Long-term care is more than a place that supports older adults who no longer live independently. It’s also their home – their personal space and a familiar environment, where they can feel safe and secure.
For those experiencing dementia, who cannot advocate for themselves, this is especially critical. New and unfamiliar environments are unsettling and often unsafe – including hospitals. If a trip to the emergency department can be avoided because it isn’t medically necessary, that is preferable – even if family members feel the hospital would be the best place for their loved one to be.
This was a priority for the health care team at Banfield Pavilion at Vancouver General Hospital (VGH) when it was reviewing the number of transfers of its long-term care residents to the VGH emergency department (ED). They were seeing six to 10 transfers each month, many of which were not medically necessary and likely avoidable.
Led by Dr. Marla Gordon, Medical Director for Long-Term Care at Vancouver Coastal Health (VCH), the Banfield team set out to turn this tide.
And they succeeded!
“This project could not have been successful without the hard work, passion and dedication of Dr. Gordon driving and leading this project, and her team at Banfield!” says Amy Chang, VCH Quality Improvement advisor for the project. “Ten change ideas and interventions were identified and tested by the project team. Analysis of the data showed a significant decline in transfers to ED (and) admissions to hospital.”
Amy said a key part of the project was taking a person- and family-centred approach, engaging families and caregivers early in goals-of-care conversations.
“By doing this, we are not only honouring their choices, needs and values, we are also respecting the frail elder population in what matters to them, and maintaining their dignity in their remaining years, especially at the end of life.”
At the start of the project, 30% of residents transferred each month went for less complex causes such as fever due to urinary tract infections. Another 30% were sent to ED for loss of consciousness and dehydration and were at end of life. Unfortunately, a significant number of elders who were at end of life were admitted to hospital and died there. Of all those who were transferred to hospital, 44% had advanced dementia; of these, 75% had family and caregivers requesting that their loved one be sent to hospital against the team’s advice.
Dr. Gordon and her team took a two-part approach to changing these statistics. First, they increased education for staff and families. For staff, this included communication skills, better assessment of resident conditions and goals of care training. For families and caregivers, this entailed learning about dementia as a progressive illness, goals of care, and helping identify what mattered most to their loved one in care.
The second part of the change involved increasing access to special medications and supplies which would otherwise only be available at the ED, enabling treatment at Banfield and avoiding a transfer to hospital.
Recognizing some transfers to hospital are necessary, the project team also worked directly with the VGH ED staff and physicians to determine a better way to communicate a specific plan why the resident was being transferred. The result was a one-page communication tool that helped both the ED team and Banfield staff understand care needs and care planning.
Within a few months of the start of this work and in the three years that followed, a review showed a sustained decrease of total number of transfers to ED, from a high of 10 residents each month to just two to three. There was also a decrease in inappropriate transfers (a non-emergency condition that does not need to be managed in ED) from four residents per month to zero to one resident per month. And, a decrease in avoidable transfers (a situation that can be prevented or managed on site) from four residents to zero residents per month. Thankfully, no more residents died in hospital at the end of life.
There were more frequent and better goals of care discussions, improved health care team collaboration and relationships, a better work relationship with the VGH ED, and improved confidence reported by nurses in their clinical skills and communication with family members. Families and caregivers said they were able to make more informed decisions because they better understood what was best for their loved ones, and they were appreciative their family member was able to remain in their home at end of life.
In addition, the education modules developed to support this project have now been added to VCH’s library and all 32 long-term care homes in VCH as well as in BC’s other health authorities have received information about how to implement this work.
“Furthermore, this project was selected to be presented in December 2022 at the internationally recognized conference of the Institute of Healthcare Improvement (IHI) and they are excited to have their learnings be spread world-wide,” says Amy.