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Lessons in Implementing a Strategy for Senior Friendly HospitalsMaking the Connection: Innovation in Older Adult Care Summerside, Prince Edward IslandOctober 17, 2014

Barbara Liu, MD, FRCPCRegional Geriatric Program of TorontoBarbara.liu@sunnybrook.ca

www.seniorfriendlyhospitals.ca

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Outline

Regional Geriatric Program & SFH framework Ontario Senior Friendly Hospital Strategy

– Priority setting, toolkit, indicators Examples of implementation

– Early mobilization – MOVE ON– Delirium prevention and management

Lessons learned

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Lessons Learned

Alignment + competing priorities Early wins versus mid to long term

sustainability Top-down versus bottom-up Hospitals are complex systems

– Standardization in the local context Basic ≠ simple

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Senior Friendly Hospitals in Ontario

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Regional Geriatric Program of Toronto

• Network of 27 hospitals in GTA• Better health outcomes for frail seniors• Service, education, evaluation and advocacy• Specialized geriatric services-

interprofessional teams– Consultation teams, GEM, AGUs/ACE– Outreach, day hospitals, clinics, falls prevention programs

• Part of the RGPs of Ontario

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The Challenge

“The right care, in the right place

at the right time”

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What we do How Who Why Where

RRGP Senior Friendly Hospital Framework

Processes of Care

Emotional & Behavioural Environment

Ethics in Clinical Care &

Research

Organizational Support

Physical Environment

RGP.toronto.on.caSeniorfriendlyhopsitals.ca

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Objective• Identify current state

Plan• Hospital self- assessments• LHIN-level roll-up• Provincial roll-up

Objective• Monitor and sustain hospital and system improvements

Future State• Prevent functional decline• Improve patient experience• Enable hospital staff• Improve equity

PHASE 1 PHASE 2 PHASE 3 - ONGOING

Objective • Close the gap

Plan• Implement hospital improvement plans• Develop key enablers

SFH “Promising Practices” Toolkit

SFH Indicators

Provincial Summary Report

Ontario Pan-LHIN Senior Friendly Hospital Strategy

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Functional DeclineImplement inter-professional early mobilization protocols across hospital departments to optimize physical function

DeliriumImplement inter-professional screening, prevention, and management protocols across hospital departments to optimize cognitive function

Provincial Summary of SFH Care - Priorities

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www.seniorfriendlyhospitals.ca

Tools for Delirium • Screen and Detect• Prevent and Manage• Monitor and evaluate

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Identification of Indicators Literature Review -Over 15,000 retrieved articles from 1991-2011

Working Group Review, Delphi Panel andConsensus Meetings

DELIRIUM

FUNCTIONAL DECLINE

406 ARTICLES

232 ARTICLES

268 POTENTIAL INDICATORS

445 POTENTIAL INDICATORS

Environmental Scan results from 68 of 155 Ontario hospitals

DELIRIUM

FUNCTIONAL DECLINE

268 INDICATORS

445 INDICATORS

18 INDICATORS

18 INDICATORS 2 INDICATORS

2 INDICATORS

WORKING GROUP REVIEW

Redundant or impractical indicators eliminated by group consensus

DELPHI PANEL VOTING- Validity- Reliability- Feasibility- Responsiveness- Ease-of-reporting- Clarity- Action-ability- Appropriateness

CONSENSUS MEETINGS (3)Implementation and technical considerations drafted

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Delirium Indicators (All Hospital Sectors)

Process

Rate of baseline delirium screening

Percentage of patients (65 and older) receiving delirium screening using a validated tool upon admission to hospital

Outcome

Rate of hospital-acquired delirium

Incidence of delirium in patients (65 and older) acquired over the course of hospital admission

Data Source and/or Tool

Confusion Assessment Method (CAM), CAM-ICU, or Intensive Care Delirium Screening Checklist (ICDSC)

ExclusionsPatients with decreased level of consciousness (unresponsive or requiring vigorous stimulation for a response); patients in palliative care

Considerations Minimum frequency of screening to capture incidence – at least daily after the initial baseline screen

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Participating Hospitals

Summary of Implementation:Delirium – 42 patient care units at 31 hospital sitesFunctional Decline – 24 patient care units at 22 hospital sites

South WestGrey Bruce Health ServicesSt Joseph's Health Care (London)St Thomas Elgin General Hospital

Erie St. Clair Hotel-Dieu Grace Healthcare

Hamilton Niagara Haldimand BrantBrant Community Healthcare SystemHamilton Health SciencesJoseph Brant Memorial HospitalNiagara Health SystemNorfolk General HospitalSt Joseph's Healthcare (Hamilton)

Toronto CentralBaycrestProvidence HealthcareSt Michael'sSunnybrook Health Sciences CentreToronto East General HospitalUniversity Health Network – TWH + TRIWest Park Healthcare Centre

South EastBrockville General Hospital

ChamplainDeep River District HospitalThe Ottawa Hospital

North EastBlind River District Health CentreEspanola Hospital & Health CentreHealth Sciences NorthKirkland District HospitalSt Joseph's General Hospital (Elliot Lake)Manitoulin Health CentreNorth Bay Regional Health CentreSensenbrenner HospitalWest Nipissing General HospitalWest Parry Sound Health Centre

North WestSt Joseph's Care Group (Thunder Bay)

CentralMarkham Stouffville HospitalNorth York General HospitalSouthlake Regional Health CentreStevenson Memorial Hospital

Central EastCampbellford Memorial HospitalLakeridge HealthNorthumberland Hills HospitalOntario Shores Centre for Mental Health SciencesPeterborough Regional Health CentreRoss Memorial HospitalThe Scarborough Hospital

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Delirium Indicators – Process IndicatorFIGURE 1 – Mean rate of baseline delirium screening by hospital (25 hospitals)

• 10 hospital sites consistently achieved mean baseline screening rates at or near 100 percent • 16 sites achieved baseline screening rates of 80 percent or greater• 5 hospitals averaged baseline screening at rates between 60 and 80 percent• 4 sites performed baseline delirium screening during the study at a rate below 50 percent.

Mean rate of baseline delirium screening over all months of data submission. Range of delirium screening rate (highest to lowest monthly compliance rates)

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Delirium Indicators – Outcome IndicatorFIGURE 3 – Monthly rate of hospital-acquired delirium.

The data shows a fairly narrow range of delirium incidence that clusters at a rate of 20 percent or below. These values are comparable to rates for hospital-acquired delirium reported in the research literature

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Delirium Indicators – Value in Driving Clinical Care

• Educating clinical staff

o increased attention to delirium, more discussion of delirium, earlier detection of delirium.

• Delirium screening and prevention as a core competency of front-line providers

• Development of care protocols

• Advancing skills

o assessing delirium in patients with dementia or aphasia

• Regular visual feedback and review of results helped generate additional buy-in and helped sustain enthusiasm

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Delirium Indicators – Recommendations

• Both the process and outcome indicators for delirium are recommended for broader implementation in all hospital sectors.

• Data for the indicators should be based on assessment results using a common clinical tool, such as the Confusion Assessment Method (CAM).

• Routine screening for delirium after the initial baseline delirium screen should occur at a minimum of once per day in all hospital sectors.

• Patients receiving palliative care should be included in the indicator technical definition.

• For sustainability purposes, electronic implementation to provide automation of data collecting and reporting process is recommended.

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Functional Decline Indicators (Acute Care Sector)

Proces

s

Rate of ADL function assessment at admission and discharge

Percentage of patients (65 and older) receiving assessment of ADL function with a validated tool at both admission and discharge

Outcome

Rate of no decline in ADL function

Percentage of patients (65 and older) with no decline in ADL function from hospital admission to hospital discharge as measured by a validated tool

Data Source and/or Tool

Barthel IndexHealth Outcomes for Better Information in Care (HOBIC) – ADL SectionAlpha-FIM Tool®

ExclusionsPatients in emergency department who are not admitted to hospital; patients in palliative care; patients admitted for day surgery procedures; patients with a length of stay <48 hours

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Functional Decline Indicators – HOBIC

FIGURE 5A – Monthly rate of ADL function assessment at both admission and discharge for hospital sites using HOBIC ADL Section

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Functional Decline Indicators – BARTHEL

FIGURE 5B – Monthly rate of ADL function assessment at both admission and discharge for hospital sites using Barthel Index.

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Functional Decline Indicators – Outcome

TABLE 7 – Monthly Rate of No Decline in ADL Function

Hospital Site

ADL Assessment Tool used

Number of consecutive months of data submitted

Monthly rate of no decline in ADL function (Range, N=number of discharges)

Overall mean rate of no decline in ADL function (N=Total number of discharges)

1 Barthel Index 9 84-93% (n=67-124) 89% (n=836)

2 Barthel Index 6 97-100% (n=13-40) 98% (n=174)

3 Barthel Index 13 67-100% (n=1-6) 95% (n=40)

4 Barthel Index 7 86-100% (n=2-12) 95% (n=59)

5 HOBIC ADL section

6 63-91% (n=17-28) 81% (n=136)

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Function Decline Indicators – Value• Even on rehab-like units – valuable for monitoring progress

• Two sites using Barthel Index suggested more frequent assessment for long-stay patients

• Interprofessional team use • Personal support workers trained to use Barthel -

professionally rewarding and helped guide care • HOBIC ADL tool

• challenges in compliance with the assessments, decreased buy-in from front-line staff, and lack of real-time data

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Functional Decline Indicators – Recommendations

• The indicators for functional decline are not recommended for broader implementation at present.

• For the assessment of ADL function in the acute care sector, a concise ADL assessment tool should be used.

• Further work to identify indicators more suitable to monitor functional status and drive early mobilization/activation processes should be undertaken.

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SFH Evaluation Working Group

Barbara Liu (Chair) Regional Geriatric Program of TorontoCarol Anderson BaycrestSherry Anderson Brockville General HospitalEmily Christoffersen Hamilton Health SciencesElla Ferris St. Michael’sSusan Franchi Thunder Bay Regional Health Sciences CentreRonaye Gilsenan Regional Geriatric Program of Eastern OntarioCharissa Levy Greater Toronto Area Rehab NetworkMonique Lloyd Registered Nurses’ Association of OntarioRyan Miller North Simcoe Muskoka Local Health Integration NetworkKelly Milne Regional Geriatric Program of Eastern OntarioElaine Murphy University Health NetworkRhonda Schwartz Central East Seniors’ Care NetworkAlisha Tharani Toronto Academic Health Sciences NetworkAda Tsang Regional Geriatric Program of TorontoSimmy Wan Central Local Health Integration NetworkKen Wong Regional Geriatric Program of Toronto

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Kawaii

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Kawaii

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Nittono H. (2012) The Power of Kawaii: Viewing Cute Images Promotes a Careful Behavior and Narrows Attentional Focus. PLoS ONE 7(9): e46362. doi:10.1371/journal.pone.0046362

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Kawaii

Mobilization of Vulnerable Elders in Ontario

Brown, C et al JAGS 2009;57:1660

Lying

Sitting

Walking

83% of measured hospital stay spent in bed

Median time spent standing or walking = 43 minutes or 3% of day

“...rest in bed is anatomically, physiologically and psychologically unsound. Look at a patient lying long in bed. What a pathetic picture he makes!

The blood clotting in his veins, the lime draining from his bones, the scybala stacking up in his colon, the flesh rotting from his seat, the urine

leaking from his distended bladder and the spirit evaporating from his soul.”

Circulatory System• Loss of plasma volume• Loss of orthostatic compensation• Increased heart rate• Development of DVT

Respiratory System• Decreased lung volume• Pooling of mucous• Cilia less effective• Decreased oxygen saturation• Aspiration• Atelectasis

Gastrointestinal System• Reflux• Loss of appetite• Decreased peristalsis• Constipation

Musculoskeletal System• Weakness• Muscle atrophy• Loss of muscle strength by 3-5%• Calcium loss from bones• Increased risk of falls due to weakness

Psychological• Anxiety• Depression• Sensory deprivation• Learned helplessness• Delirium

Genitourinary System• Incomplete bladder emptying• Formation of calculi in kidneys and infection

Complications of Immobility

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Without mobilization, elderly patients lose 1 to 5% of muscle strength each day (Annals Int Med 1993;118:219-23)

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Early mobilization –the evidence

duration of delirium (median of 2 days versus 4 days) rate of depression (odds ratio 0.14) functional status (odds ratio 2.7)

Increases rate of discharge to home (NNT =16) length of stay (1.1 days) hospital costs by $300/day

Age Ageing 2007 J Gerontol 1998; Lancet 2009, Cochrane Review 2009

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1. Encourage mobility three times a day2. Mobilization should be progressive and scaled3. Mobility assessments should be implemented

within 24 hours of the decision to admit

The key messages

Educational Interventions

Huddles Fairs Education days E-modules

Interprofessional group education/in-service 1:1 knowledge-to- practice coaching

Knowledge-to-practice coaching

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Simplified Mobility Assessment Algorithm

1. Can they respond to verbal stimuli?2. Can they roll side to side?3. Can they sit at edge of bed?4. Can they straighten one or both legs?5. Can they stand?

6. Can they transfer to a chair?

7. Can they walk a short distance?

C

B

A

Mobility Level

Dev

elop

an

indi

vidu

alize

d m

obili

ty c

are

plan

Enabling Tools

Is it feasible to mobilize frail older patients on medical units?

First step is to dangle

To Chair

Respiratory ICUIntermountain Medical CenterSalt Lake City, Utah

Respiratory ICUIntermountain Medical CenterSalt Lake City, Utah

Mobility Volunteer Program

MVP• New Support Partners

Presentation 49

Significant increase in rate of mobilization

• Significant overall improvement in rate of mobilization, with a 7.62 % increase in mobilization rate between post-intervention and pre-intervention periods (p<.0001) and a 0.43% increase in mobilization rate during intervention compared to pre-intervention periods (p=0.05).

Staff Perception of MOVE ON

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• sense of shared responsibility for mobilization

• communication • interprofessional

collaboration.

• + impact on unit culture - dispelling “sick culture”.

“I get a lot of social workers and dieticians and pharmacists asking me to come in and just get the patient up so they can sit down and talk to them, and I have no problem doing that so it’s really good to see that they’re engaged in the mobility aspect of the patient as well as, you know, their role on the team as well.”

“I think the... it brought to forefront the mobility thing, because usually when you think of people in hospital typically you think of people laying in the bed, but it changed that whole perception that, ‘Well, do they have to by laying in a bed?’ type. It’s like, you know, it’s the old-school thinking of what a hospital environment is.”

Acknowledgements

• We would like to thank the CAHO hospitals that participated in MOVE ON.

Presentation 51

Sunnybrook Health

Sciences Centre

• Over 1200 beds• Veteran’s hospital• 1st and largest regional

trauma centre in Canada

Delirium Historical references dating back 2,500 years Latin

“de” - off, away from “lira” – furrow

Previous terminology included Febrile insanity Every man’s psychosis Reversible madness Subacute befuddlement Acute confusional state Organic brain syndrome Acute brain failure

High prevalence and incidence of delirium in older patients

Prevalence at admission 14-24%Incidence 6-56%Post operative 15-53%ICU 70-87%End of life Up to 83%

Inouye SK New Engl J Med 2006;354:1157

Delirium is associated with increased mortality

MortalityDelirium No delirium

At 1 month 14% 5%At 6 months 22% 11%

12 months AHR for death=2.11 (1.18 to 3.77)

McCusker Arch Intern Med 2002;162:457Witlox JAMA 2010; 314:443

Delirium often has a protracted course

Persistent symptomsWith dementia

Without dementia

At 6 months 39% 9%At 12 months 49% 15%

•Inattention•Disorientation•Impaired memory

McCusker J Gen Intern Med 2003;18;696

Do you see what I see?

Justin Kaplan, 84 years old, Pulitzer Prize winning historian, during hospitalization for pneumonia

“Thousands of tiny little creatures, some on horseback, waving arms, carrying weapons like some grand renaissance battle, were trying to turn people into zombies. Their leader was a woman with no mouth but a very precisely cut hole in her throat.”

Yes No

Prevention of Delirium with the CHASM Care Interventions

C COGNITION AND PERCEPTION · Communicate clearly using simple sentences· Orient patient and encourage family involvement with meaningful activities· Optimize sensory inputs

H HYDRATION· Offer fluids with every encounter· Offer to open containers on meal trays· Encourage family to participate in feeding

A AGITATION · Address root cause: physical (pain, hunger, thirst, reposition, bladder/bowel, fatigue);

emotional (fear, anxiety)and environmental (temperature, noise)· Address safety issues · Match environmental stimulation· Relaxation activities (e.g. music, videos, books)

S SLEEP-WAKE CYCLE· Normalize sleep pattern and discourage daytime sleeping · Aim for uninterrupted sleep at night in quiet room with low level lighting· When possible, position patient near window

M MOBILITY · Encourage and support independence with self care and offer assistance when

required· Mobility activities 3x/day or more · Avoid foley catheters and restraints

Dec 10, 2013

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Enabling Tools & Resources

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Alignments (and hooks) Safety

– Patient– Staff

Quality Patient experience, satisfaction LOS

Ontario Coroner’s Report

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Sustainability challengesInitiative fatigue • Streamline priorities

• Look for alignments• Seek out and nurture productive

collaborationsLow hanging fruit has been picked

• Stay focused on making small improvements

• Avoid the temptation to question the method of measurement

• Manage expectations• This is a long term journey

Top down versus bottom up

• Corporate support is an enabler• Avoid the temptation to rely on it

as a driver• Ensure that interventions are

contextualizedContext has evolved

• Re-examine context

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Sustainability Senior Friendly Hospital Senior friendly hospital must be more than a

series of initiatives

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Processes of Care

Emotional & Behavioural Environment

Ethics in Clinical Care &

Research

Organizational Support

Physical Environment

1.Fn’l Decline2.Delirium

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Emotional & Behavioural Environment

Ethics in Clinical Care &

Research

Organizational Support

Physical Environment

1.Fn’l Decline2.Delirium

Process of Care

Environmental & Behavioural Environment

Ethics in Clinical Care and Research

Organizational Support

Physical Environment

1.Fn’l Decline

2.Delirium

Screen & DetectPrevent & ManageMonitor & Evaluate

Processes of Care

Emotional & Behavioral

Environ-ment

Organizational Support

Ethics in Clinical Care &

Research

Physical Environ-ment

Emotional & Behavioural Environment

Processes of Care

Ethics in Clinical Care &

Research

Organizational Support

Physical Environment

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Lessons Learned

Alignment + competing priorities Early wins versus mid to long term

sustainability Top-down versus bottom-up Hospitals are complex systems

– Standardization in the local context Basic ≠ simple

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ALynn SinghSimmy WanLisa KitchenBrian LaundryElizabeth SalvaterraMark EdmondsChristine Gagne-RodgerAlec AndersonDawn MaziakSusan GibsonKim YoungJudy BowyerJennifer McKenziePerry ComaSandra Easson-BrunoSabrina MartinRebecca McKeeJulie GirardKristy McQueenTeresa MartinsNathan FriasMelissa Kwiatkowski

TORONTO CENTRAL LHINCamille OrridgeVania SakelarisJanine HopkinsTeresa MartinsRose CookStephanie SmitSharon NavarroNathan FriasGeorgia Whitehead

RGPs OF ONTARIOBarbara LiuDavid RyanMarlene AwadKen WongAda TsangKelly MilneDavid JewellSharon MarrEleanor PlainJohn PuxtyRosemary BranderElizabeth McCarthyKim Rossi

cknowledgementsONTARIO SFH STEERINGJill Tettmann (Executive Sponsor)Barbara Liu (Co-Chair)Carol Anderson (Co-Chair)Marlene AwadKen WongAda TsangKelly MilneRonaye GilsenanDavid JewellJohn PuxtyRosemary BranderElizabeth McCarthyRhonda SchwartzGail DobellMonique Lloyd

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SFH “PROMISING PRACTICES” TOOLKITBarbara Liu (Co Chair))‐Gary Naglie (Co Chair‐Ken WongJohn PuxtyDavid JewellAnne StephensSharlene KuzikLinette PerryMaria BoyesSusan FranchiKaryn PopovichMonidipa DasguptaBruce ViellaSusan BisaillonEmily Christoffersen

SFH INDICATORSBarbara Liu (Co Chair)‐Rhonda Schwartz (Co Chair)‐Ken WongAda TsangMichelle ReyRebecca ComrieAnnette MarcuzziMarilee SuterBrian PutmanMinnie HoCarrie McAineyJohn PuxtyDana ChlemitskySharon MarrKim KohlbergerCatherine CottonKelly Milne

INDICATOR IMPLEMENTATION PLANNING GROUPBarbara Liu (co-chair)Carol Anderson (co-chair)Ken Wong (study coordinator)Ada Tsang (study coordinator)Alisha TharaniElaine MurphySherry AndersonCharissa LevyKelly MilneStephanie AmosNancy Lum WilsonCarol EdwardRyan MillerMonique LloydElla FerrisEmily ChristoffersenSusan Franchi

SUNNYBROOK SF TEAMDeborah Brown-FarrellJocelyn DenommeBeth O’LearyElmira DadmarziUmmu AlmaawiyShima Deljoomanesh

RGP OF TORONTOAda Tsang Ken WongMarlene AwadDavid RyanShirley LiKerri FisherLaurie KentJem Rosario

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Thank you