liaison services in general hospitals
TRANSCRIPT
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A successful liaison service?
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Royal Cornwall Hospital
Background history.
Service now 7 years old Monday-Friday service 9.00 - 5.00
Collaborative seamless
Service development & improvement Education
Audit & research
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Referrals
1500 per year (750 beds) 90 Cheshire 130
Guys London
Initial referrals Acute confusion DepressionDementia
After 7 years complex cases MCA DOLs
Acute confusion mild moderate depressionand dementia now treated Consultant COE
Physicians & mdts.
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Transforming acute care
Really is everybodys business
Education
Policies Pathways Guidelines
Toolkit
Relationship building Responsive service easy to reach
available to all
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What a liaison service should do
Rapid response attend MDTs
Sign post to other services
Improve patient experience
Reduce unnecessary transfers
Strengthen relationships allorganisations
Facilitate timely appropriate discharge
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Success?!
Reduction in anti psychotic medication
Dementia screen, cognitive
assessments now routine on admission
Reduction in referrals for mild/moderate
depression acute confusion and
dementia Its not a mental health thing
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Recent audit post education sessions to all
staff 2007 Lets Respect campaign
Pre audit Post audit
Sedatives 70% 20%
History 30% 70%
Communication 50% 100%
Risk assessment1
2% 90%
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Pathway Policies & Guidelines
Dementia Guidelines
Palliative care for people with dementia
Pain pathway
Minimum Restraint policy
Mental Capacity Act Policy Special observation policy
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2010
Anti psychotic policy checklist and
booklet
Relatives information pack
E learning
Worried about your memory campaign
Link nurse forum
Life story campaign
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ST A Rcampaign
Stop - All medications have side effects
Think - Why are giving this medication?
Assess - Is it still needed?
Review, reduce and discontinue
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What if ?
If we really are successful will a
Psychiatric older persons service be
required in the future???
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NHSCIOS & RCHT Nursing
Care Home Admissions Audit
Dr Fiona Boyd.
Bev Chapman
Kylie Cook
Maggie Trevethan
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Aim : To identify the numbers of
patients admitted from nursing
homes with a view to:
1. Identifying the appropriateness of admission i.e.
those requiring acute care (whether there is analternative to admission to hospital).
2. Determining a care pathway to prevent unnecessaryadmission
3. Facilitating the patient illness journey in the best
setting for the individual.4. Considering the potential cost implications of
inappropriate acute admissions of people withdementia
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Methodology
A case note audit of patients with known
diagnosis of dementia admitted into an acutedistrict hospital (Royal Cornwall Hospital)from registered nursing care homes inCornwall.
The patient cohort identified using monthlyadmission figures provided by the NHSCIO
Review of medical records in conjunction witha written proforma.
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Key areas for scrutiny included:
1. Source of referral i.e. A&E or via GP
2. Involvement of GP prior to admission
3. Hour of admission4. Reason for admission / Diagnoses
5. Length of stay
6. Place of discharge (final outcome)
7. Alternative treatment options
8. Cost implications around end of life care andadmissions
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Results
n221 case notes were reviewed
The total number of admissions from nursing homes
to Royal Cornwall Hospital during 2009 was 534. Only those with a known diagnosis of dementia were
included.
Exclusions included those attending Accident and
Emergency Dept. but not admitted, and those
attending for elective surgery.
The median age for participants was 81 (range 54-
104).
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Source ofReferrals
The number of patients
referred by GP was 90
(41%), of whom 54 (56%)
required admission for acute
care.
Pie Chart: GP Direct Admissions verses 999 Emergencies
41% (GP)
59% (999)
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GP Involvement
54% required acute
care.
543
1
3
4
5
per
cent%
AppropriAl rnati
availabl
G admissions
ercentage of G Admisions that required Acute Care
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Reasons for Admission to
RCHMedical Conditions Number of patients
(n221)
Percentage
%
Infection
LRTIUTIOther(ulcers/gangrene,meningitis)
39
23
97
17.6
Falls
Fracture
No fracture
30
16
14
13.6
Cardiac (MI,ACS,AF,CCF) 16 7.3
Stroke 14 6.3
Breathlessness and fatigue 11 5.2
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The majority of admissions were via medicine (n200 ;
90%), the rest were a mixture of orthopaedics (n11 ;
4%) and surgery (n15 ;6%).
57% (n125) patients who were admitted to RCHT
during this 11 month period did not require acute
care.
Of this group, 9 (7%) required step up care and 71
(57%) were palliative, therefore there were 45individuals (36%) who may have received care at
home thus avoiding admission.
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Length of Stay
Total LoS 2295 days. (median per head 10.4Days).
90 (41%) were necessary admissions for acutecare, and for the remainder, alternative optionscould have been offered in the care home.
Alternative group :
1. 9 patients required step up care (Los 792; mean 88,
range 52-108)
2. 71 were palliative (Los 581days) of whom aproportion were discharged back to their respectivecare homes for end of life care.
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Final Outcome (Discharge or Death).
70% of patients were
discharged back to their
original nursing home, 4%
were discharged to a step up
care and 26% died in
hospital.
Pie Chart: Final Outcome for Patient Journey.
70%
ack to N
26%
ied in
ospital
4%
tep
p
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End of Life Care
In relation to those patients with
advanced terminal phase dementia, 71
(32%) were palliative.
Died in Hospital 58
(81of EoL subgroup)
Transferred back to Home 13
(19% of EoL subgroup)
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Outcomes and Alternative Options
Alternative treatment
option
Number of patients
Antibiotics 21
Intravenous fluids 3
Bowel /bladder care 4
Pain management 7
Stroke/TIA (in severe
dementia) no intervention
4
Falls prevention 10
End of Life care plan 67
Step up place direct from
community
9
Total 125 (57%)
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Costings
Costing was not undertaken for the
whole group due to variations in coding
and additional complex care, however,figures were undertaken to establish
broad costing for end of life subgroup
& step up care.
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EoL Costing ( based of non elective
national tariff)
Total 143485 (over11 months) (Mean
124504)
Mean cost per person admitted for Eol
care 1486.24 (2020.92 +cc).
The above is based on PbR Tariff for 2010-11 these
figures were used to help quantify costing in real time.
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Costing Step up subgroup
Step up patient subgroup (n9),
Average LOS was 88 days /person.
The actual costs forrespite for > 9
days + cc = 4535 + (Aver LOS non
elect stay trim point = 47days) x 269
(non elective stay trim point 41 days
= 17178 /person.(total 154,602).
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Conclusions
Recent audit, policy and national reports
have concluded the need to move away
from costly acute care settings.
Analysis shows that acute admissions
are not cost effective and many cases
unsuitable for a person with severe endstage dementia:
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Advocacy & Best Interest
Patients with advanced dementia lack mental
capacity in decision making . Therefore when
considering the patients health this must beviewed in the context of both health and
welfare and a best interest decision should be
made by those responsible for delivering care
with regards to the appropriacy of acutehospital admission.
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Key Findings
Many patients were admitted and received
simple care interventions.
The most common included antibiotics,intravenous fluid support, urinary
catheterisation and analgesia.
All patients reside in nursing homes and a
terminal dementia lacking the mental capacity
to decide physical health interventions.
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Key findings continued.
Many patients had advanced terminal phase
dementia and as such were considered not
appropriate for treatment many died orwere discharged from RCHT with no
intervention.
These patients were identified as appropriate
for End of Life Care in the community (n67 ;30%), a further3 patient died despite
interventions.
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Improved identification of terminal
phase disease will lead to better end of
life care planning which can thenenhance decisions making regards final
care pathway and ultimately respects
the health and welfare needs ofpatients.
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Implications for Practice and
Recommendations 1 There is a clear need to identify those
with advanced terminal dementia within
their care setting and instigate plans forcare that are anticipatory, respectful of
best interest and advocacy, appropriate
to meet the needs of the individualclient.
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2 Alternative Care Options
It is hoped that by providing alternative
options of treatment delivered in the
care home by enhanced servicesAHAH/paramedics and greater
involvement of GPs and other allied
community health professionals asignificant reduction of admissions to
acute care can be achieved.
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3 EoL Planning
End of life planning / care pathways will
prevent unnecessary admission to
acute care and enhance the delivery ofpalliative care for this client group in the
care home setting.
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4 Financial Considerations
Provision of care for those withdementia is not core business for acute
care. Prevention of admission will facilitate
cost savings (via increased cuttingthroughput and elective activity).
Financial resources can be better usedin improving community based care.
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Summary
1st phase study reviewing nursing homeadmissions to RCH
59% patients did not require acute care Significant number of patients required
palliation
Invest in community care (resources and
education) Promote advanced planning & appropriate
decision making
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Thank You .