Liaison services in general hospitals

8/9/2019 Liaison services in general hospitals

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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 .

Documents

Liaison services in general hospitals