In this slideshow, Prof David Oliver, Consultant Geriatrician, Royal Berkshire NHS Foundation Trust, presents on how we can shorten and improve hospital care for older people with complex needs. Dr Thompson spoke at the Nuffield Trust ‘Reducing the length of stay’ event in September2014.

1. 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

2. 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

3. Imison et al King’s Fund 2012

5. BMJ April 2013

7. EMERGENCY READMISSIONS: ENGLAND 1999-00 to 2009-100100,000200,000300,000400,000500,000600,000700,0001999-002000-012001-022002-032003-042004-052005-062006-072007-082008-092009-10YearNumber readmissions Age 0-15Age 16-74Age 75+ Age 16+ All ages
Fastest Rise is in Over 75s

8. Wishful thinking and magic bullets on admission prevention?

9. 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.”

10. 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

11. High intensity users of hospital services have overlap of physical and social vulnerabilities

12. 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
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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

13. Fried 1999

14. How frailty presents to services (Clegg and Young Lancet 2013)
Fatigue
Weight loss
Frequent infections
“Failure to thrive”
Delirium
Falls
Immobility
Fluctuating Disability
Incontinence

15. Mudge et al (bear in mind, 10 days of bed rest = 14% loss of aerobic and 10% muscle capacity – Kortebein )

16. 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

17. The solutions I know are set out here.
Free at http://www.kingsfund.org.uk/ sites/files/kf/field/field_publication_file/making-health- care-systems-fit-ageing- population-oliver-foot- humphries-mar14.pdf
Free slideset at
http://www.kingsfund.org.uk/audio-video/improving-care- ageing-population-what- works
Blog http://www.kingsfund.org.uk/ blog/2014/03/time-has-come- make-health-and-care- services-work-our-ageing- population

18. Structure of paper
Intensely practical
Aimed at those leading local services
10 sections
For each:
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Goal
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Current situation
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“what we know can work”
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Key references and resources
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Good practice examples from around the UK (despite austerity and upheaval)
Field tested/reviewed with many service leaders
Widely endorsed. Cited by NHS England.

19. 10 Components all of equal importance with older person at the centre
End of life planning and care cuts across all

20. 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

21. Animation. Mrs Andrews’ Story from HSJ Commission
https://www.youtube.com/watch?v=Fj_9HG_TWEM

22. 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?

23. Managing the Streams – from ECIST priorities in Acute Hospitals
Identify the stream
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Short stay Sick specialty Sick general Complex
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Allocate early to teams skilled in that stream
0
50
100
150
200
250
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5
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25
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Length of stay (days)
Number of patients
Clarity of specialty criteria
Specialty case management plan at
Handover – no delays
Green bed days vs. red bed days
Short stay – manage to the hour
Maximise ambulatory care
Complex needs – how
much is decompensation?
Detect early and design
simple rules for discharge
Minimise handover
Decompensation risk
Early assertive management
Green bed days vs. red bed days