lorraine lovitt - clinical excellence commission - confusion and falls
TRANSCRIPT
Falls Prevention is everyone’s business®
Lorraine Lovitt
Lead, NSW Falls Prevention Program
Clinical Excellence Commission
Falls, Fractures & Pressure Injuries Management Conference
September 2015
Confusion and Falls
Created by nurses at Guy's and St Thomas' Barbara's Story is a series of 6 films which has changed attitudes to dementia in hospitals across the world – see complete video at: http://www.guysandstthomas.nhs.uk/news-and-events/2014-news/20140331-barbaras-story-youtube.aspx
Barbara’s Story
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Don’t let confusion cloud the risk of falls
• Confusion or cognitive impairment is a common condition for older people in hospital
• > 30% will develop confusion during an admission – commonly as a result of dementia and/or delirium
• Confusion is associated with increased adverse events including falls & death
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BE ALERT for patients with confusion
Some causes of acute confusion
• infection e.g. chest, urinary tract
• constipation / urinary retention
• effects of medications; drug/alcohol withdrawal
• pain
• dehydration, malnutrition
• anaesthetic/post operative
• being in unfamiliar surroundings – hospitals are busy and noisy
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Neuroscience Research Australia 2012
Medical Conditions
Stroke Incontinence Parkinson’s disease
Dementia Delirium
Medications
Psychoactives Four or more medications
Psychosocial & Demographic
History of falls Depression Advanced age Living alone ADL limitations Female gender Inactivity
Sensorimotor & Balance
Muscle weakness Impaired vision Reduced peripheral sensation Poor reaction time Impaired balance
Environmental
Poor footwear Home hazard External hazard Inappropriate spectacles
Falls
Risk factors for falls
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Why dementia & delirium contribute to falls
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• Muscle weakness, gait changes & poor balance
• Memory impairment
• Inability to problem solve & poor judgement
• Visual field changes
• Medications - especially psychoactive meds
• Other contributing factors to falls
– Agitation, restlessness, wandering, pain, hunger, thirst, loneliness and boredom
Because the person may forget:
• to “push the button to call the nurse”
• tubes ( IV’S & drains) are present
• to use recommended footwear
• to use their walking frame
• where the toilet is
• where they are and try to go home
Why dementia & delirium contribute to falls
Hospitalised older people with dementia
Common reasons for admission are:
• Falls-related injuries e.g. hip fractures & head injuries
(3 times as common)
• Infections e.g. UTIs, pneumonia
• Circulatory problems e.g. stroke, dehydration
Few people with dementia are admitted for dementia-related reasons
http://www.neura.edu.au/research/projects/trends-fall-related-
hospitalisations-persons-aged-65-years-and-over-nsw-1998-99-20
Harvey LA and Close JCT. Trends in fall-related hospitalisations, persons aged 65 years and over, NSW, 1998-99 to 2011-12. 2013.
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1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12
Ra
te p
er
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0,0
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po
pu
lati
on
Year
65-69 years (PAC 2.1%; 95%CI 1.6-2.7, p<0.0001)
70-74 years (PAC 2.2%; 95%CI 1.7-2.6, p<0.0001)
75-79 years (PAC 2.2%; 95%CI 1.8-2.6, p<0.0001)
80-84 years (PAC 2.5%; 95%CI 2.1-3.0, p<0.0001)
85+ years (PAC 3.3%; 95%CI 2.9-3.7, p<0.0001)
Figure 2.2: Fall-related injury hospitalisations by age group, persons aged 65 years and over, NSW, 1998-99 to 2011-12
Dementia in Australia
• 2012: 300,000 people with dementia
• 2050: 900,000 people with dementia
• >1200 new cases per week diagnosed
• At age 65: 1 in 12 people have dementia
• Approx 25,000 under age 65 with dementia
• Delaying onset of dementia by 5 years can halve the prevalence
AIHW 2012
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Australian Commission on Safety and Quality in Health Care (ACSQHC)
A better way to care
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A better way to care
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Standard CC: Comprehensive care
Standard RH: Reducing harm
Falls Systems are used to reduce the risk of consumers falling, and minimise harm from falls.
Cognitive impairment and delirium Systems are used to recognise and prevent delirium, and to manage risks of harm from cognitive impairment.
Pressure injuries Malnutrition and dehydration End-of-life care Challenging behaviours and self-harm
Review of RCAs and IIMS Data – Serious Incidents
Recommendations: • care planning of increased fall injury risk for
patients on anticoagulant therapies
• screening for delirium for all patients over 75
• promote nursing Essentials of Care Project components related to increased nursing time at the bedside, routine rounds and toileting to ensure patients’ basic needs are addressed
• fall risk management programs and policy include clear guidelines for post-fall management
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http://www.cec.health.nsw.gov.au/programs/qsa/qsa-reports-and-publications
“Management of delirium is very variable across wards, shifts, specialties etc. Delirium is managed well in the areas where we have aged care and psycho-geriatric services, unfortunately there are increasing numbers of frail elderly patients being admitted all over the district.” District level response
Recommendation
The Agency for Clinical Innovation (ACI) work with appropriate bodies such as the CEC, HETI and LHDs to develop and lead a comprehensive program for the prevention of delirium and appropriate management of patients admitted and diagnosed with delirium
Safer Systems Better Care: QSA Self Assessment Statewide Report 2011
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Facilitators for success
Leadership • Nursing • Empowered teams & accountability • Engagement with patients, families and carers • Whole of hospital targeting • Policy, knowledge information education and resources • Data: local ownership – circulated
Care of the older person in hospital Quality markers: falls, cognition, continence, pressure care,
medications and nutrition Integrated approaches to care Caring environments – design
Looking Forward
History of Falls – patients who have had a fall/present with a fall or fall in hospital are at in increased risk of falling again.
Preventing falls and harm from falls
Mental Status – patients who are confused are at an increased risk of falling & the cause of contusion needs to be investigated
Vision – patients with poor vision can fall as they are in unfamiliar environments
Toileting – patients with continence issues and/or are confused and/ or unsteady on their feet can fall attempting to get to the toilet or in the toilet area
Transfer and Mobility – patients can fall whilst being transferred or if they are unsteady and or have poor balance
Medications – patients who are on antipsychotics, antidepressants, sedatives/hypnotics or opioids are at an increased risk of a fall. Please note that if a patient is on anticoagulants they are at an increased risk of serious injury ( bleeding ) if they do fall.
Mental Status: 1. Is the patient confused? - Yes 2. Is the patient disorientated - Yes 3. Is the patient agitated? - Yes
If the answer is YES to any of these questions the person is at high risk of a fall.
The Falls Risk assessment and management plan will provide prompts for intervention.
Ontario Modified STRATIFY (Sydney Scoring) Fall Risk Screen
Falls Risk Assessment - FRAMP
Mental Status YES Mr Peters is CONFUSED prompts to do
Cognitive screen
Delirium Screen CAM
If your patient is confused Action is required
Investigate confusion and treat underlying
Assess cognition - cognition screen (e.g. AMTS) Screen and assess for delirium CAM (Confusion Assessment Method)
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CONFUSION ASSESSMENT METHOD (CAM) The CAM is a validated tool to be used in assisting with the differential diagnosis of Delirium. It should be used for any older person who appears to be disorientated / confused or who has any change in behaviour or LOC. It is important that the CAM is used in conjunction with a formal cognitive assessment (e.g. AMT/ SMMSE), good clinical and medical assessment, together with baseline cognition information from carers/family or the community or residential aged care service
1 Acute onset and
fluctuating course No Yes
Uncertain,
Specify: ____________
Is there evidence of an acute
change in mental status from
the patient’s baseline?
If so, did the abnormal
behaviour fluctuate during
the day?
e.g. tend to come and go,
or increase and decrease
in severity
2 Inattention No Yes
Uncertain,
Specify: ____________
Did the patient have
difficulty focusing attention
during the interview?
e.g. being easily
distracted, or having
difficulty keeping track
of what was being said?
3 Disorganised
thinking No Yes
Uncertain,
Specify: ____________
Was the patient’s thinking
disorganised or organised?
e.g. Rambling or
irrelevant conversation,
unclear or illogical flow
of ideas, or unpredictable
switching from one
subject to another?
4 Altered level of
consciousness No Yes
Uncertain,
Specify: ____________
Overall, how would you rate
the patient’s level of
consciousness?
Altered e.g. Vigilant,
Lethargic, Stupor, Coma,
Uncertain.
Delirium is present if features 1 and 2 AND either 3 or 4 are present
Delirium symptoms: not present / present Date: / /
Medical Officer notified? Yes / No
Cognition Screen Delirium Screen CAM
Confusion Assessment Method (CAM) • The Confusion Assessment Method (CAM) screens for
the presence of delirium.
• The ‘short version’ of CAM considers that a diagnosis of delirium is likely if the following are present: – acute onset and fluctuating course, and – inattention, and – either disorganized thinking or an altered level of
consciousness.
• Untreated delirium frequently results in adverse events & long term effects and every effort must be made to determine the underlying cause(s).
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Care of Confused Hospitalised Older Persons (CHOPs) Program
Anthea Temple Project Officer ACI
Cath Bateman Project Officer ACI
Results shown in this presentation are preliminary
Measures
• Pre Implementation systems Audit
• Environmental Audit
• Medical record Audit
• Staff knowledge and care confidence survey
• Staff and Carer focus groups
• IIMS data
• Delirium coding data
CHOPs Confusion is Identified, investigated, treated and
appropriately managed
Hospitals provide safe and supportive environments
Older people are cared for by staff that have the right
knowledge, skills and attitudes
Partnership with carers and person centred care are
key aspects of quality care
Strategies and clear leadership roles are in place to
deliver efficient and effective care for confused older people in hospital
ed Health Network
Gosford
Lismore
Prince of Wales
Phase 2 sites Hornsby
Orange
Wollongong
Broken Hill
Phase 3 sites Coffs Harbour
Maitland
Fairfield
Nepean/Springwood
Canterbury
Phase 1 sites
Implementation resources
Interesting findings
• 47% were confused
• 18% patients were admitted due to a fall
• 21/35 patients fall or # at one site
• Of those who were confused 63% had their confusion mentioned in their d/c Summary
• 57% * coded for dementia/delirium (*1 site not inc)
• 6% mortality (whole sample)
Results shown in this presentation are preliminary
Cognitive screening
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
On admission 24Hrs Total
Results shown in this presentation are preliminary
Risk screening
0%
10%
20%
30%
40%
50%
60%
70%
80%
DRAT PU Falls Nurtition
Results shown in this presentation are preliminary
Assessment
0 NOT CONFIDENT
10 VERY CONFIDENT
Staff knowledge & attitude survey
Total of 503 Staff surveyed • 61% nursing • 25% allied health • 12% medical
Results shown in this presentation are preliminary
Staff stress in management
0 NOT CONFIDENT
10 VERY CONFIDENT
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Risk identification solutions
Why are confused older people falling?
Environment is different from home
Why are confused older people falling?
Press here!
the toilet is much easier to see with green seat and lid
Why are confused older people falling?
Visual changes – can’t see the toilet
Communication
• A patient who is confused may not remember who you are or where they are: – introduce yourself – inform them they are in the hospital – let them know what you are doing
• Engage with patients family/carer – they will identify if behaviour/confusion is usual or fluctuating
T
O
P
5
Talk to the Carer
Obtain the information
Personalise the care
5 strategies developed
http://www.cec.health.nsw.gov.au/programs/partnering-with-patients#TOP5
Engage with families/carers
36.4% reduction in falls by patients with dementia by the sixth month of using TOP 5
Dot can’t sleep and gets very agitated if she doesn’t wear socks to bed.
If she walks in just socks she’ll probably fall so please remind her to put
shoes on when she gets up.
Dot always goes to the toilet about 5am. If she tries to go on her own she
might fall but she’ll never press the buzzer (she doesn’t like to “be a
bother”). Please be ready to go with her at 5am.
Make sure Dot has her handbag on her lap. If she can’t see it she’ll look
for it under the bed and has fallen like this before.
Dot is often restless in the afternoon and tends to wander but she is very
unsteady on her feet. She always used to walk the dog in the afternoon.
Tell her she doesn’t need to walk the dog today and she’ll sit down
again.
Top 5 - Carer’s Tips
What affects quality in health care?
The level of quality in hospital environments is affected by:
• (1) the quality of technical care;
• (2) the quality of interpersonal relationships;
• (3) the quality of hospital amenities and the environment
(Potter et. al, 1994. Int J of Health Care Qual Assur, Vol 7, pp.4–29).
High performing organisations
Hospitals with high levels of ‘patient care
experience’ reported by patients provide clinical
care that is higher in quality across a range of
conditions.
Jha A et al (2008) N Engl J Med 2008; 359:1921-1931.
Overview of the evidence • Refocusing care delivery around the patient • Improves patient care experience....
• Improves clinical and operational-level outcomes: – improved patient adherence
– fewer medication errors
– decreased adverse events – including falls
– improved staff satisfaction
– enhanced staff recruitment
– decreased length of stay
– decreased ED return visits
Staff can reduce patients risk of a fall
• Minimise background noise and distractions - unsettling
• Leave a night light on to guide to the bathroom
• Encourage night time sleep by reducing noise and minimising disturbance and reducing day time napping
• Ensure personal care needs are met e.g. regular toileting and assistance with meals as required.
• Provide assistance when walking as balance and strength may to be affected
• Talk to family and carers about the usual routine at home e.g. likes to shower after dinner and reads the paper after breakfast each morning
Engage with families/carers
• Place familiar objects where they can be seen e.g. photographs
• Provide personal information about the patient e.g. what they like to be called, tips for care e.g. likes, dislikes and whether an interpreter is required
• Have family or a familiar person spend time in hospital with the patient
CEC Flyers for family and carers
www.cec.health.nsw.gov.au/programs/falls-prevention/falls-one-page-flyers
PET (patient/carer experience trackers)
Education solutions
CHOPs Resources
CHOPs Tearoom
http://dementiacare.health.nsw.gov.au/courses/course/view.php?id=24
NSW Falls Prevention Network Network list serve Newsletters & updates Annual Network forum – NSW, 22 May 2015
http://fallsnetwork.neura.edu.au
Clinical Excellence Commission
http://www.cec.health.nsw.gov.au/programs/falls-prevention
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For further information:
www.cec.health.nsw.gov.au
Acknowledgements • Mark Howland & Fran Dumond, HNE LHD • Anthea Temple & Cath Bateman ACI, CHOPS • CEC April Falls Working Group