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

2. Avoidance Admission Matron
Ria Evans

3. One Call/RAIT
Right Service, Right Place, Right Time!

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

6. 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

7. 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.

8. 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

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

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

11. Docobo

12. Docobo
Identify
Observe
Treat
Monitor

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

14. Docobo

15. Docobo

16. 75% reduction in their admissions.

17. Winners!

18. 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.

19. 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.

20. 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. .

21. 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 .

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

23. 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

24. ACP/ Future planning

26. Communication tools:
SBAR
MEWS
Stop and watch

27. To request help from Matrons, phone One Call on

28. Any Questions ?
Thank you