Elise Tcharkhedian - Liverpool Hospital - Accelerated Admission Pathways for Geriatric Patients
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Transcript of Elise Tcharkhedian - Liverpool Hospital - Accelerated Admission Pathways for Geriatric Patients
Improving ED Admission processes for Older Patients – Early
Admission Pathway under Geriatrics
Elise Tcharkhedian
Senior ED/ASET Physiotherapist
Liverpool Hospital
SWSLHD
Initial trial as delirium pathway in 2011
Aim: to improve recognition, management and outcomes of older people with delirium
Under recognition and misdiagnosis can result in inappropriate or delays to appropriate treatment
Department of Geriatric Medicine and ASET concerned regarding impact of “usual” system of admission and lengthy stays in ED worsening agitation, confusion and outcomes in patients with delirium
Delirium guidelines were also promoting change
History
10% Australians >70yrs have delirium on admission to hospital, and further 8% develop during hospital stay (Travers et al 2013)
14.6% principal diagnosis delirium of patients admitted under Geriatric Medicine, Liverpool Hospital
Delirium missed by ED medical staff in 76% cases (Han & Zimmerman 2009) – then usually not dx by admitting medical staff (due to fluctuating nature, variable presentation, overlap with dementia and need for clinical diagnosis)
Lack of recognition and under-detection further impacts outcomes with 7x increased risk of mortality associated with missed delirium at admission (O’Keefe & Lavan 1999)
Extent of problem
Developed by Senior Medical staff from Department of Geriatric and Emergency Medicine, and ASET
Patients identified with delirium after triage by ASET staff (using CAM)
Rapid Identification of Delirium and Accelerated Admission Pathway
7 pathway patients significantly shorter stay in ED with median time 6.8 hrs (cf 12.1 hrs)
1 (14%) pathway pt had CRC/MET call cf 4 (21%) in control group in first 48 hrs
Significant difference in need for behavioural intervention – no pathway patient required intervention in first 48 hrs cfcontrol group where 1 (5%) required physical restraint, 5 (26%) had antipsychotic meds and 8 (42%) required 1:1 nursing care
57% admitted on pathway were reviewed by Geriatrician on day of admission cf 9.5% in control group
Initial outcomes – Delirium pathway December 2010 pilot
Following review, pathway reintroduced
First 6 months – 40 patients assessed
32 admitted via pathway
Preliminary results show for 26 patients with data, median time from triage to ASET review was 1.7 hours and for 22 patients with data median time from triage to admission was 3.4 hours
Pathway reintroduction July 2012
Pathway expanded in February 2013 to assist identifying other patients suitable for accelerated admission under Geriatric Medicine
Expansion of Pathway
Reduce LOS of targeted older adults in Liverpool ED
Improve access to timely quality healthcare (Rx commenced in ED)
Improve admission processes in ED to provide smooth transition to the Aged Care Unit
NEAT
Aim
Meets MET or clinical review criteria
More appropriate for another pathway (eg sepsis, #NOF)
Needs care by another speciality (eg cardiology)
Requires 6L or >oxygen
Chest pain or syncope or requires cardiac monitor or acute ECG changes
Guidelines – Exclusion Criteria
Delirium
Acute changes in mental state, concentration, behaviour
1-2 features and known dementia/delirium
Identified using CAM
Dementia
Presentation due to behavioural problems secondary to dementia
Exclusion: severe psychosis, aggression including violence
Guidelines – Inclusion Criteria
Falls
Increased falls
Would benefit from comprehensive geriatric assessment, medication rationalisation and MDT involvement
Exclusion: falls due to syncope, seizure or acute stroke, or injuries requiring operative management eg #NOF
Guidelines – Inclusion Criteria
Functional Decline
Acute deterioration in mobility or ability to perform ADLs (days, weeks) with a pre-existing history of functional impairment
Guidelines – Inclusion Criteria
Residents from nursing homes
Moderate to severe delirium
Recent or increasing falls
Acute changes in behaviour, function, appetite with unclear cause
Polypharmacy issues associated with need for admission
Guidelines – Inclusion Criteria
Older person at risk
Concern regarding elder abuse eg psychological, financial, physical, sexual, neglect
Unexplained malnutrition
Guidelines – Inclusion Criteria
Continuity of care
Admitted under Geriatrician in last 28 days and presenting with similar issues
Guidelines – Inclusion Criteria
Early Notification Pathway Mon-Fri 0830-1600
Triaged
Identified by ASET
Notification of admission – EDSS, ED NUM, Geri Reg, Bed management
Investigations commenced, medication chart written
Transfer to CB5A or 5B (Aged Care Unit)
Process
1. Bloods (INR if on warfarin)
2. CXR
3. ECG
4. UA and MSU – Bladder Scan
Standard Investigations
Delirium/Functional Decline
Troponin, blood cultures
Falls
Troponin, postural BP, CK if long lie/on statin medication
Appropriate xrays as indicated
Additional Tests
History of fall with head injury eg witnessed/reported head injury, evidence of head injury
History of fall but unclear if head injury & on anti-coag/ anti-platelet
New focal neurological signs
Increased confusion with fall in last 2 weeks
Reduced level of consciousness or GCS<9
Cerebral CT GuidelinesPATIENTS WHO NEED A CT PRIOR TO LEAVING ED
History of a fall, no head injury and not on anti-coag
No other cause identified for delirium following history, examination and review of standard delirium investigations
Cerebral CT GuidelinesPATIENTS WHO MAY REQUIRE CT (IF CLINICALLY
APPROPRIATE) WHICH CAN BE ORGANISED FROM THE WARD
March-July 2013
Analysis of patients admitted through Early Admission Pathway
Overall Mar Apr May June July
no. pts 37 16 4 10 5 2
met NEAT 10 7 1 1 0 1
Triage to ward
Mean (SD) mins 514+/- 319
Median in min 414 (241-631)
Hosp LOS
Mean in days 12.4+/-11.6
Median in days 8.5 (5-15)
Late arrivals outside pathway hours
Patients too sick
Bed block
Staff changes – continual education++
Reliant on ASET staffing
Barriers to Implementation
Geriatics Department Liverpool Hospital – particularly Dr Angela Khoo and Dr Rinaldo Gonzales
ASET Team Liverpool Emergency Department –particularly Margaret Moseley, ASET CNC
Acknowledgements
Travers C, Byrne G, Pachana, N, Klein K, Gray L. Delirium in Australian hospitals: a prospective study. Current Gerontology and Geriatrics Research. 2013;2013:ID284780
Han JH and Zimmerman EE. Delirium in older emergency department patients: recognition, risk factors and psychomotor subtypes. Academic Emergency Medicine.2009;16:193-200
O’Keefe ST and Lavan JN. Clinical significance of delirium subtypes in older people. Age and Ageing. 1999;28:115-119
References