Acute Care Pathway for Older People

Transcription

1 Whole Systems Meeting: Acute Care Pathway for Older People The Principal Met Hotel, King Street, Leeds, LS1 2HQ 13 th June

2 Welcome back 1.15 Welcome back & table discussions Dr Sara Humphrey Rapid Intervention and Treatment Team in Lancashire Care The Early detection for delirium project (ED4D): Implementing a quality improvement approach to the identification and management of delirium at Salford Royal Hospital Suzanne Thornber, Service Manager & James Harper, AHP Lead (Mental Health) Lancashire Care NHS Foundation Trust Dr Emma Vardy, Consultant Geriatrician, Salford Hospital 3.00 Table discussions (coffee available) 3.45 Summary of the day Dr Sara Humphrey 4.00 CLOSE Please do stay until the end if you can For those who must leave early, please complete a **lilac** evaluation form and leave on your table before you go

3 Table Discussion What can we do better How can we best support people with Behavioural and Psychological Symptoms of Dementia (BPSD) in an acute setting, care home or in the community? How can we best support people with dementia when they visit Hospital/A+E (appropriate adjustments, screening, 3 D s, appropriate and timely discharge) What can we do to support family carers and enable their involvement when they come into the acute hospital setting? How can we prevent re-admission through improved discharge & advance care planning? How can we prevent unnecessary hospital admissions?

4 Rapid Intervention & Treatment Teams LCFT

5 Where we were-case for change Large Geographical Area 8 CCGS 3 Local Authorities 4 Acute Trusts OA Bed closures in line with national strategy

6 Variation across Community Mental Health Teams (CMHT) in a number of performance and productivity parameters, rates of referral, cost of contacts per team, and number of contacts per whole time equivalent. Variation in productivity within the teams Complicated patient pathways with numerous hand off and risks Inequity of service Inconsistent triage and initial assessment through locality based Single Point of Access

7 What we aimed to do Promote faster recovery Improved service Providing a standardised approach across all areas with local variations Support timely discharge from hospital Prevent avoidable deterioration Offer of a real alternative to hospital admission Increase unscheduled care response, recognising the rise in referrals of people in crisis in care homes Avoid inappropriate admissions to care homes 8am -8pm, 7 days a week, 365 days a year

8 Benefits To provide care across a whole pathway in a seamless, integrated manner To deliver the best possible standard of care for service users and their families and carers To ensure services are safe and effective in delivering defined outcomes To enable the delivery of productivity and efficiency gains To deliver within a smaller cost envelope To deliver equitable care across Lancashire To provide a career structure for the workforce

9 Staffing Financed from existing envelope Tasked with making cost efficiencies Consolidation of smaller teams that had become unsustainable 4 larger locality teams- flexibility to respond to patient need, whilst enabling 7 day service

10 Who is in the team-mdt Approach Nurses Occupational Therapists Psychologists Consultant Psychiatrists Assistant Practitioners Health Care Support Workers

11 A Patients Story Key Points: - Patient choice in treatment - Least restrictive options explored and implemented - Carer s assessment and support included in care plan - Consideration of patient goals and role of team from outset- and acknowledgement of changing goals throughout involvement - Team based approach, with timely and considered access to wider MDT- OT and psychology, as well as nursing and medication - Patient and carer involvement in discharge care planning

12 Salford Royal NHS Foundation Trust Delirium and Dementia Project Dr Emma Vardy Clinical dementia lead Salford Care Organisation and Greater Manchester &Eastern Cheshire Strategic Clinical Network

13 GDE : Delirium and Dementia Increase detection of delirium Enhance detection of undiagnosed dementia cases Provide tailored care and improve outcomes. Clinically led IM&T led Exec Committee Risk assurance

14 Why is it important? Delirium is poorly detected Detection improves care & outcomes Delirium is about 30% preventable Early detection benefits patients and carers Type of acute brain failure Similar biomarkers to traumatic brain injury

15 How common? Delirium affects 1 in 8 acute hospital inpatients Up to 30% Emergency Department patients 15% of adult acute general patients 30% of acute geriatrics patients 10-50% of surgical patients 50% of Intensive Care patients 50% of patients post hip fracture surgery

16 TAKES 1-2 MINUTES Specificity=84% Sensitivity=90%

17 Making the case for change Delirium is distressing for patients, family and staff and has potentially life-threatening outcomes including: Higher risk of falls & other harms 3 fold higher mortality (1 in 5 dead in one month, currently 14.1%, MI and sepsis) More likely to get dementia Speeds up decline in dementia (doubles rate) More likely to go into care 2-3 fold increased length of hospital stay High readmission rate (approx 25%) If delirium is missed in ED, outcomes are much poorer for patients

18 Measurable outcomes identified by the Delirium and Dementia project Improved quality of care by increased % of over 65s receiving an ED clinical assessment also receiving a 4AT assessment Reduction in in-patient falls (for those patients with delirium) Improved quality of care by an increased % of over 65s receiving a 4AT assessment on admission to hospital Reduction in average length of stay for patients with delirium recorded as i) a health issue ii) a diagnosis Reduction in readmissions within a month of discharge for patients with delirium recorded as i) a health issue ii) a diagnosis (approx 25%) Reduced prescription rate of anti-psychotic medication (in delirium) Consistent adherence to comprehensive dementia FAIR assessment process Increased dementia diagnostic rates for over 65s, leading to earlier treatment enabling prolonged independence and delay in institutionalisation Improved mortality for patients diagnosed with delirium (currently 14.3%)

19 Early Detection for Delirium (ED4D)

20 Primary Driver Diagram 4AT Screening Tool Liaising w ith clinicians to test user friendliness of the document Technology Digital pathw ay for care bundle Evidence based -choice of delirium assessment and management tool Incorporate patient stories collection in carers training Screening 65% of 65+ admissions from the A&E department for delirium by March Improve training and education Collect patient stories Raised aw areness and mandatory training Training sessions planned for various healthcare professional groups Carer education Data collection on number of falls, specials, and use of anti psychotic medication for patients w ho have received a delirium screen and those w ho have not Leadership Develop cohort of delirium champions Identify and train ED champions, include carers

21 Technology PDSA summary Improve Training and Education Leadership - sent to ED staff and introduced 4AT into safety huddle 14/6 - GDE EPR changes implemented 19/9 - Raise awareness/introduce GDE program on the intranet for staff to see - Add info about Delirium in the Siren e-newsletter - GDE educational video development with delirium focus - Medical student project to find out understanding of 4AT and delirium - one minute wonder posters in staff room and by blood gas machine - lessons in the loo posters on the inside of bathroom doors - Introduce delirium into ED safety huddle - Delirium resource box in ED - Arrange teaching sessions for staff EAU Consultants Junior doctors Nursing staff - Daily walk around ED - New doctors induction - Presented at the team brief - Delirium champions group - Leaders forum - ED consultants updated on progress - Well done poster and feedback to ED staff

22 Update 17/22 confident in diagnosing delirium 12/22 would use 4AT 17/22 knew to use tools from EPR 2 people knew to screen >65, 15 only if confused 11/22 said delirium had been promoted Major improvement in knowledge of tool, still some preconceptions to work on!

23

24 14/06/17 Delirium discussion added to Safety Huddle in ED 12/10/17 Training session for Junior Doctors 07/12/17 New doctors induction 07/09/17 Siren newsletter containing delirium info was ed out and uploaded on the intranet 01/04/18 Doctors changeover 19/09/17: EPR changes as part of GDE Programme went live

25

26 April May June July August September October November December January February March No. of Patients Diagnosed With Delirium EPR Changes

27 Measure Baseline (1/10/16-3/3/17) Dec 17 March 18 % 4AT in ED % delirium who had a fall Mortality rate (%) Readmission within a month (%) LOS (days)

28 National Recognition icanpreventdelirium Quality Improvement Award Shortlisted for Quality Improvement Initiative of the Year HSJ Patient Safety Awards Contacted by other organisations across the country and are interested in using something similar in their departments.

29 Film Production Follow these links to watch the videos Delirium awareness = Enid's Story =

30

31 What next? Delirium screening in ED - ongoing education TIME management bundle Spread screening to Emergency Assessment Unit Improve assessment across the whole hospital Development of a blue-printing template with GDE partners Spread into community including NWAS GM delirium collaboration Ongoing QI project dementia FAIR assessment

32 Summary Used QI methodology Developed bespoke electronic documents with EPR team Engagement at all levels Culture change around delirium at Salford Royal NHS Foundation Trust and beyond

33

34 Acknowledgements GDE project team Shelley Heywood Matieusz Labiak Karen Hill Lesley Wintle Yvonne Reay Sarah Hulme Lisa Hodgson Lisa Orme Robert Dodd Nathy Connolly Jenny Wilson Mike Turner Gareth Thomas (Group Chief Clinical Information Officer) ED4D team Umang Grover Niamh Collins Beverley Thompson Louise Nutt Sarah Monks Rebecca Thompson Tony Holmes Chen Ng Alex Bagnall Fraser Brooks Suzanne Masterman Georgia Clarke Elaine Inglesby-Burke (Executive Sponsor) Collaborators Scottish Delirium Association Karen Goudie (Health Improvement Scotland) Yvonne Moulds, Julie Mardon (Crosshouse hospital) Haelo and Maxine Power

35 Thank you