A successful liaison service?

Royal Cornwall Hospital

 Background history.
 Service now 7 years old
 Monday-Friday service 9.00 - 5.00
Collaborative seamless
 Service development & improvement
 Education
 Audit & research
Referrals
 1500 per year (750 beds) 90 Cheshire 130
Guys London
 Initial referrals Acute confusion Depression
Dementia
 After 7 years complex cases MCA DOLs
 Acute confusion mild moderate depression
and dementia now treated Consultant COE
Physicians & mdts.
Transforming acute care

 Really is everybody’s business

 Education
 Policies Pathways Guidelines
 Toolkit
 Relationship building
 Responsive service easy to reach
available to all
What a liaison service should do

 Rapid response attend MDTs

 Sign post to other services
 Improve patient experience
 Reduce unnecessary transfers
 Strengthen relationships all
organisations
 Facilitate timely appropriate discharge
Success?!

 Reduction in anti psychotic medication

 Dementia screen, cognitive
assessments now routine on admission
 Reduction in referrals for mild/moderate
depression acute confusion and
dementia… Its not a mental health thing
Recent audit post education sessions to all
staff 2007 Lets Respect campaign

 Pre audit Post audit

 Sedatives 70% 20%
 History 30% 70%
 Communication 50% 100%
 Risk assessment 12% 90%
Pathway Policies & Guidelines

 Dementia Guidelines
 Palliative care for people with dementia
 Pain pathway
 Minimum Restraint policy
 Mental Capacity Act Policy
 Special observation policy
2010

 Anti psychotic policy checklist and

booklet
 Relatives information pack
 E learning
 Worried about your memory campaign
 Link nurse forum
 Life story campaign
S T A R campaign

Stop - All medications have side effects

Think - Why are giving this medication?

Assess - Is it still needed?

Review, reduce and discontinue
Public awareness
our memory bus
Research and Audit
 ARBD rehabilitation
 Admissions: residential and care homes
 End of life pathway care homes change
of read code GP practice
What if ?

 If we really are successful will a

Psychiatric older persons service be
required in the future???
 NHSCIOS & RCHT Nursing
Care Home Admissions Audit

Dr Fiona Boyd.
Bev Chapman
Kylie Cook
Maggie Trevethan
Aim : To identify the numbers of
patients admitted from nursing
homes with a view to:

1. Identifying the appropriateness of admission i.e.

those requiring acute care (whether there is an
alternative to admission to hospital).
2. Determining a care pathway to prevent unnecessary
admission
3. Facilitating the patient illness journey in the best
setting for the individual.
4. Considering the potential cost implications of
inappropriate acute admissions of people with
dementia
Methodology

 A case note audit of patients with known

diagnosis of dementia admitted into an acute
district hospital (Royal Cornwall Hospital) from
registered nursing care homes in Cornwall.
 The patient cohort identified using monthly
admission figures provided by the NHSCIO
 Review of medical records in conjunction with
a written proforma.
Key areas for scrutiny included:

1. Source of referral i.e. A&E or via GP

2. Involvement of GP prior to admission
3. Hour of admission
4. Reason for admission / Diagnoses
5. Length of stay
6. Place of discharge (final outcome)
7. Alternative treatment options
8. Cost implications around end of life care and
admissions
Results
 n221 case notes were reviewed
 The total number of admissions from nursing homes
to Royal Cornwall Hospital during 2009 was 534.
 Only those with a known diagnosis of dementia were
included.
 Exclusions included those attending Accident and
Emergency Dept. but not admitted, and those
attending for elective surgery.
 The median age for participants was 81 (range 54-
104).
 Source of Referrals

 The number of patients Pie Chart: GP Direct Admissions verses 999 Emergencies
referred by GP was 90
(41%), of whom 54 (56%)
required admission for acute
care. 41% (GP)

59% (999)
GP Involvement
 54% required acute
care.

Percentage of GP Adm isions that required Acute Care

60

50

40
percent %

30
54
20 36
Appropriate
10 Alternatives
available
0
GP adm issions
Out of Hours Admissions
 59 patients admitted
 22 (18%) were admitted between
2200hrs and 0800hrs
 23% required acute care.
 21 (35%) of the out of hours admissions
where palliative, of whom 6 (10%)
where admitted after 2200hrs - Non
were seen by GP.
Reasons for Admission to
RCH
Medical Conditions Number of patients Percentage
(n221) %

Infection 39 17.6
   
LRTI 23
UTI 9
Other(ulcers/gangrene, meningitis) 7

Falls 30 13.6
   
Fracture 16
No fracture 14

Cardiac (MI,ACS,AF,CCF) 16 7.3

Stroke 14 6.3

Breathlessness and fatigue 11 5.2

 The majority of admissions were via medicine (n200 ;
90%), the rest were a mixture of orthopaedics (n11 ;
4%) and surgery (n15 ;6%).
 57% (n125) patients who were admitted to RCHT
during this 11 month period did not require acute
care.
 Of this group, 9 (7%) required step up care and 71
(57%) were palliative, therefore there were 45
individuals (36%) who may have received care at
home thus avoiding admission.
Length of Stay
 Total LoS 2295 days. (median per head 10.4
Days).
 90 (41%) were necessary admissions for acute
care, and for the remainder, alternative options
could have been offered in the care home. 
‘Alternative group’ :
1. 9 patients required step up care (Los 792; mean 88,
range 52-108)
2. 71 were palliative (Los 581days) of whom a
proportion were discharged back to their respective
care homes for end of life care.
 Final Outcome (Discharge or Death).
 
 70% of patients were Pie Chart: Final Outcome for Patient Journey.
discharged back to their
original nursing home, 4% 4% Step Up
were discharged to a step up 26% Died in
care and 26% died in Hospital

hospital.
70% Back to NH
End of Life Care

 In relation to those patients with

advanced terminal phase dementia, 71
(32%) were palliative.
Died in Hospital 58
(81of EoL subgroup)
Transferred back to Home 13
(19% of EoL subgroup)
Outcomes and Alternative Options

Alternative treatment Number of patients

option
Antibiotics 21

Intravenous fluids 3

Bowel /bladder care 4

Pain management 7

Stroke/TIA (in severe 4

dementia) –no intervention
Falls prevention 10

End of Life care plan 67

Step up –place direct from 9

community
Total 125 (57%)
Costings

 Costing was not undertaken for the

whole group due to variations in coding
and additional complex care, however,
figures were undertaken to establish
broad ‘costing’ for end of life subgroup
& ‘step up’ care.
EoL Costing ( based of non elective
national tariff)
 Total £143485 (over 11 months) (Mean
£124504)
 Mean cost per person admitted for Eol
care £1486.24 (£2020.92 +cc).

The above is based on PbR Tariff for 2010-11 – these

figures were used to help quantify costing in real time.
Costing – ‘Step up’ subgroup

 Step up patient subgroup (n9),

 Average LOS was 88 days /person.
 The actual costs for ‘respite’ for > 9
days + cc = £4535 + (Aver LOS – non
elect stay trim point = 47days) x £269
(non elective stay trim point 41 days
= £17178 /person.(total £154,602).
Conclusions

 Recent audit, policy and national reports

have concluded the need to move away
from costly acute care settings.
 Analysis shows that acute admissions
are not cost effective and many cases
unsuitable for a person with severe end
stage dementia:
Advocacy & ‘Best Interest’
 Patients with advanced dementia lack mental
capacity in decision making . Therefore when
considering the patients health this must be
viewed in the context of both health and
welfare and a best interest decision should be
made by those responsible for delivering care
with regards to the appropriacy of acute
hospital admission.
Key Findings
 Many patients were admitted and received
simple care interventions.
 The most common included antibiotics,
intravenous fluid support, urinary
catheterisation and analgesia.
 All patients reside in nursing homes and a
terminal dementia lacking the mental capacity
to decide physical health interventions.
Key findings continued….
 Many patients had advanced terminal phase
dementia and as such were considered not
appropriate for treatment – many died or were
discharged from RCHT with no intervention.
 These patients were identified as appropriate
for End of Life Care in the community (n67 ;
30%), a further 3 patient died despite
interventions.
 Improved identification of terminal
phase disease will lead to better end of
life care planning which can then
enhance decisions making regards final
care pathway and ultimately respects
the health and welfare needs of
patients.
Implications for Practice and
Recommendations 1
 There is a clear need to identify those
with advanced terminal dementia within
their care setting and instigate plans for
care that are anticipatory, respectful of
best interest and advocacy, appropriate
to meet the needs of the individual
client.
2 Alternative Care Options

 It is hoped that by providing alternative

options of treatment delivered in the
care home by enhanced services
AHAH/paramedics and greater
involvement of GP’s and other allied
community health professionals a
significant reduction of admissions to
acute care can be achieved.
3 EoL Planning

 End of life planning / care pathways will

prevent unnecessary admission to
acute care and enhance the delivery of
palliative care for this client group in the
care home setting.
4 Financial Considerations

 Provision of care for those with

dementia is not core business for acute
care.
 Prevention of admission will facilitate
cost savings (via increased ‘cutting’
throughput and elective activity).
 Financial resources can be better used
in improving community based care.
Summary
 1st phase study reviewing nursing home
admissions to RCH
 59% patients did not require acute care
 Significant number of patients required
palliation
 Invest in community care (resources and
education)
 Promote advanced planning & appropriate
decision making
Thank You .