Improving access

What is it?

Best care for older people in hospital uses a person-centred approach and evidence-based tools and resources to identify and respond to the risks associated with hospital admission.

To provide best care we must consider how the person’s medical treatment and healthcare may limit their activity as well as impact on their level of independence and ability to return to their pre-morbid lifestyle. During their stay in hospital older people can:

• experience falls
• develop a delirium
• become malnourished or dehydrated
• develop depression
• become incontinent
• experience unidentified or poorly managed pain
• develop pressure injuries.

Any of these issues can have a significant effect on a patient’s ability to maintain a level of independence that allows them to return home.

Why is it important?

• As the population ages, older people are becoming the major user of hospital services.
• Older people who present to hospital have a significantly higher risk of experiencing functional decline.
• Older people have diverse care needs. These challenge the traditional care models of modern hospitals that focus on single disease or conditions at the expense of a holistic person-centred approach.
• Frailty is estimated to effect a quarter to a half of all older people. Being frail means that relatively minor stressors can trigger significant changes in health status.¹
• Dementia is highly prevalent in older people and becomes more prevalent with increasing age. It is estimated that between 21 and 24 per cent of those aged 85 years and over have dementia.²
• Having dementia puts patients at significantly higher risk of adverse outcomes such as falls and delirium.

How can you provide the best care for older people in hospital?

Find out what matters to your patient. It is essential to be person centred in every encounter you have with older people, their families and carers.

This approach is the cornerstone of providing the best care for older people in hospital. Consider your patient’s treatment needs in the context of their physical and mental health, their emotional and social needs.

The following evidence-based strategies will play a large role in improving your patient’s experience and outcomes in hospital:

• Treat the person not the disease. With many older people having multiple medical conditions you need to identify what is important to the person.
• Monitor the older person for signs and symptoms of clinical deterioration. Routine vital signs on their own will not alert clinicians to changes in an older person’s health status.
• Promote independence through encouraging your patient to be dressed, to self-care, mobilise and toilet themselves. Prolonged resting in bed must be avoided.
• Ensure your patient is eating and drinking. A high percentage of older people present to hospital malnourished.
• Look out for changes in cognitive and functional status, which may indicate that your patient is developing a delirium.
• Always involve family and carers in all aspects of care planning. Family and carers know the person best and can provide an understanding of pre-morbid level of function.
• Screen the older person’s family or carer for psychosocial and emotional wellbeing issues and link them with appropriate supports during their stay.
• Identify, respond and develop a plan to manage an older person’s pain. Pain is highly prevalent in older people; it is commonly under-treated and can affect an older person’s efforts to self-care.
• Review medications. Older people are more at risk of experiencing problems related to medications.
• Recommend frail older people for a comprehensive geriatric assessment. This should not be delayed because of other medical issues.

1. Clegg A, Young J, Iliffe S, Rikkert MO & Rockwood K 2013, ‘Frailty in elderly people’, Lancet, 381(9868):752-62.

2. Deloitte Access Economics 2011, Dementia Across Australia, 2011–2050, Report to Alzheimer’s Australia, Kingston.

What is it?

Communication is much more than just providing information. It is a shared process in which participants exchange information, ideas and feelings to create mutual understanding and shared meaning.¹

Communication is reflective of person centred care practices, whereby an older person is placed at the centre of a collaborative partnership with hospital staff.

The communication process is an intervention; you need to be mindful of its impact during every encounter.¹ All hospital staff have a shared role in improving communication with older patients and their family and carers while in hospital.

Why is it important?

• There is much room for improvement in the area of communication. The majority of complaints received by health services are related to dissatisfaction with the person’s experience of communication.²
• People wish to be engaged in healthcare discussions in a way they can understand.³ They want to know what you are doing and why.
• Effective communication is one way of enhancing an older person’s experience of and participation in their healthcare, leading to better health outcomes.⁴
• Improving communication:
  • Empowers older people – knowing and understanding what is happening, what to do and where to get help when needed.⁵
  • Enables older people to express their views and beliefs, identifying “what matters to them” rather than “what is the matter with them”.⁶
  • Increases a person’s capacity to manage their health condition(s).
  • Requires clear expression from the person delivering the message and the full comprehension of the person receiving the message within a two-way dialogue.

How can you improve your communication with older people?

As an individual:

• Be mindful that an admission to hospital can be a major life event for some older people.
• Introduce yourself, explaining your role and why you are seeing the person.
• Ask the older person how they would like to be addressed, making eye contact and engaging in general conversation.
• Gain consent to involve the family or carers. They can provide important information about the older person’s life.
• Screen, assess and adjust the way you respond to people who have vision, hearing, speech or cognitive impairment.
• Adjust your own voice, tone and body posture to demonstrate respect and interest.
• Listen and support an older person to express their needs and wants.
• Be mindful of not using patronising language like ‘love’ or ‘dear’ and consider how your own attitudes and value base to ageing may influence the encounter.
• Don’t refer to the person as a task, bed number or diagnosis either directly or to colleagues on the ward (acknowledging privacy and confidentiality concerns).
• Avoid using acronyms for diagnoses, hospital wards, service providers etc. that are likely to be unfamiliar to older people.
• Be sensitive to the potential impact of low literacy levels, in particular health literacy.
• Use language-specific interpreters for all important conversations.
• Use language aids to assist with day-to-day care.
• Encourage the older person to use the ‘ask me 3’ questions – “what is my main problem?”; “what do I need to do?” and “why is it important for me to do this?”. ⁷

As a team:

• Decide who will engage the older person and their family or carer in difficult conversations.
• Decide which team members will be involved in the conversations.
• Nominate one member of the team to lead the conversation.
• Discuss the routines of the hospital and explain when the older person and their family or carers will have the opportunity to discuss their concerns with the doctor/treating team.
• Provide the older person with the number of the person they can contact post discharge if they have any questions.

Consider simple adjustments:

• Check that lighting is adequate.
• Reduce reflective glare/visual distractions.
• Reduce background noise.
• Encourage the patient to use their hearing aids or amplifiers and ensure they are within reach.
• Provide quality written materials in plain language/easy English/alternative languages.
• Ensure the room set-up is as comfortable as possible when having family and carer meetings.
• Consider and respect privacy and gender differences in shared wards.

1. Hill S, Lowe DB & Ryan RE 2011, Interventions for Communication and Participation: Their Purpose and Practice. In: Hill S (ed.), The Knowledgeable Patient: Communication and Participation in Health , Wiley-Blackwell, UK.

2. Office of the Health Services Commissioner 2008, 2008 Annual Report , Office of the Health Services Commissioner , Victoria.

3. Prictor M & Hill S 2011, Does communication with consumers and carers need to improve? In: Hill S (ed.), The Knowledgeable Patient: Communication and Participation in Health , Wiley-Blackwell, UK.

4. Department of Health 2012, Best care for older people everywhere – The toolkit , State Government of Victoria, Melbourne.

5. Hill S & Draper M 2011, A new conceptual framework for advancing evidence-informed communication and participation. In: Hill S (ed.) The Knowledgeable patient: Communication and participation in health , Wiley-Blackwell, UK.

6. Berwick D 2013, A promise to learn – a commitment to act: improving the safety of patients in England . Report to the National Advisory Group on the Safety of Patients in England.

7. National Patient Safety Foundation, 2014, Ask Me 3 , Retrieved 8 Dec 2014.

What is it?

Comprehensive geriatric assessment is ‘a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail elderly person in order to develop a coordinated and integrated plan for treatment and long-term follow-up’.¹

It requires us to use a person centred approach to find out what matters to our older patients to maximise their strengths, functional independence and outcomes.

Why is it important?

• Older people are the major users of hospitals, and often have longer stays, which increases their risk of functional decline.
• Older people with frailty and multimorbidity as well as impaired cognition, poor mobility and incontinence will benefit from a comprehensive assessment.²
• Information gained from a comprehensive geriatric assessment allows clinicians to implement a person-centred care plan which can reduce functional decline, support independence and improve quality of life.
• An assessment can also facilitate discharge planning and reduce length of stay, medication use, and the need for admission to residential care.^2,3
• A comprehensive geriatric assessment is a good time to encourage the older person and their family to consider advance care planning, identify their substitute decision maker and document their decisions.

How can you carry out a comprehensive geriatric assessment?

An initial risk screen of all older people in hospital aged over 70 years should identify those who would benefit from a comprehensive assessment. This need may change during the patient’s hospital stay, as indicated by ongoing monitoring of their health status.

What does a comprehensive geriatric assessment involve?

• A specialist interdisciplinary team approach involving a geriatrician to undertake a comprehensive assessment.
• Use of validated tools to gather a complete picture of the older person’s:
  • medical health
  • physical functioning
  • psychological functioning
  • social functioning.²
• Collecting information through observation, open questioning of the older person and their family or carers, and reviewing their medical records to complement your assessment using the validated tools.

Involve the older person, their family and carers

• Assume the patient is well placed to provide accurate information unless you suspect a medical condition is significantly affecting their ability to do so.
• Consider the patient’s health literacy and their cultural and linguistic background. Check they have all their necessary aids such as hearing aids and glasses.
• Communicate clearly with the patient, their family or carer and explain why you are collecting the information and how it will inform their care plan.
• Screen the patient’s family or carer for carer stress and refer to appropriate inpatient and outpatient support services such as the Social Work team and Alzheimer’s Victoria and Carers Victoria.
• Ask the person what matters to them and what they would like to see happen next.

What to do with the information

• Communicate the outcomes of the comprehensive assessment to the person, their family, carers and all necessary staff.
• Use the assessment information to inform both the person’s care plan and their discharge plan.
• Monitor the older person’s health status and evaluate their care plan on an ongoing basis throughout their hospital stay.
• Refer to your health service’s recommended template or validated tools to collect information during the assessment.

1. Wieland D & Hirth V 2003, ‘Comprehensive geriatric assessment’, Cancer Control 10(6):454-462.

2. Australian Institute of Health and Welfare 2013, Australian hospital statistics 2011–12,Australian Institute of Health and Welfare, Canberra.

3. Centre for Applied Gerontology, Bundoora Extended Care Centre, Northern Health 2004, A guide for assessing older people in hospitals. Report to the Australian Health Ministers' Advisory Council, Victoria.

4. Ellis G & Langhorne P 2004, ‘Comprehensive geriatric assessment for older hospital patients’, British Medical Bulletin 71(1):45-59

What is it?

Cognitive impairment refers to an individual having memory and thinking problems. The person may have difficulty with learning new things, concentrating, or making decisions that affect their daily life. The most common causes of cognitive impairment among older people are dementia and delirium.¹

Dementia is a general term used to describe a form of cognitive impairment that is chronic, generally progressive and occurs over a period of months to years. It can affect memory, language, perception, personality and cognitive skills.²

Delirium is an acute disturbance of attention and cognition where the patient experiences confusion. It is temporary and is a symptom of an underlying issue.³ Delirium is often overlooked or misdiagnosed in the hospital setting.⁴

Depression is not just low mood or feeling sad, but a serious condition that needs treatment. Its symptoms can mimic those associated with cognitive impairment and it is often overlooked or misdiagnosed.

Why is it important?

• In the hospital environment almost 30 per cent of older people have cognitive impairment.⁵
• Older people with a cognitive impairment are at greater risk of:
  • malnutrition
  • dehydration
  • falls
  • hospital-acquired pressure injuries
  • developing incontinence
  • medication issues.
• These risks often lead to an increased hospital stay^6,7 and poorer outcomes for older people.
• Screening and early recognition is vital as the first presentation of cognitive impairment can occur during hospital admission.⁵
• Ten to 15 per cent of older people have delirium at admission, and a further five to 40 percent are estimated to develop it during their hospital stay. Patients with dementia have double the risk of developing delirium.⁵
• The hospital environment can increase levels of distress and disorientation experienced by people with cognitive impairment. This can put older people at risk and be distressing for staff, carers and family.
• If unrecognised, cognitive impairment can increase the likelihood that an older person will end up in a premature placement rather than return home.

How can you care for people with cognitive impairment?

All hospital staff have a shared role in caring for patients with cognitive impairment. Best practice informs us that all patients over the age of 65 should be screened for cognitive impairment at the first point of contact with the health service, and when they transition to another area in the hospital. It is vital that this screening is documented in the patient’s medical record, and that the patient’s premorbid state is taken into account.

Screen and assess patients with cognitive impairment

• Recognise the different characteristics of delirium and dementia and rule out the possibility of depression.
• It is vital that the all patients with a delirium are thoroughly investigated for the underlying cause so it can be treated.
• Use a validated screening tool for cognitive impairment. These tools enable you to determine a baseline, develop a person-centred care plan and implement risk management strategies. The most commonly used tools in hospitals include:
  • Abbreviated Mental Test (AMT)
  • Standardised Mini-Mental State Examination (SMMSE)
  • Clock Drawing Test (CDT).
• Identify the presence of behavioural and psychological symptoms of dementia (BPSD) that respond to changes in the environment:
  • aggression
  • resistance to care
  • screaming/calling out/agitation
  • wandering
  • confusion
  • withdrawal.
• Always check your observations with the person’s family or carer to ascertain if these BPSD symptoms are long standing or new. This will assist in developing an intervention plan and in forming a diagnosis.
• If the patient is displaying signs of agitation, consider whether they may need to go to the toilet, if they are hungry or are in pain.

Actively engage patients and families in all aspects of their care plan

Families and carers offer a wealth of expertise and can often suggest care strategies to minimise risk of functional decline and the person’s level of distress.

• Involve the family and carer in the care planning process and provide them with written information about cognitive and memory difficulties.
• Establish the patient’s pre-morbid cognitive status. This will help you to determine intervention strategies.
• Be mindful that a diagnosis can be quite confronting for the individual and their family and carer.
• Screen the patient’s carer and family for carer stress and refer to appropriate inpatient and outpatient support services such as the Social Work team, Alzheimer’s Victoria and Carers Victoria.
• Communicate clearly by using the strategies outlined in the Improving communication factsheet.
• Use these key points:
  • introduce yourself
  • always use the patient’s name when addressing them
  • make sure you have eye contact at all times
  • remain calm and talk in a matter-of-fact way
  • keep sentences short and simple
  • give time for a response
  • take the time to explain what you are going to do and why you are doing it
  • focus on one instruction at a time
  • repeat yourself ­– don't assume you have been understood
  • don’t offer too many choices.
• Encourage the patient and family and carer to discuss advance care planning with each other and the care team. See Advance care planning factsheet for more information.

Respond to the needs of a patient with cognitive impairment

• Adjust the immediate environment to minimise patient distress:
  
  • make every effort to reduce the number of times a patient transfers between wards
  • reduce stimulation
  • use diversional strategies such as engaging in a one-on-one conversation
  • situate the patient within sight of the nursing station
  • make sure the call bell is within the patient’s reach
  • involve the family and carers in providing direct care.
• Engage in intentional rounding (carrying out regular checks with the patient at set intervals). Assist the patient with eating, drinking, pain relief, ambulation, regular toileting and repositioning (as required).
• Some hospitals place the cognitive impairment identifier (cii), the information about me form, and a universal falls symbol above a patient’s bed, which acts as a communication tool to all staff.
• Consider whether your health service could complete an environmental audit.
  
  • Improving the environment for older people in health services: an audit tool
  • Dementia Enabling Environment Principles.

Monitor and evaluate a patient’s ongoing care

• Document all interventions, and in conjunction with family and staff monitor whether they have been successful.
• Formally handover that the older person has a cognitive concern and any strategies that you have found helpful to respond to these concerns:
  • between nursing shifts
  • within interdisciplinary care planning meetings
  • when the patient transfers to another area of the health service.

All healthcare organisations and clinicians must practice in alignment with the National Safety and Quality Health Service Standards.

1. Milisen K, Braes T, Fick DM & Foreman MD 2006, ‘Cognitive Assessment and Differentiating the 3 Ds (Dementia, Depression, Delirium)’, Nursing Clinics of North America, 41(3):1-22.

2. Australian Institute of Health and Welfare 2012, Dementia in Australia, Australian Institute of Health and Welfare, Canberra, Australia.

3. Clinical Epidemiology and Health Service Evaluation Unit, Melbourne Health 2006, Clinical Practice Guidelines for the Management of Delirium in Older People. Report to Australian Health Ministers’ Advisory Council.

4. Inouye S, Foreman M, Mion L, Katz K & Cooney L. 2001, ‘Nurses' recognition of delirium and its symptoms – Comparison of nurse and researcher ratings’, Archives of Internal Medicine, 160(20):2467-2473.

5. Travers C, Byrne G, Pachana N, Klein K & Gray L. 2013, ‘Prospective observational study of dementia and delirium in the acute hospital setting’, Internal Medicine Journal, 43(3):262-269.

6. Australian Institute of Health and Welfare 2013, Dementia care in hospitals: costs and strategies, Australian Institute of Health and Welfare, Canberra, Australia.

7. Bail K, Berry H, Grealish L, Draper B, Karmel R, Gibson D & Peut A 2013, ‘Potentially preventable complications of urinary tract infections, pressure areas, pneumonia, and delirium in hospitalised dementia patients: retrospective cohort study’, BMJ Open, 3(6):2770.

What is it?

Multimorbidity is the presence of multiple diseases and medical conditions – chronic or acute – in the one person.¹ A recognition of multimorbidity requires these multiple diseases and conditions to be treated concurrently without a hierarchical order.²

Aspects of the patient’s context – biopsychosocial factors, risk factors, support networks, health care consumption and the patient’s coping strategies – may function as modifiers of the effects of multimorbidity.³ Multimorbidity requires a holistic approach which puts the patient, not the disease, at the centre of the plan.⁴

Why is it important?

• Multimorbidity is associated with more complex clinical management, poor treatment outcomes, longer hospital stays, increased healthcare costs and increased risk of readmission.
• The prevalence of multimorbidity increases substantially with age.⁵ More than half of older people have three or more chronic diseases.⁴ These may include cancer, diabetes, asthma, arthritis, pain and mental illness.
• Current clinical guidelines have a single disease focus and rarely consider the cumulative impact of multimorbidity. This can lead to inefficient care which is inconvenient and unsatisfactory to both patients and clinicians.^6,7
• Older people with multimorbidity are more likely to have a poorer quality of life, experiencing depression, premature mortality and frequent hospital admissions.^6,8
• Older people with multimorbidity are often prescribed multiple medications (polypharmacy). Those on five or more medications are three times more likely to be taking inappropriate medications and are at greater risk of an adverse drug reaction or medication errors. Non-adherence to prescribed regimes, and the interaction of drugs and multiple diseases can affect the burden of care.⁶
• Eighty per cent of older people report having poor health literacy that impacts on their ability to understand and use health information.⁹

How can you respond to the needs of older people with multimorbidity?

All hospital staff have a shared role in identifying and responding to multimorbidity in patients.

To provide best care:

• Ensure that the patient’s medical history is complete and that medication safety and quality systems are in place to monitor the management of multimorbidity.
• Check that mental health issues such as depression and cognitive issues such as dementia are recognised as multimorbidity.
• Consult with the patient and their family and carers to determine what the patient’s primary concerns are.
• Engage an interdisciplinary team to manage the patient’s multimorbidity.

Involve patients, their family and carers in the management of multimorbidity

• Find out what is most important to the patient, their family and carers in determining the treatment or care plan.
• Ask the patient about their experience of their multimorbidity, and what they want from their treatment.
• Consider the patient’s health literacy level and their understanding of multimorbidity.
• Encourage shared decision-making so the patient and their family or carer are engaged in the management of their conditions.
• Encourage the discussion of advance care planning with the patient and their family or carer.

Assess medication safety in older people with multimorbidity

• Discuss the need for a medication review with the patient, their family or carer, the multidisciplinary team and the patient’s GP.
• Check the patient’s understanding of their medication needs.
• Minimise the risks to the patient associated with polypharmacy and medication non-adherence.

Ensure continuity of care for patients with multimorbidity

• Engage the patient’s other care providers such as pharmacists, specialists, case managers and GPs to provide a coordinated service.
• Make sure the patient and their family or carers are involved in the management of multimorbidity and care plan processes.
• Ensure there are mechanisms in place to monitor older people with multimorbidity and escalate their care when required.
• Review and ongoing appraisal of the revised care plan is required when the patient’s circumstances and goals of care change. Ideally this should be coordinated through a single clinician who intimately knows the patient, the issues and the care goals.

1. Akker Mvd, Buntinx F & Knottnerus JA 1996, ‘Comorbidity or multimorbidity’, The European Journal of General Practice, 2(2):65.

2. Akker Mvd, Buntinx F, Roos S & Knottnerus JA 2001, ‘Problems in determining occurrence rates of multimorbidity’, Journal of Clinical Epidemiology 54(7):675-679.

3. Le Reste JY, Nabbe P, Manceau B, Lygidakis C, Doerr C, Lingner H, Czachowski S, Munoz M, Argyriadou S, Claveria A, Le Floch B, Barais M, Bower P, Van Marwijk H, Van Royen P & Lietard C 2013, ‘The European General Practice Research Network presents a comprehensive definition of multimorbidity in family medicine and long term care, following a systematic review of relevant literature’, Journal of the American Medical Directors Association, 14(5):319-25.

4. Boyd C, McNabney M, Brandt N, Correa-de-Araujuo R, Daniel M, Epplin J, Fried T, Goldstein M, Holmes H, Ritchie C & Shega J 2012, ‘Guiding principles for the care of older adults with multimorbidity: an approach for clinicians: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity’ J Am Geriatr Soc, 60(10):E1-E25.

5. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S & Guthrie B 2013, ‘Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study’, Lancet, 380(9836):37-43.

6. Salisbury C 2013, ‘Multimorbidity: time for action rather than words’, British Journal of General Practice:64-65.

7. Vitry A & Zhang Y 2008, ‘Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions’, MJA, 189(7):360-365.

8. Australian Institute of Health and Welfare 2012, Australia's Health 2012, Australian Institute of Health and Welfare Canberra, Australia.

9. Department of Health 2012, Best care for older people everywhere – The toolkit, State Government of Victoria, Melbourne.

What is it?

An adverse event is an incident that results in harm to the patient. Adverse events commonly experienced in hospitals by patients over 70 include falls, medication errors, malnutrition, incontinence, and hospital-acquired pressure injuries and infections.

What we do or do not do to identify and respond to issues such as malnutrition, uncontrolled pain and unrecognised delirium can contribute to a patient experiencing an adverse event and, in turn, functional decline.

Why is it important?

Physical and cognitive functional decline is often unrelated to the primary reason a person presents to hospital and can have a significant impact on a person’s ability to perform activities of daily living.

• Older people are particularly vulnerable to experiencing adverse events due to inherent complexity in managing their care and a decline in physiological reserves. Approximately three in four older adults have complex multimorbidity¹, and one in two older people take over four medications.²
• Approximately one in 20 patients experience an adverse event while in hospital.³
• Patients with adverse events stay about ten days longer and have over seven times the risk of an in-hospital death than those without complications.⁴

How can you prevent an adverse event?

Adverse events can be prevented through screening and early identification of the factors that put older people at risk.^3,5

Patients aged 70 years and over should be screened to determine the risks of adverse events, and undergo a comprehensive interdisciplinary assessment where risk is identified.

Effective communication with patients, their family, carers and other healthcare professionals is important in preventing adverse events for older people in hospital.⁵ A lack of communication and collaboration between health professionals is a common factor in the majority of adverse events.⁶

All staff have a shared role in preventing harm to older patients.

Make sure you are familiar with your health service’s official policy regarding the prevention of adverse events.

Screen and assess patients to minimise the risk of adverse events

• Use validated tools to screen for the risk of adverse events such as: falls, medication errors, malnutrition, continence, delirium and hospital-acquired pressure injuries.
• Ensure screening and assessment are undertaken at admission and transition to other areas in the health service.

Engage patients, families and carers in the care plan

• Encourage patients, family and carers to ask questions when you discuss risk factors and preventative measures:
  • Consider the patient’s health literacy and their cultural and linguistic background.
  • Check the patient has all necessary aids such as glasses and hearing aids.
• Involve patients, family and carers in clinical handover processes and the care plan.
• Ensure patients, family and carers know how to identify and respond to clinical deterioration.

Respond to a patient who has a high risk of experiencing an adverse event

• Undertake a comprehensive geriatric assessment – with interdisciplinary team input – to ensure that risk is addressed and preventative strategies are included in the patient’s care plan.
• Discuss preventative strategies (such as a medication review) with the patient and their family or carer and implement any changes to reduce the risk of an adverse event.
• Communicate adverse event risk factors to other staff involved in caring for the patient, for example by using alert symbols above patient beds, during team meetings and on clinical handover.
• Ensure that critical information, such as a medication list or falls history, is transferred, acted upon, and documented during clinical handover. Many health services use the framework ISBAR (identify, situation, background, assessment and recommendation) when transferring patient information during clinical handover.

Respond to a patient who has experienced an adverse event

• Provide the necessary care to address the impact of the adverse event on the patient.
• Inform and involve the patient and their family or carers of the adverse event and the strategies used to minimise risks.
• Review all preventative strategies and assessment procedures to minimise further adverse events occurring.
• Refer to the relevant specialist for best practice advice and management.
• Monitor and evaluate the outcomes of the ongoing care plan and adjust as necessary.

Monitor a patient’s ongoing care

• Ensure you deliver person-centred care in agreement with the patient’s monitoring plan, including documenting the type and frequency of observations to be recorded for the patient.
• Engage in intentional rounding (carrying out regular checks with the patient at set intervals) and assist the patient with eating, drinking, pain relief, ambulation, regular toileting and repositioning (as required).
• Escalate the care of a patient whose condition deteriorates.

The National Safety and Quality Health Service Standards provide a useful resource for hospital staff to prevent adverse events and harm to the patients.

1. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S & Guthrie B 2013, ‘Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study’, Lancet, 380(9836):37-43.

2. Morgan TK, Williamson M, Pirotta M, Stewart K, Myers SP & Barnes J 2012, ‘A national census of medicines use: a 24-hour snapshot of Australians aged 50 years and older’, Med J Aust, 196(1):50-53.

3. Australian Institute of Health and Welfare 2012, Australia's Health 2012, Australian Institute of Health and Welfare, Canberra, Australia.

4. Ehsani JP, Jackson T & Duckett SJ 2006, ‘The incidence and cost of adverse events in Victorian hospitals 2003–04’, The Medical Journal of Australia, 184(11):551.

5. Department of Health 2012, Best care for older people everywhere – The toolkit, State Government of Victoria, Melbourne.

6. Mansah M, Griffiths R, Fernandez R, Chang E & Thuy Tran D 2014, ‘Older folks in hospitals: the contributing factors and recommendations for incident prevention’, Journal of Patient Safety, 10(3):146-153

What is it?

Evidence-based practice (EBP) is an approach to care that integrates the best available research evidence with clinical expertise and patient values.¹

It involves translating evidence into practice, also known as knowledge translation, and ensuring that ‘stakeholders (health practitioners, patients, family and carers) are aware of and use research evidence to inform their health and healthcare decision-making’.²

Why is it important?

Implementing clinical knowledge, and introducing new interventions and therapies, is an important way to minimise functional decline in older people.

• Four in 10 adult patients receive care that is not based on current evidence or guidelines, including ineffective, unnecessary or potentially harmful treatments.²
• Despite the availability of evidence-based guidelines, there are significant gaps in implementing evidence into routine clinical practice.³
• Translating evidence into practice can not only improve outcomes and quality of life for older people, it can also improve productivity and reduce healthcare costs.¹

How can you implement evidence-based initiatives to improve outcomes for older people?

Implementing evidence-based practice is a key part of improving outcomes for older people in hospital. When considering current best practice in the areas of nutrition, cognition, continence, medication, skin integrity, and mobility and self-care, a good first reference is the Older people in hospital website.

The National Safety and Quality Health Service Standards outlines the standards for providing best evidence care for older people in hospital.

The ‘how to’ guide: turning knowledge into practice in the care of older people identifies a five-stage process to implementing change, which can be applied to translate evidence into practice.

Identify a practice that could be improved

• Select an area of interest in your clinical practice that could be improved – for example falls, medication errors or malnutrition.
• Identify current best practice guidelines and evidence-based interventions associated with improved outcomes.
• With your team, select an appropriate intervention and outcome measures that will influence your practice.
• Collaborate with quality teams and researchers with expertise in the area you are focussing on.

Barriers, enablers and issues

• Identify the barriers to implementing change. This includes anything that might obstruct or slow down the adoption of a new clinical intervention, such as feasibility, existing care processes or existing team culture.
• Explore the enablers to implementing change. This includes anything that might assist or encourage take up of a new evidence-based practice, such as positive staff attitudes, funding or alignment with accreditation standards.
• Consider issues for any data collection for measuring the effectiveness of your intervention.
• Plan for sustainability to ensure the change can be maintained.

The intervention

• Tailor the intervention to fit within the appropriate policies, standards and guidelines.
• Engage and communicate with relevant stakeholders including staff, patients, family and carers to promote and facilitate adoption of the new intervention.
• Consider implementing a plan-do-study-act cycle from the ‘how to’ guide in which interventions are introduced and tested in the real work setting, in a sequence of repeating, smaller quality cycles.

What did and didn’t work

• Monitor patient outcomes following the adoption of a new intervention.
• Measure the impacts of translating evidence in your current practice.
• Outline an evaluation to measure outcomes and demonstrate any improvement.

Maintaining the intervention

• Adapt and integrate the new intervention within the current systems taking into account funding and resources.
• Ensure all new staff receive ongoing training.
• Maintain ongoing communication, engagement and partnerships with relevant stakeholders and the broader network.

1. Sackett D et al. 2000, ‘Evidence-Based Medicine: How to Practice and Teach’ EBM, 2nd edition. Churchill Livingstone, Edinburgh, p1.

2. Grimshaw JM, Eccles MP, Lavis JN, Hill SJ & Squires JE 2012, ‘Knowledge translation of research findings’, Implement Sci, 7(50):50.

3. Runciman WB, Hunt TD, Hannaford NA, Hibbert PD, Westbrook JI, Coiera EW, Day RO, Hindmarsh DM, McGlynn EA & Braithwaite J 2012, ‘CareTrack: assessing the appropriateness of health care delivery in Australia’, Med J Aust, 197(2):100-5.

What is it?

An interdisciplinary approach involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities.¹

A team of clinicians from different disciplines, together with the patient, undertakes assessment, diagnosis, intervention, goal-setting and the creation of a care plan. The patient, their family and carers are involved in any discussions about their condition, prognosis and care plan.²

In contrast, a multidisciplinary approach involves team members working independently to create discipline-specific care plans that are implemented simultaneously, but without explicit regard to their interaction.³

Depending on the resources of the individual health service, a combination of the two approaches may be used when caring for older people.

Why is it important?

• Older people in hospitals often have a number of different diagnoses and consequently have multiple and complex needs. Compared to younger age groups, a greater proportion of older people require an interdisciplinary approach to their care in order to deal with complex multimorbidity, social and psychological issues.³
• The best possible outcomes for older people are achieved through a consultative, collaborative approach to care that actively involves the patient, their family/carers and an interdisciplinary team.¹
• An interdisciplinary approach can help avoid risk averse thinking by weighing up the risk against benefits for the patient.
• An interdisciplinary approach can improve patient outcomes, healthcare processes and levels of satisfaction.^4,5 It can also reduce length of stay ^6,7 and avoid duplication of assessments, leading to more comprehensive and holistic records of care.⁸
• The opportunity for discussion created by interdisciplinary care planning can be used for the patient, their family and carers to develop their ongoing plan.³

How can you adopt an interdisciplinary approach to caring for older people?

The care team need to work together, utilising an interdisciplinary approach, to provide and implement a care plan that meets the patient’s goals and needs.

All health care professionals have a shared role in providing person-centred care for older people.

Elements integral to a successful interdisciplinary approach

Leadership

Positive leadership and management give clear direction and vision for the team through:

• Promoting an atmosphere of trust where contributions are valued and consensus is fostered.
• Ensuring that the necessary resources, infrastructure and training are available, as well as a mix of skills, competencies and personalities amongst team members.⁹

Person-centred practice

Well-integrated and coordinated care that is based on the needs of the patient can contribute to reducing delays to provision of care and duplicating assessment.¹

• Involving the patient in all aspects of their care empowers them to speak up and contribute to decision-making.
• Formulating shared standardised interdisciplinary care plans and records of care to contribute to holistic and comprehensive person-centred care.

Teamwork

An interdisciplinary approach relies on health professionals from different disciplines, along with the patient, working collaboratively as a team. The most effective teams share responsibilities and promote role interdependence while respecting individual members’ experience and autonomy.⁹

• Ensure team members have clear goals, and an understanding of their shared roles and responsibilities within the team structure.⁵
• Participate in joint assessment, diagnosis and goal setting.
• Recognise the overlap in knowledge and expertise of staff from different disciplines.⁸
• Encourage team cohesiveness and creativity through team commitment and the identification of mutual goals.⁵
• Encourage less experienced team members to ask questions which may give rise to creative ideas and alternative perspectives.⁵
• Establish teams with members from diverse disciplines to foster higher overall effectiveness, and hold regular team meetings which are associated with higher levels of innovation.¹⁰

Communication

Communication across disciplines, care providers and with the patient and their family/carers, is essential to setting the goals that most accurately reflect the person’s desires and needs.

• Involve the patient’s GP or pharmacist to increase the success of the intervention.¹¹
• Communicate openly to encourage genuine collaboration. A breakdown of communications between health professionals is a common factor in hospital errors and adverse events.^4,12
• Document assessments and ensure clinical handover documents are completed thoroughly and stored in a central place.
• completed thoroughly and stored in a central place.

1. Department of Human Services 2008, Health independence programs guidelines, State Government, Melbourne.

2. Jessup RL 2007, ‘Interdisciplinary versus multidisciplinary care teams: do we understand the difference?’, Australian Health Review, 31(3):330-331.

3. Continuing Care Section, Programs Branch, Metropolitan Health and Aged Care Services Division, Department of Human Services 2003, Improving care for older people: a policy for health services, State Government of Victoria, Melbourne. .

4. Fewster-Thuente L & Velsor-Friedrich B 2008, ‘Interdisciplinary collaboration for healthcare professionals’, Nursing Administration Quarterly, 32(1):40-48.

5. Youngwerth J & Twaddle M 2011, ‘Cultures of Interdisciplinary Teams: How to Foster Good Dynamics’, Journal of Palliative Medicine, 14(5):650-654.

6. Curley C, McEachern JE & Speroff T 1998, ‘A firm trial of interdisciplinary rounds on the inpatient medical wards – An intervention designed using continuous quality improvement’, Medical Care, 36(8):AS4-AS12.

7. Curley C, McEachern JE & Speroff T 1998, ‘A firm trial of interdisciplinary rounds on the inpatient medical wards – An intervention designed using continuous quality improvement’, Medical Care, 36(8):AS4-AS12.

8. Jacob A, Roe D, Merrigan R & Brown T 2013, ‘The Casey Allied Health Model of Interdisciplinary Care (CAHMIC): Development and implementation’, International Journal of Therapy & Rehabilitation, 20(8):387-395.

9. Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P & Roots A 2013, ‘Ten principles of good interdisciplinary team work. Human Resources for Health’, 11(1):1-11. doi:10.1186/1478-4491-11-19.

10. Xyrichis A & Lowton K 2008, ‘What fosters or prevents interprofessional teamworking in primary and community care? A literature review’, International Journal of Nursing Studies, 45:140-153.

11. Nazir A, Unroe K, Tegeler M, Khan B, Azar J & Boustani M, 2013, ‘Systematic Review of Interdisciplinary Interventions in Nursing Homes’, Journal of the American Medical Directors Association, 14(7):471-478.

12. Mansah M, Griffiths R, Fernandez R, Chang E & Thuy Tran D 2014, ‘Older folks in hospitals: the contributing factors and recommendations for incident prevention’, Journal of Patient Safety, 10(3):146-153.

What is it?

Advance care planning is a process that enables a person to express their wishes for care, levels of treatment and acceptable health outcomes.

When an advance care plan is documented it can guide clinical decision-making should a person be unable to participate in making decisions for themselves.¹

Advance care planning is a values-based approach with two main aspects:

• discussing and documenting, a person's wishes in an advance care directive.
• appointing a medical treatment decision maker.

In Victoria, a person can create a legally binding advance care directive. A person’s advance care directive can include general statements about their values, medical preferences and what they would like their medical treatment decision maker to consider when acting on their behalf. It can also include instructional statements, in which a person may consent to or refuse a particular medical treatment.

However, people may use a range of documents to express their values and preferences for care and treatment. Health services must give due consideration to a person’s advance care planning documentation, whatever form it takes.

Why is it important?

Advance care planning has wide-ranging benefits including:

• improving the quality of life of the older person
• reducing the stress and anxiety in family members²
• supporting clinicians to provide person-centred care
• improving professional satisfaction.

’Advance care planning helps to give me an ongoing voice in the level of medical treatment and quality of life I want, while I can still have my say.’ Maryan Tozer, healthcare consumer.

How can you guide a person in advance care planning?

All healthcare professionals have a shared role in providing the best care for older people. Person-centred care is central to advance care planning and involves having a conversation with a person about their future health outcomes and respecting their choices.

Make it part of your daily practice

There is no better time than now to have a conversation about advance care planning – it is a conversation that needs to happen over time, not just at the end of life. Advance care planning needs to be embedded into an older person’s usual care.

Having the conversation

Communication, particularly the skill of listening, is central to good advance care planning.

Older people rely on the expertise of the medical team to guide their decision making and to initiate a conversation to assist them to clarify their priorities. Having a values-based conversation provides you with an opportunity to encourage an older person to explain what is important to them and for you to assist them to document their goals.

Some ways to start the discussion about advance care planning include:

• ‘Your health is quite good at the moment, so now is a good opportunity to talk about the future.’
• ‘Let’s talk about what would happen if you couldn’t make decisions.’
• ‘Who would make decisions for you and would they know what you would want?’

Some things to keep in mind

• Listen to the person – encourage them to express their fears, wishes and feelings. Ask them how they’re coping, and look for potential cues which may indicate that they want to discuss future plans.
• Be honest, straightforward and sensitive.
• It is often helpful to introduce the idea of advance care planning first, and discuss in more detail later.
• Encourage the person to speak with their family, friends and treating team about their wishes for future care.
• Consider health outcomes in terms of pain, cognition, eating, mobility, continence and what the person would find acceptable and the compromises they would be willing to make.

What to do after the conversation

You can help a person document their advance care plan in the following ways:

• Follow your health service’s policy.
• Give the person an advance care directive form. If your health service does not have one, there is a template available on the advance care planning forms page.
• Create an alert in the medical record that a person has an advance care directive and/or an appointed medical treatment decision maker.
• Document the conversation and decisions on an advance care planning discussion record.

Encourage or assist the person to:

• Write down their wishes for medical treatment in an advance care directive.
• Appoint a medical treatment decision maker.
• Have a conversation about their future preferences and choices with their family and friends, particularly their medical treatment decision maker.
• Provide copies of their advance care directive to their medical treatment decision maker, GP, local hospital, and those involved in providing their care.
• Keep the originals.

1. Department of Health 2014, Advance care planning: have the conversation. A strategy for Victorian health services 2014–2018, State Government of Victoria, Melbourne.

2. Detering KM, Hancock AD, Reade MC & Silvester W 2010, ‘The impact of advance care planning on end of life care in elderly patients: randomised controlled trial’, British Medical Journal, 340.

What is it?

The complex needs of an older person, together with increasing age, means that the older person will often experience multiple transitions during their hospital admission.¹

There may be a need to transfer the care of older people during a hospital admission for the following reasons:

• Planned and emergency transfers between the treating teams and specialities.
• Planned and emergency transfers between wards or units for the most appropriate or specialty care or completion of care (e.g. between emergency departments, short stay units, general medical, surgical departments, geriatric evaluation management units, ongoing rehabilitation or transition care programs).
• Transfers into ambulatory settings such as Hospital in the Home.

Why is it important?

Older people are the major users of hospitals and often have longer stays. In 2011–2012, people aged 65 years and older accounted for almost half of patient days.² The importance of mitigating the risks associated with discharge planning are well known in the hospital setting. However, identifying and responding to the same risks when an older person transitions within the hospital need greater care and consideration.

Each treating team of the hospital needs to consider strategic ways they can identify and respond to risks associated with these transitions. Implementing a person-centred approach is essential in minimising these risks.

The consequences of multiple transitions for older people include:

• Increased risk of adverse events.
• Increased risk of functional decline.
• Increased risk of unnecessary tests and procedures.
• Poor, or no communication, between staff members, older people, their families and carers, which can contribute to the risk of conflict and formal complaints.
• Increased risk of loss of continuity of care.
• Increased risk of developing delirium.
• Potential delay in delivery of information held in medical records.
• Increased length of stay for the older person.
• Increased risk of premature readmission to hospital.
• Possible residential care placement.
• Practical concerns such as misplacement of hearing aids, glasses, teeth and walking aids – all of which play a large role in promoting a person’s independence and participation in their own care.

How can you determine the risks associated with transitions for an older person?

Engage the older person

• Ascertain the needs and preferences of the older person on admission.
• Include the older person, carer, family members and general practitioner in all decision-making and keep them informed of any changes to the care plan.
• Use the following questions to guide conversation:
  • Is the older person aware of the reason for transition?
  • Is the family or carer aware of the reason for transition?
  • Have you considered using written or audio-visual materials to communicate the reasons for transition?
• Ensure the older person and their family and carers have adequate opportunity to ask questions.
• Employ the ‘teach-back method’.
• Give the older person or their family and carers the information.
• Ask them to use their own words to confirm their understanding.
• Re-phrase or use other strategies to ensure they understand and can repeat the information accurately (if necessary).³
• Bear in mind that you may need to repeat the conversation, or have the conversation at another time better suited to the older person.

Ensure team collaboration

• Identify and respond to risks of functional decline before, during and after the transition.
• Ensure that critical information, such as a medication list or falls history, is transferred, acted upon, and documented during clinical handover. Many health services use the framework ISBAR (identify, situation, background, assessment and recommendation) when transferring patient information during clinical handover.
• Advocate for the older person as part of the interdisciplinary team.
• Ensure vital tasks are delegated and followed up.

Consider practical issues

• Ensure the older person has their belongings (including glasses, hearing aids, dentures and walking aids) when they are transferred.
• Ensure that all medications, the patient summary and full medical history are transported with the older person.
• Ensure the older person’s family or carer has the exact details of the impending destination.
• On arrival to the new ward welcome the patient and ensure they are orientated to the bathrooms and the ward routines.

1. Department of Health 2014, Advance care planning: have the conversation. A strategy for Victorian health services 2014–2018, State Government of Victoria, Melbourne.

2. Australian Institute of Health and Welfare 2007, Older Australia at a glance (fourth edition), Australian Institute of Health and Welfare, Canberra, Australia.

3. UnityPoint Health 2014, Always Use Teach-Back! Retrieved 9 Dec 2014