Transcript Dr Gideon Caplan - Ageing Research Online

National Symposium on Ageing Research
-The Practitioner, Industry and Community
Perspectives
Discharge of Elderly from the
Emergency Department (DEED)
Dr Gideon Caplan
Director, Post Acute Care Services
Prince of Wales Hospital, Sydney
How do ideas become action in
health







Academic path
Demonstrate a need
Prove something works
Evidence of cost
effectiveness
Write submissions
Pray for funds
Evaluate role out





Political path
Need is spelled out in
papers
Daily Telegraph and
Sydney Morning Medical
Journal
Throw money at it +++
Next year change tack
completely
The Health system - 2001


Three arms
Medicare
 Public Hospitals
 Pharmaceutical
Benefits Scheme
 Increase
over last 5
yrs in C/W funding
 15%
 17%
 48%
The idea

PACS 1989
 Respiratory Outreach
Service (Chronic and
Complex Care for COPD)
in 1993
 In 1994 we looked around
 Leading source of
complaints to the hospital
was from older people in
the ED
Older patients in the ED

Older patients more frequently
– present
– present by ambulance
– are admitted to hospital
 to ICU
 to CCU
The future

Given the 4x increase in % of people 80+ the
future of emergency medicine is geriatrics
 Will our hospitals be overwhelmed?
 Are we the King Canutes of the medical system?
Can we intervene before
admission is inevitable?

Can we predict admission ?
 What are the risk factors for admission?
Discharged Elderly from the
Emergency Department
(DEED)

Studies in England, America and Australia
demonstrate that DEED have a high rate of
admission
 <65 yo 1/12 admission rate = 0
 75+ yo 1/12 admission rate ~ 20%
Which older patients
discharged from the ED will be
admitted within the next
month?

Unstable angina/ other medical conditions?
 End-stage malignancy?
 Require surgery but too sick for anaesthetic?
 Infections treated with wrong antibiotics?
Next step

1994. Grant of $50,000 from Commonwealth
Dept of Human Services and Health, National
Hospital Quality Management Program
DEED I Study: Risk factors

468 patients community or hostel living 75+
DEED
 Study: 1 year
 65% living independently
 Assessed prospectively for diagnoses, function,
community services
 Followed for 4 weeks
 17.1% admitted
No disease or disease category
was predictive of admission over
the next month
Risk factors for admission
DEED I

Dependency in IADL
– Unable to manage transport, finance, medications
independently

Receiving Community supports
– Community Nurse
– MOW

Living alone
 Cognitive impairment
Logical conclusion

If these problems are causative...
 If it is possible to address these problems…
 Comprehensive geriatric assessment
 ??? decrease subsequent admission rate
So what?

Geriatrics has been taught
in all of our medical
schools for >20 years
 Doctors today know how
to assess older patients
Come fly
with me!
Percent assessed
Assessment of function in ED
80
70
60
50
40
30
20
10
0
P<0.001
Interns/RMOs
Registrars/
Specialists
0=3 4=5 6=7 8
9
10 11 12
IADL Score
Discharge of Elderly from the
Emergency Department II The DEED II Study
Funded by Commonwealth Department of Human
Services and Health National Demonstration
Hospitals Program Phase 1 1995
DEED II Study: ? Prevention

Randomised controlled trial
 700 patients 75+ discharged from ED
 Treatment group randomised to immediate (<24
hrs) assessment and intervention by
multidisciplinary team
 Geriatrician, Nurses, Allied Health
 Interventions targeted to patients needs
 Follow-up: 1, 3, 6,12,18 months
Interventions

Average number of new problems identified and
acted on = 1.65
 Actions included referral to
– GP
– Specialist
– Allied Health
– Nursing
– Other
Types of problems (%)
Medical problems
ADLs/IADLs
Medications
Ulcers/skin
Mobility/falls
Psych/carers
Cognitive
Total
33.6%
19.2%
15.2%
10.4%
8.3%
6.3%
3.1%
100%
Action on problems (%)
Nurse
Specialist/hospital
General Practitioner
Physiotherapist
Occupational Therapist
Other
Total
31.1
18.9
18.5
10.7
8.2
12.6
100
Change in Barthel Index:
Change in Score
0.5
0
-0.5
*
-1
Intervention
Control
**
**
**
-1.5
-2
**
-2.5
0
3
6
Months
12
**
18
*p<.05
**p<0.001
compared to
baseline
Change in Mental Status
Questionnaire
0.2
Change in MSQ
0
-0.2
-0.4
Intervention
Control
*
-0.6
**
-0.8
**
-1
**
-1.2
0
3
6
Months
12
18
*p<.05
**p<.001
compared
to baseline
Admissions
18 Months
One month
25
*
60
* p<0.05
** p<0.001
**
50
20
40
15
Treatment
Control
30
10
20
5
10
0
0
Emerg
Elective
Any
Emergency
Change in total function by date of first emergency admission
0
-2
-4
-6
0--3m
***
-8
***
***
-10
***
-12
*** p<0.001
0
3
6
months
12
18
Change in total function by date of first emergency admission
0
-2
-4
*
*
-6
***
-8
***
0--3m
3--6m
***
-10
***
-12
0
3
6
months
12
18
* p<0.05
***p<0.001
Change in total function by date of first emergency admission
0
-2
-4
*
-6
***
***
***
-8
*
***
0--3m
3--6m
6---12m
***
-10
***
-12
0
3
6
months
12
18
* p<0.05
*** p<0.001
Change in total function acc. to
date of first emergency admission
0
0--3m
-2
3--6m
-4
*
-6
***
-8
*
***
***
12--18m
***
***
***
-10
***
-12
0
3
6---12m
6
months
12
18
Never
admitted
* p<0.05
*** p<0.001
Conclusion

Older patients sent home from the ED are at
increased risk of deterioration
 Comprehensive geriatric assessment and shortterm intervention improves function and
outcomes.
Was this a clever idea?

No. At exactly the same time in US and Canada
other researchers were doing almost identical
studies
 One replicated our findings
 Other a negative study
 But we didn’t find out about their work till 2000
So, how to roll it out in Australia

NDHP 3 (1999) + 4 (2002). POWH again a lead
hospital
 Able to roll out DEED service in 5 collaborating
hospitals with success each time
 NDHP also provided a national platform
 Other hospital adopted the change spontaneously
 Government Action Plan (NSW) and HARP
Victoria both cited NDHP
NSW GAP

Another winter bed crisis
 Looming election
 ASET (Aged Services Emergency Teams) to
improve care of elderly in ED
– Multidisciplinary assessments
– Better discharge planning
– Admission avoidance
– $220K to metropolitan hospitals recurrent
Who should decide what to
research?

Revive the concept of the clinician-scientist
 Empower clinicians, carrot and stick approach
 Stimulate them to explore observations