Lorraine Lovitt - Clinical Excellence Commission - Confusion and Falls

Falls Prevention is everyone’s business®

Lorraine Lovitt

Lead, NSW Falls Prevention Program

Clinical Excellence Commission

Falls, Fractures & Pressure Injuries Management Conference

September 2015

Confusion and Falls

[email protected]

Created by nurses at Guy's and St Thomas' Barbara's Story is a series of 6 films which has changed attitudes to dementia in hospitals across the world – see complete video at: http://www.guysandstthomas.nhs.uk/news-and-events/2014-news/20140331-barbaras-story-youtube.aspx

Barbara’s Story

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Don’t let confusion cloud the risk of falls

• Confusion or cognitive impairment is a common condition for older people in hospital

• > 30% will develop confusion during an admission – commonly as a result of dementia and/or delirium

• Confusion is associated with increased adverse events including falls & death

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BE ALERT for patients with confusion

Some causes of acute confusion

• infection e.g. chest, urinary tract

• constipation / urinary retention

• effects of medications; drug/alcohol withdrawal

• pain

• dehydration, malnutrition

• anaesthetic/post operative

• being in unfamiliar surroundings – hospitals are busy and noisy

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Neuroscience Research Australia 2012

Medical Conditions

Stroke Incontinence Parkinson’s disease

Dementia Delirium

Medications

Psychoactives Four or more medications

Psychosocial & Demographic

History of falls Depression Advanced age Living alone ADL limitations Female gender Inactivity

Sensorimotor & Balance

Muscle weakness Impaired vision Reduced peripheral sensation Poor reaction time Impaired balance

Environmental

Poor footwear Home hazard External hazard Inappropriate spectacles

Falls

Risk factors for falls

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Why dementia & delirium contribute to falls

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• Muscle weakness, gait changes & poor balance

• Memory impairment

• Inability to problem solve & poor judgement

• Visual field changes

• Medications - especially psychoactive meds

• Other contributing factors to falls

– Agitation, restlessness, wandering, pain, hunger, thirst, loneliness and boredom

Because the person may forget:

• to “push the button to call the nurse”

• tubes ( IV’S & drains) are present

• to use recommended footwear

• to use their walking frame

• where the toilet is

• where they are and try to go home

Why dementia & delirium contribute to falls

Hospitalised older people with dementia

Common reasons for admission are:

• Falls-related injuries e.g. hip fractures & head injuries

(3 times as common)

• Infections e.g. UTIs, pneumonia

• Circulatory problems e.g. stroke, dehydration

Few people with dementia are admitted for dementia-related reasons

http://www.neura.edu.au/research/projects/trends-fall-related-

hospitalisations-persons-aged-65-years-and-over-nsw-1998-99-20

Harvey LA and Close JCT. Trends in fall-related hospitalisations, persons aged 65 years and over, NSW, 1998-99 to 2011-12. 2013.

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

Ra

te p

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0,0

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Year

65-69 years (PAC 2.1%; 95%CI 1.6-2.7, p<0.0001)

70-74 years (PAC 2.2%; 95%CI 1.7-2.6, p<0.0001)

75-79 years (PAC 2.2%; 95%CI 1.8-2.6, p<0.0001)

80-84 years (PAC 2.5%; 95%CI 2.1-3.0, p<0.0001)

85+ years (PAC 3.3%; 95%CI 2.9-3.7, p<0.0001)

Figure 2.2: Fall-related injury hospitalisations by age group, persons aged 65 years and over, NSW, 1998-99 to 2011-12

Dementia in Australia

• 2012: 300,000 people with dementia

• 2050: 900,000 people with dementia

• >1200 new cases per week diagnosed

• At age 65: 1 in 12 people have dementia

• Approx 25,000 under age 65 with dementia

• Delaying onset of dementia by 5 years can halve the prevalence

AIHW 2012

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Australian Commission on Safety and Quality in Health Care (ACSQHC)

A better way to care

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A better way to care

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Standard CC: Comprehensive care

Standard RH: Reducing harm

Falls Systems are used to reduce the risk of consumers falling, and minimise harm from falls.

Cognitive impairment and delirium Systems are used to recognise and prevent delirium, and to manage risks of harm from cognitive impairment.

Pressure injuries Malnutrition and dehydration End-of-life care Challenging behaviours and self-harm

Review of RCAs and IIMS Data – Serious Incidents

Recommendations: • care planning of increased fall injury risk for

patients on anticoagulant therapies

• screening for delirium for all patients over 75

• promote nursing Essentials of Care Project components related to increased nursing time at the bedside, routine rounds and toileting to ensure patients’ basic needs are addressed

• fall risk management programs and policy include clear guidelines for post-fall management

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http://www.cec.health.nsw.gov.au/programs/qsa/qsa-reports-and-publications

“Management of delirium is very variable across wards, shifts, specialties etc. Delirium is managed well in the areas where we have aged care and psycho-geriatric services, unfortunately there are increasing numbers of frail elderly patients being admitted all over the district.” District level response

Recommendation

The Agency for Clinical Innovation (ACI) work with appropriate bodies such as the CEC, HETI and LHDs to develop and lead a comprehensive program for the prevention of delirium and appropriate management of patients admitted and diagnosed with delirium

Safer Systems Better Care: QSA Self Assessment Statewide Report 2011

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Facilitators for success

Leadership • Nursing • Empowered teams & accountability • Engagement with patients, families and carers • Whole of hospital targeting • Policy, knowledge information education and resources • Data: local ownership – circulated

Care of the older person in hospital Quality markers: falls, cognition, continence, pressure care,

medications and nutrition Integrated approaches to care Caring environments – design

Looking Forward

History of Falls – patients who have had a fall/present with a fall or fall in hospital are at in increased risk of falling again.

Preventing falls and harm from falls

Mental Status – patients who are confused are at an increased risk of falling & the cause of contusion needs to be investigated

Vision – patients with poor vision can fall as they are in unfamiliar environments

Toileting – patients with continence issues and/or are confused and/ or unsteady on their feet can fall attempting to get to the toilet or in the toilet area

Transfer and Mobility – patients can fall whilst being transferred or if they are unsteady and or have poor balance

Medications – patients who are on antipsychotics, antidepressants, sedatives/hypnotics or opioids are at an increased risk of a fall. Please note that if a patient is on anticoagulants they are at an increased risk of serious injury ( bleeding ) if they do fall.

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www.cec.health.nsw.gov.au/fallsprevention

Mental Status: 1. Is the patient confused? - Yes 2. Is the patient disorientated - Yes 3. Is the patient agitated? - Yes

If the answer is YES to any of these questions the person is at high risk of a fall.

The Falls Risk assessment and management plan will provide prompts for intervention.

Ontario Modified STRATIFY (Sydney Scoring) Fall Risk Screen

Falls Risk Assessment - FRAMP

Mental Status YES Mr Peters is CONFUSED prompts to do

Cognitive screen

Delirium Screen CAM

If your patient is confused Action is required

Investigate confusion and treat underlying

Assess cognition - cognition screen (e.g. AMTS) Screen and assess for delirium CAM (Confusion Assessment Method)

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CONFUSION ASSESSMENT METHOD (CAM) The CAM is a validated tool to be used in assisting with the differential diagnosis of Delirium. It should be used for any older person who appears to be disorientated / confused or who has any change in behaviour or LOC. It is important that the CAM is used in conjunction with a formal cognitive assessment (e.g. AMT/ SMMSE), good clinical and medical assessment, together with baseline cognition information from carers/family or the community or residential aged care service

1 Acute onset and

fluctuating course No Yes

Uncertain,

Specify: ____________

Is there evidence of an acute

change in mental status from

the patient’s baseline?

If so, did the abnormal

behaviour fluctuate during

the day?

e.g. tend to come and go,

or increase and decrease

in severity

2 Inattention No Yes

Uncertain,

Specify: ____________

Did the patient have

difficulty focusing attention

during the interview?

e.g. being easily

distracted, or having

difficulty keeping track

of what was being said?

3 Disorganised

thinking No Yes

Uncertain,

Specify: ____________

Was the patient’s thinking

disorganised or organised?

e.g. Rambling or

irrelevant conversation,

unclear or illogical flow

of ideas, or unpredictable

switching from one

subject to another?

4 Altered level of

consciousness No Yes

Uncertain,

Specify: ____________

Overall, how would you rate

the patient’s level of

consciousness?

Altered e.g. Vigilant,

Lethargic, Stupor, Coma,

Uncertain.

Delirium is present if features 1 and 2 AND either 3 or 4 are present

Delirium symptoms: not present / present Date: / /

Medical Officer notified? Yes / No

Cognition Screen Delirium Screen CAM

Confusion Assessment Method (CAM) • The Confusion Assessment Method (CAM) screens for

the presence of delirium.

• The ‘short version’ of CAM considers that a diagnosis of delirium is likely if the following are present: – acute onset and fluctuating course, and – inattention, and – either disorganized thinking or an altered level of

consciousness.

• Untreated delirium frequently results in adverse events & long term effects and every effort must be made to determine the underlying cause(s).

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Care of Confused Hospitalised Older Persons (CHOPs) Program

Anthea Temple Project Officer ACI

Cath Bateman Project Officer ACI

Results shown in this presentation are preliminary

Measures

• Pre Implementation systems Audit

• Environmental Audit

• Medical record Audit

• Staff knowledge and care confidence survey

• Staff and Carer focus groups

• IIMS data

• Delirium coding data

CHOPs Confusion is Identified, investigated, treated and

appropriately managed

Hospitals provide safe and supportive environments

Older people are cared for by staff that have the right

knowledge, skills and attitudes

Partnership with carers and person centred care are

key aspects of quality care

Strategies and clear leadership roles are in place to

deliver efficient and effective care for confused older people in hospital

ed Health Network

Gosford

Lismore

Prince of Wales

Phase 2 sites Hornsby

Orange

Wollongong

Broken Hill

[email protected]

Phase 3 sites Coffs Harbour

Maitland

Fairfield

Nepean/Springwood

Canterbury

Phase 1 sites

Implementation resources

Interesting findings

• 47% were confused

• 18% patients were admitted due to a fall

• 21/35 patients fall or # at one site

• Of those who were confused 63% had their confusion mentioned in their d/c Summary

• 57% * coded for dementia/delirium (*1 site not inc)

• 6% mortality (whole sample)

Results shown in this presentation are preliminary

Cognitive screening

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

On admission 24Hrs Total

Results shown in this presentation are preliminary

Risk screening

0%

10%

20%

30%

40%

50%

60%

70%

80%

DRAT PU Falls Nurtition

Results shown in this presentation are preliminary

Assessment

0 NOT CONFIDENT

10 VERY CONFIDENT

Staff knowledge & attitude survey

Total of 503 Staff surveyed • 61% nursing • 25% allied health • 12% medical

Results shown in this presentation are preliminary

Staff stress in management

0 NOT CONFIDENT

10 VERY CONFIDENT

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Risk identification solutions

Why are confused older people falling?

Environment is different from home

Why are confused older people falling?

Press here!

the toilet is much easier to see with green seat and lid

Why are confused older people falling?

Visual changes – can’t see the toilet

Communication

• A patient who is confused may not remember who you are or where they are: – introduce yourself – inform them they are in the hospital – let them know what you are doing

• Engage with patients family/carer – they will identify if behaviour/confusion is usual or fluctuating

T

O

P

5

Talk to the Carer

Obtain the information

Personalise the care

5 strategies developed

http://www.cec.health.nsw.gov.au/programs/partnering-with-patients#TOP5

Engage with families/carers

36.4% reduction in falls by patients with dementia by the sixth month of using TOP 5

Dot can’t sleep and gets very agitated if she doesn’t wear socks to bed.

If she walks in just socks she’ll probably fall so please remind her to put

shoes on when she gets up.

Dot always goes to the toilet about 5am. If she tries to go on her own she

might fall but she’ll never press the buzzer (she doesn’t like to “be a

bother”). Please be ready to go with her at 5am.

Make sure Dot has her handbag on her lap. If she can’t see it she’ll look

for it under the bed and has fallen like this before.

Dot is often restless in the afternoon and tends to wander but she is very

unsteady on her feet. She always used to walk the dog in the afternoon.

Tell her she doesn’t need to walk the dog today and she’ll sit down

again.

Top 5 - Carer’s Tips

What affects quality in health care?

The level of quality in hospital environments is affected by:

• (1) the quality of technical care;

• (2) the quality of interpersonal relationships;

• (3) the quality of hospital amenities and the environment

(Potter et. al, 1994. Int J of Health Care Qual Assur, Vol 7, pp.4–29).

High performing organisations

Hospitals with high levels of ‘patient care

experience’ reported by patients provide clinical

care that is higher in quality across a range of

conditions.

Jha A et al (2008) N Engl J Med 2008; 359:1921-1931.

Overview of the evidence • Refocusing care delivery around the patient • Improves patient care experience....

• Improves clinical and operational-level outcomes: – improved patient adherence

– fewer medication errors

– decreased adverse events – including falls

– improved staff satisfaction

– enhanced staff recruitment

– decreased length of stay

– decreased ED return visits

Staff can reduce patients risk of a fall

• Minimise background noise and distractions - unsettling

• Leave a night light on to guide to the bathroom

• Encourage night time sleep by reducing noise and minimising disturbance and reducing day time napping

• Ensure personal care needs are met e.g. regular toileting and assistance with meals as required.

• Provide assistance when walking as balance and strength may to be affected

• Talk to family and carers about the usual routine at home e.g. likes to shower after dinner and reads the paper after breakfast each morning

Engage with families/carers

• Place familiar objects where they can be seen e.g. photographs

• Provide personal information about the patient e.g. what they like to be called, tips for care e.g. likes, dislikes and whether an interpreter is required

• Have family or a familiar person spend time in hospital with the patient

CEC Flyers for family and carers

www.cec.health.nsw.gov.au/programs/falls-prevention/falls-one-page-flyers

PET (patient/carer experience trackers)

Education solutions

CHOPs Resources

CHOPs Tearoom

http://dementiacare.health.nsw.gov.au/courses/course/view.php?id=24

NSW Falls Prevention Network Network list serve Newsletters & updates Annual Network forum – NSW, 22 May 2015

http://fallsnetwork.neura.edu.au

Clinical Excellence Commission

http://www.cec.health.nsw.gov.au/programs/falls-prevention

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For further information:

[email protected]

www.cec.health.nsw.gov.au

Acknowledgements • Mark Howland & Fran Dumond, HNE LHD • Anthea Temple & Cath Bateman ACI, CHOPS • CEC April Falls Working Group