Interface Medicine and the Future Hospital

Transcription

1 Interface Medicine and the Future Hospital Prof Dan Lasserson MA MD FRCP Edin MRCGP Senior Interface Physician in Acute and Complex Medicine Dept of Geratology, OUH NHS FT Associate Professor, Nuffield Department of

2 CONTENTS Future Hospital principles and the interface with the community Evidence for ambulatory emergency care Delivering ambulatory emergency care Critical enablers and realities International models and NHS England vanguards Implementing the Future Hospital vision

3 Future Hospital Principles the interface with the community A Medical Division that has in-hospital and community based components Ambulatory emergency care should be the default for all patients, unless admission required on clinical need Develop specialist models of care that operate beyond the hospital walls, providing care integrated with community providers/gps, particularly into care homes Clinical Coordination centre that can match care needs with capacity/capability across the health economy (to include Urgent Care, Out of Hours care, Medical Division)

4 Future Hospital Principles the interface with the community Do services deliver continuity of care? Do services deliver patient-centred, compassionate and holistic care? Do services deliver for vulnerable patients and for patients with complex needs?

5 Future Hospital Commission, Royal College of Physicians 2013 The hospital - community interface

6 Ambulatory Emergency Care Evidence Enablers Realities Future Hospital Commission, Royal College of Physicians 2013

7 What is ambulatory emergency care? Diagnosis, observation, treatment, rehabilitation not provided in the traditional hospital bed base or outpatients Improved patient experience, reduce negative impact of hospital admission, cost-effectiveness Needs observation periods, rapid diagnostics, decision-makers, reassessments Communication with a capable community

8 A Post Hospital Syndrome? Medicare readmissions in US ( >65 years) after index admissions for acute MI, pneumonia, heart failure 18-25% readmitted within 30 days, mostly with different conditions Interpreted as a transient, acquired generalised increase in risk for multiple conditions JAMA 2013;309 (4): NEJM 2013;368:

9 Reducing the trauma of hospitalisation Depersonalisation/stress of admission, sleep deprivation, reduced mobility, loss of strength, poor appetite / nutrition, medication effects JAMA Viewpoint May 2014, Detsky A.,Krumholz. H

10 Randomised trials of ambulatory emergency care / Hospital in the home Small trials (n ) Mostly single, differentiated presentations (IECOPD, decompensated HF) Randomised after initial acute assessment in ED Treatment regimes in H@H arms altered to fit practicalities of domiciliary treatment e.g. once daily IV antibiotics

11 Randomised trials of ambulatory emergency care / Hospital in the home Systematic review of randomised trials Patients treated in the home rather than hospital Reduced mortality OR 0.79 ( ) Had less chance of readmission after acute treatment Better patient and carer experience Overall costs were reduced Caplan G. et al MJA 2012;197:

12 Delivering ambulatory emergency care Community based acute multidisciplinary assessment and treatment Working outside the hospital walls Integrated working with community partners Improve patient and carer experience of acute assessment and treatment

13 Emergency Multidisciplinary Unit (EMU) Accessible, rapid, multidisciplinary diagnosis and treatment from a community setting Credible alternative to acute hospital admission Personalised acute care process, tailored to risk, patient and carer preference Platform for innovation in care models for older patients living with frailty

14 Emergency Multidisciplinary Unit (EMU) Shopfloor Disciplines Nursing Physiotherapy Occupational therapy Social work Transport Medical interface capability, drawn from 1 and 2 care clinicians Rapid diagnostics for senior led decision making

15 Emergency Multidisciplinary Unit (EMU) Investigations POC bloods Na, K, urea, creatinine, calcium, glucose, blood gases, lactate, INR, haemoglobin, troponin, CRP Plain X-Ray (no cross-sectional imaging) Interface multidisciplinary team care : delivers enabling care alongside interventions traditionally delivered in an acute hospital, in settings close to home Intravenous fluid, diuresis, antibiotics, blood products Frequent assessment/monitoring (therapist, nursing, social, medical care) Care Pathways Ambulatory care Bed based care (community or acute)

16 Emergency Multidisciplinary Unit (EMU) 7/7 working - weekday 8am 8pm, weekend 10am 4pm Step up GPs if considering admission paramedics community team Step down Referrals from OUH Vertical integration Home nursing team IV, clinical monitoring Direct admission to acute trust geriatric service

17 Acutely unwell frail older adult living at home/care home Patient Flow Primary Care Paramedic Community team EMU referral Dedicated transport EMU assessment and treatment Home Community hospital Acute

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19 i-stat i-stat Point of Care vs Laboratory controlled lab based studies Sodium i-stat V Lab (mmol/l) Line X=Y 6 Potassium i-stat V Lab (mmol/l) Line X=Y Laboratory Laboratory

20 Point of Care vs Laboratory in routine clinical use

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24 INR

25 Importance of POC testing in community settings

26 Selecting patients for ambulatory emergency care Fundamental element of Future Hospital report is ambulatory emergency care What is the level of agreement over which patients are suitable to be ambulated in acute illness?

27 Selecting patients for ambulatory emergency care

28 Selecting patients for ambulatory emergency care Outcome = discharge within 12 hours of referral to medicine Independent predictors summed into the Amb score Ala L. et al Clin Med 2012;12 (5):420-6

29 Selecting patients for ambulatory emergency care 533 consecutive acute referrals median age 80 yrs, 59% female, mean Barthel = % referred by paramedics, 85% referred by GPs 13.3% from care home/supported living Of those living at home 23% had a care package, 40% living alone

30 Selecting patients for ambulatory emergency care 533 consecutive acute referrals - presentations 48% decreased mobility/functional decline 37% breathlessness 20% falls 18% acute confusion 43% deemed to have increased care needs

31 Selecting patients for ambulatory emergency care Pathway outcomes at 30 days after referral 61% remained on an ambulatory pathway 10% initially ambulatory then escalated to acute care 28% initially admitted 9% transfer to acute hospital bed 19% admitted to community hospital bed

32 AMB score predicting continued ambulatory status at 30 days Optimal cut point = 4.5 This identifies 75% of all ambulatory patients 34% of all those who needed admission would be thought to ambulatory At Ala et al cut point = 5 This identifies 56% of ambulatory patients

33 AMB score predicting continued ambulatory status at 30 days Ala et al. had an AUC = 0.91 (0.77 in Oxford data) Different outcomes used (12 hour discharge vs. 30 day ambulatory pathway) In their data at a cut off of 5 This identifies 96% of patients discharged at 12 hours At the same time, if used, it would think that 38% of patients needing to stay longer would be able to be discharged

34 AMB score and 30 day pathway

35 Is there an alternative score? NEWS?

36 Selecting patients for ambulatory emergency care From observational data there appears to be wide variation in % of referrals that may be suitable for ambulatory care AMB score derived and validated against a same day discharge outcome, not successful ambulatory treatment AMB score validates less well in an external setting and against a clinical outcome New scores/different predictors may be helpful for selecting ambulatory care pathways

37 Realities of ambulatory emergency care Fundamental principle of the Future Hospital but we don t know how best to select for ambulatory care In settings where referrals are pre-selected for potential suitability for ambulatory emergency care with multidisciplinary input, 40% of patients will need a bed based care pathway at some point within 30 days of assessment Patient and carer experience

38 New care models for working outside the hospital walls International models address integrated working across primary and secondary care for acute illness Comprehensive Care Physician Model Focus on patients at increased risk of hospitalisation Provide acute inpatient care AND chronic care Ownership of care across healthcare settings Health Aff (Millwood) May ; 33(5):

39 Extensivist models of care CareMore model Intensive management of frail and chronically ill population Extensivist manages both the in-patient admission and post discharge follow up care (JAGS 2011;59:158-60) BMJ adverts beginning to use the Extensivist label.

40 NHS England Vanguards Nine integrated acute and primary care systems funded Common partnership acute/community/ccg/gp providers/local government Variety of critical enablers population based outcome contracts, joint ventures Adapting international models to the NHS

41 Contributing to the Future Hospital Vision Progression from current context Systematic study of ambulatory emergency care Evidence for selection, outcomes and patient/carer experience The resources and skills of the hospitalist outside the hospital walls

42 Interface Medicine and the Future Hospital Prof Dan Lasserson MA MD FRCP Edin MRCGP Senior Interface Physician in Acute and Complex Medicine Dept of Geratology, OUH NHS FT Associate Professor, Nuffield Department of