Prof. Len Gray, University of Queensland - Developing a Complete “System” of Care for Older...

Centre for Research in Geriatric Medicine

Centre for Online Health



OLDER PEOPLE IN THE

EMERGENCY DEPARTMENT:

THE INTERRAI “SOLUTION”

Professor Len Gray

July 2014



Acknowledgements


– Melinda Martin-Khan (Research Fellow)

– Ellen Burkett (PhD Candidate)

– Linda Schnikter (PhD Candidate)

International contributors

– John Hirdes (University of Waterloo, Canada)

– Andrew Costa (McGill University, Canada)



Older people have complex needs

High admission rates to hospital from ED

High levels of morbidity

– Multiple medical problems

– Cognitive impairment common

– Frequently disabled prior to becoming unwell

Small but complex population arriving from

RACFs



Geriatric syndromes are common

0

20

40

60

80

100

Australia Belgium Canada Germany Iceland India Sweden AllNations

Pre

vale

nce %

Premorbid

Admission

Source: Gray, L.C., Peel, N.M., Costa, A.P., Burkett, E., et al. Profiles of Older Patients in the emergency

Department: Findings from the interRAI Multinational Emergency Department Study. Annals of Emergency

Medicine 2013: 20 (10)



Some attendances may be avoidable…

Patients with minor medical issues that can be

managed elsewhere

– RACFs

– Re-attendances of patients discharged from ED



Some presentations aren’t a good ED “fit”

Older patients without major medical issues

requiring urgent treatment

– Subacute presentations with major functional or

psychosocial issues

– Patients requiring essential, but minor, diagnostic review



Transfers from RACFs can be reduced?

Incidence > 30 transfers / 100 residents / year – Arendts G, Howard K. Age And Ageing 2010;39:306-12.

36% of ED transfers are inappropriate – Saliba D, Kington R, Buchanan J, et al. JAGS 2000;48:154-63.

31% of ED arrivals from RACFs could be avoided – Codde J, Arendts G, Frankel J, et al. Australasian Journal On Ageing

2010;29:150-4

There is some evidence that the rate can be reduced – Arendts G, Reibel T, Codde J, Frankel J. Australasian Journal On Ageing

2010;29:61-5

Methods might include advance care planning, better treatment of acute illnesses & improved primary care – Arendts G, Howard K. Age And Ageing 2010;39:306-12.



How can the process be improved?

Older people with complex functional and psychosocial needs should be identified promptly

If home discharge is contemplated, detailed assessment may be required in the ED

Frail patients may have special treatment requirements within the ED and affiliated treatment areas

Discharged patients can be supported in their usual environment

Preventive strategies can be implemented in RACFs



Structured assessment may assist…

Early screening to identify patients with complex

needs

Support tools for assessment and discharge

preparation within the ED

www.interrai.org

Structured Assessment for Acute Care:

The interRAI Acute Care Mini-Suite



Comprehensive Geriatric Assessment

Identification of geriatric syndromes

Assessment of functional performance and

capacity

Evaluation of recent changes

Elucidation of diagnoses influencing function

Understanding the social and physical

environment

Monitoring performance over time



The Hospital Journey

ED Acute Care Post - Acute Care Post - Acute Community

Care

CAM AMT

CAM MMSE Waterlow FRAT MNA

FIM MMSE GDS

Barthel MMSE

Result: Inconsistent data format; high documentation burden; poor compliance; no data sharing



Why use a Clinical Decision Support

System?

Consistent recording of important clinical features

Readiness for electronic format

Ability to share information across care settings

Automated interpretation of clinical information

Ability to delegate clinical tasks away from

specialists

Background administrative reporting at low cost



Second generation assessment systems

First generation

(compilation)

Assembly of best of breed syndrome specific instruments

Strengths

• Minimum preparation

• Instruments already tested

• Familiarity

Weaknesses

• Gaps

• Redundancy

• Inconsistent scoring

Second generation (built for purpose)

Items developed to support derivative products Strengths • Good match with desired

purpose • Consistent scoring • Minimum redundancy Weaknesses • Expensive to develop &

implement • Require computerisation



Constructing a Patient Profile

Clinical Observations Scales to measure severity

Screeners

to identify problems & estimate risk

Quality Indicators

to assess performance

Clinical Action Points

to prioritise interventions

Casemix tools to understand cost

Patient Profile



The interRAI AC

Diagnostic

screeners

Delirium

Dementia

Depression

Malnutrition

Risk assessment

Delirium

Pressure ulcer

Falls

Functional decline

Institutional care

Readmission

Severity measures

Delirium

Cognition

Communication

Mood

ADL

IADL

Pain

Nutrition Recommendations

(CAPs)

ADL

Cognition

Communication

Delirium

Depression

Pain

Pressure ulcer

Institutional risk

Readmission

Medications

Quality indicators

Self care, mobility,

IDC, falls, pressure

ulcer, institutional

placement

Clin

ical

observ

ations



Patient profile



Striving for high scientific quality

All elements are subjected to intensive

psychometric testing

Standard for integrated scales and screeners:

performance at least as good at existing

“standalone” equivalents

Research findings are published in the peer-

reviewed literature

Training manuals for all instruments

18

www.interrai.org 19

interRAI AC

interRAI HC

interRAI ED Screener

Ward Admission Assessment

[PURPLE BOX]

SPECIALIST GERIATRIC ASSESSMENT

GENERAL ASSESSMENT

interRAI AC-PAC

interRAI ED CA

General ward geriatric care

www.interrai.org 20

ED Acute Post Acute Community

A P A A D D D

Core observations

Setting specific observations

P = premorbid

A = admission

D - discharge



Scaling across the Continuum

21

0

2

4

6

8

10

Short ADL Scale



The Hospital Mini-Suite: Progress

ED screener – Available

ED assessment – Late 2014

Nurse administered screener – In development

Acute Care - Available

Post-acute care - Late 2014

Home care – Available




THE INTERRAI ED TOOLKIT



Targeting assessment: The ED Screener

To identify, soon after arrival at ED, patients

who…

– If to be discharged home, are at risk of re-

attendance AND

– If to be admitted to hospital, are at risk of

prolonged stay or discharge to institutional care

In other words…

Comprehensive Geriatric Assessment is

recommended



Screener Structure



Predictive validity compared



The ED Screener

Comprises 11 items

Average to complete 45 seconds

Suitable for administration by general ED or

specialist ED nurses

Available as an iPhone or Android Application



The interRAI ED Contact Assessment

30 item mini-CGA

Domains – Cognition, mood, ADL, pain…

Premorbid vs current functional status

Outputs – Diagnostic and risk screeners

– Suggestions for care planning

Requires 20-60 minutes to complete – Nurse administered

– Training required

– Software required



The interRAI solution summarised

Purpose built case finding and assessment

system for older people in the ED

Grounded in an extensive, ongoing multi-national

research program

Linked to a “whole of system” assessment and

care planning system for hospital and community

care



Further research…

Development of Quality Indicators for care of

older persons in the ED (CRGM) 2015

Multi-national validation study of the ED screener

(McGill, Waterloo, CRGM) 2015

Proof of concept testing of the ED Assessment

system for the Australian context (CRGM) 2015

Telehealth intervention for RACFs – a cluster

RCT (CRGM – COH) 2016



Learn more about us...

COH

http://www.uq.edu.au/coh

CRGM www.som.uq.edu.au/research/crgm

interRAI Australia

www.interrai-au.org

RAIplus

www.raiplus.com

CeGA Online

www.cegaonline.com

http://www.uq.edu.au/coh

http://www.som.uq.edu.au/research/crgm

http://www.interrai-au.org/



http://www.raiplus.com/

http://www.cegaonline.com/

Prof. Len Gray, University of Queensland - Developing a Complete “System” of Care for Older...

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