Liz Lees - Heart of England NHS Foundation Trust - Improving Patient Flow and Care Transfer through Risk Assessment

Improving patient flow & transfer of care

through risk assessment

Liz Lees RGN, Dip N., BSc (hons.), Dip HSM, MSc, PGR

PhD Student (NIHR CDR Fellowship)

University of Manchester &

Consultant Nurse Heart of England NHS Foundation Trust

Presentation for: Inaugural Transfer of Care Conference, Sydney 2015

ROAD: “Risk Objective Assessment for Discharge”

Today’s presentation


• Contextual introductions • What’s the problem anyway? • Let’s talk about risk & what we mean • My review of risk assessment tools • Practicalities of risk assessment • Centrality of patient and carer in the risk

process

Introduction • Year 2 PhD: Nurse with NIHR Fellowship

• Topic: Patient discharge from hospital

• Context: acute hospital, emergency care

• 2014: Realist literature review of risk assessment tools & Scoping review of Policy/best practice guidance

• Methodology: Case Study (Yin, 2011)


Context: Geographically


Context: Clinically

• Acute Medicine Unit • With 84 beds (assessment, ambulatory care,

admission beds, cardiac unit and CDU) • Length of patient stay permitted <48 hours • 2000 patients per month referred • Numerous contemporary roles

Focus is on: a. Patient assessment b. Patient stabilization c. Diagnosis & transfer d. Discharge

Presentation for: Inaugural Transfer of Care Conference, Sydney

2015

Discharge planning:

What is the problem?



“Unsafe transitions, uncoordinated visits and multiple and uncoordinated assessments on the part of professionals”……

Department of Health, 2013, p 11.

“reviewing patients ongoing risk level important to see if new risks had developed is important”

Graham et al, 2013.

Risk assessment tools focus upon the definition and refining of which questions are most pertinent to ask patients yet there is a paucity of literature, which includes carers and their perspectives

Grimmer et al, 2004, Huby et al, 2004.

“Anticipatory assessment of discharge needs will not anticipate obstacles to daily living if undertaken while still hospitalized”

Bobay et al, 2010

What do we mean by risk?


• Risk and readmissions • Risk and extended (perceived as prolonged) length of

stay • Risk and predictive use of resources post discharge • Risk and adverse outcomes (excluding readmissions,

e.g., functional decline). • Risk and the early identification of discharge planning

needs • Risk in relation to an ‘early discharge’

What do we mean by risk?


Antecedents: Less than satisfactory prior living circumstances (socially isolated) A sudden event e.g., a fall Being new to a caring role/in poor health as a carer Critical Attributes: Additional change in circumstances, e.g. mobility limitations Actual ability to of patient or carer to cope Number of occurrences of the problem Consequences: Limits persons self care ability/lifestyle Needs new services at home Permanency of change (s)

Scholarly Literature Review of ‘discharge’ risk assessment tools

To establish if there is a gap in the evidence base in relation to risk assessment in preparation for

discharge, to assess adult patients who are admitted to & discharged from

emergency care.


Literature review questions 1. What, if any risk tools exist to assess

discharge needs for adult patients being admitted to & transferred from emergency care?

2. What is known about the issues related to the use of discharge risk assessment tools?

3. Are any risk tools embedded in practice?


Search strategy

PATIENT DISCHARGE

“The administrative process of discharging the patient, live or dead from Hospitals or other

health facilities”

The US National Library of Medicine, (2005:2014)



Inclusion & exclusion of tools Inclusion Exclusion

Patients in acute environment requiring discharge from hospital

Not used in acute clinical area

To identify items of risk to assist planning of discharge

Another focus of risk; readmissions, general nursing assessments

Aimed at reducing length of stay Functional decline

Improving quality of assessment of risk for discharge

Needs post discharge (assessment of services)

Risk tool must be in use Tool is in continued development

Steps to development discussed


Question 1:Risk tools • Tools in evolution since 1998 from USA

• PRA – Priority Risk Assessment

• UNAI – Uniform Needs Assessment Instrument

• Gradually been reduced to 4 core questions

• DRS – Discharge Risk Screening tool

• Implemented (limited success) here in Sydney

• RHDS – Readiness for hospital discharge scale

• Sensitivity to respond to identified risk items


Key occupants of the literature Key developers: Typology of tools • USA – Pennsylvania (Holland & Bowles) RISK & COMPLEXITY & TRANSITIONS • Hong Kong (Yam & Wong) PROCESS & BARRIERS • Republic of Ireland (Weis then Coffey et al) PREPARATION & TRANSITIONS • USA (Bobay et al, Meleis et al) QUALITY OF TEACHING • Wenger (building on Bowling) TYPES OF SOCIAL NETWORKS

Key followers: • Australia (Graham) SCREENING & UNDERSTANDING & BARRIERS • Canada (Policy developers) Key implementer: • Holland


Question 2: What were the issues?

1. The transferability of tools

2. The specificity and sensitivity of items

3. The lack of follow on re-assessment

4. Staff compliance

5. Dearth of implementation science


Question 3: any tools embedded?


• Functional adaptation • Functional limited • Professional perception • Patients perception & expectation • Carers perception & expectation

= Weighting of risk Very tricky!

So, if you were trying to do this…… • Consider timing of assessments • Types of professionals who are best to

assess • Types of risk assessment used • Types of services needed (as a

consequence) • Needs that occur immediately after

discharge


BEFORE

ADMISSION

FEEDBACK

FOLLOW UP

Improving

Access for

Emergency

Admissions

Improving

the

Assessment

Process

Improving

Discharge or

Transfer

Planning

(Flow) (Quality) (Collaboration)

Liz Lees Consultant Nurse

Birmingham Heartlands Hospital

Movement of information

Summary & Reflection

‘risk assessment for discharge & transfer may inform practice, the reality is that practice is substantiated through process contingencies

adopted by clinical staff’….


Moving forward: research aim

To explore and understand the feasibility issues & contingencies that surround discharge practice, process

and risk assessment;

prior to the introduction of discharge risk screening, within an exemplar acute medical unit in the UK.


Questions

Thank you for listening


Liz Lees - Heart of England NHS Foundation Trust - Improving Patient Flow and Care Transfer through Risk Assessment

Healthcare

risk objective assessment

patient flow transfer

beds assessment

emergency care

ambulatory care

risk process

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