Evidence of HELP Effectiveness

Hamilton Health Sciences HELP Workshop, December 10, 2013

Ontario Context: Why HELP?

• Aging population- 14.2% at present, 23.6 % by 2036

• Excellent Care for All – patient experience

• Provincial Senior Friendly Hospital Initiative- delirium and functional decline indicators

• Fiscal Environment 2

Common Geriatric Syndromes

Fx decline, Falls

Polypharm

DeliriumDementiaDepression

Malnutrition, dehydration

Shared Risk Factors Geriatric Syndromes

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Shared risk factors – older age, cognitive impairment , functional impairment and impaired mobility Inouye S. et al. J Am Geriatr Soc. 2007 May; 55(5): 780–791.

Before HELP: The Yale Geriatric Care Program

OBJECTIVE: • A nursing-centered intervention to prevent functional decline

among hospitalized elderly medical patients.DESIGN: • Prospective matched cohort study on medicine wardsPATIENTS: • 216 patients aged ≥70 years (85 intervention and 131 control

patients).INTERVENTION: • identification and surveillance of frail older patients, twice-

weekly rounds of the Geriatric Care Team, and a nursing educational program.

RESULTS: reduction in functional decline in high risk from 64% in controls to 41% in the intervention group

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Inouye, Sk et al, A controlled trial of a nursing-centered intervention in hospitalized elderly medical patients: the Yale Geriatric Care Program.. J Am Geriatr Soc. 1993;41(12)

Yale Geriatric Care Program- Resources

• 2-4 Geriatric Resource Nurses- ward staff with extra training

• CNS , Gerontology

• Geriatrician

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The Yale Geriatric Care Program: Challenges

• initial difficulties with recruitment and retainment of geriatric resource nurses (due to high nursing turnover and the increased time commitment required),

• breakdown in communication and carryover of recommendations between nursing shifts,

• and obstacles to communication between the nursing and medical staff.

• compliance 7

Yale Delirium Prevention Trial, 1999

• Controlled intervention trial

• N= 852 admissions to acute medical wards

• Standardized protocols targeting delirium risk factors:

• Cognitive Impairment

• Sleep Deprivation

• Immobility and new onset functional deficit

• Vision Impairment and Hearing Impairment

• Dehydration Inouye SK, et al. N Engl J Med 1999;340:669-76

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Elder Life Program Interventions

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•Reality orientation

•Therapeutic Activities Program

Cognitive Impairment•Visi

on/Hearing Aids

•Adaptive Equipment

Vision/Hearing Impairment

•Early Mobilization

•Minimizing immobilizing equipment

Immobilization

•Nonpharmacologic approaches to sleep/anxiety

•Restricted use of sleeping medications

Psychoactive Medication Use

•Early recognition

•Volume repletion

Dehydration

•Noise reduction strategies

•Sleep enhancement program

Sleep Deprivation

Risk Factors Intervention

HELP Resources

• Elder life Specialist

• Volunteers - 3 x day, 7 days week

• Elder life Nurse Specialist

• Geriatrician

• Administrative support

The Hospital Elder Life program (©2000,Sharon K. Inouye,MD,MPH)10

Yale Delirium Prevention Trial

• Significant reduction in the development of delirium (9.9% of intervention patients vs. 15% of usual care patients, odds radio = 0.60, P=0.02).

• Significant reduction in total number of days with delirium (105 vs. 161 in usual care, P=0.02).

• Significant reduction in functional decline and nursing home placement

Inouye SK, et al. N Engl J Med 1999;340:669-76 11

Other Hospital Elder Life Program Interventions

• Geriatric nursing assessment and intervention• Interdisciplinary rounds• Geriatrician consultation• Interdisciplinary consultation• Provider education program• Community linkages and telephone follow-up

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The Hospital Elder Life Program (©2000,Sharon K. Inouye,MD,MPH)

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Delirium Prevention Trial: Significance

• First demonstration of delirium as a preventable medical condition

• Targeted multicomponent strategy works• Significant reduction in delirium and total delirium days• No significant effect on delirium severity or recurrence• Primary prevention of delirium likely to be most

effective treatment strategy• Effectiveness and cost-effectiveness of the program has

been demonstrated in multiple studies.

The Hospital Elder Life Program (©2000,Sharon K. Inouye,MD,MPH)

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HELP Websitehttp://hospitalelderlifeprogram.org

• How to materials: HELP manuals, videos • Educational materials: on acute hospital care and

delirium in older persons for consumers, families, caregivers

• Reference list: brief list by topic; comprehensive searchable bibliography

• HELP: general background information and study results

The Hospital Elder Life Program (©2000,Sharon K. Inouye,MD,MPH)

Sustainability of HELP:Will HELP Work in Other Settings?

The Hospital Elder Life Program (©2000,Sharon K.

Inouye,MD,MPH)

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HELP at Shadyside -UPMC

• Shadyside -500 bed community hospital in Pittsburgh• Delirium rate: pre HELP 2001: 46% 2008: 18%• 2011 –Hospital acquired delirium: less than 4%• LOS decreased, delirious and non delirious patients• Total patients served: 2008: 7,000 on 6 units• Paid staff 7.6, 107 volunteers, 4 medical units, 1 orthopedic unit, 1

neurosurgical• Cost savings $2,031,440 annually

Rubin FH (2011) J Am Geriatr Soc.

HELP in Taiwan

Modified hospital elder life program Design:• 2200 bed urban hospital , Pre-post comparative• 3 HELP interventions (mobility, nutrition and cognitive activities) delivered

by a study nurseParticipants: • 77 usual care, 102 HELP intervention abdominal surgical patients,

matchedMeasures: • change in ADL, nutrition and cognitive status from admission to discharge Outcomes: • Delirium rate HELP group (0%); control group (16.7%) (p < 0.001).• ADL and nutritional decline: HELP group < control (p < 0.001)

Chen, C. et al. Nursing Research, 61(2), 2012

HELP in Australia

Stage 1 Design: Population– Stage 1 pre/post study on one ward: 21 patients usual

care, 16 pts HELP interventions delivered by volunteersStage 1 Outcome:

– Delirium rate: HELP 6.3%; control 38% (P = 0.032)Stage 2 Design:

– Expanded to 5 wards - sitter use as decreased by 314 hours/month

Stage 2 Outcome:– Cost savings: $129,186 annually

.Caplan GA. Recruitment of volunteers to improve vitality in the

elderly: the REVIVE study. Intern Med J. 2007 Feb;37(2):95-100

HELP in Spain

• Controlled intervention study• 542 medical pts, age 70 +, at risk• Usual care and HELP interventions • Interventions = educational and HELP clinical protocols • delivered by nurses, residents and physicians with a

CNS monitoring and prompting compliance • Outcomes: delirium 11.7% HELP; 18.5 % usual care,

P=0.005,• Functional decline: 45.5% HELP, vs 56.3% in UC, P=.03• 75% adherence

Vidan, M., An Intervention Integrated into Daily Clinical Practice Reduces the Incidence of Delirium During Hospitalization in Elderly Patients JAGS 57:2029–2036, 2009

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France: Confucius Study Protocol

• DESIGN Stepped wedge cluster randomized trial• SETTING 3 surgical wards, 3 university hospitals

in France (N,360)• INTERVENTION: Mobile geriatric teams + some

HELP protocols (sensory and orientation) + staff education + case review of delirium

• OUTCOMES to be measured; delirium rate and severity, LOS, morbidity, mortality

20Mouchoux, C. et al., BMC Geriatrics, 11(25), 2011

HELP at Trillium Health Center Mississagua, Ontario

• Study Design: Retrospective Cohort within context of a Quality Improvement (QI) Model

• Control Group – Usual Care: N=72,admitted to medicine within 12 months before HELP

• Study Group ‐ HELP: N=141 Patients on medicine who met HELP program criteria and participated in program interventions.

• Results: Delirium rate 22% before HELP, 7 % after Discharged home: 7% more Mortality: 11% lesshttp://www.gerontario.org/documents/B4%20Prevention%20of%20Delirium%20and

%20Functional%20Decline%20Among%20Hospitalized%20Elder%20Patients.pdf

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Potential for HELP in Long Term Care

OBJECTIVES: To identify potentially modifiable environmental factors and patient vulnerability associated with severity of delirium symptoms

DESIGN: Prospective, observational cohort study.SETTING: Seven long-term care (LTC) facilities, Montreal • Two hundred seventy-two LTC residents over 65 MEASUREMENTS: Weekly assessments (for up to 6 months) of

the severity of delirium symptoms using the Delirium Index (DI), environmental risk factors, and number of medications and baseline vulnerability

McCusker,J , Environmental Factors Predict Severity of Delirium Symptoms in LTC Residents with and without Deliirum . JAGS

61:502–511, 2013

Results continued RESULTS: Six potentially modifiable environmental factors predicted weekly changes

in Delirium Index • absence of reading glasses• aids to orientation• family member • glass of water • presence of bed rails and other restraints • prescription of two or more new medications• Residents with dementia appeared to be more sensitive to the effects of

these factorsCONCLUSION: • Six environmental factors and prescription of two or more new

medications predicted changes in the severity of delirium symptoms.

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Could Family Deliver HELP interventions?

Descriptive , feasibility intervention study of family delivery of HELP protocols

15 patient/family caregiver dyads (42 approached), on HELPProtocols and completion rates: orientation protocol (83.52%)vision protocol (81.48%), therapeutic activities protocol (76.92%,),hearing protocol (73.58%)early mobilization protocol (55.29%)Barriers and Enablers: partnerships, therapeutic

relationships , environment J 24Rosenbloom-Brunton DA et al Gerontol Nurs. 2010 Sep;36(9):22-33;.

Family Delivering Delirium Prevention Strategies in Chile

OBJECTIVE: assess the efficacy of family intervention to prevent delirium

METHODS: • 287 hospitalized patients at intermediate or high risk of

developing delirium• randomized to receive a non-pharmacological intervention

(orientation, sensory support) delivered by family members (144 patients) or usual care (143 patients).

RESULTS: delirium rate • 5.6% in the intervention group; 13.3% in the control group • (relative risk: 0.41; confidence interval: 0.19-0.92; P = 0.027)CONCLUSION: • non-pharmacological prevention of delirium delivered by family

members reduces delirium risk25Martinez FTAge Ageining 2012 Sep;41(5):629-34. 2012 May 15.

Preventing delirium in an acute hospital using a non-pharmacological intervention.

Challenges and Predictors of Success

Challenges in New Program Implementation

Strategies for Addressing Challenges

1. Gaining internal support for the program

•Identify key constituents •Develop and target individualized messages

2. Ensuring Effective clinician leadership

•Identify clinical leaders with credibility with in the hospital•Retain clinical leaders with adequate time and budget

3. Integrating with existing geriatric programs

•Sharing of resources•Emphasis on complementing rather than competing

26Bradley et al, JAGS 2004;52: 1875-1882

Bradley: Survey of 9 US hospitals implementing HELP

Challenges and Predictors of Success

Challenges in New Program Implementation

Strategies for Addressing Challenges

4. Balancing Program fidelity with hospital –specific circumstances

•Implementing program as designed originally - include all interventions

5. Documenting and publicizing positive outcomes

•Gather and summarize data•Use language that is relative to audience•Present data regularly

6. Maintaining Momentum •Manage expectations – implementation may take more than one year•Plan for staff turnover

27Bradley JAGS 2004;52: 1875-1882

Could HELP work with fewer staff resources?

• Who in your setting could recruit, train and schedule volunteers?

• Is there someone else who can deliver on the interventions?

• Who could screen and enroll patients? Could they be identified automatically on admission?

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Ontario HELP Uptake

• Ontario HELP Network-22 sites -quarterly teleconference to share ideas, data and challenges

• Waterloo-Wellington LHIN is supporting five sites to start HELP

• Trillium and HHS are piloting Family HELP interventions

• Small hospitals report challenges in resources needed for HELP start up

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