Lessons in Implementing a Strategy for Senior
Friendly Hospitals
Making the Connection: Innovation in Older Adult Care
Summerside, Prince Edward Island
October 17, 2014
Barbara Liu, MD, FRCPC
Regional Geriatric Program of Toronto
Barbara.liu@sunnybrook.ca
www.seniorfriendlyhospitals.ca
1
Outline
 Regional Geriatric Program & SFH framework
 Ontario Senior Friendly Hospital Strategy
– Priority setting, toolkit, indicators
 Examples of implementation
– Early mobilization – MOVE ON
– Delirium prevention and management
 Lessons learned
2
Lessons Learned
 Alignment + competing priorities
 Early wins versus mid to long term
sustainability
 Top-down versus bottom-up
 Hospitals are complex systems
– Standardization in the local context
 Basic ≠ simple
3
Senior Friendly Hospitals in Ontario
4
Regional Geriatric Program of
Toronto
•
•
•
•
Network of 27 hospitals in GTA
Better health outcomes for frail seniors
Service, education, evaluation and advocacy
Specialized geriatric servicesinterprofessional teams
– Consultation teams, GEM, AGUs/ACE
– Outreach, day hospitals, clinics, falls prevention programs
• Part of the RGPs of Ontario
5
The Challenge
“The right care,
in the right place
at the right time”
6
RRGP Senior Friendly Hospital Framework
Processes of
Care
Emotional &
Behavioural
Environment
Ethics in
Clinical Care &
Research
Organizational
Support
Physical
Environment
What we do
How
Who
Why
Where
RGP.toronto.on.ca
Seniorfriendlyhopsitals.ca
7
Ontario Pan-LHIN Senior Friendly Hospital Strategy
PHASE 1
PHASE 2
SFH Indicators
Objective
• Identify current
state
Plan
• Hospital selfassessments
• LHIN-level roll-up
• Provincial roll-up
Provincial Summary
Report
PHASE 3 - ONGOING
Objective
• Close the gap
Plan
• Implement hospital
improvement plans
• Develop key enablers
Objective
• Monitor and sustain hospital
and system improvements
Future State
• Prevent functional decline
• Improve patient experience
• Enable hospital staff
• Improve equity
SFH “Promising
Practices” Toolkit
8
Provincial Summary of SFH Care - Priorities
Functional Decline
Implement inter-professional
early mobilization protocols
across hospital departments
to optimize physical function
Delirium
Implement inter-professional
screening, prevention, and
management protocols across
hospital departments to
optimize cognitive function
9
www.seniorfriendlyhospitals.ca
10
Tools for Delirium
• Screen and Detect
• Prevent and Manage
• Monitor and evaluate
Identification of Indicators
Literature Review -Over 15,000 retrieved articles from 1991-2011
DELIRIUM
406 ARTICLES
268 POTENTIAL INDICATORS
Environmental Scan results from 68 of 155 Ontario hospitals
FUNCTIONAL DECLINE
232 ARTICLES
Working Group Review, Delphi Panel and
Consensus Meetings
DELIRIUM
268 INDICATORS
445 INDICATORS
FUNCTIONAL DECLINE
WORKING
GROUP REVIEW
Redundant or
18 INDICATORS
impractical
18 INDICATORS
indicators
eliminated by
group consensus
445 POTENTIAL INDICATORS
-
DELPHI PANEL VOTING
Validity
Reliability
Feasibility
Responsiveness
Ease-of-reporting
Clarity
2 INDICATORS
Action-ability
2 INDICATORS
Appropriateness
CONSENSUS MEETINGS (3)
Implementation and technical
considerations drafted
12
Process
Rate of baseline
delirium screening
Percentage of patients (65 and older) receiving
delirium screening using a validated tool upon
admission to hospital
Outcome
Delirium Indicators (All Hospital Sectors)
Rate of hospitalacquired delirium
Incidence of delirium in patients (65 and older)
acquired over the course of hospital admission
Data Source and/or
Tool
Confusion Assessment Method (CAM), CAM-ICU, or
Intensive Care Delirium Screening Checklist (ICDSC)
Exclusions
Considerations
Patients with decreased level of consciousness
(unresponsive or requiring vigorous stimulation for a
response); patients in palliative care
Minimum frequency of screening to capture incidence –
at least daily after the initial baseline screen
13
Participating Hospitals
South West
Grey Bruce Health Services
St Joseph's Health Care (London)
St Thomas Elgin General Hospital
Erie St. Clair
Hotel-Dieu Grace Healthcare
Hamilton Niagara Haldimand Brant
Brant Community Healthcare System
Hamilton Health Sciences
Joseph Brant Memorial Hospital
Niagara Health System
Norfolk General Hospital
St Joseph's Healthcare (Hamilton)
Toronto Central
Baycrest
Providence Healthcare
St Michael's
Sunnybrook Health Sciences Centre
Toronto East General Hospital
University Health Network – TWH + TRI
West Park Healthcare Centre
Central
Markham Stouffville Hospital
North York General Hospital
Southlake Regional Health Centre
Stevenson Memorial Hospital
Central East
Campbellford Memorial Hospital
Lakeridge Health
Northumberland Hills Hospital
Ontario Shores Centre for Mental
Health Sciences
Peterborough Regional Health
Centre
Ross Memorial Hospital
The Scarborough Hospital
South East
Brockville General Hospital
Champlain
Deep River District Hospital
The Ottawa Hospital
North East
Blind River District Health Centre
Espanola Hospital & Health Centre
Health Sciences North
Kirkland District Hospital
St Joseph's General Hospital
(Elliot Lake)
Manitoulin Health Centre
North Bay Regional Health Centre
Sensenbrenner Hospital
West Nipissing General Hospital
West Parry Sound Health Centre
North West
St Joseph's Care Group
(Thunder Bay)
Summary of Implementation:
Delirium – 42 patient care units at 31 hospital sites
Functional Decline – 24 patient care units at 22 hospital sites
14
Delirium Indicators – Process Indicator
FIGURE 1 – Mean rate of baseline delirium screening by hospital (25 hospitals)
Mean rate of baseline delirium screening over all months of data submission.
Range of delirium screening rate (highest to lowest monthly compliance rates)
•
•
•
•
10 hospital sites consistently achieved mean baseline screening rates at or near 100 percent
16 sites achieved baseline screening rates of 80 percent or greater
5 hospitals averaged baseline screening at rates between 60 and 80 percent
4 sites performed baseline delirium screening during the study at a rate below 50 percent.
15
Delirium Indicators – Outcome Indicator
FIGURE 3 – Monthly rate of hospital-acquired delirium.
The data shows a fairly narrow range of delirium incidence that clusters at a rate of 20 percent
or below. These values are comparable to rates for hospital-acquired delirium reported in the
research literature
16
Delirium Indicators – Value in Driving Clinical Care
• Educating clinical staff
o increased attention to delirium, more discussion of delirium, earlier
detection of delirium.
• Delirium screening and prevention as a core competency of frontline providers
• Development of care protocols
• Advancing skills
o assessing delirium in patients with dementia or aphasia
• Regular visual feedback and review of results helped generate
additional buy-in and helped sustain enthusiasm
17
Delirium Indicators – Recommendations
• Both the process and outcome indicators for delirium are
recommended for broader implementation in all hospital sectors.
• Data for the indicators should be based on assessment results using
a common clinical tool, such as the Confusion Assessment Method
(CAM).
• Routine screening for delirium after the initial baseline delirium
screen should occur at a minimum of once per day in all hospital
sectors.
• Patients receiving palliative care should be included in the indicator
technical definition.
• For sustainability purposes, electronic implementation to provide
automation of data collecting and reporting process is
recommended.
18
Outcome
Process
Functional Decline Indicators (Acute Care Sector)
Rate of ADL function
assessment at
admission and
discharge
Percentage of patients (65 and older) receiving
assessment of ADL function with a validated tool
at both admission and discharge
Rate of no decline in
ADL function
Percentage of patients (65 and older) with no
decline in ADL function from hospital admission to
hospital discharge as measured by a validated tool
Barthel Index
Health Outcomes for Better Information in Care (HOBIC) – ADL
Data Source and/or Tool
Section
Alpha-FIM Tool®
Patients in emergency department who are not admitted to
hospital; patients in palliative care; patients admitted for day
Exclusions
surgery procedures; patients with a length of stay <48 hours
19
Functional Decline Indicators – HOBIC
FIGURE 5A – Monthly rate of ADL function assessment at both admission and discharge for
hospital sites using HOBIC ADL Section
20
Functional Decline Indicators – BARTHEL
FIGURE 5B – Monthly rate of ADL function assessment at both admission and discharge for
hospital sites using Barthel Index.
21
Functional Decline Indicators – Outcome
TABLE 7 – Monthly Rate of No Decline in ADL Function
Hospital
Site
ADL
Assessment
Tool used
Number of
consecutive
months of
data
submitted
Monthly rate of no
decline in ADL
function (Range,
N=number of
discharges)
Overall mean rate of no
decline in ADL function
(N=Total number of
discharges)
1
Barthel Index
9
84-93% (n=67-124)
89% (n=836)
2
Barthel Index
6
97-100% (n=13-40)
98% (n=174)
3
Barthel Index
13
67-100% (n=1-6)
95% (n=40)
4
Barthel Index
7
86-100% (n=2-12)
95% (n=59)
5
HOBIC ADL
section
6
63-91% (n=17-28)
81% (n=136)
22
Function Decline Indicators – Value
• Even on rehab-like units – valuable for monitoring progress
• Two sites using Barthel Index suggested more frequent
assessment for long-stay patients
• Interprofessional team use
• Personal support workers trained to use Barthel professionally rewarding and helped guide care
• HOBIC ADL tool
• challenges in compliance with the assessments, decreased
buy-in from front-line staff, and lack of real-time data
23
Functional Decline Indicators – Recommendations
• The indicators for functional decline are not recommended for
broader implementation at present.
• For the assessment of ADL function in the acute care sector, a
concise ADL assessment tool should be used.
• Further work to identify indicators more suitable to monitor
functional status and drive early mobilization/activation processes
should be undertaken.
24
SFH Evaluation Working Group
Barbara Liu (Chair)
Carol Anderson
Sherry Anderson
Emily Christoffersen
Ella Ferris
Susan Franchi
Ronaye Gilsenan
Charissa Levy
Monique Lloyd
Ryan Miller
Kelly Milne
Elaine Murphy
Rhonda Schwartz
Alisha Tharani
Ada Tsang
Simmy Wan
Ken Wong
Regional Geriatric Program of Toronto
Baycrest
Brockville General Hospital
Hamilton Health Sciences
St. Michael’s
Thunder Bay Regional Health Sciences Centre
Regional Geriatric Program of Eastern Ontario
Greater Toronto Area Rehab Network
Registered Nurses’ Association of Ontario
North Simcoe Muskoka Local Health Integration Network
Regional Geriatric Program of Eastern Ontario
University Health Network
Central East Seniors’ Care Network
Toronto Academic Health Sciences Network
Regional Geriatric Program of Toronto
Central Local Health Integration Network
Regional Geriatric Program of Toronto
25
26
Kawaii
27
Kawaii
28
Nittono H. (2012) The Power of Kawaii: Viewing Cute Images Promotes a Careful Behavior
and Narrows Attentional Focus.
PLoS ONE 7(9): e46362. doi:10.1371/journal.pone.0046362
29
Kawaii
30
Mobilization of Vulnerable Elders
in Ontario
Lying
 83% of measured hospital stay spent in bed
Sitting
 Median time spent standing or walking
= 43 minutes or 3% of day
Brown, C et al JAGS 2009;57:1660
Walking
“...rest in bed is anatomically, physiologically and
psychologically unsound. Look at a patient lying long in
bed. What a pathetic picture he makes!
The blood clotting in his veins, the lime draining from his
bones, the scybala stacking up in his colon, the flesh
rotting from his seat, the urine leaking from his
distended bladder and the spirit evaporating from his
soul.”
Complications of Immobility
Psychological
Respiratory System
•
•
•
•
•
•
Decreased lung volume
Pooling of mucous
Cilia less effective
Decreased oxygen saturation
Aspiration
Atelectasis
Gastrointestinal System
•
•
•
•
Reflux
Loss of appetite
Decreased peristalsis
Constipation
•
•
•
•
•
Anxiety
Depression
Sensory deprivation
Learned helplessness
Delirium
Circulatory System
•
•
•
•
Loss of plasma volume
Loss of orthostatic compensation
Increased heart rate
Development of DVT
Genitourinary System
Musculoskeletal System
•
•
•
•
•
Weakness
Muscle atrophy
Loss of muscle strength by 3-5%
Calcium loss from bones
Increased risk of falls due to weakness
• Incomplete bladder emptying
• Formation of calculi in
kidneys and infection
3535
3636
3737
 Without mobilization, elderly
patients lose 1 to 5% of muscle
strength each day
(Annals Int Med 1993;118:219-23)
3838
Early mobilization –the evidence
  duration of delirium (median of 2 days versus 4 days)
  rate of depression (odds ratio 0.14)
  functional status (odds ratio 2.7)
  Increases rate of discharge to home (NNT =16)
  length of stay (1.1 days)
  hospital costs by $300/day
Age Ageing 2007 J Gerontol 1998; Lancet 2009, Cochrane Review
2009
39
The key messages
1. Encourage mobility three times a day
2. Mobilization should be progressive and scaled
3. Mobility assessments should be implemented
within 24 hours of the decision to admit
4040
Educational Interventions






Interprofessional group education/in-service
1:1 knowledge-to- practice coaching
Huddles
Fairs
Education days
E-modules
Knowledge-to-practice coaching
42
Mobility
1. Can they respond to verbal stimuli? Level
2.
3.
4.
5.
Can they roll side to side?
C
Can they sit at edge of bed?
Can they straighten one or both legs?
Can they stand?
6. Can they transfer to a chair?
B
7. Can they walk a short distance?
A
Develop an individualized
mobility care plan
Simplified Mobility Assessment Algorithm
Enabling Tools
Is it feasible to
mobilize frail
older patients
on medical
units?
First step is to dangle
To Chair
Respiratory ICU
Intermountain Medical
Center
Salt Lake City, Utah
Respiratory ICU
Intermountain
Medical Center
Salt Lake City,
Utah
Mobility Volunteer
Program
MVP
• New Support Partners
Significant increase in rate
of mobilization
•
Significant overall improvement in rate of mobilization, with a 7.62 %
increase in mobilization rate between post-intervention and preintervention periods (p<.0001) and a 0.43% increase in mobilization
rate during intervention compared to pre-intervention periods (p=0.05).
Presentation
49
Staff Perception of MOVE ON
•  sense of shared
responsibility for mobilization
•  communication
•  interprofessional
collaboration.
• + impact on unit culture dispelling “sick culture”.
“I get a lot of social workers and
dieticians and pharmacists asking me
to come in and just get the patient up
so they can sit down and talk to them,
and I have no problem doing that so
it’s really good to see that they’re
engaged in the mobility aspect of the
patient as well as, you know, their role
on the team as well.”
“I think the... it brought to forefront
the mobility thing, because usually
when you think of people in hospital
typically you think of people laying in
the bed, but it changed that whole
perception that, ‘Well, do they have to
by laying in a bed?’ type. It’s like, you
know, it’s the old-school thinking of
what a hospital environment is.”
Presentation
50
Acknowledgements
• We would like to thank the CAHO hospitals
that participated in MOVE ON.
Presentation
51
Sunnybrook
Health
Sciences
Centre
• Over 1200 beds
• Veteran’s hospital
• 1st and largest regional
trauma centre in Canada
Delirium
 Historical references dating back 2,500 years
 Latin
 “de” - off, away from
 “lira” – furrow
 Previous terminology included







Febrile insanity
Every man’s psychosis
Reversible madness
Subacute befuddlement
Acute confusional state
Organic brain syndrome
Acute brain failure
High prevalence and incidence of
delirium in older patients
Prevalence at admission
Incidence
Post operative
ICU
End of life
14-24%
6-56%
15-53%
70-87%
Up to 83%
Inouye SK New Engl J Med 2006;354:1157
Delirium is associated with
increased mortality
At 1 month
At 6 months
Delirium
14%
22%
Mortality
No delirium
5%
11%
12 months AHR for death=2.11 (1.18 to 3.77)
McCusker Arch Intern Med 2002;162:457
Witlox JAMA 2010; 314:443
Delirium often has a protracted course
At 6 months
At 12 months
Persistent symptoms
With
Without
dementia
dementia
39%
9%
49%
15%
•Inattention
•Disorientation
•Impaired memory
McCusker J Gen Intern Med 2003;18;696
Do you see what I see?
Justin Kaplan, 84 years old,
Pulitzer Prize winning historian, during
hospitalization for pneumonia
“Thousands of tiny little
creatures, some on
horseback, waving arms,
carrying weapons like some
grand renaissance battle,
were trying to turn people
into zombies. Their leader
was a woman with no mouth
but a very precisely cut hole
in her throat.”
Yes
No
Prevention of Delirium with the CHASM Care Interventions
C
COGNITION AND PERCEPTION
 Communicate clearly using simple sentences
 Orient patient and encourage family involvement with meaningful activities
 Optimize sensory inputs
H
HYDRATION
 Offer fluids with every encounter
 Offer to open containers on meal trays
 Encourage family to participate in feeding
AGITATION
 Address root cause: physical (pain, hunger, thirst, reposition, bladder/bowel, fatigue);
emotional (fear, anxiety)and environmental (temperature, noise)
 Address safety issues
 Match environmental stimulation
 Relaxation activities (e.g. music, videos, books)
A
S
M
SLEEP-WAKE CYCLE
 Normalize sleep pattern and discourage daytime sleeping
 Aim for uninterrupted sleep at night in quiet room with low level lighting
 When possible, position patient near window
MOBILITY
 Encourage and support independence with self care and offer assistance when
required
 Mobility activities 3x/day or more
 Avoid foley catheters and restraints
Dec 10, 2013
Enabling Tools &
Resources
6363
Alignments (and hooks)
 Safety
– Patient
– Staff
 Quality
 Patient experience, satisfaction
 LOS
Ontario Coroner’s Report
64
Sustainability challenges
Initiative fatigue
• Streamline priorities
• Look for alignments
• Seek out and nurture productive
collaborations
Low hanging fruit
has been picked
• Stay focused on making small
improvements
• Avoid the temptation to question
the method of measurement
• Manage expectations
• This is a long term journey
Top down versus
bottom up
• Corporate support is an enabler
• Avoid the temptation to rely on it
as a driver
• Ensure that interventions are
contextualized
Context has
evolved
• Re-examine context
65
Sustainability Senior Friendly Hospital
 Senior friendly hospital must be more than a
series of initiatives
66
1.Fn’l
Processes
Decline
of
2.Delirium
Care
Emotional &
Behavioural
Environment
Ethics in
Clinical Care &
Research
Organizational
Support
Physical
Environment
67
1.Fn’l Decline
2.Delirium
Emotional &
Behavioural
Environment
Ethics in
Clinical Care &
Research
Organizational
Support
Physical
Environment
Screen & Detect
Prevent & Manage
Monitor & Evaluate
1.Fn’l
Decline
Process
Environmental
& Behavioural
Environment
of
Care
2.Delirium
Physical
Environment
Ethics in Clinical
Care and
Research
Organizational
Support
68
Ethics in
Clinical Care &
Research
Processes of
Care
Processes of
Care
Emotional &
Behavioural
Environment
Organizational Support
Organizational
Support
Emotional &
Behavioral
Environ-ment
Ethics in
Clinical Care &
Research
Physical
Environment
Physical
Environ-ment
Lessons Learned
 Alignment + competing priorities
 Early wins versus mid to long term
sustainability
 Top-down versus bottom-up
 Hospitals are complex systems
– Standardization in the local context
 Basic ≠ simple
70
Acknowledgements
TORONTO CENTRAL LHIN
Camille Orridge
Vania Sakelaris
Janine Hopkins
Teresa Martins
Rose Cook
Stephanie Smit
Sharon Navarro
Nathan Frias
Georgia Whitehead
RGPs OF ONTARIO
Barbara Liu
David Ryan
Marlene Awad
Ken Wong
Ada Tsang
Kelly Milne
David Jewell
Sharon Marr
Eleanor Plain
John Puxty
Rosemary Brander
Elizabeth McCarthy
Kim Rossi
ONTARIO SFH STEERING
Jill Tettmann (Executive Sponsor)
Barbara Liu (Co-Chair)
Carol Anderson (Co-Chair)
Marlene Awad
Ken Wong
Ada Tsang
Kelly Milne
Ronaye Gilsenan
David Jewell
John Puxty
Rosemary Brander
Elizabeth McCarthy
Rhonda Schwartz
Gail Dobell
Monique Lloyd
Lynn Singh
Simmy Wan
Lisa Kitchen
Brian Laundry
Elizabeth Salvaterra
Mark Edmonds
Christine Gagne-Rodger
Alec Anderson
Dawn Maziak
Susan Gibson
Kim Young
Judy Bowyer
Jennifer McKenzie
Perry Coma
Sandra Easson-Bruno
Sabrina Martin
Rebecca McKee
Julie Girard
Kristy McQueen
Teresa Martins
Nathan Frias
Melissa Kwiatkowski
71
SFH “PROMISING
PRACTICES” TOOLKIT
Barbara Liu (Co‐Chair))
Gary Naglie (Co‐Chair
Ken Wong
John Puxty
David Jewell
Anne Stephens
Sharlene Kuzik
Linette Perry
Maria Boyes
Susan Franchi
Karyn Popovich
Monidipa Dasgupta
Bruce Viella
Susan Bisaillon
Emily Christoffersen
SFH INDICATORS
Barbara Liu (Co‐Chair)
Rhonda Schwartz (Co‐Chair)
Ken Wong
Ada Tsang
Michelle Rey
Rebecca Comrie
Annette Marcuzzi
Marilee Suter
Brian Putman
Minnie Ho
Carrie McAiney
John Puxty
Dana Chlemitsky
Sharon Marr
Kim Kohlberger
Catherine Cotton
Kelly Milne
INDICATOR IMPLEMENTATION
PLANNING GROUP
Barbara Liu (co-chair)
Carol Anderson (co-chair)
Ken Wong (study coordinator)
Ada Tsang (study coordinator)
Alisha Tharani
Elaine Murphy
Sherry Anderson
Charissa Levy
Kelly Milne
Stephanie Amos
Nancy Lum Wilson
Carol Edward
Ryan Miller
Monique Lloyd
Ella Ferris
Emily Christoffersen
Susan Franchi
SUNNYBROOK SF TEAM
Deborah Brown-Farrell
Jocelyn Denomme
Beth O’Leary
Elmira Dadmarzi
Ummu Almaawiy
Shima Deljoomanesh
RGP OF TORONTO
Ada Tsang
Ken Wong
Marlene Awad
David Ryan
Shirley Li
Kerri Fisher
Laurie Kent
Jem Rosario
72
Thank you
73