IMPROVING CARE FOR OLDER PEOPLE

IMPROVEMENT PLANNING AND ENGAGEMENT EVENT

26 FEBRUARY 2014

IMPROVING CARE FOR OLDER PEOPLE

IMPROVEMENT PLANNING AND ENGAGEMENT EVENT

Reflecting on our journey............

Karen Goudie - National Clinical Lead

Michelle Miller - Improvement Advisor

Healthcare Improvement Scotland

Critical Assimilation and Analysis

Evidence + Inspection Themes + Expert Opinion = Focus

“THINK DELIRIUM”

Engagement with Scottish Delirium Association + Delirium Sub-group formed

Improvement Support: Early Management of Delirium

WHERE WERE WE IN 2012?

“Improving Care for Older

People in Acute Care by 2014”

WHAT WE HEARD AT THE START....

What is delirium?

Limited screening for

delirium.......

which tool to use?....

How do we best

manage someone

with delirium?

How do we best

involve families?

CARE OF INDIVIDUALS

A YEAR ON....WHERE WERE WE IN APRIL 2013

Initial test sites identified

TIME Delirium Care Bundle ready for testing....

Adaptations to the Bundle – checklist developed

Interviews with patients, families and staff

#TIMEBUNDLE

4AT WITH TIME BUNDLE

REPEAT SCREEN

Raising awareness of delirium

Testing of tools in 9 NHS Boards

Growing clinical engagement (120 people today)

Published: Report on experience of patients, staff and families

Series of clips frailty and delirium

Education Poster and SDA Pathway

Information Leaflet

Resource Toolkit (available early April)

Learnpro modules (NHS Education for Scotland)

Data and Flash reports to show improvement/progress

Building connections with other programmes to share good practice and streamline

measurement activity

Supporting local and national improvement as part of the quality improvement cycle

WHERE ARE WE NOW...

IMPROVING CARE

Improving compliance - identification of delirium and testing care bundle

NHS Borders

NHS Highland NHS Greater Glasgow & Clyde

NHS Tayside

NHS Forth Valley

TEST SITE DATA

< 8/10 4AT completed

0

1

2

3

4

5

2.12.13

09.12.13

16.12.13

23.12.13

30.12.13

06.01.14

13.01.14

20.01.14

27.01.14

03.02.14

NHS Borders – Compliance with 4AT

SHARING OUR RESULTS.. MORE DATA

Pilot commenced

All pts 75 + 4AT completed

All pts 75 + 4AT completed

All pts 75 + 4AT completed 15 out of 16 pts

screened O/A 10 out of 11 pts screened O/A

0

10

20

30

40

50

60

70

80

90

100

Jul-13

Aug-1

3

Sep-1

3

Oct-

13

Nov-1

3

Dec-1

3

Jan-1

4

% c

om

pli

an

ce

Delirium Screening

NHS Highland – 4AT

SHARING OUR RESULTS.. MORE DATA

0

10

20

30

40

50

60

70

80

90

100

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

#N

/A

Pe

rce

nt

co

mp

lia

nce

Delirium Bundle: Element Compliance

Think abut possible triggers

Investigate

Manage

Explain

NHS Highland – Compliance with bundle

TESTING TO DATE.. A&A • National Measures:

1.% patients cognitively screened on admission >65yrs

2.% compliance with TIME bundle

3. time taken to implement TIME bundle

• Local Measures

4.reduction of psychotropic medication on discharge

5.reduction in falls

6.reduction in pressure ulcers

7.reduction in V & A incidents

8.reduction in average LOS

0

10

20

30

40

50

60

03

-Feb

-14

10

-Feb

-14

17

-Feb

-14

24

-Feb

-14

03

-Mar

-14

10

-Mar

-14

17

-Mar

-14

24

-Mar

-14

31

-Mar

-14

07

-Ap

r-1

4

14

-Ap

r-1

4

21

-Ap

r-1

4

28

-Ap

r-1

4

05

-May

-14

12

-May

-14

19

-May

-14

26

-May

-14

02

-Ju

n-1

4

09

-Ju

n-1

4

% c

om

plia

nce

Patients >65 who have had a 4AT on admission to ST 16

GOLDEN JUBILEE

compliance with AMT4 in patients > 65 years in orthopaedic surgery admissions

0

10

20

30

40

50

60

70

80

90

100

19/03/13

03/04/13

08/04/13

15/04/13

22/04/13

29/04/13

06/05/13

13/05/13

20/05/13

27/05/13

03/06/13

10/06/13

17/06/13

24/06/13

16/01/14

date

pe

rce

nta

ge

Linear (Subgroup)

Measure

NHS GREATER GLASGOW & CLYDE

BEHIND EVERY DOT..... IS A PERSON

JOEY HEPBURN

TWENTY (ONE) TIPS FOR JUNIOR DOCTORS

BENEFITS OF THE APPROACH

RESULTS FROM NHS FORTH VALLEY

Linda Wolff

Consultant Psychiatrist

NHS Forth Valley

Preventing and Improving Delirium in Patients over 65 with

hip fracture.

Improving care for older people in acute care Team Flash report

Keep in touch

Results so far Meet the team

Lessons Learned

1 5 4 3 2

Team Assessment Scale

See overleaf for information on scale

Staff Training Delirium management protocol Delirium Care Bundle Cognitive assessment pathway – tests of change Run charts Improved ward signage Repeat Staff questionnaire Carer revisited ward

Contact linda.wolff@nhs.net.

2 charge nurses orthopaedic ward and rehab ward Geriatrician Advanced nurse practitioner Physiotherapist Quality Improvement advisor Consultant psychiatrist Orthopaedic surgeon SETTING: acute orthopaedic unit

Contributing to the National Improving Care for Older People workstream at HIS

COGNITIVE ASSESSMENT PATHWAY FOR HIP FRACTURE PATIENTS ≥ 65

PROTOCOL Step Assessment Planned Intervention

Step 1

Detection of

those at

risk

Assess all patients over 65 being

admitted to the ward for cognitive

impairment with in 24 hours using the

AMT 10

FOR ALL PATIENTS WITH AMT <9:

follow steps 2-5

AMT 10 to be carried out as

per flow chart

Patients with Dementia

Diagnosis to be offered

Butterfly Scheme

Step 2

Assess those

at high

risk of

delirium

Assess for delirium using CAM

DAILY

Consider Adults with Incapacity (AWI)

Daily CAM to be done by

trained ward staff on

patients with AMT <9

Step 3

Communicati

on with

carer

Nursing staff:

Check usual cognition

Check usual drugs

Ask about alcohol

If appropriate give information about

delirium

Use “This is me”

Nursing/ AHP

( Comfort check

list)

Maximise effective

communication – ensure patient

has hearing aid and glasses

Reassure patient

Ensure good nutrition

Ensure good Hydration- fluid

intake minimum1Litre/ 24 hours

Ensure pain relief - use Abbey

Pain Scale

Avoid catheters but consider

retention/ bladder scan

Avoid constipation

Maintain sleep pattern- quiet

ward

Mobilise from 1st day post op

Use Butterfly when

appropriate

Nurses use Abbey Pain

Scale

Involve carers

Use ‘This is Me’

All ward staff:

Environment

Ensure:

day/ night cycle maintained

signage

clocks

calendar

Avoid loud noises

Signage for toilets and

orientation

Step Assessment Planned Intervention

Step 4

Management of

delirium

If CAM + document Delirium diagnosis

in casenotes

Investigate cause of delirium and

treat according to guidance

Doctors follow Guidance for

investigation and treatment

of delirium

Doctors Document delirium in case notes

Complete AWI documentation if

appropriate

Medication review:

oCheck Carer info/med

reconciliation

Avoid sudden drug withdrawal- benzo/

alcohol

Ensure pain relief

Avoid anti-cholinergic

Avoid sedation

If distressed or psychotic start with

haloperidol 0.25mg bd up to 2mg in 24

hours. Review daily

Avoid constipation

Investigate and treat fever

Doctors follow ward delirium

guidance

Follow analgesia Guidance

Use Butterfly when

appropriate

Step 5

Monitor

Response

Repeat CAM daily- 2 or more

negative CAM suggests

improvement.

Consider repeating AMT10 to

indicate progress.

If distress persists, refer to OAP

Liaison service

Document in clinical

notes

Step 6

At discharge

Ward Doctor: ensure discharge

document mentions delirium code

diagnosis, mention risk factor for

dementia and advise follow up of

cognitive impairment- CMHTE or

GP

Prompt ward doctors

DELIRIUM BUNDLE

1.CAM completed

2.1L fluid in first 24 hours

3. Analgesia prescribed and given

4. Up to sit within 24 hours

5. Delirium documented Discharge letter

All or nothing

JULY 2013 - 24 PTS

• 66% AMT10

• 62% of those had AMT <9

• 9/10 had a CAM performed

• 33% of those CAM +ve

• AWI challenges

0%

18%

40%

32%

17%

55%

64%

33% 36%

50%

75%

100%

0%

50%

20%

0%

40% 40%

60% 60%

20%

40%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Nov 1

1

Dec 1

1

Feb 1

2

Mar

12

May 1

2

Jul 12

Sep 1

2

Feb 1

3

Apr

13

Jul 13

Aug 1

3

Jan 1

3

Apr

13

May 1

3

Jun 1

3

Jul 13

Aug 1

3

Sep 1

3

Oct 13

Jan 1

4

AMT10 and CAM Compliance

AMT10 %

compliance

0

10

20

30

40

50

60

70

80

90

100

Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

Perc

en

tag

e c

om

plian

ce

Measure 1: CAM Done

2 CAM in first

48 hours

CAM daily since

admission to ward

until 2 consecutive

negative CAM

2 CAM completed in

48 hours of AMT10

CAM daily until 2

consecutive -ve CAM

CAM Daily since

admission to ward for

first 7 days

0

10

20

30

40

50

60

70

80

90

100

Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

Perc

en

tag

e c

om

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ce

Measure 2: Fluid chart shows intake greater than 1 litre every 24 hours

Fluid chart shows

intake greater than 1

litre every 24 hours

until 72 hours post op

Fluid intake

shows greater

than 1 litre in 24

hours

0

10

20

30

40

50

60

70

80

90

100

Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

Perc

en

tag

e c

om

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an

ce

Measure 3: Regular analgesia prescribed according to protocol and given i.e. on Kardex

Regular analgesia

prescribed and given

i.e. on Kardex

Dihydrocodine or

other opiate

(oramorph or

oxycodone)

prescribed

regularly and

given i.e. on

Kardex

0

10

20

30

40

50

60

70

80

90

100

Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

Perc

en

tag

e c

om

pli

an

ce

Measure 4: A minimum of up to sit in a chair within 24 hours of surgery

0

10

20

30

40

50

60

70

80

90

100

Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

Perc

en

tag

e c

om

plian

ce

Measure 5: Diagnosis or suspicion of delirium

has been documented

Not

Coding on discharge

documentation contains

delirium and advises GP

Diagnosis of

delirium is

documented in the Diagnosis of

delirium is

documented in

the casenotes

by a doctor

0

10

20

30

40

50

60

70

80

90

100

Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

Perc

en

tag

e c

om

plian

ce

Composite Measure: Have all 5 measures been achieved for this patient?

Unavailable

STAFF QUESTIONNAIRE 2011

• Confident in identification

• Confident in detecting pain

• Confident in communicating

• Over 50% unsure whether cognitive screening

was happening

• Overwhelming request for education and

support in providing care

STAFF QUESTIONNAIRE 2013

agreed/ strongly agreed had improved confidence in

knowledge 100%

caring 100%

communicating with relatives 96%

detection of delirium 96%

communicating with patients 93%

delirium screening 93%

using protocol 90%

cognitive assessment 90%

using Abbey Pain Scale 68%

“As staff now have improved knowledge this will benefit patients with delirium.”

“Staff awareness has improved and knowledge and skills have been developed

regarding communication improving the pathway for the patient.”

“Knowledge has improved our ability to identify this in turn assists the patient

and staff to deliver more effective care.”

“Early detection has improved. Better management of patients with delirium -

improved skills.”

“Better use of CAM to identify patients. Better review of medications, treatment

of pain and constipation, encouraging fluids.

Generally less use of haloperidol.”

STAFF COMMENTS

STAFF COMMENTS:

“It’s opened my eyes…better understanding it’s the

illness-it’s not them”

“I’m more aware of relatives”

“ we recognise delirium and act on it more quickly”

“ I’m more comfortable with treating delirium”

“If we treat early they get better quicker and we can

discharge home rather than to a community ward”

“ fewer severe delirium cases”

“Complaints are much fewer”

CARER REVISIT TO WARD

• Anxiety

• Open discussion and listening

• Documentation, posters, signage, clocks

• Met nurses on shift

• Further areas for improvement identified

• Letter of thanks

CHALLENGES/ LESSONS LEARNED

• Delirium Bundle measures are exacting

• Fluid balance sheets not filed

• AWI irregularities

• CAM challenges moving to the4AT

• Families more involved

• Outcome measures – LOS, Complaints

difficult to measure

TEAM ASSESSMENT SCALE 3.5-4

• Steering group meets monthly ( 2 years)

• Testing and data collection – (18 months)

• Moderate improvement in process measures-

cognitive assessment, delirium documentation,

analgesia compliance

• Sustained improvement in one outcome

measure-staff questionnaire

• Spread to another acute ward

IMPROVING CARE FOR OLDER PEOPLE

IMPROVEMENT PLANNING AND ENGAGEMENT EVENT

Delirium Educational Resources

Patricia Howie

Education Projects Manager

NHS Education for Scotland

Delirium Modules Update

Patricia Howie

26. 02.2014

NES Delirium Modules

• Enhance knowledge and skills of all health and social care staff-not just acute general hospitals

• Bring developed on learnpro

• Content completed December 2013

• 2 Modules- An introduction to delirium and CPD Module

Next Steps

• Video of Personal Account of Delirium

• Circulate to Development Group and others for comment- First week March 2014

• Finalise- March 2014

• Launch- April 2014

• Mobile App being developed and launch- April 2014