understanding the impact of environment relocation the...deaths (14% of the patient population)...

Understanding the

Impact of Environment

Relocation

March 2011

K. Farmer, S. Farmer, C. Poirier,

C. Tuan

The Effect on the Geriatric Population

When Seniors Relocate

Adapting to a new environment requires: Establishment of new friendships

New routines

Time to increase familiarity

Adjusting to relocation can cause: Disorientation

Idealization of the lost environment

Anger or depression

Confusion, illness, or grief

Mortality

Relocation Stress Syndrome

SMHC Redevelopment Project

Sept 2006 capital construction of a new 105-bed facility begins:

Design concepts used in the new building include:

Smaller home-like units

Individual patient rooms

Ensuite barrier-free washrooms

Single function areas such as dining rooms

Nov 2008 staff and patients in the Geriatric Program move into the Tyndall Building

What is an Institutional

Environment?

Restrictiveness or regimentation of the living

environment

Access to personal belongings

Multiple-occupancy rooms

Meal tray service

Large-scale wards (>20 patients)

Restricted outdoor access

Institutional Environment

Institutional Environment

Institutional Environment

Institutional Environment

Institutional Environment

What is a Home-Like

Environment?

Smaller units (max. 15 patients)

Single-occupancy rooms

Private bathrooms

Dining & TV area

Inviting public areas (windows, color scheme)

Places for small groups

Meaningful wandering spaces

Positive and secure outdoor space

Home-like Environment

Home-like Environment

Home-Like Environment

Home-Like Environment

Home-Like Environment

Relocation Study

Objective: To document the experience of geriatric patients with persistent psychiatric illness and/or progressive cognitive impairment before and after their move to the Tyndall Building.

Methods

January 1/08: Geriatric inpatients > 65 years of age

9-months pre-move and 9-months post-move

Morbidity/Mortality Rates

Weight & Diet

Agitation/Aggression

PRN Medication Use

Falls

Functional Status

Participants

N=36

58% men 42% women

44% primary dx schizophrenia, 31% dx dementia, 25% other

Average age 75 years (range 66-87 years)

Average Duration of current admission: 14 years (range 1 year,1 month to 67 years, 4 months)

Results: Morbidity/Mortality

No change in overall mortality rates

During 9-month pre-move period: 12 patient

deaths (14% of the patient population)

During the 9-month period post-move: 11

patient deaths (15% of the patient population)

Pneumonia was primary cause of death pre-

move and post-move

Increased community discharges post-move

Results: Weight

64% of participants

experienced some degree of

weight loss

None of these patients dropped

below their healthy weight

range

Post-move slightly more

patients were within their

healthy weight range

Results: Diet Requirements

50% of patients required change

(downgrade) in diet texture. However, the

percentage of patients requiring texture-

modified diets did not change pre/post move.

Fewer patients required therapeutic diets

post-move.

The most commonly prescribed diets were:

low sodium and moderate reducing.

Results: Infections

All infectious

illnesses

were reduced

post-move

except

bladder

infections

0

20

40

60

80

100

120

140

160

Resp Skin UTI Ear Eye Oral GI Total

9-mos pre-move

9-mos post-move

Results: Agitation/Aggression

Significant reduction in frequency of reported

behavioral occurrences

0

5

10

15

20

25

30

35

40

Nov'07 - Aug'08 Nov'08 - Aug'09

All Patients

Study Participants

Results: PRN Use

70% of patients studied

showed reduction in use of

PRN bisacodyl

suppositories for bowel

management

PRN use of antipsychotic

medication for

agitation/aggression was

reduced in 58% of patients

Results: Seclusion Use

38% reduction in seclusion incidents

0

50

100

150

200

250

300

350

Feb'08 - Oct'08 Dec'08 - Aug'09

All Patients

Study Participants

Results: Falls

Number of Falls per 1000 pt days

0

2

4

6

8

10

12

14

January 1 - October 31, 2008 January 1 - October 31, 2009

Nu

mb

er

of

fall

s p

er

pa

tie

nt

da

ys

Results: Location of Falls

Location of Falls in Geriatric Program 2008

47%

15%

23%

1%

7%6%

Bedroom

Bathroom

Dayroom

Dining Room

Hallway

Other

Location of Falls in Geriatric Program 2009

48%

3%13%

12%

13%

11%

Bedroom

Bathroom

Dayroom

Dining Room

Hallyway

Other

Results: Falls

Of the 224 falls in 2008

54% were unwitnessed

44% were witnessed

1% information

unavailable

Of the 271 falls in 2009

69% were unwitnessed

31% were witnessed

0.3% information

unavailable

Results: Functional Status

Crichton Modified

Behavioral Rating Scale

7 domains

Mobility

19% improved; 51%

remained unchanged

Orientation

41% improved; 35%

unchanged

Results: Functional Status

Communication

24% improved; 65%

unchanged

Restlessness

46% improved; 32%

unchanged

Results: Functional Status

Dressing

24% improved; 51% unchanged

Feeding

27% improved; 38% unchanged

Continence

22% improved; 59% unchanged

Conclusions

Improvements in

functional status

combined with reduced

aggression/agitation

A home-like environment

can maximize recovery

and facilitate successful

community reintegration

Minimizing Adverse Effects

Visiting the new location

Involvement of family and/or friends

Introductions to new staff and residents before the move

Involvement in the relocation process

Offering choices

Preparatory conversations

Moving to a home-like

environment

Questions/Comments?