‘Senior friendly’ hospital care
Ottawa’s hospitals have learned that simply keeping older patients moving regularly dramatically improves their mental and physical states, writes
The Ottawa Hospital Civic campus’s Move On program aims to keep old bodies strong by getting patients up and moving three times a day.
Hospitals can be dangerous places for older adults. So when Emil Lokar, 70, arrived at the Civic campus of The Ottawa Hospital, the medical team knew he needed extra attention.
The retired glassworker from Barrhaven was seriously ill with flu and pneumonia. He also has heart disease and is a cancer survivor. “He couldn’t breathe,” recalls his wife Marianna Pilat. He was so weak “he couldn’t even squeeze my hand.”
Lokar became a candidate for the hospital’s new program, Move On, which stands for Mobilization of Vulnerable Elders in Ontario. It aims to keep old bodies strong by getting patients up and moving at least three times a day.
Bedridden seniors lose muscle strength rapidly. Studies show that one-third of older patients lose the ability to move around and look after themselves. Half of those don’t regain it, affecting the possibility of returning to their own home. Movement is critical to their recovery.
“It’s not OK any more for the frail elderly just to stay in bed,” says Ottawa Hospital geriatrician Dr. Barbara Power.
“We are trying to prevent the mental and physical decline that can occur as a consequence of being admitted to hospital. The goal is to get seniors home sooner and healthier.”
Early and consistent exercise is one example of how hospitals in Ottawa are changing standard practice to address an aging population. The effort is part of a provincewide Senior Friendly Hospital strategy, led by local health integration networks (LHINs).
Over the past year, all adult hospitals in Ontario were required to take steps to improve care for patients aged 65 and older.
In particular, they needed to address two common and serious complications of hospital stays for the elderly — functional decline and delirium.
Other senior-friendly practices include measures for preventing falls and pressure ulcers, and providing handrails in hallways and adjustable beds.
‘It’s not OK any more for the frail elderly just to stay in bed. We are trying to prevent the mental and physical decline that can occur as a consequence of being admitted to hospital.’
BARBARA POWER
Ottawa Hospital geriatrician
“Hospitalization can become a pivotal event in the lives of many seniors, drastically changing the course of their lives, independent of the effect of their illness or injury,” writes Ottawa health planning consultant Cal Martell.
There is a strong financial incentive to focus on the elderly. Seniors account for 63 per cent of all acute in-patient days and 43 per cent of all provincial health expenditures in Ontario. The numbers are expected to grow as the population ages.
“Seniors make up the vast majority of people who are in hospitals,” says Chantale LeClerc, head of the Champlain LHIN. “If we meet the needs of seniors, it will benefit everybody else.”
The word “friendly” doesn’t convey the importance of what is going on, says Dr. Frank Molnar, medical director of the Regional Geriatric Program of Eastern Ontario, which provides education and guidance to hospitals.
“It is really about integrating effective and efficient seniors’ care into the everyday operations of hospitals,” he says. “It is a major innovation and revolution in how our hospitals treat seniors.
■ Lokar was an active person who played soccer until the age of 60. He was admitted last February to the intensive care unit where he was on a mechanical ventilator and feeding tube.
From the first day, physiotherapists were helping him to sit upright on the side of his bed. “This was totally a team effort because the ICU nurse and the patient-care assistant were required to help move Mr. Lokar as well as make sure the ventilator and all the lines he had inserted were handled safely,” says Vicki Thomson, a geriatric specialist and educational coordinator for Move On.
Throughout Lokar’s six weeks in hospital, he did daily exercises, first in bed, later in a gym. A card beside his bed served as a reminder: “Have you moved today?” In addition to muscle loss, prolonged bed rest can lead to problems with breathing, bed sores, weakness, tiredness, and confusion, blood pressure and depression. “I knew if I stay there in bed, I will be worse,” said Lokar.
After four weeks he took his first steps with a four-wheeled walker. It was an emotional moment. “He was crying. I was crying,” Pilat recalls. “Nobody knew if he could stand.” Lokar left hospital earlier this month “a very happy man and walking upright and strong, and looking forward to getting back to his garden,” said Thomson.
Move On is a research project funded by the ministry of health. The Montfort Hospital in Ottawa is also taking part.
It encourages activity by patients such as sitting on the bed to bathe or eat, sitting on a chair with visitors, and going to the washroom. A pilot study in Toronto found that by doing this, patients, on average, spent one day less in hospital.
“It’s a culture shift for everybody — staff, patients and families,” says Power, lead investigator for the Move On project at the Ottawa Hospital. “We tend to encourage keeping patients in bed. We have them hooked up to different lines and put the sides of their bed rails up. We foster that immobility process.”
Part of becoming a seniorfriendly hospital is changing attitudes, says Kelly Milne, program director for the Regional Geriatric Program of Eastern Ontario. “It’s quite easy to leave the older adult in their hospital bed,” he says. “The attitude tends to be ‘ Well they’re old and frail and really can’t do anything for themselves.’”
Milne sees it as a form of ageism. “They should be treated the same as a 45-year-old would be in terms of getting them up
sooner rather than later.”
■ Hospitalization can have a dramatic effect on patients. Sleep is disrupted. There are frightening noises, equipment and procedures. Nothing is familiar.
One of the hazards is delirium, a brain attack characterized by sudden confusion and often accompanied by hallucinations and agitation. It can lead to long-term mental impairment and even hasten death.
Anyone can get delirium but older people are at higher risk. It affects about 20 per cent of hospitalized seniors.
For the past two years, the Ottawa Hospital has worked to improve recognition, prevention and treatment of delirium in the emergency room.
“The thing we know about delirium is that it gets missed,” says Laura Wilding, advanced practice nurse in geriatric emergency medicine. It’s hard to distinguish delirium, characterized by its sudden onset, and dementia, which is a slower, irreversible impairment. Triggers include infections, surgery, kidney dysfunction, heart attack, stroke and drugs. Treatment in hospital is a major factor.
A patient who comes to emergency with a broken hip will receive antibiotics and painkillers. They will be kept without food or drink prior to surgery. “Those are all things that put you more at risk of developing delirium,” says Wilding.
Because patients often spend time in emergency awaiting a hospital bed, there’s a lot that emergency staff can do, says Wilding. “The sooner you recognize it and begin treatment, the better your outcomes.”
The hospital has provided education for staff and introduced a bedside screening tool to help nurses diagnose delirium. If they think a patient has it, a physician will do a standardized set of tests to make sure no contributing factor, such as a urinary tract infection, has been overlooked.
Meanwhile, to increase activity, the Queensway-Carleton Hospital has undertaken to reduce use of urinary catheters. They are often needlessly used in older patients.
A catheter is a tube inserted into a patient’s bladder via the urethra, draining urine into a bag. “It’s easy to overuse,” says Cathie Gray, a clinical nurse specialist at the QueenswayCarleton. It can seem “kinder” to give a catheter to an 80-yearold with a broken hip rather than risk discomfort or pain with a bedpan, she says.
However, catheters can increase risk of infection, set off delirium and prevent patients getting up and moving. “If you’ve got a catheter, you’re less likely to be walking around and mobilizing, because you’re carrying this bag around,” says LeClerc. In the longer term, the Queensway-Carleton expects to boost the geriatric expertise of its nurses through an American-based certification program called NICHE (Nurses Improving Care for Healthsystem Elders).
■
Many of today’s hospital problems are blamed on an aging society.
These include wait lists, cancelled surgeries, overflowing emergency rooms and socalled “alternate-level-of-care” patients who occupy acutecare beds while waiting to go elsewhere, often a long-term care home. Senior-friendly advocates say such problems reflect a failure to adapt to seniors’ needs. Conventional hospital treatment is not well designed for older patients who may have multiple health problems. It focuses on acute illness, not on preventing frailty.
“Most of our alternate-levelof-care reduction programs have an excessive focus downstream,” says Molnar. ”What to do after a senior has deteriorated in hospital to the point of needing a nursing home.”
Senior-friendly hospitals look “upstream” to improve seniors’ care in order to prevent deterioration, he says. “As it continues to evolve and become more central to hospital function, it will have greater and greater positive impacts on acute care.”