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