The challenge
Older adults today account for only 16 percent of Canada’s population, but represent 42 percent of hospitalizations, 58 percent of hospital days and 60 percent of hospital-related expenditures. Meanwhile, the number of people aged 65 and older is expected to double over the next 20 years.
Older Canadians often arrive at hospitals with many inter-related chronic, acute health and social issues. Yet this population is often not well served by hospital-based models of care, which provides us with an opportunity to rethink how we organize and deliver care for seniors.
Mount Sinai Hospital in Toronto has spearheaded the Acute Care for Elders (ACE) Strategy and, as a result, has become Canada’s most widely recognized elder-friendly hospital. The ACE model of care spans the continuum of the emergency department, inpatient, outpatient and community care, delivering seamless care to older adults.
In its initial years at Mount Sinai, ACE has shown remarkable outcomes for patients, providers and health systems, including a 28 percent drop in total hospital lengths of stay, a 93 percent decline in the occurrence of pressure ulcers, 14 percent fewer readmissions within 30 days, and 11 percent fewer patients remaining in institutional care. For Mount Sinai, acute care cost savings from these improvements amounted to nearly $6.7 million in 2014.
CFHI, working with the Canadian Frailty Network and Sinai Health System, launched a 12-month quality improvement collaborative in 2016–2017 to spread the ACE initiative. Seventeen Canadian teams and one international team participated, with Canadian teams each receiving up to $40,000 in funding, and all receiving coaching, educational materials and tools to support the adaptation of Mount Sinai’s elder-friendly practices and models of care to their local contexts. Resources included an online learning platform, educational webinars, an in-person workshop, and ongoing support from the ACE collaborative faculty and staff.
The program’s objectives included supporting teams in becoming experts in healthcare practices that benefit older patients, as well as improving the patients’ and their families’ experiences of care. Other aims were to improve the coordination of care across the continuum from emergency room to inpatient to home and community care. Ultimately, the goal of the ACE collaborative is better system outcomes for older Canadians, such as reduced hospital stays and fewer complications resulting from inpatient admissions.
The solution
Of the 18 teams that participated in CFHI’s ACE collaborative, six implemented behaviour management strategies to improve the delivery of care to older patients. Behaviour management strategies provide staff with the training and resources they need to care for older patients at risk of exhibiting physically responsive behaviours while they are in hospital.
Behaviour management programs have two key areas of focus: they support staff in identifying risk factors for behaviour early, before an incident takes place; and they provide staff with access to a specialist team of mental health clinicians with behavioural expertise. Together, these supports help front-line staff deliver compassionate care to vulnerable patients and determine a strategy for managing a care plan for older patients at risk of exhibiting responsive behaviours.
William Osler Health System (Osler) is one of the six ACE teams that implemented a behaviour management strategy. Osler, which includes Brampton Civic and Etobicoke General Hospitals, as well as Peel Memorial Centre for Integrated Health and Wellness, is among Ontario’s largest community hospital systems, serving a population of more than 1.3 million people across its catchment area. The Central West Local Health Integration Network (LHIN), in which Osler sites are located, will see a 60 percent increase in the seniors population over the next decade and an associated 46 percent rise in the prevalence of dementia over five years.
Osler is also the lead hospital for the Central West LHIN’s Regional Specialized Geriatrics Service and, as such, has made advancing care for seniors a key priority. “When you see the statistics on our local rise in the prevalence of dementia, it reinforces the view that progressive geriatric services need to be given priority, and that is what Osler is doing,” said Dr. Sudip Saha, Division Head Geriatric Medicine and Medical Director Seniors Health.
Dr. Saha explained that medical literature supports the notion of a bidirectional relationship between dementia and delirium. “Having dementia increases your risk of developing delirium – and having delirium increases the likelihood that a patient may have underlying dementia.” Patients, when delirious, can exhibit challenging behaviours and can benefit from being in an environment where healthcare professionals have delirium expertise. Delirium can lead to many grave health consequences, such as increased mortality, institutionalization, and higher chances of functional and cognitive decline. Delirium also results in higher length of stay in hospital and higher healthcare costs and increased caregiver burden. These realities make detecting delirium a high priority for hospitals.
“A strategy that delivers patient-centred care can prevent these adverse outcomes, and constitutes an Osler priority going forward,” said Dr. Saha. “Understandably, we’re looking to increase the level of specialization of our nursing staff and also our volunteer services to raise levels of awareness and expertise in dealing with delirium.”
To bring such a strategy to fruition, Osler launched a pilot project in 2015 into delirium management for seniors with hip fractures. Osler implemented the Confusion Assessment Method (CAM), a four-question assessment that measures whether a patient has had an acute onset of delirium or change in mental status; and the Hospital Elder Life Program (HELP), a comprehensive patient care program for volunteers that is effective in preventing and managing delirium in older adults. Results showed a decrease in the incidence of delirium, shorter stays in acute care, more confidence among the nursing staff and more satisfaction among patients, families, staff and volunteers.
Osler used the ACE collaborative to focus and build on the pilot’s positive results, setting a long-term goal to develop and implement a standard approach to delirium assessment, prevention and management for patients over the age of 65 across the hospital.
“Prevalence statistics suggest that, at the time of admission to hospital, 14 to 24 percent of people would fulfill criteria for a diagnosis of delirium,” said Dr. Saha. Osler implemented a refreshed version of its CAM in the ACE unit and trained staff to have a high index of suspicion for delirium. Nursing staff were provided with training on evidence-based interventions for delirium prevention and delirium management based on best-practices guidelines. Osler’s focus was on using behaviour-management based, non-pharmacological approaches and avoiding the use of physical and chemical restraints.
“For preventing and managing delirium, our approach relies largely on improving patients’ accessibility to specialized geriatric services,” said Dr. Saha. “We focus on augmenting their medical environment in simple ways: reorienting them to where they are by making sure they know the date and time; using care paradigms that maximize normal sleep cycles, because sleep deprivation can be a major cause of delirium; minimizing the use of soft restraints, which worsen long-term outcomes for these patients; and maximizing the use of visual and hearing aids, which helps patients interact with their environment.”
Dr. Saha said one of the keys to detecting delirium has been raising awareness among nursing staff about the importance of the CAM tool and making sure it is used in an order set. Osler also developed a behaviour-mapping tool as part of its order set. The tool is developed from the Dementia Observation System to identify responsive behaviours and triggers, as well as strategies for managing behaviours without chemical or physical restraints.
For patients at high risk for delirium, Osler uses HELP volunteers to provide cognitive stimulation, mealtime support and assistance with mobility. Osler has also purchased some senior-friendly activities for patients to use, including music, knitting supplies and simple sorting activities – whatever is most appropriate for the patients’ cognitive needs. Family education and involvement in delirium prevention was also a crucial component of this project and Osler developed multilingual education booklets and a poster to engage patients and families.
Dr. Saha stressed the importance of using an interdisciplinary approach in detecting, preventing and managing delirium in older patients. “In addition to the role that nurses play, physiotherapists can help keep patients mobile, and occupational therapists can maximize the possibilities for addressing visual and hearing issues. Pharmacists play a crucial role in assessing patients’ prescriptions daily and ensuring that medications known to worsen delirium are not prescribed unless absolutely necessary.”
Dr. Saha also stressed the key role of family. “This is the role we as healthcare providers cannot play. The published literature tells us that outcomes are much better if the family is more involved in the patient’s care.”
Critical at all steps of Osler’s delirium-management roll out was staff education, which included lunch and learns, examination of delirium management case studies, and Gentle Persuasive Approaches training – a full day of training on conflict negotiation and de-escalation with a focus on patients with dementia and delirium. Osler also used delirium champions (specially trained nurses) to mentor other nurses during the course of a shift for ongoing support.
Results
In assessing delirium, Osler achieved screening rates of more than 90 percent, with nurses administering the CAM tool. Detection of delirium was accurate more than 80 percent of the time. Meanwhile, over 80 percent of surveyed nursing staff said they felt confident detecting and managing delirium following education.
In preventing delirium, the HELP volunteer program showed a 30 percent increase in the number of referrals for volunteer involvement. The program has recruited more than 60 volunteers for five acute care areas at Osler.
As anticipated, Osler initially noticed a trend of increased delirium incidence, indicating improved detection of delirium (from 4 percent in August 2016 to 16 percent in January 2017). With these processes in place, the team has started to see a decrease in the incidence of delirium, with an average of 13 percent from January to August 2017. Osler has set a target of less than 12.8 percent for delirium incidence on its ACE/medicine unit.
In managing delirium, Osler’s ACE unit has achieved an 80 percent compliance rate for use of the appropriate tools, which includes the delirium order set (more than 83 percent compliance) and behaviour mapping (80 percent compliance).
Osler saw a significant increase in the number of consultations with geriatricians and pharmacists – a key to managing delirium in older adults. To evaluate the project, Osler compared a pre-intervention group of delirious patients to a post-intervention group of delirious patients who had order sets in place. Twenty percent of the pre-intervention group had geriatric assessments, and 40 percent of the post-intervention group had assessments. None of the pre-intervention group had pharmacy consultations, and more than 70 percent of the post-intervention group had pharmacy consultations.
By May 2017, William Osler had educated 95 percent of its ACE unit staff in Gentle Persuasive Approaches and was in the process of training additional volunteers for using HELP.
Sustainability
As Dr. Saha puts it, there is no magic cure for conditions such as delirium that Osler is working to detect, manage and prevent. But with ample evidence that Canada’s population is aging, the importance of such work has never been higher.
He said that, in the context of shrinking healthcare budgets, Osler is careful about using and implementing sustainable, long-term change. “We do not believe in short-term work. We believe in undertaking work that is sustainable and that can be sustained in all areas of the hospital. Dr. Saha said that Osler’s ACE unit will continue to spread its work on delirium to other relevant areas of Osler’s sites.
More specifically, Osler’s Delirium Detection, Prevention and Management program is being implemented gradually throughout the hospital. As each department implements the process, they are tasked with collecting data on the rate of screening and the use of delirium management tools.
Osler was in the midst of a new educational roll out in early 2018; the team had received approval to continue carrying out monthly Gentle Persuasive Approaches training sessions that are open to all staff. Close to 200 Osler staff have received the training since the ACE collaborative started.
Spread
Osler’s ACE project has led to the development of a corporate working group. The group has developed the components of the project into a new policy called the Delirium Detection, Prevention and Management Policy, which was approved by Osler’s Inter-professional and Medical Advisory Councils in November 2017.
The ACE team has put together education packages and organizes train-the-trainer sessions so that all programs are ready to adopt the tools they need to implement effective delirium detection, prevention and management strategies.
Scale
Many other hospitals are developing and implementing delirium-management and senior-friendly practices.
One website called Senior Friendly Hospitals provides resources for healthcare organizations building better health outcomes for frail seniors. It presents the Ontario Senior Friendly Hospital (SFH) framework, an evidence-based blueprint that hospitals can use to guide improvements in services.