Penny Bond is Improvement Support Team Leader in Healthcare Improvement Scotland leading a national programme of work to improve older people’s acute care. She tweets at @opachis. Here she talks about a collaborative national approach to improving the identification and management of frailty and delirium in older people admitted to acute hospitals.
‘Improve care for older people in acute care by March 2014.’ This was the request made to Healthcare Improvement Scotland (HIS) in April 2012. From an improvement perspective this felt like an ‘end world hunger’ type of aim! Given that the vast majority of patients in hospital are over the age of 65 and these numbers are predicted to increase by 50% over the next 20 years we needed to really focus this work by identifying where there were shared priorities and opportunities for improvement.
Health Service Researchers supported us with scoping the initial parameters for this work through a review of the evidence, including published evidence and looking at the themes emerging from inspection reports as well as consulting with a wide range of stakeholders. What quickly became apparent was that the care of frail older people coming into hospital was a growing area of concern across NHS Scotland. Opportunities for improvement emerged in relation to the identification of frail older people in order for their care to be planned and managed appropriately. Colleagues in the Scottish Delirium Association were developing a delirium pathway at the time that we were scoping this work and were keen to work with us. Consequently we have concentrated on identifying and responding to the needs of frail older people with a specific focus on how we identify and manage delirium.
Evidence tells us that making sure frail older people get the right care in the right place at the right time can have really significant benefits in terms of things like length of stay and admissions to long term care. There are also cost benefits, not just monetary costs but critically human costs, thinking about individuals’ experience of care. While delirium is often linked to frailty that’s not always the case and we know that delirium often goes undetected and that failure to detect it is again associated with worse outcomes such as increased risk of dementia, increased length of stay in hospital, increased risk of new admission to long-term care and even death.
The identification and management of frail individuals and/or those with a delirium is complex and the initial focus of this work has been on ensuring reliable processes are in place to support improved outcomes. A number of resources have been developed and tested in collaboration with clinicians across Scotland to support both the identification and management of frailty and delirium.
Including patient and carer experience of delirium was key in shaping the ‘TIME’ to think delirium bundle. TIME refers to triggers, investigations, management and critically engagement of family and carers. How often do we hear phrases like “This isn’t my Mum” or “I don’t recognise my Dad”. The value of listening to family members can’t be under estimated. Our recent ‘Focus on Frailty’ report highlights a number of case studies focused on improving care of frail older people.
A collaborative approach has been adopted to bring together healthcare teams from across Scotland to test out changes, share and spread good practice and provide improvement support. There are 14 territorial health boards in Scotland with test site teams in each board working with us. Capturing and sharing existing good practice has been hugely valuable. Although teams are at different stages in their improvement journey what is very evident is the shared commitment to improving older people’s acute care and to learning from each other. A number of national events have brought teams together from across Scotland to facilitate that sharing of ideas, experience and expertise. Feedback from these events has shown that they are a real catalyst for teams to take learning back to their own areas of work and test out improvement ideas. Individual teams are gathering data and showing real progress in terms of building reliable processes and these are being reported through local flash reports.