National Symposium on Ageing Research -The Practitioner, Industry and Community Perspectives

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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

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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

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The Health system - 2001

• Three arms
• Medicare
• Public Hospitals
• Pharmaceutical Benefits Scheme

• Increase over last 5 yrs in C/W funding
• 15
• 17
• 48

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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

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Older patients in the ED

• Older patients more frequently
• present
• present by ambulance
• are admitted to hospital
• to ICU
• to CCU

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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?

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Can we intervene before admission is inevitable?

• Can we predict admission ?
• What are the risk factors for admission?

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Discharged Elderly from the Emergency Department
(DEED)

• Studies in England, America and Australia
  demonstrate that DEED have a high rate of
  admission
• lt65 yo 1/12 admission rate 0
• 75 yo 1/12 admission rate 20

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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?

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Next step

• 1994. Grant of 50,000 from Commonwealth Dept of
  Human Services and Health, National Hospital
  Quality Management Program

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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

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No disease or disease category was predictive of
admission over the next month
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Risk factors for admissionDEED I

• Dependency in IADL
• Unable to manage transport, finance, medications
  independently
• Receiving Community supports
• Community Nurse
• MOW
• Living alone
• Cognitive impairment

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Logical conclusion

• If these problems are causative...
• If it is possible to address these problems
• Comprehensive geriatric assessment
• ??? decrease subsequent admission rate

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So what?

• Geriatrics has been taught in all of our medical
  schools for gt20 years
• Doctors today know how to assess older patients

Come fly with me!
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Assessment of function in ED
Plt0.001
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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

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DEED II Study ? Prevention

• Randomised controlled trial
• 700 patients 75 discharged from ED
• Treatment group randomised to immediate (lt24 hrs)
  assessment and intervention by multidisciplinary
  team
• Geriatrician, Nurses, Allied Health
• Interventions targeted to patients needs
• Follow-up 1, 3, 6,12,18 months

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Interventions

• Average number of new problems identified and
  acted on 1.65
• Actions included referral to
• GP
• Specialist
• Allied Health
• Nursing
• Other

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Types of problems ()
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Action on problems ()
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Change in Barthel Index




plt.05 plt0.001 compared to baseline


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Change in Mental Status Questionnaire



plt.05 plt.001 compared to baseline

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Admissions
plt0.05 plt0.001


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Change in total function by date of first
emergency admission
Change in sum of function




plt0.001
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Change in total function by date of first
emergency admission
Change in sum of function






plt0.05 plt0.001
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Change in total function by date of first
emergency admission
Change in sum of function








plt0.05 plt0.001
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Change in total function acc. to date of first
emergency admission
Change in sum of function









plt0.05 plt0.001
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Conclusion

• Older patients sent home from the ED are at
  increased risk of deterioration
• Comprehensive geriatric assessment and short-term
  intervention improves function and outcomes.

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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 didnt find out about their work till 2000

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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

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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

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Who should decide what to research?

• Revive the concept of the clinician-scientist
• Empower clinicians, carrot and stick approach
• Stimulate them to explore observations