SENIORS FRIENDLY HOSPITALS: Its Good for Business

1
SENIORS FRIENDLY HOSPITALS Its Good for
Business!

• Dr John Puxty

2
Problems Facing Hospitals Regarding Services to
the Elderly

• Demographic pressures
• Budget constraints
• Acute and complex continuing care cuts
• Systems change lacks synchronization

3
Use of KGH Emergency Department 1998-99

• 65 group accounted for 21 emergency room use
• 75 group accounted for 11 emergency room use
• Over 40 of those over 75 years attending
  emergency were admitted compared to less than 12
  below 65 years of age

4
Illustrative Case
82 year old woman newly admitted to RH Confused
at RH sent to ER Climbs out falls agitated
and restless Tx Restrained New Diagnosis -
Fractured R. hip -gt OR 5 Days Post Surgery
-gt Diagnoses Demented, Aggressive,
incontinent, ALC
5
Problems Facing the Elderly admitted to Hospital

• Diagnostic Challenge
• Hospitalization creates problems
• Despite evidence for their value there is a lack
  of bench marks for specialized geriatric services
• Limited use of best practice models

6
Problems Facing the Elderly admitted to Hospital
7
Problems with Hospitals Environment

• Unfamiliar
• Poor visual cues (floors/walls, lighting)
• Lack of Signage
• Noise
• Furniture (high beds, sharp corners)

8
Problems with Hospitals Mobility

• Hospitalization promotes secondary losses in
  function
• Decline in muscle strength and mass results fall
  below threshold of function

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Functional Decline Associated With Hospitalization
(Sager et al 1996)
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Problems with Hospitals Mobility

• Hospitalization promotes secondary losses in
  function
• Decline in muscle strength and mass results fall
  below threshold of function
• Rehabilitation of function takes 2-3X longer than
  period of inactivity

11
Problems with Hospitals Malnutrition

• Possibly 50 of hospitalized elderly have
  protein-calorie malnutrition
• Less than half recognized
• Impacts on surgical outcome, wound healing,
  immune function, rehabilitation and skin care

12
Problems with Hospitals Impaired Hydration

• Total body fluids declines with age
• Reduced thirst mechanism
• Impaired urinary concentration mechanisms
• Associated co-morbidities (pyrexia,
  hyperventilation, diarhoea, CCF)
• Immobility reduces intra-vascular volumes
  (restraints)
• Consequences includes postural hypotension, falls
  and immobility

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Problems with Hospitals Staff
Knowledge Understanding frailty Aging
physiology Pharmacology Skills
Communication (vision, hearing,
language) Skin care
Mobilization Attitudes Biases
Expectations Respect
14
Negative Consequences of Reduced LOS
Polypharmacy Less rehabilitation Multiple
admissions Community services stressed Crisis
admissions to LTC
15
Incidence of Adverse Events in Hospital

• 20 one or more events Schimmel 1964
• 29 of elderly 12.2 traumatic Riechel 1965
• 36 of medical inpatients Steel 1981
• 41 of elderly 15 total Gillick 1982
• Canadian Adverse Events 2004
• 7.5 adverse events, ? Preventable 36.9
• Delirium mentioned in clinical outcomes
• CMAJ 2004 23 AE after discharge (1/2
  preventable)
  

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RISKS OF IATROGENIC COMPLICATIONS

• Rates of iatrogenic complications in 29-38
  older hospitalized patients (Reichel
• 1965, Steel 1981, Becker 1987).
• Increased risk of complications in older 3 5
  fold patients (Gillick 1982, Brennan 1991).

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COMPLICATIONS OF HOSPITALIZATION
Hospitalization
Precipitating Factors/ Medical Interventions
Complications

• Categories of Complications Rates
• Delirium 25-60
• Functional decline 34-50
• Adverse drug events 54
• Operative complications 52
• Diagnostic or therapeutic mishaps 31
• Nosocomial infections 17
• Physical injury/falls 15
• Pressure sores 10
• Pulmonary embolism 3

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Examples of Best Practice Models

• ACE Hospital units (Landerfield et al, NEJM 1997)
• Rehabilitation in sub-acute care units
• Case management of CCF in the elderly (Rich et
  al, NEJM 1995)
• Case identification in emergency dept using ISAR
  (McCusker et al JAGS 1999)

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Illustrative Case
82 year old woman newly admitted to RH Confused
at RH sent to ER

• last two years there has been some   slightly
  forgetfulness noted by her family.
• PMH hypertension, osteoarthritis and cataracts.
• She consulted her local MD seven months ago
  complaining of lethargy, lack of interest and
  poor sleep initiation
• Her current medications include
• Hydrochlorothiazide 25 mg OD
• Amitriptyline 50 mg qhs
• Oxazepam 15-30 mg qhs
• Occasional Alcohol use.
• Today issues of confused and unsteady

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Illustrative Case
82 year old woman newly admitted to RH Confused
at RH sent to ER Climbs out falls agitated
and restless Tx Restrained
21
Illustrative Case
82 year old woman newly admitted to RH Confused
at RH sent to ER
Identify high-risk profile Reassure,
re-orientate, sitter Minimize environmental
hazards bed height, rails, visual cues
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Illustrative Case
82 year old woman newly admitted to RH Confused
at RH sent to ER Climbs out falls agitated
and restless Tx Restrained
Careful assessment of injury Avoid use of
restraints
23
Illustrative Case
82 year old woman newly admitted to RH Confused
at RH sent to ER Climbs out falls agitated
and restless Tx Restrained New Diagnosis -
Fractured R. hip -gt OR
24
Illustrative Case
82 year old woman newly admitted to RH Confused
at RH sent to ER Climbs out falls agitated
and restless Tx Restrained New Diagnosis -
Fractured R. hip -gt OR 5 Days Post Surgery
-gt Diagnoses Demented, Aggressive,
incontinent, ALC
25
Illustrative Case
82 year old woman newly admitted to RH Confused
at RH sent to ER Climbs out falls agitated
and restless Tx Restrained New Diagnosis -
Fractured R. hip -gt OR
The procedure is uncomplicated and she returns to
the ward with a urinary catheter, orders for
post-operative analgesia, prn oxazepam and
intravenous fluids. On the first post-operative
day some agitation and disorientation is noted.
Her IV has to be resited repeatedly because of
her fidgeting and handling of the IV site.
Physical restraints and prn haldol are ordered.
The nursing report notes persisting and
increasing difficulty in managing abnormal
behaviors
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Illustrative Case
82 year old woman newly admitted to RH Confused
at RH sent to ER Climbs out falls agitated
and restless Tx Restrained New Diagnosis -
Fractured R. hip -gt OR 5 Days Post Surgery
-gt Diagnoses Demented, Aggressive,
incontinent, ALC
27
Illustrative Case
82 year old woman newly admitted to RH Confused
at RH sent to ER Climbs out falls agitated
and restless Tx Restrained New Diagnosis -
Fractured R. hip -gt OR 5 Days Post Surgery
-gt Diagnoses Demented, Aggressive,
incontinent, ALC Silent Diagnoses Delirium,
Pressure Sore, Dehydration, Polypharmacy, R
monoparesis
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CURRENT IMPACT OF DELIRIUM

• 35 of the U.S. population aged 65 years is
  hospitalized each year accounting for gt 40 of
  all inpatient days
• Assuming a delirium rate of 20
• 7 of all persons 65 years will develop
• delirium annually
• Delirium will complicate hospital stay for gt 2.2
  million persons/year, involving gt 17.5 million
• in-patient days/year
• Estimated costs gt 8 billion/year

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How well do we detect Delirium?

• Only 15-30 identified in Emergency Dept
• Only 30-50 have symptoms/signs documented by
  MDs during admission
• RNs document 60-90
• Even if symptoms/signs noted commonly
  misdiagnosed for dementia or depression

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Sobering Facts (1)

• 40 of Fallers presenting to AE will suffer a
  within one year
• 23,375 Hip s in Canada in 1993/94 (expected to
  rise to 88,125 in 2041)
• Average LOS 21 days so they use at least 465,000
  bed days per year
• 7 short-term mortality rising to 20-35 within
  one year!

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Sobering Facts (2)

• Less than 40 of hip patients will regain
  previous level of ambulation!
• 90 of fallers sent home from AE have no
  change in fall-risk factors
• Restraints increase incidence of serious falls
• 40 of admissions to LTC are frequent fallers
• Fall rate increases in first six weeks in LTC!

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Sobering Facts (3)

• Women post hip prescribed Ca, Oestrogens,
  Biphosphnates at same rate as age-matched
  controls (Kamel et al 1999, Bellantonio 1999,
  Torgerson 1998)
• Males post hip only 4 prescribed Ca and 25
  Vitamin D (Colon-Emeric et al 2000)

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Value of Assessment and Treatment of Falls

• Randomized study of fallers presenting to AE
  -184 interventions vs 213 normally managed
  controls - resulted in reduction in further
  falls over one year (183 vs 510) (Tinetti et al
  1994).
• Randomized study of fallers in LTC - 79
  intervention and 81 controls - resulted after 2
  years in 26 fewer hospitalizations and 52
  reduction in hospital days
• Home OT assessment post discharge results in 36
  reduction of fall rate (Cumming et al 2000)

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Small changes can result in major functional
gains!
Flooring/mats Foot wear Walking aides Surface
heights Chairs/bed Wall bars Lighting
35
Iatrogenic Illness on a General Medical Service

• 815 consecutive admissions to a University
  hospital
• Illness resulting from diagnostic procedure or
  treatment or injuries, decubiti, other
• 36 experienced iatrogenic illness
• 9 major
• 2 contributed to death (equivalent to 200,000
  deaths in US per year)
• Steel K et al. N Eng J Med. 1981 304 638

36
Polypharmacy

• Seniors accounts for 25 prescriptions
• Drugs account for 15 Health Care costs
• Only 15 of community elderly take no prescribed
  medications
• Over 75 year old take on average nearly 3
  prescribed medications and 1.5 across the counter
  meds daily!
• In surveys of community elderly serious
  comprehension problems in 12-16
• Contrast with complacency in Tx

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Complacency in applying Tx Guidelines

• Post MI less likely receive Thrombolysis, ASA,
  Beta-blockers or Cardiac Catherization (Mahon et
  al 1999)
• Evidence of under utilization of Warfarin in
  chronic AF (Mendelson 1998)

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Adverse Drug Reactions

• Unfortunately very common
• Suggested contribute to at least 10-15 hospital
  admissions
• Likelihood increases with number of medications
• Includes complications with serious functional
  consequence eg falls -gt Hip

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Why do we prescribe excess medications?

• Increasing age associated with higher prevalence
  of many diseases
• Need to treat
• High volume of visits
• Reduced LOS
• prn as required orders become regular
  prescriptions
• Inappropriate belief patient will go elsewhere
  for meds

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Solutions A Framework

• Hospital culture must recognize need to develop
  elder friendly hospitals
• Respect for individual
• Staff development
• Create appropriate physical environment
• Programming

41
Creating the Physical Environment

• Accessibility eg parking
• Signage size, colour
• Colour contrast, texture
• Furniture
• Equipment
• Noise
• Light
• Architects
• Hospitality industry

42
Acute Care for the Elderly (ACE) Unit

• Randomized controlled trial of acute admissions
  aged 70 to a community hospital
• ACE Unit n 767
• Usual care n 764
• ALOS, costs, readmissions No difference
• ADL decline NH placement 34 vs. 40 (p
  0.027)
• Satisfaction higher for patients, caregivers,
  physicians, nurses (p lt .05)
• (Counsell SR et al. J Am Geriatr Soc. 2000 48
  1572)

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Medical Unit to Improve Function(ACE Unit)

• Randomized Controlled Trial
• Special unit n 327 Usual care n 324
• University affiliated hospital
• Outcome ALOS and 5 Basic ADLs
• (Landefeld CS et al. N Engl J Med. 1995 332
  1338)

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Medical Unit to Improve Function(ACE Unit)
Special Usual MLOS 7.3 8.3 Much
better 21 13 Better 13
11 Same 50 54 Worse 7
13 Much worse 9 8 To LTC
14 22 (Landefeld CS et al. N Engl J
Med. 1995 332 1338)
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Medical Team Coordinator (MTC)

• Randomized controlled trial of
• Usual care plus MTC n 136
• Usual care n 131
• Mean LOS 7.43 ( 6.33) vs 9.40 ( 8.97)
• Mortality, discharge destination no difference
• Patient satisfaction 89 vs 62 p lt 0.05
• (Moher D et al. CMAJ 1992 146 511-515)

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Primary Functions of the Medical Team Coordinator
(MTC)

• Actively participate in daily ward rounds
• Collaborate with health care professionals to
  enhance patient care or expedite discharge
• Assist with initial assessment of patients
  home situation
• Coordinate tests and procedures retrieve and
  report results
• Generate and distribute daily by census
• Coordinate call schedule for house staff
• Retrieve medical information not in patients
  chart
• Organize weekly rounds, presentations and
  lectures by guest speakers
• Assess team efficiency act as troubleshooter

(Moher D et al. CMAJ. 1992 146 511)
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THE HOSPITAL ELDER LIFE PROGRAM(HELP)

• A Model of Care to Prevent Delirium and
  Functional Decline in Hospitalized Older Patients
• Inouye SK, et al. J Am Geriatric Soc.
  2000481697-1706

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HOSPITAL ELDER LIFE PROGRAMGOALS

• An innovative approach to improving hospital
• care for older patients, with primary goals of
• Maintaining physical and cognitive
• functioning throughout hospitalization
• Maximizing independence at discharge
• Assisting with the transition from hospital to
  home
• Preventing unplanned readmission

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UNIQUE ASPECTS OF HELP

• Hospital-wide focus geriatric unit is not
  required
• Provision of skilled staff and trained volunteers
• to carry out interventions
• Use of practical interventions directed at 6
  known
• risk factors for cognitive and functional
  decline
• Targeting of program towards appropriate
• patients
• Standard quality assurance procedures

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ELDER LIFE PROGRAM INTERVENTIONS

• Risk Factors Intervention
• Cognitive Impairment. Reality orientation
• Therapeutic Activities Program
• Vision/Hearing Impairment Vision/Hearing Aids
• Adaptive Equipment
• Immobilization.. Early Mobilization
• Minimizing immobilizing equipment
• Psychoactive Medication Use Nonpharmacologic
  approaches to sleep/anxiety
• Restricted use of sleeping medications
• Dehydration.. Early recognition
• Volume repletion
• Sleep Deprivation. Noise reduction
  strategies
• Sleep enhancement program

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OTHER HOSPITAL ELDER LIFE PROGRAM INTERVENTIONS

• Geriatric nursing assessment and intervention
• Interdisciplinary rounds
• Geriatrician consultation
• Interdisciplinary consultation
• Provider education program
• Community linkages and telephone follow-up

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INTERVENTION PROCESS

• Screening all patients ? 70 years are screened
• Inclusion as inclusive as possible, must have
  at
• least one risk factor for cognitive/functional
  decline
• Exclusion minimized, mainly inability to
  participate
• in interventions
• Assignment after screening, patients assigned
  to
• interventions based on their risk factors by
  Elder Life
• Specialists. Individualized menu of
  interventions
• Adherence completion of all interventions
  tracked
• daily by Elder Life Specialists

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HELP INCLUSION CRITERIA

• Age 70 years and older
• At least one risk factor for cognitive or
• functional decline
• (a) cognitive impairment-MMSElt24
• (b) mobility or ADL impairment
• (c) dehydration-BUN/Cr ratio ?18
• (d) vision impairment
• (e) hearing impairment
• Able to communicate verbally or in
• writing

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HELP EXCLUSION CRITERIA

• Coma
• Severe aphasia
• Intubated on ventilator
• Terminal condition
• Combative or dangerous behavior
• Severe psychotic disorder
• Severe dementia (e.g., unable to communicate)
• Respiratory isolation (e.g., tuberculosis)
• Discharge within 48 hours of admission
• Refusal by patient, family, or physician
• Other (i.e., cannot participate in interventions)

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QUALITY ASSURANCE PROCEDURES

• Key to the programs effectiveness
• Procedures include
• Daily review of intervention adherence
• Monthly Elder Life Program Working Group
• Monthly Program Director meeting with individual
  staff
• Twice yearly staff performance checks with
  paired
• standardization
• Quarterly volunteer performance assessment with
• competency based checklists
• Patient-Family Survey

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VOLUNTEERS

• Unique role Hands-on
• Selection criteria Responsibility, caring, and
  respect for older persons.
• Commitment Minimum of one 4 hour shift/week for
  6 months
• Training Intensive, 16 hours didactic group,
  followed by 16 hours one-on-one training with
  patients
• Quality checks Quarterly competency-basedcheckl
  ists
• Volunteer retention Daily staff communication,
  quarterly educational/support session, monthly
  newsletter, and incentive awards

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YALE DELIRIUM PREVENTION TRIAL RESULTS
58
HELP RESULTS(N 1716 admissions of 1507
patients)

• 
  ADHERENCE
• Adherence Rate, patient-days, n ()
• Complete Partial
  Non-adherence Total days
• assigned
• 23,152 (62) 10,036 (27)
  3,943 (11)
  37,131
• FUNCTIONAL OUTCOMES
• Outcome HELP
  Medical Literature Delirium
• 
  
  Prevention Trial
• 
  
  Control Group
• MMSE decline by ? 2 pts, 8 14-56
  26
• admission to discharge
• ADL decline by ? 2 pts, 14
  34-50 33
• admission to discharge

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HOSPITAL COST-EFFECTIVENESS RESULTS (N 852)

• Intermediate risk patients (72 of sample), HELP
  resulted in lower overall hospital costs,
  averaging 831 per patient (range 415-1,689)
• Savings offset intervention costs, thus, HELP is
  cost-effective for intermediate risk patients
• Savings occur across every cost category (e.g.,
  nursing, room, diagnostic procedures, ICU)
• Cost-effectiveness not demonstrated for high-risk
  patients
• Rizzo JA, et al. Medical Care 200139740-52

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HELP PROGRAM BENEFITS

• Innovative program, prevents decline in older
  patients
• Ethical, high face validity
• Quality improvement, better outcomes/patient
  satisfaction
• Cost-effective
• Creation of center of excellence in geriatric
  care
• Volunteer base human element and community
  linkage
• Enhanced public relations
• Provision of nursing education and support
  improved nursing job satisfaction and retention
• Educational site for geriatric care
• Training site for nurses aides and sitters
• Prepares hospitals to cope with our aging society

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Conclusions

• Traditional Hospitals are hazardous to the
  Elderly
• Need to recognize and change the culture and
  environment
• Strategies such as ACE, MTC, HELP do improve
  outcomes
• Require coordinated action by planners,
  administration, architects, health professionals
  and educators

62
Helpful Resources

• Hospital Elder Help Program http//elderlife.med.y
  ale.edu/public/public-main.php
• Making Health Care Safer http//www.ahrq.gov/clin
  ic/ptsafety/
• Physical Environment Considerations
  www.rgapottawa.com