Older people with complex
needs in acute hospital beds
Prof David Oliver
Consultant Geriatrician, Visiting Fellow, King’s Fund & BGS
President-elect
Nuffield Trust Workshop 14th October 2014
Major geographical variation in admission
rates and bed occupancy in over 65s
Kings Fund Report Emergency
Bed Use in Older People 2012.
Imison C et al
Imison et al
King’s Fund 2012
BMJ April 2013
EMERGENCY READMISSIONS: ENGLAND 1999-00 to 2009-10
700,000
Age 0-15
600,000
Age 16-74
Age 75+
Age 16+
Number readmissions
500,000
All ages
Fastest Rise is in Over 75s
400,000
300,000
200,000
100,000
0
1999-00 2000-01
2001-02 2002-03 2003-04
2004-05 2005-06 2006-07 2007-08
Year
2008-09 2009-10
Wishful thinking and magic bullets on
admission prevention?
Marion McMurdo
BMJ Letters Jan 2013
“SO MAKE HOSPITALS GOOD FOR OLD PEOPLE”
"Hospitals are very bad places for old, frail people" asserts David
Nicholson, chief executive of the NHS Commissioning Board, and
suggests alternatives to hospital must be found Following this
logic perhaps the solution to the lack of compassion in nurses to
which he also refers might equally well be solved by admitting to
hospital only patients who are not in need of compassion?
“Here is a radical suggestion - make hospitals good places for old
people. Few national providers would make such a blatantly ageist
inference that its "core business" was too tricky to manage, and
propose to solve "the problem" by ceasing to attempt to deal with
it. The greatest burden of ill health falls on older people, making
them the group encountered most commonly in clinical practice.
But is appears that the impertinence of our older population in
actually becoming unwell, and so requiring care, will no longer be
tolerated in hospitals. The acute care of older people has
progressed through being an inconvenience to being an
anathema.”
Over 65s in hospital (England)
(DH analysis of HES data)
60% admissions
70% bed days
85% delayed transfers
65% emergency
readmissions
75% deaths in hospital
25% bed days are in over
85s
80% of all stays over 2
weeks
High intensity users of hospital services
have overlap of physical and social
vulnerabilities
Modern Hospital Casemix
1 in 4 adult beds occupied by someone with dementia (stay an
average 7 days longer)
Delirium affects 1 in 4 patients over 65
Urinary incontinence 1 in 4 over 65
1 in 4 over 65 have evidence of malnutrition
Falls and falls injuries account for more bed days than MI and
Stroke Combined
Falls = 35% safety incidents (median age 82)
Most over admissions over 70 have functional impairment and
some need for MDT rehab (Hubbard 2005) – median barthel 12
Hip fracture is a good example
– Median Age 84, 12 month mortality 20-30%, 1 in 3 have
dementia, 1 in 3 suffer delirium, 1 in 3 never return to former
residence, 1 in 4 from care homes
Fried 1999
How frailty presents to services
Lancet 2013)
(Clegg and Young
Fatigue
Weight loss
Frequent infections
“Failure to thrive”
Delirium
Falls
Immobility
Fluctuating Disability
Incontinence
Mudge et al
(bear in mind, 10 days of bed rest = 14% loss of
aerobic and 10% muscle capacity – Kortebein )
Harms of hospitalisation for frail older
people
Conventional big ticket safety incidents
Poorly planned discharge
Care transitions/co-ordination/communication
Delirium
Immobility
Incontinence
Malnutrition
Institutionalisation
Decompensation
Premature decisions about future care needs in
wrong setting
The solutions I know are set out here.
Free at
http://www.kingsfund.org.uk/
sites/files/kf/field/field_public
ation_file/making-healthcare-systems-fit-ageingpopulation-oliver-foothumphries-mar14.pdf
Free slideset at
http://www.kingsfund.org.uk/au
dio-video/improving-careageing-population-whatworks
Blog
http://www.kingsfund.org.uk/
blog/2014/03/time-has-comemake-health-and-careservices-work-our-ageingpopulation
Structure of paper
Intensely practical
Aimed at those leading local services
10 sections
For each:
–
–
–
–
–
Goal
Current situation
“what we know can work”
Key references and resources
Good practice examples from around the UK (despite
austerity and upheaval)
Field tested/reviewed with many service leaders
Widely endorsed. Cited by NHS England.
10 Components
all of equal
importance with
older person at
the centre
End of life
planning and
care cuts
across all
A story of how care can go wrong
from HSJ commission on frail older people in hospital
Even when people are essentially caring and
trying to do their best
From my work on HSJ Commission on care for
frail older people
During the animation, please watch actively
Please reflect:
“at every single stage, what could we have done
differently to help support Mrs Andrews and her
family?”
Including what happened before she fell
Animation. Mrs Andrews’ Story
from HSJ Commission
https://www.youtube.com/watch?v=Fj_9HG_TWE
M
Mrs Andrew’s Story
Going through the
components
What could/should
have happened
instead?
Many solutions lie
either side of bed
based acute care
pathway
LOS may be the
wrong measure –
bed occupancy and
% of discharges
within timeframes
better?
Managing the Streams – from ECIST priorities in Acute Hospitals
Identify the stream
– Short stay
Sick specialty
Sick general
– Allocate early to teams skilled in that stream
Complex
Number of patients
250
Short stay – manage to the hour
Maximise ambulatory care
200
150
100
50
Clarity of specialty criteria
Specialty case management plan at
Handover – no delays
Green bed days vs. red bed days
Minimise handover
Decompensation risk
Early assertive management
Green bed days vs. red bed days
Complex needs – how
much is decompensation?
Detect early and design
simple rules for discharge
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59
Length of stay (days)