Improving ED Admission processes for Older Patients – Early

Admission Pathway under Geriatrics

Elise Tcharkhedian

Senior ED/ASET Physiotherapist

Liverpool Hospital

SWSLHD

Initial trial as delirium pathway in 2011

Aim: to improve recognition, management and outcomes of older people with delirium

Under recognition and misdiagnosis can result in inappropriate or delays to appropriate treatment

Department of Geriatric Medicine and ASET concerned regarding impact of “usual” system of admission and lengthy stays in ED worsening agitation, confusion and outcomes in patients with delirium

Delirium guidelines were also promoting change

History

10% Australians >70yrs have delirium on admission to hospital, and further 8% develop during hospital stay (Travers et al 2013)

14.6% principal diagnosis delirium of patients admitted under Geriatric Medicine, Liverpool Hospital

Delirium missed by ED medical staff in 76% cases (Han & Zimmerman 2009) – then usually not dx by admitting medical staff (due to fluctuating nature, variable presentation, overlap with dementia and need for clinical diagnosis)

Lack of recognition and under-detection further impacts outcomes with 7x increased risk of mortality associated with missed delirium at admission (O’Keefe & Lavan 1999)

Extent of problem

Developed by Senior Medical staff from Department of Geriatric and Emergency Medicine, and ASET

Patients identified with delirium after triage by ASET staff (using CAM)

Rapid Identification of Delirium and Accelerated Admission Pathway

7 pathway patients significantly shorter stay in ED with median time 6.8 hrs (cf 12.1 hrs)

1 (14%) pathway pt had CRC/MET call cf 4 (21%) in control group in first 48 hrs

Significant difference in need for behavioural intervention – no pathway patient required intervention in first 48 hrs cfcontrol group where 1 (5%) required physical restraint, 5 (26%) had antipsychotic meds and 8 (42%) required 1:1 nursing care

57% admitted on pathway were reviewed by Geriatrician on day of admission cf 9.5% in control group

Initial outcomes – Delirium pathway December 2010 pilot

Following review, pathway reintroduced

First 6 months – 40 patients assessed

32 admitted via pathway

Preliminary results show for 26 patients with data, median time from triage to ASET review was 1.7 hours and for 22 patients with data median time from triage to admission was 3.4 hours

Pathway reintroduction July 2012

Pathway expanded in February 2013 to assist identifying other patients suitable for accelerated admission under Geriatric Medicine

Expansion of Pathway

Reduce LOS of targeted older adults in Liverpool ED

Improve access to timely quality healthcare (Rx commenced in ED)

Improve admission processes in ED to provide smooth transition to the Aged Care Unit

NEAT

Aim

Meets MET or clinical review criteria

More appropriate for another pathway (eg sepsis, #NOF)

Needs care by another speciality (eg cardiology)

Requires 6L or >oxygen

Chest pain or syncope or requires cardiac monitor or acute ECG changes

Guidelines – Exclusion Criteria

Delirium

Acute changes in mental state, concentration, behaviour

1-2 features and known dementia/delirium

Identified using CAM

Dementia

Presentation due to behavioural problems secondary to dementia

Exclusion: severe psychosis, aggression including violence

Guidelines – Inclusion Criteria

Falls

Increased falls

Would benefit from comprehensive geriatric assessment, medication rationalisation and MDT involvement

Exclusion: falls due to syncope, seizure or acute stroke, or injuries requiring operative management eg #NOF

Guidelines – Inclusion Criteria

Functional Decline

Acute deterioration in mobility or ability to perform ADLs (days, weeks) with a pre-existing history of functional impairment

Guidelines – Inclusion Criteria

Residents from nursing homes

Moderate to severe delirium

Recent or increasing falls

Acute changes in behaviour, function, appetite with unclear cause

Polypharmacy issues associated with need for admission

Guidelines – Inclusion Criteria

Older person at risk

Concern regarding elder abuse eg psychological, financial, physical, sexual, neglect

Unexplained malnutrition

Guidelines – Inclusion Criteria

Continuity of care

Admitted under Geriatrician in last 28 days and presenting with similar issues

Guidelines – Inclusion Criteria

Early Notification Pathway Mon-Fri 0830-1600

Triaged

Identified by ASET

Notification of admission – EDSS, ED NUM, Geri Reg, Bed management

Investigations commenced, medication chart written

Transfer to CB5A or 5B (Aged Care Unit)

Process

1. Bloods (INR if on warfarin)

2. CXR

3. ECG

4. UA and MSU – Bladder Scan

Standard Investigations

Delirium/Functional Decline

Troponin, blood cultures

Falls

Troponin, postural BP, CK if long lie/on statin medication

Appropriate xrays as indicated

Additional Tests

History of fall with head injury eg witnessed/reported head injury, evidence of head injury

History of fall but unclear if head injury & on anti-coag/ anti-platelet

New focal neurological signs

Increased confusion with fall in last 2 weeks

Reduced level of consciousness or GCS<9

Cerebral CT GuidelinesPATIENTS WHO NEED A CT PRIOR TO LEAVING ED

History of a fall, no head injury and not on anti-coag

No other cause identified for delirium following history, examination and review of standard delirium investigations

Cerebral CT GuidelinesPATIENTS WHO MAY REQUIRE CT (IF CLINICALLY

APPROPRIATE) WHICH CAN BE ORGANISED FROM THE WARD

March-July 2013

Analysis of patients admitted through Early Admission Pathway

Overall Mar Apr May June July

no. pts 37 16 4 10 5 2

met NEAT 10 7 1 1 0 1

Triage to ward

Mean (SD) mins 514+/- 319

Median in min 414 (241-631)

Hosp LOS

Mean in days 12.4+/-11.6

Median in days 8.5 (5-15)

Late arrivals outside pathway hours

Patients too sick

Bed block

Staff changes – continual education++

Reliant on ASET staffing

Barriers to Implementation

Geriatics Department Liverpool Hospital – particularly Dr Angela Khoo and Dr Rinaldo Gonzales

ASET Team Liverpool Emergency Department –particularly Margaret Moseley, ASET CNC

Acknowledgements

Travers C, Byrne G, Pachana, N, Klein K, Gray L. Delirium in Australian hospitals: a prospective study. Current Gerontology and Geriatrics Research. 2013;2013:ID284780

Han JH and Zimmerman EE. Delirium in older emergency department patients: recognition, risk factors and psychomotor subtypes. Academic Emergency Medicine.2009;16:193-200

O’Keefe ST and Lavan JN. Clinical significance of delirium subtypes in older people. Age and Ageing. 1999;28:115-119

References