Care of the Elderly 1

Care of the Elderly 1

Contents Summary... 3 Introduction... 4 National Trends 4 Older people's Care in Dumfries & Galloway... 6 Professional Body Recommendation 11 Experience from elsewhere..12 Models for Care of the Elderly NHS D&G....13 2

Care of the Elderly services Summary Dumfries and Galloway Royal Infirmary(DGRI) is the District General Hospital for Dumfries and Galloway. It provides a wide range of services to a population of approximately 148,000 people from a large and predominantly rural geographical area. As the range of specialties offered within the hospital has increased DGRI has successfully adapted both internally and externally to meet the demands however, a recent physical condition survey has indicated that the hospital now needs redevelopment and modernisation. This redevelopment in combination with the recent review of services within the Local Health Partnership affords us the opportunity to redesign the future configuration of clinical services throughout NHS D&G to ensure it remains fit for purpose for the future. As one work stream within the Model Of Care redesign for the future a multidisciplinary group has been convened to address the issue of how best to deliver Care of the Elderly services within NHS D&G Membership of the Care of the Elderly Model of Care Group includes: Dr George Rhind Consultant Geriatrician ( chair) Janice Cluckie Charge Nurse Ward 18 Susan Maxwell Senior Physiotherapist D&GRI Ebby Sigmund Head OT D&GRI Lorna Carr Head OT community services NHS D&G Chris Wallace Rehabilitation Services Nithsdale Graham Haining Community Hospital Nurse Manager Annandale and Eskdale representing Nurse Managers in LHPs David Potter LHP General Manager Annandale and Eskdale and MCN manager for stroke and CHD Angela Wilson District Nurse Waverley Janet Yule/ Kathleen Ord Capacity Managers Jean Muir Commissioning Services Manager Mr Iain Muir Consultant Surgeon Rob Ryan Social worker Gail Edgar STARS Gail Robertson Discharge Co-ordinator Dr Derek Wooff GP Stranraer The purpose of this paper is to Highlight the some of the current difficulties in the current care of the elderly pathway Provide background information on national trends Identify and evaluate a number of possible options to address the problems being experienced. 3

Introduction Two-thirds of NHS beds are occupied by people aged 65 years or older. Older people can frequently present problems for diagnosis and management and have a greater sensitivity to adverse effects of pharmacological agents and therefore an increased tendency to display adverse effects of drug treatments 1. Current service provision within NHS D&G is arranged around specialised departments and wards which are focused upon the provision of excellent practice for the individual specialised area. The changing demographics towards an increasingly older population will result in an increase in the proportion of elderly people admitted as an inpatient. Trends (data provided by Carolyn Hunter-Rowe Senior Health Intelligence Analyst.) Population Projections The latest projections from the General Register Office for Scotland (GROS) show that the over-65s population in Dumfries and Galloway is likely to grow by 63% by 2031 (39% for those aged 65-74 and 93% in the over-75s). This could mean that the over 75s population will increase from 13,800 in 2006 to almost 27,000 in 2031. Figure 1: Estimated population change in Dumfries and Galloway from 2006 to 2031 Population Projections for Dumfries & Galloway in 15 year Age Bands (2006 based, GROS) % change from 2006 100% 80% 60% 40% 20% 0% -20% 93% 39% 75+ 65-74 50-64 30-49 16-29 0-15 -40% 2006 2011 2016 2021 2026 2031 Year (Source: GROS, 2006-based model) 4

Table 1 quantifies the anticipated population changes for the whole of Dumfries and Galloway based on Registrar General projections for Scotland at 5-year intervals up to 2031. Age Group 2006 2011 2016 2021 2026 2031 <65 117,486 113,979 109,209 105,338 100,382 94,170 65-74 16,745 18,279 20,741 21,382 21,478 23,225 75+ 13,799 15,425 17,708 20,581 24,348 26,666 All Ages 148,030 147,683 147,658 147,301 146,208 144,061 Care of the Elderly Services in Dumfries & Galloway The current model within the Dumfries and Galloway Royal Infirmary consists of two wards, one which also accommodates the stroke unit, and access to consultant-led intermediate care beds. Most patients are referred to the Care of the Elderly wards either directly from the medical admission unit or via referral from specialty wards. The majority of patients over the age of 85 receiving care with DGRI receive assessment or intervention from the Care of the Elderly team. Patients are also referred to the Care of the Elderly wards following planned and emergency admissions to both general surgery and orthopaedics. Patient attends Accident and Emergency Medical Assessment Unit Specialty ward Care of the Elderly ward Discharge to Community Hospital Discharge to Home There are currently 52 designated Care of the Elderly beds, which includes the 10 bedded stroke unit. Current activity Methodology: Data were extracted from the Inpatients Business Objects Universe V3 on 12 th February 2008. Data was limited to the 12 month period 1st January 2007 to 31st December 2007 (which may not be currently 100% complete due to delays caused by the ratification process). The data set was limited to episode admissions to the DGRI to geriatric medicine. [Location code: Y104H], [Specialty: AB] 5

Overview of Activity: 1. Current Activity In 2007 there were 1,410 inpatient episode admissions to the Care of the Elderly service, the majority of which are classified as internal transfers. These admissions had a total length of stay of 15,601 days, and a mean length of stay of 11.1 days. There were only 25 day case admissions. Additionally there were 1,306 patients seen at Care of the Elderly outpatient clinics in 2007. Category Type 2007 New 495 Outpatients Return 811 Total 1,306 Day case 25 Ward 12 645 Inpatients Ward 18 621 Other 144 Total 1,410 Total Activity 2,741 2. Age Profile The majority of patients admitted to the Care of the Elderly service are over the age of 80. In 2007 there were 570 admissions (40%) by those aged under 80, and 870 admissions (60%) by those aged 80+. The over 80 s had a total length of stay of 10,202 days in hospital. The average length of stay for those aged 80+ was 12.1 days, and for the under 80 s it was 9.5 days. Episodes Length of Stay (days) Age Band Sum % Sum % Under 65 55 3.9% 482 3.1% 65-69 yrs 73 5.2% 691 4.4% 70-74 yrs 178 12.6% 1,613 10.3% 75-79 yrs 264 18.7% 2,613 16.7% 80-84 yrs 341 24.2% 4,049 26.0% 85-89 298 21.1% 3,826 24.5% 90+ 201 14.3% 2,327 14.9% Total 1,410 100.0% 15,601 100.0% 6

Care of the Elderly Episodes by Age Band, 2007 30% 25% 20% Percent 15% 10% 5% 0% 65-69 yrs 70-74 yrs 75-79 yrs 80-84 yrs 85-89 90+ Age on Admission 3. Main Conditions The main reasons for admission in 2007 were grouped into three broad patient groups: runners, repeaters and strangers. Runners are normally the top 50% of admissions by volume, are usually accounted for by 5-6 conditions, are highly predictable and can be standardised. Repeaters are the next 45% by volume, the conditions are slightly more varied but still have high repeatability. Strangers occupy the bottom 5% by volume. There were 8 conditions with over 40 admissions in 2007 which were identified as runners within the Care of the Elderly service. These were stroke, ischaemic heart disease, UTI, heart failure, pneumonia, syncope and collapse, unspecified acute lower respiratory infection and chronic obstructive pulmonary disease. These 8 conditions covered 40% of the admissions and 40.3% of the total bed days. The repeaters group, which had between 6 and 40 admissions, included chest pain, abnormalities of gait, dementia, iron deficiency anaemia and Parkinson s disease. The strangers, with less than 5 admissions, included osteoporosis, lower limb ulcers, symptoms and signs associated with food and fluid intake, and gastritis and duodenitis. 7

Main Reason for Admission by ICD10 Code, Care of the Elderly 2007 Percent of Admissions 50 40 30 20 10 0 Stroke Ischaemic HD UTI Heart failure Pneumonia Syncope/ Collapse Unspec lower resp infection Chest pain Abnormalities of gait Dementia Transient cerebral ischaemic attacks Anaemia Parkinsons Senility Osteoporosis Other diseases of bilary tract Ulcer of lower limb Symptoms and signs - fluid/food intake Runners Repeaters Strangers Group of Patients 4. Top 10 Conditions The top 10 conditions for the Care of the Elderly service at the DGRI in 2007 are shown below. The main condition was cerebral infarction, with 124 episodes and 1,319 total bed days. Within the top 10, the condition with the lowest average length of stay was chest pain (4.2 days) and the condition with the highest average length of stay was pneumonia (15.0 days). The overall mean length of stay for the top 10 conditions was 11.1 days. ICD10 Codes Condition Total Bed days Mean LOS I63 Cerebral infarction 124 1,319 10.6 N39 UTI, proteinuria, incontinence 64 733 11.5 I50 Heart failure 62 763 12.3 J18 Pneumonia, organism unspecified 56 840 15.0 R55 Syncope and collapse 45 328 7.3 J22 Unspec acute lower respiratory infection 44 617 14.0 J44 Other COPD 41 394 9.6 R07 Pain in throat and chest 37 154 4.2 I20 Angina pectoris 36 228 6.3 R26 Abnormalities of gait and mobility 34 431 12.7 8

Top 10 Care of the Elderly Conditions 2007 (n=1,410) Condition Abnormalities of gait and mobility Angina pectoris Pain in throat and chest Other COPD Unspec acute lower respiratory infection Syncope and collapse Pneumonia, organism unspecified Heart failure UTI, proteinuria, incontinence Cerebral infarction 0 25 50 75 100 125 Admissions Top 10 Care of the Elderly Conditions by Total Length of Stay 2007 (n=15,610) Condition Pain in throat and chest Angina pectoris Syncope and collapse Other COPD Abnormalities of gait and mobility Unspec acute lower respiratory infection UTI, proteinuria, incontinence Heart failure Pneumonia, organism unspecified Cerebral infarction 0 200 400 600 800 1000 1200 1400 Length of Stay (days) 5. Length of Stay The length of stay for Care of the Elderly inpatient admissions were grouped together into four broad categories: short stay less than 5 days, long stay 6 10 days, long stay 11 20 days and very long stay over 20 days. Length of Stay Inpatient Admissions Length of Stay (days) Total % Total % 0-5 days 444 31.6% 1276 8.2% 6-10 days 427 30.4% 3260 20.9% 11-20 days 343 24.4% 5039 32.3% Over 20 days 191 13.6% 6026 38.6% Total 1,405 100.0% 15,601 100.0% 9

Care of the Elderly Episodes by Length of Stay, 2007 % Admissions % Bed days Percent of Episodes 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 0-5 days 6-10 days 11-20 days Over 20 days Length of Stay The number of inpatient episodes and the total bed days attributed to the top 10 conditions within each length of stay category is shown below. The length of stay attributed to a single condition depends on the coding of the main diagnosis on discharge, and co-morbidities influencing overall length of stay may exist. There were 3 conditions where short stay patients (length of stay 5 days or less) accounted for over 50 of the episodes. These were syncope and collapse, chest pain and angina pectoris, ischaemic heart disease and other cardiac arrhythmias. The biggest impact on hospital beds from long stay patients over 20 days is for cerebral infarction, pneumonia, heart failure and unspecified acute lower respiratory infection. 125 Top 10 Care of the Elderly Episodes by Length of Stay Group 2007 0-5 days 6-10 days 11-20 days Over 20 days Number of Episodes 100 75 50 25 0 Cerebral infarction UTI, proteinuria, incontinence Heart failure Pneumonia, organism unspecified Syncope and collapse Unspec acute lower respiratory Other COPD Pain in throat and chest Angina pectoris Abnormalities of gait and mobility ICD10 Main Condition Code NB. It is to be noted that historically stroke/ cerebral infarction patients accessing the Care of the Elderly may have been acute episodes following admission to a the Stroke Unit or have been patients for whom cerebral 10

infarction is a pre-existing condition. The Model of Care work stream considering Acute Stroke identifies the patient journeys for acute stroke patients, which in the majority of models removes a stroke journey which passes through the DGRI based Care of the Elderly beds, and should be considered separately from this document. Patients for whom cerebral infarction is a pre-existing condition will still, where appropriate, will access care from the Care of the Elderly teams. Professional Body Recommendations A review of the existing literature suggests that there should be a specialist old age multidisciplinary team with the following core members in all general hospitals: consultants in old age (geriatric) medicine specialist nurses / nurse consultants physiotherapists, occupational therapists and speech and language therapists (including at advanced practitioner and consultant level) dieticians social workers / care managers pharmacists. This team should be based around a specialist unit which will serve as a centre of excellence for developing and disseminating best multidisciplinary practice throughout general and acute wards and A&E Departments. General staff and trainees from medicine, nursing and members of the allied health professions should rotate through these units to develop skills in the care of older people with complex problems.. These mechanisms are required to ensure that older people receive the care they need in hospital. But different models of care can deliver these benefits. The relationship between old age and general medical contributions to acute care in hospitals is organised according to three predominant models: Age-defined models where patients are admitted to specialist or general medical wards (with a degree of flexibility) around an agreed chronological age (usually 75). This is the predominant UK model. Age-defined wards were developed initially in response to concerns that the needs of older people were being overlooked in general wards where there were people of all ages. Dedicated resources and environments have an opportunity to provide older people with better, higher quality, more specific services. Success will depend on the wards being on the main acute site with full access to other specialities and not singled out for a lower level of resource provision Integrated models where all physicians receive patients irrespective of age. The acute care of patients of all ages is undertaken on acute wards where specialists in old age medicine work with physicians in specialties within an integrated team. The aim is for older people to be treated to the same standards and have access to specialist advice on the same basis as younger people although they also have access to consultants in old age medicine as required. Success will depend on the acute general medical workload of these consultants being such that their skills are available to those older people who most need them and on the hospital having designated wards for specialist rehabilitation following acute care. Needs-based models where patients are allocated on admission either to specialist wards for older people or to general wards, based on locally 11

agreed criteria. Decisions on the most appropriate ward are based on perceived clinical need (complexity, non-specific frailties of old age not chronological age). Admission to the specialist wards is usually arranged direct from the community or following the acute medical take. Success will depend on there being clear and agreed operational policies which are closely adhered to at all times, together with sufficient resources on the main acute site to ensure reliable access without delay for all those who need it. 1 There is no evidence to support one model over the other. The recent review of acute medical care by the Acute Medicine Task Force 2 cautions against the development of direct streaming of patients towards a specialist geriatric medicine bed base as impractical and unworkable. The task force recommends the following : Early engagement and in-reach from the specialist geriatric teams ( including the wider multidisciplinary team) Transfer arrangements should begin early and be proactively managed with the involvement of the specialist multidisciplinary team Elderly patients requiring acute inpatient care should be transferred to the appropriate bed base whether that is in an acute or intermediate care facility with support from the specialist care of the elderly teams to facilitate repatriation to the patient s home Transfers of older people must be minimised, especially at night, to reduce clinical risk and risk of delirium. Expanding capacity in intermediate care and community hospitals, especially in the out of hours period, to facilitate transfer of care to an appropriate facility. The National Service Framework for Older people also highlights the need for close working between surgical and care of the elderly teams. Specialist attention is particularly relevant for older people undergoing surgery. With advancing age, there is an increased risk of post-operative complications. The oldest patients also have a high incidence of co-existing diseases which will further increase their post-operative risk. The 1999 National Confidential Enquiry into Peri-operative Deaths (NCEPOD) report highlighted the requirement for surgeons and physicians or care of the elderly consultants to work co-operatively to ensure good care. Dementia in the Acute Hospital setting Older people who are admitted to hospital with physical problems may also be suffering from depression or dementia or both. The care of older people with mental health problems, especially those associated with behavioural disturbance in a general hospital setting often poses problems. Other patients may be distressed by behavioural disturbance in others. This can lead to inappropriate and unnecessary use of sedative drugs which reduce rehabilitation potential. Clear guidelines for involving specialist mental health services in the care of older people in hospital should be developed, and staff on wards where there is a high level of mental health problems, should be trained to recognise and manage behavioural problems appropriately. ( see dementia model of care papers). 1 National Service Framework for Older People D.O.H p 58-59 2 Acute medical care. The right person, in the right setting- first time. Oct 07, Royal College of Physicians. P 34-35 12

Experience from elsewhere. The model of care group reviewed the care of the elderly processes within Tayside. Ninewells is the acute hospital for Tayside and serves a population of 300,000-350,000 and there are 10 Community or Medicine for the Elderly Hospitals within the region. On arrival at Ninewells initial acute care is provided from a 31 bedded Acute Medical Assessment Unit ( AMAU) which steps down into a 6 bedded High Dependency Unit and a 14 bedded Short Stay Ward. While in the Acute Medical Assessment Unit patients are reviewed by the Assessment Team for Older People who identify those patients who may go home directly from AMAU, transfer to the community hospitals within the region, require admitted to the care of the elderly beds within the short stay ward, transfer to the 12 bedded care of the elderly specialty base or be supported within other specialty wards. The input of the assessment of the Assessment Team for Older People in MAU and access to short stay wards resulted in increase in transfers from AMAU to community hospitals which range from 2.3-8.7 times previous transfer activity depending upon site and with a corresponding reduction in average length of stay of 19.3% and a reduction in bed occupancy and sleepers within Ninewells. The patients being transferred to the community hospitals fulfil the following admission criteria: Cannot have needs that would be better met by specialist team in Ninewells Must need care in a hospital bed. Patients transferred to Community Hospital inpatient beds are supported by a consultant who works across acute and community and by enhancing the role of the community teams: Pharmacist transcribe discharge script Nurse prescribing Nurses canulate, administer IVs and undertake venepuncture Frequent use of Early Supported Discharge Service Excellent social work links with senior social worker attending our MDT meetings Good implementation of flow improvement initiatives The flow improvement initiatives include: Morning discharge Nurse led discharge Expected Date and Destination of Discharge Nurse led admission Models of Care of the Elderly Service for NHS D&G The group have been considering 2 main models for service delivery for the future: Model A The first model under consideration is based upon the age defined model with patients over the age of 85 years and those patients between 65 and 85 years suffering from defined conditions being transferred from the Acute Assessment Unit directly to the specialist Care of the Elderly bed base. Here the patients will receive 13

in-reach specialty care from other medical specialties if required and have their overall care co-ordinated and managed by the care of the elderly consultants. This model requires an increased care of the elderly bed base. M odel B This model is based upon the integrated model with patients transferring to the most appropriate specialty bed base where they will receive support from the specialist care of the elderly teams to facilitate repatriation to the speciality bed base, intermediate care resources/ facilities or home. In this model each Care of the Elderly Consultant is responsible for patients within a defined geographical region and will work very closely with the intermediate care hospitals and community teams in supporting the patient s re-enablement and return to community. 14