Centre for Research in GeriatricMedicine
Centre for Online Health
Centre for Research in Geriatric Medicine
Centre for Onl...
Centre for Research in GeriatricMedicine
Centre for Online Health
Acknowledgements
 Centre for Research in Geriatric Medi...
Centre for Research in GeriatricMedicine
Centre for Online Health
Older people have complex needs
 High admission rates t...
Centre for Research in GeriatricMedicine
Centre for Online Health
Geriatric syndromes are common
0
20
40
60
80
100
Austral...
Centre for Research in GeriatricMedicine
Centre for Online Health
Some attendances may be avoidable…
 Patients with minor...
Centre for Research in GeriatricMedicine
Centre for Online Health
Some presentations aren’t a good ED “fit”
 Older patien...
Centre for Research in GeriatricMedicine
Centre for Online Health
Transfers from RACFs can be reduced?
 Incidence > 30 tr...
Centre for Research in GeriatricMedicine
Centre for Online Health
How can the process be improved?
 Older people with com...
Centre for Research in GeriatricMedicine
Centre for Online Health
Structured assessment may assist…
 Early screening to i...
www.interrai.org
Structured Assessment for Acute Care:
The interRAI Acute Care Mini-Suite
Centre for Research in GeriatricMedicine
Centre for Online Health
Comprehensive Geriatric Assessment
 Identification of g...
Centre for Research in GeriatricMedicine
Centre for Online Health
The Hospital Journey
ED Acute Care Post - Acute Care
Pos...
Centre for Research in GeriatricMedicine
Centre for Online Health
Why use a Clinical Decision Support
System?
 Consistent...
Centre for Research in GeriatricMedicine
Centre for Online Health
Second generation assessment systems
First generation
(c...
Centre for Research in GeriatricMedicine
Centre for Online Health
Constructing a Patient Profile
Clinical
Observations Sca...
Centre for Research in GeriatricMedicine
Centre for Online Health
The interRAI AC
Diagnostic
screeners
Delirium
Dementia
D...
Centre for Research in GeriatricMedicine
Centre for Online Health
Patient profile
Centre for Research in GeriatricMedicine
Centre for Online Health
Striving for high scientific quality
 All elements are ...
www.interrai.org19
interRAI AC
interRAI HC
interRAI ED Screener
Ward Admission
Assessment
[PURPLE BOX]
SPECIALIST GERIATRI...
www.interrai.org20
ED Acute Post Acute Community
AP A A DD D
Core observations
Setting specific observations
P = premorbid...
Centre for Research in GeriatricMedicine
Centre for Online Health
Scaling across the Continuum
21
0
2
4
6
8
10
Short ADL S...
Centre for Research in GeriatricMedicine
Centre for Online Health
The Hospital Mini-Suite: Progress
 ED screener – Availa...
Centre for Research in GeriatricMedicine
Centre for Online Health
Centre for Research in Geriatric Medicine
THE INTERRAI E...
Centre for Research in GeriatricMedicine
Centre for Online Health
Targeting assessment: The ED Screener
 To identify, soo...
Centre for Research in GeriatricMedicine
Centre for Online Health
Screener Structure
Centre for Research in GeriatricMedicine
Centre for Online Health
Predictive validity compared
Centre for Research in GeriatricMedicine
Centre for Online Health
The ED Screener
 Comprises 11 items
 Average to comple...
Centre for Research in GeriatricMedicine
Centre for Online Health
Centre for Research in GeriatricMedicine
Centre for Online Health
Centre for Research in GeriatricMedicine
Centre for Online Health
Centre for Research in GeriatricMedicine
Centre for Online Health
Centre for Research in GeriatricMedicine
Centre for Online Health
The interRAI ED Contact Assessment
 30 item mini-CGA
 ...
Centre for Research in GeriatricMedicine
Centre for Online Health
The interRAI solution summarised
 Purpose built case fi...
Centre for Research in GeriatricMedicine
Centre for Online Health
Further research…
 Development of Quality Indicators fo...
Centre for Research in GeriatricMedicine
Centre for Online Health
Learn more about us...
COH
http://www.uq.edu.au/coh
CRGM...
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Prof. Len Gray, University of Queensland - Developing a Complete “System” of Care for Older People in Hospital: The InterRAI “Solution”

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Prof. Len Gray delivered the presentation at the 2014 Emergency Department Management Conference.

The 2014 Emergency Department Management Conference explored areas such as how to improve access to care, clinical redesign, NEAT compliance, patient flow, point of care testing, geriatric care, and enhance the performance of Emergency Department.

For more information about the event, please visit: http://bit.ly/edmanagement14

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Prof. Len Gray, University of Queensland - Developing a Complete “System” of Care for Older People in Hospital: The InterRAI “Solution”

  1. 1. Centre for Research in GeriatricMedicine Centre for Online Health Centre for Research in Geriatric Medicine Centre for Online Health OLDER PEOPLE IN THE EMERGENCY DEPARTMENT: THE INTERRAI “SOLUTION” Professor Len Gray July 2014
  2. 2. Centre for Research in GeriatricMedicine Centre for Online Health Acknowledgements  Centre for Research in Geriatric Medicine – 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)
  3. 3. Centre for Research in GeriatricMedicine Centre for Online Health 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
  4. 4. Centre for Research in GeriatricMedicine Centre for Online Health Geriatric syndromes are common 0 20 40 60 80 100 Australia Belgium Canada Germany Iceland India Sweden All Nations Prevalence% 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)
  5. 5. Centre for Research in GeriatricMedicine Centre for Online Health Some attendances may be avoidable…  Patients with minor medical issues that can be managed elsewhere – RACFs – Re-attendances of patients discharged from ED
  6. 6. Centre for Research in GeriatricMedicine Centre for Online Health 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
  7. 7. Centre for Research in GeriatricMedicine Centre for Online Health 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.
  8. 8. Centre for Research in GeriatricMedicine Centre for Online Health 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
  9. 9. Centre for Research in GeriatricMedicine Centre for Online Health Structured assessment may assist…  Early screening to identify patients with complex needs  Support tools for assessment and discharge preparation within the ED
  10. 10. www.interrai.org Structured Assessment for Acute Care: The interRAI Acute Care Mini-Suite
  11. 11. Centre for Research in GeriatricMedicine Centre for Online Health 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
  12. 12. Centre for Research in GeriatricMedicine Centre for Online Health 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
  13. 13. Centre for Research in GeriatricMedicine Centre for Online Health 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
  14. 14. Centre for Research in GeriatricMedicine Centre for Online Health 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
  15. 15. Centre for Research in GeriatricMedicine Centre for Online Health 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
  16. 16. Centre for Research in GeriatricMedicine Centre for Online Health 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 Clinical observations
  17. 17. Centre for Research in GeriatricMedicine Centre for Online Health Patient profile
  18. 18. Centre for Research in GeriatricMedicine Centre for Online Health 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
  19. 19. www.interrai.org19 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
  20. 20. www.interrai.org20 ED Acute Post Acute Community AP A A DD D Core observations Setting specific observations P = premorbid A = admission D - discharge
  21. 21. Centre for Research in GeriatricMedicine Centre for Online Health Scaling across the Continuum 21 0 2 4 6 8 10 Short ADL Scale
  22. 22. Centre for Research in GeriatricMedicine Centre for Online Health 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
  23. 23. Centre for Research in GeriatricMedicine Centre for Online Health Centre for Research in Geriatric Medicine THE INTERRAI ED TOOLKIT
  24. 24. Centre for Research in GeriatricMedicine Centre for Online Health 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
  25. 25. Centre for Research in GeriatricMedicine Centre for Online Health Screener Structure
  26. 26. Centre for Research in GeriatricMedicine Centre for Online Health Predictive validity compared
  27. 27. Centre for Research in GeriatricMedicine Centre for Online Health 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
  28. 28. Centre for Research in GeriatricMedicine Centre for Online Health
  29. 29. Centre for Research in GeriatricMedicine Centre for Online Health
  30. 30. Centre for Research in GeriatricMedicine Centre for Online Health
  31. 31. Centre for Research in GeriatricMedicine Centre for Online Health
  32. 32. Centre for Research in GeriatricMedicine Centre for Online Health 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
  33. 33. Centre for Research in GeriatricMedicine Centre for Online Health 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
  34. 34. Centre for Research in GeriatricMedicine Centre for Online Health 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
  35. 35. Centre for Research in GeriatricMedicine Centre for Online Health 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

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