and intervening in delirium Mobilisation programs on all units Other MUHC groups have expressed interest in taking up the challenge May be better positioned to sustain a program of this nature. May implement a modified program based on our experiences

41 Questions??? Comments??