[Rescuing the Frail Elderly

Transcription

1 [Rescuing the Frail Elderly & Failure to Rescue] Chris Subbe

2 Conflicts of Interest

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4 Populations

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6 Mrs LLewelyn

7 Frail elderly patient & RRS Defining Frailty Impact on Outcomes in Critical Illness Operationalising Frailty for Acute Care

8 Defining Frailty

9 Frailty? Physical Psychological Functional Prognostic impact

10 Fried s Cycle of Frailty Fried LP et al. in Hazzards WR. Principles of Geriatric Med. & Gerontology. McGraw Hill, 1998.

11 Phenotype of frailty 1. Decreased grip strength 2. Self-reported exhaustion 3. Unintentional weight loss > 4.5 kg over past year 4. Slow walking speed 5. Low physical activity Frail: 3 criteria present Fried LP et al. J Gerontol A Biol Sci Med Sci 2001, 56:M146-M156.

12 Model of Accumulating Deficits Rockwood K CMAJ 2005; 173:

13 Model of Accumulating Deficits Rockwood K CMAJ 2005; 173:

14 Age vs Satisfaction 1040 ICU patients Age was not a major contributor to the variance in outcome The elderly demonstrated more positive health attitudes than younger survivors. Functional capacity was significantly associated with health attitudes of younger patients, but not for older survivors. Rockwood K. Crit Care Med. 1993;21:687-91

15 Age vs Your Doctor Pearlman RA. Journal of gerontology 1988; 43.2:25-30.

16 Measuring Frailty

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18 Rapid Night 20 nights x 4 wards Patient and team characteristics 109 patients + recurrent triggers Only 18 call-outs: 1 death & 1 ICU admission. but 24 died within 30 days Death more likely after doctor called! More call-outs with cancer

19 Patient related factors Dementia Care home Frail DNAR order Terminal Cancer COPD LTOT

20 Clinical Frailty Night CFS Call-out

21 Managing risk in hospital? Total Improved Died

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23 Frailty & ICU Setting: 8 bedded ICU Aim: Feasibility of assessment tools 56 sets of notes of patients 70 Age 80 (SD 4) - 33 men 4 patients came from care homes, 22 lived on their own. APACHE II 19 (SD7), LOS: ICU 5 days (IQR 3-7); Hospital 16 (IQR 7-26) Ismail N, Keating D, Subbe CP, Thorpe CM, ICS 2012

24 Frailty & ICU ISAR 3 (IQR 2-4) Barthel-Index 75 (IQR ) Katz 6 (IQR 4-6) CFS 6 (IQR 4-6) DUKE index?; SHARE? CFS but not age over 80 ~ mortality (p<0.045) CFS 6 ~ hospital LOS 15 days or more (p<0.02) Ismail N, Keating D, Subbe CP, Thorpe CM, ICS 2012

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26 Fair & Frailty Old Frail Clinical outcomes might be related to frailty Screen early Speak to patients & families!

27 What is Failure to Rescue?

28 Measures: Failure to Rescue In-hospital complications in surgery Ghaferi AA. Ann Surg 2009;250:

29 The Deteriorating Patient Record - Recognize - Report - Respond

30 Measures: Failure to Rescue

31 Measures: Failure to Rescue

32 The Deteriorating Patient Record - Recognize - Report - Respond

33 Failure to Rescue & Human Factors Communication Hierarchies Situational awareness Mental modelling

34 Failure to Rescue & Human Factors Communication ~ SBAR Hierarchies ~ Safety brief Situational awareness ~ Simulation Mental modelling ~ Check lists

35 Staffing & Failure to Rescue FTR + 16% per additional patient per nurse + 26% mortality with lowest staffing levels Kane R. Medical Care 2007; 45: Rafferty AM. International Journal of Nursing Studies 2007; 44: Ball J. RCN London 2009

36 FTR from Dr Foster Unit Design: Cross sectional observational ( ) Participants: 66,100,672 surgical admissions Results: Secondary diagnosis 26% to 40%. Lower rates FTR if more clinically qualified staffing per bed higher ratio doctors /nurses (p<0.05). Griffiths P et al. Int J of Nursing Studies 2012

37 Multi-disciplinary Audit EvaLuating Outcomes of Rapid Response (MAELOR)

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39 Measuring Failure to Rescue Outcomes Positive Negative ICU admission Timely admission S2D < 4 hours Delayed admission S2D > 4 hours Alive on Ward No longer triggering Still triggering Deceased Others Terminal Care & DNAR order Terminal Care & DNAR order New Pathology Cardio-Pulmonary Arrest Lost to Follow up

40 Measuring Failure to Rescue Outcomes Positive Negative ICU admission Alive on Ward Deceased Others Timely admission S2D < 4 hours 5% No longer triggering 48% Terminal Care & DNAR order 1% Alive & DNAR order 18% New Pathology Delayed admission S2D > 4 hours 9% Still triggering 16% Cardio-Pulmonary Arrest 1% Lost to Follow up 0%

41 1. Morris A. CCR March 2013.

42 The Deteriorating Patient Record - Recognize - Report - Respond

43 Thank you / Diolch n Fawr christian.subbe@wales.nhs.uk