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The identification of clinical indicators for the Council of Australian Governments (COAG) Long Stay Older Patients (LSOP) initiative Jo Tropea Program manager Clinical Epidemiology & Health Service Evaluation Unit, RMH Acknowledgements CEHSEU project team Caroline Brand Bhasker Amatya Alex Gorelik Wendy Lemaire Project Expert Advisory Group DHS project team Background information 2004 national functional decline guidelines developed 2007 an update of high level evidence and recommendations by DHS In Victoria as part of the national COAG LSOP – ICOP and HARP CDM initiatives Development of an implementation resource toolkit for minimising functional decline (DHS - NARI) Clinical indicator project Background information 10 FD care domains: Cognition and emotional health – delirium, dementia & depression Mobility, vigour and self care Continence Nutrition Skin integrity Medication management Person centred care Assessment Clinical indicators project Identify existing evidence based clinical indicators (CI) CI are intended to capture any changes in structures, processes and/or outcomes of health care associated with the implementation of the FD toolkit Structure – attributes of the settings in which care occurs (eg equipment, HR) Process – what is actually done in giving and receiving care Outcome – measures describe the effects of care on health status of patients Purpose of the indicator set Primary purpose To assess the impact of activities designed to minimise functional decline (FD) among older hospitalised people Secondary purposes To measure effectiveness of FD guideline implementation To monitor and drive improvement design to optimise health outcomes related to FD Methods of CI identification & selection Identify existing indicator sets Literature review Knowledge from previous projects Assess the identified indicator sets Summarised the potential indicator set Selection of draft indicators EAG assessed each indicator in three consensus rounds Used a modified Delphi technique CEHSEU Project team Are they applicable to patient population and FD domains? NO Exclude YES Round 1 consensus method R1 results: Group median scores Score frequencies R2 results: Group median scores Score frequencies Round 2 consensus method Consensus ‘exclude with recommendation for future development’ Round 3 consensus method Consensus ‘exclude’ Include in final set Results Literature review 55 international and national indicator sets identified, 14 met the inclusion criteria From these sets we selected 63 individual indicators Limitations – limited evidence base, mainly expert opinion Mapped across FD care domains & according to type of indicator FD care domain Cognition (8) Structure Process Outcome - 8 1* Mobility (15) Continence (2) Nutrition (3) Skin (10) - 3 2 3 6 12 5* Medication (10) P-C care (5) - 8 2 - 4 1 Assessment (5) Others (5) - 5 5 1* * Includes an indicator which can be used to measure a process & outcome Round 1 of the consensus method All 13 EAG members participated in R1 Summary of literature review and each indicator set provided Instruction manual Assessed each indicator according to Importance and relevance to the purposes of the project Scientific attributes Practicality to implement Assessment of cognitive function #4.1 (ACHS Internal medicine) Definition Indicator Topic: Assessment of cognitive function. Numerator Total number of patients admitted to a geriatric medicine or geriatric rehabilitation unit for whom there is documented assessment of mental function on admission or during admission when more appropriate, during the 6 month time period Denominator Total number of patients admitted to a geriatric medicine or geriatric rehabilitation unit, during the 6 month time period Data source Clinical data Administrative data Type of indicator Process Level of evidence Unsure, not provided. Name of data set Australian Council on Healthcare Standards (ACHS) Internal Medicine Clinical Indicators (Indicator 4.1) Other Assessment of cognitive function must be performed using Mini Mental State Examination (MMSE) or the Abbreviated Mental Test Score (AMTS). (i) The indicator is relevant and important to project purposes Disagree Agree 1 2 3 4 5 6 7 8 9 (ii) The indicator has robust scientific attributes Disagree Agree 1 2 3 4 5 6 7 8 9 (iii) The indicator is practical to implement Disagree Agree 1 2 3 4 5 6 7 8 9 Round 1 Median group scores showed: 47 (75%) were considered to be highly important and relevant median group score ≥ 7 7 (11%) were considered to be highly scientifically robust 22 (35%) were considered to be highly practical to implement Comments Difficulties with implementation Indicator definitions Limited evidence base related to the indicator Lack of reliable and accurate data Round 2 of the consensus method All 13 EAG members participated in R2 Based on their individual rating and the group median scores, EAG were asked to prioritise inclusion of the indicator for: System surveillance at a State level System surveillance at an organisational level Supporting implementation of the FD guidelines at an organisation or clinical team level Round 1 results (i) The indicator is relevant and important to project purposes Disagree 1 Frequency of R1 responses Agree 2 0 3 0 4 0 5 0 6 1 7 0 8 5 9 2 4 (ii) The indicator has robust scientific attributes Disagree 1 Frequency of R1 responses Agree 2 0 3 2 4 2 5 1 6 2 7 2 8 2 9 1 0 (iii) The indicator is practical to implement Disagree 1 Frequency of R1 responses Agree 2 0 3 0 4 0 5 2 6 1 7 5 8 1 9 1 2 Based on your scores and considering the group’s scores of the indicator in Round 1, overall how would you prioritise inclusion of this indicator in the draft indicator set for: (i) System surveillance at a State level Low 1 High 2 3 4 5 6 7 8 9 (ii) System surveillance at an organisational level Low 1 High 2 3 4 5 6 7 8 9 (iii) Supporting implementation of the functional decline guidelines at an organisation or clinical team level Low 1 Comments: High 2 3 4 5 6 7 8 9 Round 2 results High group median scores ≥ 7 35 (56%) for supporting implementation of the guidelines 22 (35%) for system surveillance at an organisational level 9 (14%) for system surveillance at a state level Round 3 – face to face meeting 9 EAG members participated DHS project team and DHS coding expert Consensus reached to include 20 indicators in the Most of the indicators draft set were modified slightly 2 3 2 3 4 3 1 2 to suit the purpose of cognition and emotional health mobility, vigour and self-care the set, the local context & best practice continence nutrition skin integrity medication management person-centred care assessment Final set & recommendations 19 indicators included in the final set Following EAG review – 2 falls indicators merged into 1 1. Cognition & emotional health 1.1 Cognitive screen 1.2 Screen for postoperative delirium 2. Mobility, vigour and self-care 2.1 Inpatient fall evaluation 2.2 Falls related injuries including fractures 3. Continence 3.1 Indwelling bladder catheter 3.2 Long-term urethral catheter use 4. Nutrition 4.1 Oral intake evaluation in hospital 4.2 Alimentation for patient who cannot eat 4.3 Nutritional supplementation of malnourished patients Final set & recommendations 5. Skin integrity 5.1 Pressure ulcer risk assessment 5.2 Pressure ulcer preventive intervention 5.3 Pressure ulcer assessment 5.4 Identification of pressure ulcers (incidence) 6. Medication management 6.1 Current medications 6.2 Medication therapy changes 6.3 Sedative use at discharge 7. Person-centred care 7.1 Provision of written care plans to patients at discharge 8. Assessment 8.1 Discharge assessment 8.2 Assessment of physical function Gaps identified & recommendations 8 indicators were excluded with the recommendation for further development Delirium evaluation – investigation for cause Physical restraint indicators Outcome indicators that assess unplanned and unexpected hospital readmission rates within 14 days Discharge destination Hospital wide medication policies such as review by clinical pharmacist Recommendations Development of 8 structural indicators Education and training Environmental audit Person-centred care policy Clinical program Workforce planning and service model Recommendations Key areas that require future process and outcome indicator development Emotional health – process & outcome Falls risk screening - process Continence screening – process Incidence of delirium, depression, falls, incontinence (outcome) Thank you