Background At a Royal Physician`s meeting 2011, John Gladman, Professor of Geriatrics in Nottingham explained that the one system known to reduce hospital admission is multi factorial intervention into nursing homes by a Geriatric Service. He said that to reduce hospital admissions by one, fifty people need to be treated. Professor Ian Philip asked what evidence was there for admission avoidance? The only proven one was Nursing Home Liaison. 75+ health checks, community Matrons, carer support, early dementia diagnosis and fall clinics have not proven themselves.
Antrim ED Attendances from Nursing and Residential homes There were 3,604 attendance to Antrim ED from nursing and residential homes between 1 April 2009 to 31 January 2011 (22 months). Average of 5.4 attendances per day. 2,291 (64%) of these patients were admitted. The 3,604 attendances were occasioned by 1,515 individual residents, 859 (57%) of whom attended more than once during the review period. One resident attended 24 times. 52% of attendances occurred between 9am and 5pm, 32% between 5pm and midnight and 15% between midnight and 9am.
Transforming your Care Is based on the principle that we overuse hospitals. Many patients present at emergency departments because there are no alternatives in place. Problems with shortage of beds, trolley waits, transport difficulties, crowded emergency departments
Taking the above into consideration the NHSCT acute services directorate conducted a review of services for older people with the following objective: To work with nursing and residential homes to keep residents healthy.
PNH Outreach Pilot Consultant Geriatrician and Pharmacist to review residents Particularly focusing on those with unstable chronic disease, high risk medication, a history of falls, or recent attendance at an emergency department.
Prior to Home Visit (Geriatrician) The patients names are sent to consultants secretary who sources their medical notes. Consultant then reviews the patients charts in particular noting any recent attendance at Antrim ED or admissions to the ward. Could that admission have been avoided and is it possible to reduce their chances of reattending ?
Prior to Home Visit (Pharmacist) Obtains a copy of the Patients current kardex from the PNH. Obtains a current drug history from the patients GP. Completes a medicines reconciliation and a review of current medication. Reviews any recent Laboratory results in view of repeat or recent acute medication particularly considering renal and hepatic function. Prepares a list of possible recommendations for the visit.
The visits One visit per week for a 3 hour period. Approximately 6 patients per week are reviewed. Nursing staff prioritised patients most suitable for intervention to be reviewed first. During the visit medications were adjusted, kardexes endorsed, referrals arranged, tests ordered, advice given etc.
Post visit Following review a letter was sent to the patients GP ± recommendations for changes in management or detailing changes which had already been actioned. Copy also kept in residents notes in the home and the hospital medical notes.
Interventions Average of 16 interventions per visit. Average of 2.8 interventions per patient. Most common interventions were -: stopping medication, endorsement of product information on the kardex e.g. strength, starting new medications. Least common interventions were -: change of product, advising relatives and advising the patient themselves rather than staff.
Going forward Nursing Homes will be invited to participate in the project Once participation has been agreed, an initial meeting is held with Consultant Geriatrician, Trust management, Pharmacist, and Nursing Home Managers. Agree scoop and timescale of intervention Agree how residents are prioritised
Consultant writes to GP practices whose patients may be involved. Home informs residents and their families. Home emails list of patients to be seen in advance to consultants secretary and pharmacist. Prior to clinic consultant reviews patient hospital notes and pharmacist reviews medication history
Consultant and pharmacist will involve home of any suggested changes in management. Any suggested changes are sent to GP If any further intervention is required eg advanced care planning discusssions involving relatives, the home is informed so this can be arranged.
Causeway area No geriatrician available to support the project. Homes in this area will be visited in the same way by an experienced pharmacist who is also an independent prescriber.
ALL residents remain under the care of their GP, they are not taken over by the consultant Post intervention meeting at home to discuss any issues arising, and to address any training needs. Trust community and palliative care staff also attend this meeting to provide information and support.