Older people with complex needs in acute hospital beds

Prof David Oliver

Consultant Geriatrician, Visiting Fellow, King’s Fund & BGS President-elect

Nuffield Trust Workshop 14th October 2014

Major geographical variation in admission rates and bed occupancy in over 65s

Kings Fund Report Emergency Bed Use in Older People 2012. Imison C et al

Imison et al King’s Fund 2012

BMJ April 2013

EMERGENCY READMISSIONS: ENGLAND 1999-00 to 2009-10

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Age 0-15Age 16-74Age 75+Age 16+All ages

Fastest Rise is in Over 75s

Wishful thinking and magic bullets on admission prevention?

Marion McMurdo BMJ Letters Jan 2013

“SO MAKE HOSPITALS GOOD FOR OLD PEOPLE” "Hospitals are very bad places for old, frail people" asserts David Nicholson, chief executive of the NHS Commissioning Board, and suggests alternatives to hospital must be found Following this logic perhaps the solution to the lack of compassion in nurses to which he also refers might equally well be solved by admitting to hospital only patients who are not in need of compassion? “Here is a radical suggestion - make hospitals good places for old people. Few national providers would make such a blatantly ageist inference that its "core business" was too tricky to manage, and propose to solve "the problem" by ceasing to attempt to deal with it. The greatest burden of ill health falls on older people, making them the group encountered most commonly in clinical practice. But is appears that the impertinence of our older population in actually becoming unwell, and so requiring care, will no longer be tolerated in hospitals. The acute care of older people has progressed through being an inconvenience to being an anathema.”

Over 65s in hospital (England) (DH analysis of HES data)

60% admissions 70% bed days 85% delayed transfers 65% emergency readmissions 75% deaths in hospital 25% bed days are in over 85s 80% of all stays over 2 weeks

High intensity users of hospital services have overlap of physical and social vulnerabilities

Modern Hospital Casemix

1 in 4 adult beds occupied by someone with dementia (stay an average 7 days longer) Delirium affects 1 in 4 patients over 65 Urinary incontinence 1 in 4 over 65 1 in 4 over 65 have evidence of malnutrition Falls and falls injuries account for more bed days than MI and Stroke Combined Falls = 35% safety incidents (median age 82) Most over admissions over 70 have functional impairment and some need for MDT rehab (Hubbard 2005) – median barthel 12 Hip fracture is a good example – Median Age 84, 12 month mortality 20-30%, 1 in 3 have

dementia, 1 in 3 suffer delirium, 1 in 3 never return to former residence, 1 in 4 from care homes

Fried 1999

How frailty presents to services (Clegg and Young Lancet 2013)

Fatigue Weight loss Frequent infections “Failure to thrive” Delirium Falls Immobility Fluctuating Disability Incontinence

Mudge et al (bear in mind, 10 days of bed rest = 14% loss of aerobic and 10% muscle capacity – Kortebein )

Harms of hospitalisation for frail older people

Conventional big ticket safety incidents Poorly planned discharge Care transitions/co-ordination/communication Delirium Immobility Incontinence Malnutrition Institutionalisation Decompensation Premature decisions about future care needs in wrong setting

The solutions I know are set out here.

Free at http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/making-health-care-systems-fit-ageing-population-oliver-foot-humphries-mar14.pdf Free slideset at

http://www.kingsfund.org.uk/audio-video/improving-care-ageing-population-what-works

Blog http://www.kingsfund.org.uk/blog/2014/03/time-has-come-make-health-and-care-services-work-our-ageing-population

Structure of paper

Intensely practical Aimed at those leading local services 10 sections For each: – Goal – Current situation – “what we know can work” – Key references and resources – Good practice examples from around the UK (despite

austerity and upheaval) Field tested/reviewed with many service leaders Widely endorsed. Cited by NHS England.

10 Components all of equal importance with older person at the centre

End of life planning and care cuts across all

A story of how care can go wrong from HSJ commission on frail older people in hospital

Even when people are essentially caring and trying to do their best From my work on HSJ Commission on care for frail older people During the animation, please watch actively Please reflect: “at every single stage, what could we have done differently to help support Mrs Andrews and her family?” Including what happened before she fell

Animation. Mrs Andrews’ Story from HSJ Commission

https://www.youtube.com/watch?v=Fj_9HG_TWEM

Mrs Andrew’s Story

Going through the components What could/should have happened instead? Many solutions lie either side of bed based acute care pathway LOS may be the wrong measure – bed occupancy and % of discharges within timeframes better?

Managing the Streams – from ECIST priorities in Acute Hospitals

Identify the stream – Short stay Sick specialty Sick general Complex – Allocate early to teams skilled in that stream

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Clarity of specialty criteria Specialty case management plan at

Handover – no delays Green bed days vs. red bed days

Short stay – manage to the hour Maximise ambulatory care

Complex needs – how much is decompensation? Detect early and design

simple rules for discharge

Minimise handover Decompensation risk

Early assertive management Green bed days vs. red bed days