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 Initiativedelirium and functional decline indicators
• Fiscal Environment
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Common Geriatric Syndromes
Fx decline,
Falls
Delirium
Dementia
Depression
Malnutrition,
dehydration
Polypharm
Shared Risk Factors Geriatric
Syndromes
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.
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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 wards
PATIENTS:
• 216 patients aged ≥70 years (85 intervention and 131 control
patients).
INTERVENTION:
• identification and surveillance of frail older patients, twiceweekly 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
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)
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Yale Geriatric Care ProgramResources
• 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
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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
Risk Factors
Cognitive Impairment
Intervention
• Reality orientation
• Therapeutic Activities Program
Vision/Hearing
Impairment
• Vision/Hearing Aids
• Adaptive Equipment
Immobilization
• Early Mobilization
• Minimizing immobilizing equipment
Psychoactive
Medication Use
• Nonpharmacologic approaches to sleep/anxiety
• Restricted use of sleeping medications
Dehydration
Sleep Deprivation
• Early recognition
• Volume repletion
• Noise reduction strategies
• Sleep enhancement program
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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)
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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
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Other Hospital Elder Life Program Interventions
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•
•
•
•
•
Geriatric nursing assessment and intervention
Interdisciplinary rounds
Geriatrician consultation
Interdisciplinary consultation
Provider education program
Community linkages and telephone follow-up
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 Website
http://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)
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Sustainability of HELP:
Will HELP Work in Other Settings?
The Hospital Elder Life
Program (©2000,Sharon K.
Inouye,MD,MPH)
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.
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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 nurse
Participants:
• 77 usual care, 102 HELP intervention abdominal surgical
patients, matched
Measures:
• 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 volunteers
Stage 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
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•
•
•
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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
Mouchoux, C. et al., BMC Geriatrics, 11(25), 2011
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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% less
http://www.gerontario.org/documents/B4%20Prevention%20of%20Delirium%20and
%20Functional%20Decline%20Among%20Hospitalized%20Elder%20Patients.pdf 21
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 factors
CONCLUSION:
• 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
HELP
Protocols 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
Rosenbloom-Brunton DA et al Gerontol Nurs. 2010 Sep;36(9):22-33;.
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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 risk
Martinez FTAge Ageining 2012 Sep;41(5):629-34. 2012 May 15.
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Preventing delirium in an acute hospital using a non-pharmacological intervention.
Challenges and Predictors of Success
Bradley: Survey of 9 US hospitals implementing HELP
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
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Bradley et al, JAGS 2004;52: 1875-1882
Challenges and Predictors of Success
Challenges in New Program
Implementation
4. Balancing Program fidelity
with hospital –specific
circumstances
Strategies for Addressing Challenges
•Implementing program as designed
originally - include all interventions
5. Documenting and publicizing •Gather and summarize data
positive outcomes
•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
Bradley JAGS 2004;52: 1875-1882 27
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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