the revolving door: reducing representations from an acute medical unit

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


• 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 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 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


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


Study 1

Stage 1

Quantitative - patient self-reported measures / medical notes

Qualitative interviewing – patients, family carers and staff

Stage 2

Data linkage 2002-2004


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




AMU

admission

Rapid

treatment of

acute illness

Patient living

with chronic

illness at home

or in aged care




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



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




AMU

admission

Rapid

treatment of

acute illness

AMU discharge

Bed

pressures

affect staff






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




AMU

admission

Rapid

treatment of

acute illness

AMU discharge

Bed

pressures

affect staff






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



available hospital

resources)

Patient living

with chronic

illness at home

or in aged care

Seriously

compromised

health status




AMU

admission

Rapid

treatment of

acute illness

AMU discharge

Hospital

re-presentation

Repeated

exacerbation or

further or unresolved

acute illness

Bed

pressures

affect staff






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



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


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


2304 pts aged 65 yrs and older + Discharged from AMU

8.2% re-presented to ED by 7 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







Predictors of death within 2 years: Co-morbidities

Older

Male

Re-presenting within 7 days

Heart failure on index AMU admission

Evaluating







* 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

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

1. Folstein ,MF, Folstein, SE, McHugh, PR. “Mini Mental State”: A practical method for grading the

cognitive state of patients for clinicians. Journal of Psychiatric Research. 1975; 12:189-198. 2. Collin, C, Wade, DT, Davies, S & Horne, V. The Barthel ADL Index: A reliability study. Int Disability Study.

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.

7. Bull, MJ, Hansen, HE, & Gross, GE. A professional-patient partnership model of discharge planning with elders hospitalised with heart failure. App Nsg Res. 2000; 13: 19-28.

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

the revolving door: reducing representations from an acute medical unit

Health & Medicine