GERONTOLOGY/ALTERNATE LEVEL OF CARE/HOME CARE/REHAB
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The Ontario senior friendly hospital strategy and indicator development BY K. WONG, A. TSANG AND B. LIU
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ntario’s population is aging and the fastest growing age group is the oldest and most frail. Already, patients 65 years of age and older account for over sixty per cent of inpatient days in the province’s hospitals. During a hospital admission, frail older patients in hospital are at increased risk for adverse outcomes and complications, many of which are preventable. For many seniors, hospitalization can be a pivotal event. It can add years and quality to their lives or place them at risk of losing independence and functional ability. In order to better meet the unique care needs of older patients in hospital and improve outcomes, the Ontario Senior Friendly Hospital (SFH) Strategy was launched under the leadership of the province’s Local Health Integration Networks (LHINs) and Regional Geriatric Programs (RGPs). This was guided by the evidence-informed RGPs of Ontario SFH Framework. The five domains of the SFH framework provide a multi-dimensional, organizationwide approach to the design of hospital care for frail seniors. The first phase in the Ontario SFH Strategy comprised a prov-
ince-wide environmental scan of hospitals which identified promising practices, gaps, and identified hospital-acquired delirium and functional decline as clinical priorities for quality improvement.
For many seniors, hospitalization can be a pivotal event. It can add years and quality to their lives or place them at risk of losing independence and functional ability. These results were recently published in the Journal of the American Geriatrics Society by the RGP of Toronto (Wong et al., 2014). Subsequent phases of the strategy saw the implementation of a web-based toolkit (www.seniorfriendlyhospitals.ca), and the identification of SFH indicators to monitor hospital practice in delirium and functional decline.
With assistance from the Li Ka Shing Knowledge Institute, St. Michael’s, the RGP conducted a literature review to identify possible indicators related to delirium or functional decline in hospitalized seniors. Over 12,000 citations were identified. Eventually 638 full papers were abstracted, yielding 713 potential indicators for consideration by an expert panel. The panel comprised 31 members with a spread of expertise, including clinicians, researchers, educators, administrators, decision support and policy makers. The membership also reflected the diversity of hospitals in Ontario by size, geography and type of service provided. In order to examine the influence of different documentation systems, the panel included a mix of hospitals using paper-based and electronic medical records. Additional details regarding the process are available at www.seniorfriendlyhospitals.ca Gail Dobell, Director of Evaluation and Research at Health Quality Ontario, provided expert facilitation of a modifiedDelphi process in order to reach consensus on a short list of 36 possible indicators. After a round of voting and three
consensus meetings, the panel identified a pair of indicators for each of delirium and functional decline. The paired indicators included a process and outcome indicator. • Rate of baseline delirium screening • Rate of hospital-acquired delirium • Rate of ADL function assessment at admission and discharge • Rate of no decline in ADL function Even though the process was very rigorous, the group felt that it was important to evaluate the feasibility and clinical value of the indicators. With support from the LHINs and RGP colleagues across Ontario, the RGP of Toronto coordinated an evaluation of the SFH indicators. Fortyfour hospitals across 10 LHINs volunteered to implement the delirium and/or functional decline indicators on at least one entire patient care unit, and submit data that would be analyzed to determine the feasibility and clinical value of reporting these indicators. The delirium indicators saw high compliance, promoted clinical learning, and triggered the implementation of prevention and management strategies. Continued on page 27
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