Hospital Admissions Avoidance YODO: You Only Die Once, getting it right every time Hospital Admissions Avoidance (South) Speaker: Ria Evans

Avoidance Admission Matron Ria Evans

One Call/RAIT Right Service, Right Place, Right Time! 01903 254789

The Team Ria Evans Michelle Nolan Fiona Stevens Sonja Osborne Support from Dr Saunders and Jackie Pace

This is project started on 9th May 2011 and was initially to be a seconded post for six months this was extended in March 2012. Nurse–Led proactive service to support Nursing and Residential Care Homes in the coastal strip and to act as an expert resource to develop best practice for clinical staff. Patients are proactively managed in the community to prevent admission or prevent further admissions. This project was supported by the DOME consultants at Worthing and Chichester

The service is effective because there is a shared understanding and a commitment to a common goal. This is a fantastic example of multiagency integrated working across West Sussex.  Secamb, SS,QPOs,Commissioners dementia nurses, in reach team IV nurses, infection control, diabetes. RAIT CM for N & CHs ensures care is the right service, right place and right time for the patient.

Main lines of AA Medication for exacerbation of LTC CAUTI Urosepis in elderly Medication management Falls ACP IV / Sc fluids Bladder scan SBAR MEWS Teaching Clinical assistance Telephone support In reach into acute EF to prevent admissions

Community Geriatrician Rapid Access Care of Elderly Clinics – Pt Triaged and seen within 2 weeks. If clinically appropriate seen within 24 hours.

Telehealth We have used telehealth to assist with admissions. Digital system where pt observation input and when outside of parameters sent to us.

Docobo

Docobo Identify Observe Treat Monitor

Over 300 NH & CH are being offered the devices In phased approach

Docobo

Docobo

75% reduction in their admissions.

Winners!

PEACE plans We have done PEACE plans – which are Proactive Elderly Persons’ Advisory CarE). discussions are an important means of improving end of life care and enabling better planning and provision of care in line with the needs and preferences of patients, their carers and family members.

The practice of ACP affirms the use of advance statements, in which people are able to clarify their wishes, needs and preferences for the kind of care they would like to receive. It can also include advance decisions or refusals of specific treatments including cardio-pulmonary resuscitation, and the appointment of a person to act as a proxy surrogate e.g. Lasting Power of Attorney.

PEACE plan Anticipatory Care Plan    Possible developments specific to the person e.g. chest infection Action Category (see 4.1 below) Comments Please also see supplementary notes for care home staff (appendix 2) 1  M can get aggressive/agitated       HOME  Ensure M is not constipated , check bowel chart increase aperients. May need suppositories 2 M has poor dietary intake  Oral fluids or food as tolerated and as often as tolerated. M will not be distressed by thirst / hunger, but ensure food and fluids are offered if tolerated. For comfort ensure mouth is clean and comfortable. Artificial feeding would not be in M best interest. Low intake is very likely. .

PEACE plan M has fallen previously HOME  Examine for injury.    If fracture suspected may require admission to hospital for adequate palliative management or operative stabilization.  Give analgesia prior to transfer.  If no injury, consider cause of fall.   Consider need for crash mats, low bed, increased supervision and assistance with toileting and transfers. Serious unexpected event.    If an incident occurs and admission is not in Mrs M best interest .Call Gp/CM to ensure all comfort measures are in place within New Grange, If no simple reversible causes, GP to prescribe end of life medications. GP to refer to the hospice to support end of life care, if felt appropriate Patient has no signs of life. GP to review and confirm death Inform solicitor in the morning .

PEACE plan Peace plan were nurse led with the support of consultant to sign them off. GP had copy care home staff.

Fragility Associated with ↑ risk of poor outcomes with frail individuals at ↑ risk of hospitalization The need to identify early interventions to help support and maintain frail people

ACP/ Future planning

Communication tools: SBAR MEWS Stop and watch

To request help from Matrons, phone One Call on 01903 254789

Any Questions ? Thank you