Anne Scott Advanced Nurse Practitioner Medicine of the Elderly Royal Infirmary of Edinburgh

1. Anne Scott Advanced Nurse PractitionerMedicine of the ElderlyRoyal Infirmary of Edinburgh Nurses General knowledge of Elderly Care and specifics of the Comprehensive Geriatric Assessment process. TarGetEd

2. Aims of presentation • Why did I put myself forward? • The process and how I engaged with it • What question and perceived outcomes • Audit and questionnaire • Preliminary findings • Educational tools • Next steps • Summary and experience • Questions

3. Why? • Need for experience off and support in research process (NMC and RCN) • Keen to engage with research within hospital setting regarding care of older people. • Wanted to look specifically at an element of nursing role

4. Engagement – starting the process • Form from PROP • Question • Methods and data sources • Out puts and communications • Resources • Own team (Medics and nurse manager) agreed to support • Met others in project both in hospital and at PROP study days in Edinburgh University • Deciding on my specific question

5. Questions!!!!!!!! • Are older people different? • What do we need to do to support them in hospital and out of hospital? • How do we measure frailty? Fit 80 year old, 64 year old with multiple physical issues • What is in the community? Telecare, telehealth, hospital at home, rehabilitation in the community, Carer support • What do we assess? Do we know importance? Do we respond to information gathered? • Comprehensive Geriatric Assessment – evidence to support use of CGA improves outcomes in the care of older people.

6. Literature search • Meta analysis by Ellis showed benefit of process • Patients more likely to be in own home 12 mths after hospital if CGA occurred • British Geriatric society recommends use of CGA – ‘good Practice’

7. Comprehensive Geriatric Assessment? • Process used to identify and address issues in older people – involves multi disciplinary team • Social, health, financial, psychological aspects • Aspects specific to nursing assessment in first few days of hospital admission

8. What was the goal of my work? • Highlight the importance of Comprehensive Geriatric Assessment (CGA) within the nursing population in hospital • Development of teaching tool and ongoing educational support for nurses regularly caring for older people • Improve patient experience and outcomes • Improve own practice, skills and knowledge

9. Start of the ‘work’ • Audit case notes and look at documentation by nurses of ‘frailty tools’. Specific elements of CGA to be looked at • Falls assessments • Nutrition • Tissue viability • Continence and toileting issues • Cognitive

10. Questionnaire • Use of CGA as guide to appropriate questions • Design questionnaire (difficult!) • Target group of nurses cross specialities in admission and assessment areas • Role out questionnaire • Analyse results

11. Who to ask? • Trained nurses in Medical, surgical, orthopaedic and Medicine of the elderly • First few days/hours of admission crucial to care • Large numbers of older people at hospital ‘front door’

12. Role out • Proposal to research team of own speciality • Explanation of work and proposal of research and agreement from Nurse managers and charge nurses • Sent out 50 questionnaires to trained staff in 4 distinct clinical areas

13. Audit and Returns • Audited 22 sets of notes over 72 hour period • Good response from Medical and surgical areas • 40 returned out of 55 sent

14. Results from notes

15. Main results

16. Main results Frailty

17. Main results - Nutrition • Nutrition – effects healing and ability to respond to acute physical insults, particularly in the elderly. Good knowledge base

18. Main results – bowels and bladder

19. Main results - cognitive • Dementia and delirium – common issues in older patients in hospital • Important nurses know the difference between dementia and delirium. Often nurses first to identify issue

20. cognitive – investigation and reviews

21. TarGetEd Prompt for elderly patient assessments

22. Hb115 – 160 WBC 4.0 - 11.0  Plate 150 - 350 Urea 2.5 - 6.6  Na 135 - 145  K+ 3.6 - 5  Creat 60 - 120  GFR >60  Reduced in anaemia. Blood loss? Chronic? Diet? Fluid status can affect Hb – can drop acutely with hydration Raised infection also can be decreased infection, immuno suppression. Elderly sometimes delayed response to acute sepsis Low haematological issue – check for bleeding, bruises, high - ?infection Low indicate alcohol/liver issues. High dehydration, check meds – ongoing diuretics Abnormal can cause confusion, drowsy/coma, falls, suggests fluid problems, endocrine disorder K+ changes due to medication, diabetic, hydration. Can cause arrhythmias Creatinine – raised in renal failure, changes can indicate muscle loss GFR – often reduced in elderly as part of normal aging process. Decrease can influence medication choices and radiological investigations requiring contrast Targeted

23. Surgical patients should have had short period of post operative care before referral are made to attempt to gage patients need for rehab. If considering rehab or identification of needs have been made please discuss/refer with therapy teams for assessments

24. The Poster!

25. Significant issue • Prompt card and lanyard – not possible • Infection control, health and safety issues, already several ‘prompt’ cards inexistence

26. Information and results so far • Good level of knowledge and ability in cohort of nurses in front door areas • High level of returns suggests an appetite for engagement from nurses • Significant differences of approaches and knowledge– cognition, frailty, knowledge of community services • Further investigation and progression would be beneficial • Short talks • Articles into local news letters • Sharing results • Further work especially regarding the community and hospital interface • Own knowledge of research and CGA improved

27. Next steps • Ongoing promotion of CGA through own role • Further areas for research/investigation or extension of excising work regarding CGA • Continued engagement from own work place in support, skills and knowledge of research and older people care • Development of closer ties with other hospitals addressing similar patient population and processes

28. More recognition of the comprehensive geriatric assessment within the nursing population in hospital Development of teaching tool and ongoing educational support for nurses regularly caring for older people Improve patient experience and outcomes Improve own practice, skills and knowledge Yes Yes – even if its not what I’d been aiming for Need further investigation Yes What was the goal of my work?

29. Would I do it again? Did I think the process valuable? What have I gained? What has the organisation gained? What implications does it have to older people in hospital? Yes! Yes Knowledge of nurses experience and practices in assessment areas A poster! Highlighted elderly assessments Finally

30. Thanks