The Revolving Door: Reducing Representations from
an Acute Medical Unit
Dr Susan Slatyer
Collaborators
• Associate Professor Chris Toye (SCGH/Curtin)
• Dr James Williamson (Specialist Gen Med HOD)
• Ms Anne Matt...
The Acute Medical Unit
• Growing + ageing population
• Pressure on acute care hospitals
• UK Australia NZ - Short-stay med...
The Acute Medical Unit
• 30 beds (15-20 admissions per day)
• Complex medical patients
• Up to 72 hours
• Rapid assessment...
The Acute Medical Unit
The Problem
AMU clinical staff  Some older patients were representing back to
hospital within a sh...
The Acute Medical Unit
The Problem
AMU clinical staff  Some older patients were representing back to
hospital within a sh...
Action Research Methodology
Evaluating
Reflecting
Planning
Implementing
Action Research Methodology
Evaluating
Evaluating the problem
Study 1
Aim
Determine the predictors for early re-presentation to
hospital of older patients who ar...
Evaluating the problem
Study 1
Aim
Determine the predictors for early re-presentation to
hospital of older patients who ar...
Evaluating the problem
Study 1
Stage 1
 Quantitative - patient self-reported measures / medical notes
 Qualitative inter...
Evaluating the problem
Study 1
Stage 1
 Quantitative - patient self-reported measures / medical notes
 Qualitative inter...
Evaluating
Patients (n=12)
• Mean age: 81.6 yrs
• Median length of stay: 2 days (range, 1 hour – 4 days)
• Mean time to re...
Evaluating
Patients (n=12)
 Mini-Mental State Examination1: excluded below 17
 Barthel’s Activities of Daily Living2: 11...
Evaluating
Family caregivers (n=15)
 Reported health status: Excellent (n=1) to poor (n=2); almost 50% (n=7) reported
goo...
Evaluating
Health professionals (n=35)
Hospital Community
Health care role n % n %
Registered Nurse 6 17.1 3 8.6
Nurse spe...
Evaluating
Qualitative interviews
 The health trajectory “Borderline”
I had breathing problems all the time … my breathin...
Evaluating
Qualitative interviews
 The health trajectory “Borderline”
I had breathing problems all the time … my breathin...
Exacerbation of chronic disease
or acute on chronic illness -
underlying deteriorating trajectory
Patient living
with chro...
Exacerbation of chronic disease
or acute on chronic illness -
underlying deteriorating trajectory
AMU
admission
Rapid
trea...
Exacerbation of chronic disease
or acute on chronic illness -
underlying deteriorating trajectory
AMU
admission
Rapid
trea...
Exacerbation of chronic disease
or acute on chronic illness -
underlying deteriorating
trajectory
AMU
admission
Rapid
trea...
Exacerbation of chronic disease
or acute on chronic illness -
underlying deteriorating trajectory
AMU
admission
Rapid
trea...
Exacerbation of chronic disease
or acute on chronic illness -
underlying deteriorating trajectory
AMU
admission
Rapid
trea...
Seriously
compromised
health status
Exacerbation of chronic disease
or acute on chronic illness -
underlying deteriorating...
Date of download: 7/23/2013
Copyright © 2012 American Medical
Association. All rights reserved.
From: Patterns of Function...
Stage 2 Data linkage 2002-2004
 2304 pts Aged 65 yrs and older + Discharged from AMU
 61.6% female (n=1419)
 Most femal...
Stage 2 Data linkage 2002-2004
 2304 pts Aged 65 yrs and older + Discharged from AMU
 AMU data set linked to
 WA Hospit...
Stage 2 Data linkage 2002-2004
 2304 pts aged 65 yrs and older + Discharged from AMU
 8.2% re-presented to ED by 7 days
...
Stage 2 Data linkage 2002-2004
 2304 pts aged 65 yrs and older + Discharged from AMU
 8.2% re-presented to ED by 7 days
...
Evaluating
Stage 2 Data linkage 2002-2004
 2304 pts aged 65 yrs and older + Discharged from AMU
 8.2% re-presented to ED...
Findings
Reasons for representations
 Natural history of illness / deteriorating
 Complex - Co-morbidities / polypharmac...
The Big Picture?
 Important to identify caregivers + communicate with them
 Improve communication to improve transitions...
Study 2 (2009-2010)
Evaluating
Reflecting
On findings
Planning
Working party
New tool
Implementing
Piloting
Reflection
 16.9% had represented to an ED within 28 days of AMU discharge
 Reasons for representation
 Failed to under...
Planning
Study 2
Working party
 Led by an AMU clinical nurse
 Unit staff developed a new nursing and allied health Disch...
Planning and Implementing
Working party
 Led by an AMU clinical nurse
 Unit staff developed a new nursing and allied hea...
Evaluation
Baseline data (Time 1) Follow up data (Time 2)
31 days before change 31 days after change
All patients discharg...
Evaluation
Time 1 compared to Time 2
Evaluation
Time 1 compared to Time 2
Evaluation
Time 1 compared to Time 2
Study 3 (2011)
Evaluating
Audit tool
Reflecting
Staff focus group
Planning
Draft 1 booklet
Expert panel
Draft 2 booklet
Im...
Evaluation
Study 3
• Audit of the DCTP tool
300 forms
Completed by nursing staff
Use of jargon
‘Not applicable’ or
‘Refer ...
Reflection
3rd study
 Focus group
AAU nursing and allied health staff
Nurses using forms to communicate with aged care
Al...
Planning
Study 3
 AAU Working party
 Consultation
AAU staff
Hospital individuals/groups
 Booklet - Draft 1
AAU staff
Ex...
Implementing
Study 3
 Booklet Draft 2
Piloted
3 weeks
425 AAU patients
54% received booklet (n=229)
Evaluating
3rd study
 Audit
 Patient/carer feedback
 Staff focus group
Inconsistent provision
Overall favourable
Most u...
Summary
 AMUs are effective - manage acute illness + respond to pressure
on health system
 Patients with complex chronic...
References
Arendts, G, MacKenzie, J, Lee, JK. Discharge planning and patient satisfaction in an emergency short-stay unit....
References
Instruments
1. Folstein ,MF, Folstein, SE, McHugh, PR. “Mini Mental State”: A practical method for grading the
...
Acknowledgements
The AMU based clinicians who requested this study for
their commitment to excellence and the improvement ...
The Revolving Door: Reducing Representations from an Acute Medical Unit
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The Revolving Door: Reducing Representations from an Acute Medical Unit

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Dr Susan Slatyer of Sir Charles Gairdner Hospital delivered this presentation as part of the 4th Annual Reducing Hospital Readmissions & Discharge Planning Conference – A conference to identify, predict and prevent unplanned readmissions and improve discharge processes. IIR Healthcare's inaugural Canadian Reducing Hospital Readmissions & Discharge Planning Conference will take place in Vancouver in late October 2013. Find out more at http://www.healthcareconferences.ca/readmissions/agenda

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The Revolving Door: Reducing Representations from an Acute Medical Unit

  1. 1. The Revolving Door: Reducing Representations from an Acute Medical Unit Dr Susan Slatyer
  2. 2. Collaborators • Associate Professor Chris Toye (SCGH/Curtin) • Dr James Williamson (Specialist Gen Med HOD) • Ms Anne Matthews (CNS) • Ms Dee Whitty (CNS) • Ms Jeanne Young (CNC Research) • Mr Andrew Hill (CNC Aged Care) • Associate Professor Anne Williams (SCGH/ECU) • Ms Susan Slatyer (SCGH/ECU) Project staff Ms Aurora Popescu (ECU) Mr Jai Rowe (SCGH) Ms Katrina Fyfe (SCGH/Curtin)
  3. 3. The Acute Medical Unit • Growing + ageing population • Pressure on acute care hospitals • UK Australia NZ - Short-stay medical units • Older patients = Key users • KPIs – LOS, Readmissions (Downing et al, 2008; Scott et al., 2008) • Effective
  4. 4. The Acute Medical Unit • 30 beds (15-20 admissions per day) • Complex medical patients • Up to 72 hours • Rapid assessment and treatment • Discharge (home or residential care) or transfer • Discharge letter / medications • Rapid GP follow-up
  5. 5. The Acute Medical Unit The Problem AMU clinical staff  Some older patients were representing back to hospital within a short time Literature  Experiences of older AMU patients not explored  Older people at risk of readmission (Williams & Fitton 1988)   LOS may  risk of readmission for older patients (Dobranska & Newell, 2006)  Australian pts 47-78 yrs short-stay unit - readmisson 9% (Arendts et al., 2006)
  6. 6. The Acute Medical Unit The Problem AMU clinical staff  Some older patients were representing back to hospital within a short time Literature  Relapse of existing condition, cardiac & pulmonary  New problem  Carer problem  Medication issue  Comorbidities (Williams & Fitton 1988, Munshi et al., 2002; Juan et al., 2006, Westert et al., 2002 )
  7. 7. Action Research Methodology Evaluating Reflecting Planning Implementing
  8. 8. Action Research Methodology Evaluating
  9. 9. Evaluating the problem Study 1 Aim Determine the predictors for early re-presentation to hospital of older patients who are discharged from the AMU
  10. 10. Evaluating the problem Study 1 Aim Determine the predictors for early re-presentation to hospital of older patients who are discharged from the AMU Literature  Early representation - within 28 days  Older patients - aged 65 years or older
  11. 11. Evaluating the problem Study 1 Stage 1  Quantitative - patient self-reported measures / medical notes  Qualitative interviewing – patients, family carers and staff Stage 2  Data linkage 2002-2004
  12. 12. Evaluating the problem Study 1 Stage 1  Quantitative - patient self-reported measures / medical notes  Qualitative interviewing – patients, family carers and staff Sample  12 patients  15 family carers (10 dyads, 2 extra patients, 5 extra family members)  35 multidisciplinary hospital + community based health care staff
  13. 13. Evaluating Patients (n=12) • Mean age: 81.6 yrs • Median length of stay: 2 days (range, 1 hour – 4 days) • Mean time to re-presentation: 12.6 days • No of medications: 1 – 14 (mean, 7.7 medications) • Health problems: 3 cardio/resp, 2 gastrointestinal, 2 renal/urinary
  14. 14. Evaluating Patients (n=12)  Mini-Mental State Examination1: excluded below 17  Barthel’s Activities of Daily Living2: 11 = 85.0 or higher  Nottingham Health Profile3: concerned about physical ability + sleep  Network Assessment Instrument4: 11 = within 10 km, (7 within 1km)
  15. 15. Evaluating Family caregivers (n=15)  Reported health status: Excellent (n=1) to poor (n=2); almost 50% (n=7) reported good health  Provided cooking, cleaning, help with activities of daily living, shopping, and transport  Family’ perceptions of the patient’s health status at re-presentation generally consistent with patient Relationship n % Wife/husband 8 53.3 Sibling 1 6.7 Son/daughter 6 40.0 15 100.0
  16. 16. Evaluating Health professionals (n=35) Hospital Community Health care role n % n % Registered Nurse 6 17.1 3 8.6 Nurse specialist 7 20.0 2 5.7 Allied health 6 17.1 0 0.0 Medical 9 25.7 1 2.9 Carer 0 0.0 1 2.9 Total 28 80.0 7 20.0
  17. 17. Evaluating Qualitative interviews  The health trajectory “Borderline” I had breathing problems all the time … my breathing is getting worse … I’ve never been gasping like that before … haven’t been able to do things, like even walking to the bus stop was killing me (Patient)
  18. 18. Evaluating Qualitative interviews  The health trajectory “Borderline” I had breathing problems all the time … my breathing is getting worse … I’ve never been gasping like that before … haven’t been able to do things, like even walking to the bus stop was killing me (Patient)  Communication challenges The first time it was angina … this time they said it was angina but angina doesn’t keep filling up your lungs with fluid … my daughter says she looked on the internet … and now its his liver and all (Family)  Discharge readiness I was very weak … anxious … going home … what if it happens again and its fatal? (Patient)  The decision to return She couldn’t breathe … the ambulance blokes said “are your Mum’s lips normally purple?” (Family)
  19. 19. Exacerbation of chronic disease or acute on chronic illness - underlying deteriorating trajectory Patient living with chronic illness at home or in aged care
  20. 20. Exacerbation of chronic disease or acute on chronic illness - underlying deteriorating trajectory AMU admission Rapid treatment of acute illness Patient living with chronic illness at home or in aged care
  21. 21. Exacerbation of chronic disease or acute on chronic illness - underlying deteriorating trajectory AMU admission Rapid treatment of acute illness Bed pressures affect staff & patient In hospital communication prioritisation: Intra-team, intra- hospital, team- patient, team- family Staff assessment of overall patient health & care status in pressured environment Patient living with chronic illness at home or in aged care
  22. 22. Exacerbation of chronic disease or acute on chronic illness - underlying deteriorating trajectory AMU admission Rapid treatment of acute illness AMU discharge Bed pressures affect staff & patient Return to baseline - Patient desires to be home, ability to manage assessed seems to be adequate, borderline criteria In hospital communication prioritisation: Intra-team, intra- hospital, team- patient, team- family Staff assessment of overall patient health & care status in pressured environment Patient living with chronic illness at home or in aged care
  23. 23. Exacerbation of chronic disease or acute on chronic illness - underlying deteriorating trajectory AMU admission Rapid treatment of acute illness AMU discharge Bed pressures affect staff & patient Return to baseline - Patient desires to be home, ability to manage assessed seems to be adequate, borderline criteria In hospital communication prioritisation: Intra-team, intra- hospital, team- patient, team- family Staff assessment of overall patient health & care status in pressured environment Discharge communication effectiveness: with community services/aged care, GP, patient, family (use of available hospital resources) Patient living with chronic illness at home or in aged care
  24. 24. Exacerbation of chronic disease or acute on chronic illness - underlying deteriorating trajectory AMU admission Rapid treatment of acute illness AMU discharge Bed pressures affect staff & patient Return to baseline - Patient desires to be home, ability to manage assessed seems to be adequate, borderline criteria In hospital communication prioritisation: Intra-team, intra- hospital, team- patient, team- family GP limitations: availability, continuity, understanding of individual’s overall health status, access to specialist advice if needed Patient & family understanding - of health needs & trajectory, medications, how to recognise deterioration, how to negotiate the system Community service limitations: lag time when need for higher level services, aged care resources, specialist O/P appt., CDM program Staff assessment of overall patient health & care status in pressured environment Family limitations: sandwich generation, patient is carer, lives alone, resisting services Discharge communication effectiveness: with community services/aged care, GP, patient, family (use of available hospital resources) Patient living with chronic illness at home or in aged care
  25. 25. Seriously compromised health status Exacerbation of chronic disease or acute on chronic illness - underlying deteriorating trajectory AMU admission Rapid treatment of acute illness AMU discharge Hospital re-presentation Repeated exacerbation or further or unresolved acute illness Bed pressures affect staff & patient Return to baseline - Patient desires to be home, ability to manage assessed seems to be adequate, borderline criteria In hospital communication prioritisation: Intra-team, intra- hospital, team- patient, team- family GP limitations: availability, continuity, understanding of individual’s overall health status, access to specialist advice if needed Patient & family understanding - of health needs & trajectory, medications, how to recognise deterioration, how to negotiate the system Community service limitations: lag time when need for higher level services, aged care resources, specialist O/P appt., CDM program Staff assessment of overall patient health & care status in pressured environment Family limitations: sandwich generation, patient is carer, lives alone, resisting services The aftermath - Patients & families are often distressed and anxious. However, the experience can lead to greater understanding and planning for the future Discharge communication effectiveness: with community services/aged care, GP, patient, family (use of available hospital resources) Patient living with chronic illness at home or in aged care
  26. 26. Date of download: 7/23/2013 Copyright © 2012 American Medical Association. All rights reserved. From: Patterns of Functional Decline at the End of Life JAMA. 2003;289(18):2387-2392. doi:10.1001/jama.289.18.2387 Reproduced with permission. Figure Legend:
  27. 27. Stage 2 Data linkage 2002-2004  2304 pts Aged 65 yrs and older + Discharged from AMU  61.6% female (n=1419)  Most females aged 80yrs+ ; Most males aged 65-80 yrs  57.4% at least 1 co-morbidity (18.4% had 3+)  74% index AMU triaged as ‘emergency’ or ‘urgent’  Circulatory system disorders 25% index AMU admission
  28. 28. Stage 2 Data linkage 2002-2004  2304 pts Aged 65 yrs and older + Discharged from AMU  AMU data set linked to  WA Hospital Mortality Dataset  WA Hospital Morbidity Dataset  Emergency Dept Information System
  29. 29. Stage 2 Data linkage 2002-2004  2304 pts aged 65 yrs and older + Discharged from AMU  8.2% re-presented to ED by 7 days  16.9% re-presented to ED by 28 days  22.2% readmitted to hospital by 28days  20.4% died in study period Predictors of re-presentation: Co-morbidities Older Male ‘Out of hours’ admission
  30. 30. Stage 2 Data linkage 2002-2004  2304 pts aged 65 yrs and older + Discharged from AMU  8.2% re-presented to ED by 7 days  16.9% re-presented to ED by 28 days  22.2% readmitted to hospital by 28days  20.4% died in study period Predictors of death within 2 years: Co-morbidities Older Male Re-presenting within 7 days Heart failure on index AMU admission
  31. 31. Evaluating Stage 2 Data linkage 2002-2004  2304 pts aged 65 yrs and older + Discharged from AMU  8.2% re-presented to ED by 7 days  16.9% re-presented to ED by 28 days  22.2% readmitted to hospital by 28days  20.4% died in study period * Only 0.9-3.4% of variation in models explained Limitation • No access to data on function, cognition, place of residence, carer situation
  32. 32. Findings Reasons for representations  Natural history of illness / deteriorating  Complex - Co-morbidities / polypharmacy  Failed to understand the context of the acute illness  Distress when serious symptoms occurred = No clear plan in place  Reported receiving little information about illness (not understood / not remembered)  Difficulty accessing services promptly after discharge
  33. 33. The Big Picture?  Important to identify caregivers + communicate with them  Improve communication to improve transitions  Team approach – communication and continuity  Palliative approach: Managing symptoms Managing related distress Inclusion of family Goals of care/treatment plans Advance care planning Role for: Advanced practice nurse – gerontology + pall care expertise
  34. 34. Study 2 (2009-2010) Evaluating Reflecting On findings Planning Working party New tool Implementing Piloting
  35. 35. Reflection  16.9% had represented to an ED within 28 days of AMU discharge  Reasons for representation  Failed to understand the context of the acute illness  Distress at serious symptoms  No clear plan in place  Communication imperative
  36. 36. Planning Study 2 Working party  Led by an AMU clinical nurse  Unit staff developed a new nursing and allied health Discharge Care Plan
  37. 37. Planning and Implementing Working party  Led by an AMU clinical nurse  Unit staff developed a new nursing and allied health Discharge Care Plan New form piloted  All nursing and allied health staff  Completed new form  Sent original home with patient  Photocopy retained on ward
  38. 38. Evaluation Baseline data (Time 1) Follow up data (Time 2) 31 days before change 31 days after change All patients discharged + ‘family carer’ + aged care staff  Satisfaction (CSQ-85,6,7)  Care continuity (CCQ7)  Preparedness for discharge (Single item scale7) AMU staff (Time 2 only)  Feasibility, sustainability, impact of new forms
  39. 39. Evaluation Time 1 compared to Time 2
  40. 40. Evaluation Time 1 compared to Time 2
  41. 41. Evaluation Time 1 compared to Time 2
  42. 42. Study 3 (2011) Evaluating Audit tool Reflecting Staff focus group Planning Draft 1 booklet Expert panel Draft 2 booklet Implementing Pilot draft 2 booklet
  43. 43. Evaluation Study 3 • Audit of the DCTP tool 300 forms Completed by nursing staff Use of jargon ‘Not applicable’ or ‘Refer to discharge letter’
  44. 44. Reflection 3rd study  Focus group AAU nursing and allied health staff Nurses using forms to communicate with aged care Allied health communicating directly **Defaulted to a nursing transfer form**  Suggested Discharge booklet Tick boxes when no action required Pack with community resources
  45. 45. Planning Study 3  AAU Working party  Consultation AAU staff Hospital individuals/groups  Booklet - Draft 1 AAU staff Expert panel  Booklet - Draft 2
  46. 46. Implementing Study 3  Booklet Draft 2 Piloted 3 weeks 425 AAU patients 54% received booklet (n=229)
  47. 47. Evaluating 3rd study  Audit  Patient/carer feedback  Staff focus group Inconsistent provision Overall favourable Most useful – Organisations – Contact numbers Few booklets had anything written  Booklet and process refined
  48. 48. Summary  AMUs are effective - manage acute illness + respond to pressure on health system  Patients with complex chronic health problems and recurrent symptoms (deteriorating trajectory)  Uncertainty + increasing limitation + emotional legacy of acute symptoms  Increased patient throughput in the AMU must be matched by enhanced communication - anticipated care needs and how to meet these  Team approach with role for Advanced Practice Nurse with gerontology and palliative care expertise
  49. 49. References Arendts, G, MacKenzie, J, Lee, JK. Discharge planning and patient satisfaction in an emergency short-stay unit. Emergency Medicine Australasia. 2009; 18:7-14. Dobrzanska, L, Newell, R. Readmissions: a primary care examination of reasons for readmission of older people and possible readmission risk factors. Journal of Clinical Nursing. 2006; 15:599-606. Downing, H, Scott, C, Kelly, C. Evaluation of a dedicated short stay unit for medical admissions. Clinical Medicine. 2008; 8:18-20. Juan, A, Salazar, A, Alvarez, A, Perez, JR, Garcia, L, Corbella, X. Effectiveness and safety of an emergency short- stay unit as an alternative to standard inpatient hospital admission. Emergency Medicine Journal. 2006; 23:833-837. Munshi, S, Lakhani, D, Ageed, A, Evans, SN. Readmissions of older people to acute medical units. Nursing Older People. 2002; 14:14-16. Scott, I, Vaughan, L, Bell, D. Effectiveness of acute medical units in hospitals: A systematic review. International Journal for Quality in Healthcare. 2009; 21:397-407. Slatyer, S, Toye, C, Popescu, A, Young, J, Matthews, A, Hill, A, Williamson, DJ. Early re-presentation to hospital after discharge from an acute medical unit: perspectives of older patients, their family caregivers and health professionals, Journal of Clinical Nursing. 2013; 22: 445-455. Westert, GP, Lagoe, RJ, Keskimaki, I, Leyland, A, Murphy, M. An international study of hospital readmissions and related utilization in Europe and the USA. Health Policy. 2002; 61:269-278. Williams, EI, Fitton, F. Factors affecting early unplanned readmissions of elderly patients to hospital. British Medical Journal. 1988; 297:784-787.
  50. 50. References Instruments 1. Folstein ,MF, Folstein, SE, McHugh, PR. “Mini Mental State”: A practical method for grading the cognitive state of patients for clinicians. Journal of Psychiatric Research. 1975; 12:189-198. 2. Collin, C, Wade, DT, Davies, S & Horne, V. The Barthel ADL Index: A reliability study. Int Disability Study. 1988; 10: 61-3. 3. Hunt, SM. Measuring health in clinical care and clinical trials. In Teeling-Smith, G. (ed) Measuring health: a practical approach. Chichester, UK: John Wiley; 1988. 4. Wenger, GC. Support networks of older people: A guide for practitioners. Centre for Social Policy Research and Development, University of Wales; 1994. 5. Attkisson, CC, & Zwick, R. The client satisfaction questionnaire: Psychometric properties and correlations with service utilization and psychotherapy outcome. Evaluation and Program Planning. 1982; 5: 233-7. 6. Pascoe, GC, & Attkisson, CC. The evaluation ranking scale: A new methodology for assessing satisfaction. Evaluation and Program Planning. 1983; 6: 335-47. 7. Bull, MJ, Hansen, HE, & Gross, GE. A professional-patient partnership model of discharge planning with elders hospitalised with heart failure. App Nsg Res. 2000; 13: 19-28.
  51. 51. Acknowledgements The AMU based clinicians who requested this study for their commitment to excellence and the improvement of patient care. The patients and family caregivers who so generously gave of their time and shared their experiences. Funded by Edith Cowan University Industry Collaboration Scheme
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