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Dr Susan Slatyer of Sir Charles Gairdner Hospital delivered this presentation as part of the 4th Annual Reducing Hospital Readmissions & Discharge Planning Conference – A conference to identify, predict and prevent unplanned readmissions and improve discharge processes. IIR Healthcare's inaugural Canadian Reducing Hospital Readmissions & Discharge Planning Conference will take place in Vancouver in late October 2013. Find out more at http://www.healthcareconferences.ca/readmissions/agenda
Citation preview
The Revolving Door: Reducing Representations from
an Acute Medical Unit
Dr Susan Slatyer
Collaborators
• Associate Professor Chris Toye (SCGH/Curtin)
• Dr James Williamson (Specialist Gen Med HOD)
• Ms Anne Matthews (CNS)
• Ms Dee Whitty (CNS)
• Ms Jeanne Young (CNC Research)
• Mr Andrew Hill (CNC Aged Care)
• Associate Professor Anne Williams (SCGH/ECU)
• Ms Susan Slatyer (SCGH/ECU)
Project staff
Ms Aurora Popescu (ECU) Mr Jai Rowe (SCGH)
Ms Katrina Fyfe (SCGH/Curtin)
The Acute Medical Unit
• Growing + ageing population
• Pressure on acute care hospitals
• UK Australia NZ - Short-stay medical units
• Older patients = Key users
• KPIs – LOS, Readmissions (Downing et al, 2008; Scott et al., 2008)
• Effective
The Acute Medical Unit
• 30 beds (15-20 admissions per day)
• Complex medical patients
• Up to 72 hours
• Rapid assessment and treatment
• Discharge (home or residential care) or transfer
• Discharge letter / medications
• Rapid GP follow-up
The Acute Medical Unit
The Problem
AMU clinical staff Some older patients were representing back to
hospital within a short time
Literature Experiences of older AMU patients not explored
Older people at risk of readmission (Williams & Fitton 1988)
LOS may risk of readmission for older patients (Dobranska & Newell, 2006)
Australian pts 47-78 yrs short-stay unit - readmisson 9% (Arendts et al., 2006)
The Acute Medical Unit
The Problem
AMU clinical staff Some older patients were representing back to
hospital within a short time
Literature
Relapse of existing condition, cardiac & pulmonary
New problem
Carer problem
Medication issue
Comorbidities (Williams & Fitton 1988, Munshi et al., 2002; Juan et al., 2006, Westert et al., 2002 )
Action Research Methodology
Evaluating
Reflecting
Planning
Implementing
Action Research Methodology
Evaluating
Evaluating the problem
Study 1
Aim
Determine the predictors for early re-presentation to
hospital of older patients who are discharged from the
AMU
Evaluating the problem
Study 1
Aim
Determine the predictors for early re-presentation to
hospital of older patients who are discharged from the
AMU
Literature
Early representation - within 28 days
Older patients - aged 65 years or older
Evaluating the problem
Study 1
Stage 1
Quantitative - patient self-reported measures / medical notes
Qualitative interviewing – patients, family carers and staff
Stage 2
Data linkage 2002-2004
Evaluating the problem
Study 1
Stage 1
Quantitative - patient self-reported measures / medical notes
Qualitative interviewing – patients, family carers and staff
Sample
12 patients
15 family carers
(10 dyads, 2 extra patients, 5 extra family members)
35 multidisciplinary hospital + community based health care staff
Evaluating
Patients (n=12)
• Mean age: 81.6 yrs
• Median length of stay: 2 days (range, 1 hour – 4 days)
• Mean time to re-presentation: 12.6 days
• No of medications: 1 – 14 (mean, 7.7 medications)
• Health problems: 3 cardio/resp, 2 gastrointestinal, 2 renal/urinary
Evaluating
Patients (n=12)
Mini-Mental State Examination1: excluded below 17
Barthel’s Activities of Daily Living2: 11 = 85.0 or higher
Nottingham Health Profile3: concerned about physical ability + sleep
Network Assessment Instrument4: 11 = within 10 km, (7 within 1km)
Evaluating
Family caregivers (n=15)
Reported health status: Excellent (n=1) to poor (n=2); almost 50% (n=7) reported
good health
Provided cooking, cleaning, help with activities of daily living, shopping, and
transport
Family’ perceptions of the patient’s health status at re-presentation generally
consistent with patient
Relationship n %
Wife/husband 8 53.3
Sibling 1 6.7
Son/daughter 6 40.0
15 100.0
Evaluating
Health professionals (n=35)
Hospital Community
Health care role n % n %
Registered Nurse 6 17.1 3 8.6
Nurse specialist 7 20.0 2 5.7
Allied health 6 17.1 0 0.0
Medical 9 25.7 1 2.9
Carer 0 0.0 1 2.9
Total 28 80.0 7 20.0
Evaluating
Qualitative interviews
The health trajectory “Borderline” I had breathing problems all the time … my breathing is getting worse … I’ve never been
gasping like that before … haven’t been able to do things, like even walking to the bus stop
was killing me (Patient)
Evaluating
Qualitative interviews
The health trajectory “Borderline” I had breathing problems all the time … my breathing is getting worse … I’ve never been
gasping like that before … haven’t been able to do things, like even walking to the bus stop
was killing me (Patient)
Communication challenges The first time it was angina … this time they said it was angina but angina doesn’t keep filling
up your lungs with fluid … my daughter says she looked on the internet … and now its his
liver and all (Family)
Discharge readiness I was very weak … anxious … going home … what if it happens again and its fatal? (Patient)
The decision to return
She couldn’t breathe … the ambulance blokes said “are your Mum’s lips normally purple?”
(Family)
Exacerbation of chronic disease
or acute on chronic illness -
underlying deteriorating trajectory
Patient living
with chronic
illness at home
or in aged care
Exacerbation of chronic disease
or acute on chronic illness -
underlying deteriorating trajectory
AMU
admission
Rapid
treatment of
acute illness
Patient living
with chronic
illness at home
or in aged care
Exacerbation of chronic disease
or acute on chronic illness -
underlying deteriorating trajectory
AMU
admission
Rapid
treatment of
acute illness Bed
pressures
affect staff
& patient
In hospital
communication
prioritisation:
Intra-team, intra-
hospital, team-
patient, team-
family
Staff
assessment of
overall patient
health & care
status in
pressured
environment
Patient living
with chronic
illness at home
or in aged care
Exacerbation of chronic disease
or acute on chronic illness -
underlying deteriorating
trajectory
AMU
admission
Rapid
treatment of
acute illness
AMU discharge
Bed
pressures
affect staff
& patient Return to baseline -
Patient desires to be
home, ability to manage
assessed seems to be
adequate, borderline
criteria
In hospital
communication
prioritisation:
Intra-team, intra-
hospital, team-
patient, team-
family
Staff
assessment of
overall patient
health & care
status in
pressured
environment
Patient living
with chronic
illness at home
or in aged care
Exacerbation of chronic disease
or acute on chronic illness -
underlying deteriorating trajectory
AMU
admission
Rapid
treatment of
acute illness
AMU discharge
Bed
pressures
affect staff
& patient Return to baseline -
Patient desires to be
home, ability to manage
assessed seems to be
adequate, borderline
criteria
In hospital
communication
prioritisation:
Intra-team, intra-
hospital, team-
patient, team-
family
Staff
assessment of
overall patient
health & care
status in
pressured
environment
Discharge
communication
effectiveness: with
community
services/aged care, GP,
patient, family (use of
available hospital
resources)
Patient living
with chronic
illness at home
or in aged care
Exacerbation of chronic disease
or acute on chronic illness -
underlying deteriorating trajectory
AMU
admission
Rapid
treatment of
acute illness
AMU discharge
Bed
pressures
affect staff
& patient Return to baseline -
Patient desires to be
home, ability to manage
assessed seems to be
adequate, borderline
criteria
In hospital
communication
prioritisation:
Intra-team, intra-
hospital, team-
patient, team-
family
GP limitations:
availability, continuity,
understanding of
individual’s overall health
status, access to
specialist advice if
needed
Patient & family
understanding -
of health needs &
trajectory,
medications, how
to recognise
deterioration, how
to negotiate the
system
Community service
limitations: lag time
when need for higher
level services, aged
care resources,
specialist O/P appt.,
CDM program
Staff
assessment of
overall patient
health & care
status in
pressured
environment
Family
limitations:
sandwich
generation, patient
is carer, lives
alone, resisting
services
Discharge
communication
effectiveness: with
community
services/aged care, GP,
patient, family (use of
available hospital
resources)
Patient living
with chronic
illness at home
or in aged care
Seriously
compromised
health status
Exacerbation of chronic disease
or acute on chronic illness -
underlying deteriorating trajectory
AMU
admission
Rapid
treatment of
acute illness
AMU discharge
Hospital
re-presentation
Repeated
exacerbation or
further or unresolved
acute illness
Bed
pressures
affect staff
& patient Return to baseline -
Patient desires to be
home, ability to manage
assessed seems to be
adequate, borderline
criteria
In hospital
communication
prioritisation:
Intra-team, intra-
hospital, team-
patient, team-
family
GP limitations:
availability, continuity,
understanding of
individual’s overall health
status, access to
specialist advice if
needed
Patient & family
understanding -
of health needs &
trajectory,
medications, how
to recognise
deterioration, how
to negotiate the
system
Community service
limitations: lag time
when need for higher
level services, aged
care resources,
specialist O/P appt.,
CDM program
Staff
assessment of
overall patient
health & care
status in
pressured
environment
Family
limitations:
sandwich
generation, patient
is carer, lives
alone, resisting
services
The aftermath -
Patients & families
are often
distressed and
anxious. However,
the experience can
lead to greater
understanding and
planning for the
future
Discharge
communication
effectiveness: with
community
services/aged care, GP,
patient, family (use of
available hospital
resources)
Patient living
with chronic
illness at home
or in aged care
Date of download: 7/23/2013 Copyright © 2012 American Medical
Association. All rights reserved.
From: Patterns of Functional Decline at the End of Life
JAMA. 2003;289(18):2387-2392. doi:10.1001/jama.289.18.2387
Reproduced with permission.
Figure Legend:
Stage 2 Data linkage 2002-2004
2304 pts Aged 65 yrs and older + Discharged from AMU
61.6% female (n=1419)
Most females aged 80yrs+ ; Most males aged 65-80 yrs
57.4% at least 1 co-morbidity (18.4% had 3+)
74% index AMU triaged as ‘emergency’ or ‘urgent’
Circulatory system disorders 25% index AMU admission
Stage 2 Data linkage 2002-2004
2304 pts Aged 65 yrs and older + Discharged from AMU
AMU data set linked to
WA Hospital Mortality Dataset
WA Hospital Morbidity Dataset
Emergency Dept Information System
Stage 2 Data linkage 2002-2004
2304 pts aged 65 yrs and older + Discharged from AMU
8.2% re-presented to ED by 7 days
16.9% re-presented to ED by 28 days
22.2% readmitted to hospital by 28days
20.4% died in study period
Predictors of re-presentation: Co-morbidities
Older
Male
‘Out of hours’ admission
Stage 2 Data linkage 2002-2004
2304 pts aged 65 yrs and older + Discharged from AMU
8.2% re-presented to ED by 7 days
16.9% re-presented to ED by 28 days
22.2% readmitted to hospital by 28days
20.4% died in study period
Predictors of death within 2 years: Co-morbidities
Older
Male
Re-presenting within 7 days
Heart failure on index AMU admission
Evaluating
Stage 2 Data linkage 2002-2004
2304 pts aged 65 yrs and older + Discharged from AMU
8.2% re-presented to ED by 7 days
16.9% re-presented to ED by 28 days
22.2% readmitted to hospital by 28days
20.4% died in study period
* Only 0.9-3.4% of variation in models explained
Limitation
• No access to data on function, cognition, place of residence,
carer situation
Findings
Reasons for representations
Natural history of illness / deteriorating
Complex - Co-morbidities / polypharmacy
Failed to understand the context of the acute illness
Distress when serious symptoms occurred = No clear plan in
place
Reported receiving little information about illness (not understood
/ not remembered)
Difficulty accessing services promptly after discharge
The Big Picture?
Important to identify caregivers + communicate with them
Improve communication to improve transitions
Team approach – communication and continuity
Palliative approach:
Managing symptoms
Managing related distress
Inclusion of family
Goals of care/treatment plans
Advance care planning
Role for: Advanced practice nurse – gerontology + pall care expertise
Study 2 (2009-2010)
Evaluating
Reflecting On findings
Planning Working party
New tool
Implementing Piloting
Reflection
16.9% had represented to an ED within 28 days of AMU discharge
Reasons for representation
Failed to understand the context of the acute illness
Distress at serious symptoms
No clear plan in place
Communication imperative
Planning
Study 2
Working party
Led by an AMU clinical nurse
Unit staff developed a new nursing and allied health Discharge
Care Plan
Planning and Implementing
Working party
Led by an AMU clinical nurse
Unit staff developed a new nursing and allied health Discharge
Care Plan
New form piloted
All nursing and allied health staff
Completed new form
Sent original home with patient
Photocopy retained on ward
Evaluation
Baseline data (Time 1) Follow up data (Time 2)
31 days before change 31 days after change
All patients discharged + ‘family carer’ + aged care staff
Satisfaction (CSQ-85,6,7)
Care continuity (CCQ7)
Preparedness for discharge (Single item scale7)
AMU staff (Time 2 only)
Feasibility, sustainability, impact of new forms
Evaluation
Time 1 compared to Time 2
Evaluation
Time 1 compared to Time 2
Evaluation
Time 1 compared to Time 2
Study 3 (2011)
Evaluating Audit tool
Reflecting Staff focus group
Planning Draft 1 booklet
Expert panel
Draft 2 booklet
Implementing Pilot
draft 2 booklet
Evaluation
Study 3
• Audit of the DCTP tool
300 forms
Completed by nursing staff
Use of jargon
‘Not applicable’ or
‘Refer to discharge letter’
Reflection
3rd study
Focus group
AAU nursing and allied health staff
Nurses using forms to communicate with aged care
Allied health communicating directly
**Defaulted to a nursing transfer form**
Suggested Discharge booklet
Tick boxes when no action required
Pack with community resources
Planning
Study 3
AAU Working party
Consultation
AAU staff
Hospital individuals/groups
Booklet - Draft 1
AAU staff
Expert panel
Booklet - Draft 2
Implementing
Study 3
Booklet Draft 2
Piloted
3 weeks
425 AAU patients
54% received booklet (n=229)
Evaluating
3rd study
Audit
Patient/carer feedback
Staff focus group
Inconsistent provision
Overall favourable
Most useful – Organisations
– Contact numbers
Few booklets had anything written
Booklet and process refined
Summary
AMUs are effective - manage acute illness + respond to pressure
on health system
Patients with complex chronic health problems and recurrent
symptoms (deteriorating trajectory)
Uncertainty + increasing limitation + emotional legacy of acute
symptoms
Increased patient throughput in the AMU must be matched by
enhanced communication - anticipated care needs and how to
meet these
Team approach with role for Advanced Practice Nurse with
gerontology and palliative care expertise
• Prolonged engagement between researchers and
practitioners
• This program of research has resulted in:
Lasting practice change
Publishable research
The contribution of patients, carers, AAU staff and community-based
health practitioners is acknowledged
References Arendts, G, MacKenzie, J, Lee, JK. Discharge planning and patient satisfaction in an emergency short-stay unit. Emergency Medicine Australasia. 2009; 18:7-14. Dobrzanska, L, Newell, R. Readmissions: a primary care examination of reasons for readmission of older people and possible readmission risk factors. Journal of Clinical Nursing. 2006; 15:599-606. Downing, H, Scott, C, Kelly, C. Evaluation of a dedicated short stay unit for medical admissions. Clinical Medicine. 2008; 8:18-20. Juan, A, Salazar, A, Alvarez, A, Perez, JR, Garcia, L, Corbella, X. Effectiveness and safety of an emergency short-stay unit as an alternative to standard inpatient hospital admission. Emergency Medicine Journal. 2006; 23:833-837. Munshi, S, Lakhani, D, Ageed, A, Evans, SN. Readmissions of older people to acute medical units. Nursing Older People. 2002; 14:14-16. Scott, I, Vaughan, L, Bell, D. Effectiveness of acute medical units in hospitals: A systematic review. International Journal for Quality in Healthcare. 2009; 21:397-407. Slatyer, S, Toye, C, Popescu, A, Young, J, Matthews, A, Hill, A, Williamson, DJ. Early re-presentation to hospital after discharge from an acute medical unit: perspectives of older patients, their family caregivers and health professionals, Journal of Clinical Nursing. 2013; 22: 445-455. Westert, GP, Lagoe, RJ, Keskimaki, I, Leyland, A, Murphy, M. An international study of hospital readmissions and related utilization in Europe and the USA. Health Policy. 2002; 61:269-278. Williams, EI, Fitton, F. Factors affecting early unplanned readmissions of elderly patients to hospital. British Medical Journal. 1988; 297:784-787.
References Instruments
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1988; 10: 61-3. 3. Hunt, SM. Measuring health in clinical care and clinical trials. In Teeling-Smith, G. (ed) Measuring
health: a practical approach. Chichester, UK: John Wiley; 1988. 4. Wenger, GC. Support networks of older people: A guide for practitioners. Centre for Social Policy
Research and Development, University of Wales; 1994. 5. Attkisson, CC, & Zwick, R. The client satisfaction questionnaire: Psychometric properties and
correlations with service utilization and psychotherapy outcome. Evaluation and Program Planning. 1982; 5: 233-7.
6. Pascoe, GC, & Attkisson, CC. The evaluation ranking scale: A new methodology for assessing satisfaction. Evaluation and Program Planning. 1983; 6: 335-47.
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Acknowledgements
The AMU based clinicians who requested this study for
their commitment to excellence and the improvement of
patient care.
The patients and family caregivers who so generously gave
of their time and shared their experiences.
Funded by
Edith Cowan University Industry Collaboration Scheme