Admission

Background

Older people account for >40% of acute hospital admissions. Delivering alternatives to hospital admission and community-integrated care closer to home are increasing priorities. We aimed to develop an Emergency Department (ED) Frailty MDT to provide rapid assessment, early Comprehensive Geriatric Assessment (CGA), and reduce inpatient admission rates for frail older people.

Methods

From November 2023 to April 2024, a newly formed Royal Infirmary of Edinburgh ED Frailty team delivered CGA for older adults aged ≥75 (≥65 if care home resident) with Clinical Frailty Scores ≥5 in the ED. The ED Frailty Team consists of an Emergency Medicine Consultant with an interest in Frailty, a Consultant Geriatrician, two Frailty Advanced Nurse Practitioners, an Occupational Therapy Advanced Practitioner, Occupational Therapists and a HomeFirst Social worker. We prioritised patients who were most likely to achieve same-day discharge. We built on strong integrated community pathways including Hospital @ Home, Rapid Access Day Hospital, and Discharge2Assess. We evaluated efficacy and safety using readmission and mortality rates.

Results

We reviewed 344 patients and discharged 209/344 (60.7%) of frail older patients who were awaiting medical beds. We discharged 114/209 (54.5%) with Hospital @ Home; 49/209 (23.4%) with rapid access Day Hospital; 21/209 (10%) home with GP follow-up; 18/209 (8.6%) home with no follow-up; 5/209 (2.3%) home with other community follow-up; and 2/209 (1%) home with ambulatory care. Discharged patients had a 19.4% 30-day representation rate and a 5.8% 30-day mortality rate. Admissions from ED amongst Edinburgh city residents reduced from 60% to 43% in 75-85 year olds and from 52% to 46% in the 85+ age group.

Conclusion

ED Frailty MDTs can effectively deliver CGA in an Emergency Department setting, facilitating admission avoidance and delivery of integrated care closer to home that is effective and safe.

Introduction
An Acute Frailty Team pilot was launched in December 2022 at the QEH. The aim was to reduce unnecessary hospital admissions and length of stay (LOS) by providing interventions in the Emergency Admissions Unit (EAU), through comprehensive geriatric assessment. Following the pilot’s success additional recruitment was made to the multi-disciplinary team (MDT) and the service revaluated. The MDT consists of a Consultant Geriatrician, Specialist Frailty Practitioner, Frailty Fellow, Physiotherapist, Technical Instructor, Occupational Therapist, and Pharmacist.

Method
To allow comparisons a pre-pilot control group audit of 100 patients ≥65 with a clinical frailty score >5 was undertaken. This data has subsequently then been compared to a phase-1 (Consultant Geriatrician, Specialist Frailty Practitioner team) audit of 121 patients and a phase-2 (full MDT) audit of 133 patients with the same parameters.

Results

The creation and expansion of the acute frailty team has reduced the average length of stay from 13.8 days, pre-pilot, to 9.4 days in phase-1 and subsequently been maintained at 9.56 days during phase-2. More frail patients are now being discharged from the emergency admission unit (EAU). Pre-pilot 7% of patients were discharged from EAU, increasing to 13% during phase-1 and 18.75% phase-2. 16% of patients were originally discharged within 72 hours of admission, this increased to 20% during phase-1 and 24.81% phase-2. This is also reflected in 7-day discharge data (37%, to 39% to 44.36%).

Conclusion(s)
MDT expansion of the acute frailty team at the QEH has resulted in improved recognition and holistic assessment of frail patients’ needs and reduced their length of stay.

Background: North Middlesex University Hospital runs an outpatient frailty service offering Comprehensive Geriatric Assessment. There is a daily ‘hot slot’ for patients who may otherwise require unplanned admission if not seen within seven days. Aim was to improve slot utilisation from 50 to 100%, with appropriate admission avoidance referrals by June 2023. Empty slots result in an inefficient use of resources, increased workload in other departments and reduced opportunity for patients to benefit from the service. 

Methods: We audited hot slots in November and December 2022, marking slots as ‘filled’ or ‘unfilled’. In January 2023 we established a clear referral process for hot slots, implemented an education programme to increase awareness of the availability and referral criteria, and increased Consultant availability in the department. We then re-audited the hot slots from February to April 2023 and analysed data, conducted statistical testing and produced visual representation of the data.  

Results: After exclusion of periods where hot slots were closed (n=13) including industrial action, bank holidays and times with below minimum staffing; 82 slots were audited, pre-intervention (n=39) and post-intervention (n=43). The utilisation of hot slots increased from 51% pre-intervention to 86% post-intervention. Fisher's exact test showed statistical significance (p<0.0007). Intervention did not improve appropriate use of hot slots (41% to 35%). 

Conclusions: Interventions increased utilisation of hot slots but fell short of the targeted 100% utilisation rate. We plan to make the hot slot available exclusively to the Geriatric Emergency Medicine (GEM) team for one week in August to assess whether this increases utilisation of the hot slot. We intend to further analyse the data to review the appropriateness of referrals and help identify other ways to improve this. We anticipate our service will expand frailty frontline provision plans to help meet rising need for urgent outpatient frailty care. 

Introduction

In the UK, fifty-three percent of hospitalised older people with dementia have multimorbidity, and are at an increased risk of hospital readmission within 30 days from discharge. Between 20-40% of these readmissions are preventable [1]. Current research focused on the biological causes of readmissions. However, older people with dementia have additional psychosocial factors increasing their risk of readmission. The aim of this scoping review was to identify psychosocial determinants within the context of known biological factors.

Methods

Electronic databases MEDLINE, EMBASE, CINAHL and PsychInfo were searched from inception until July 2022. Quantitative and qualitative studies in English including adults aged 65 years and over with dementia, their care workers and informal carers were considered if they investigated readmission. An inductive approach was adopted to map determinants of hospital readmission. Identified themes were described as narrative categories.

Results

Seventeen studies including 7,194,878 participants met our inclusion criteria from a total of 4736 articles. Sixteen quantitative studies included observational cohort and randomised controlled trial designs. One American study was qualitative. Ten studies were based in the USA, and one study each from Taiwan, Australia, Canada, Sweden, Japan, Denmark, and The Netherlands. Large hospital and insurance records provided data in over 2 million patients in one American study. Identified psychosocial determinants included inadequate hospital discharge planning, limited interdisciplinary collaboration, and socioeconomic inequalities among ethnic minorities. Biological determinants included reduced mobility and accumulation of comorbidities. Use of antipsychotic medications might explain the interplay between biological and psychosocial determinants.

Conclusion

Poorly defined roles and responsibilities of health and social care professionals and poor communication during care transitions increase the risk of readmission in older people with dementia.

Reference

1. Godard‐Sebillotte C, Strumpf E, Sourial N, et al L. Primary care continuity and potentially avoidable hospitalization in persons with dementia. J Am Geriatr Soc. 2021;69(5):1208-20.

Introduction: The number one reason for older people to be taken to hospital emergency departments is a fall¹. An “Ambulance Improvement Programme Pillar”² is trying to reduce conveyance to hospital for falls, however it is not understood how the attending clinician’s confidence impacts decision-making.

Objectives:

1.  Assess recruitment rate.

2.  Assess feasibility of online survey delivery.

3.  Determine the experiences and confidence of frontline emergency clinicians in attending older adults who have fallen.

Method:

Online cross-sectional survey, undertaken in one English ambulance service in May 2023. 

Demographics were collected from participants about their role, along with 5-point Likert scales of confidence.

Data were summarised using descriptive statistics and Chi-square analyses to compare confidence between localities and years’ experience.

Results:

81 responses were received from across the regional ambulance service’s 16 localities.

76% of respondents were paramedics, other respondents were emergency medical technicians and student paramedics.

53% were aged 25-34.

60% of respondents rated being ‘somewhat confident’ to ‘How confident do you feel in assessing older adults who have fallen?’, responses ranged between ‘Neither confident nor unconfident’ to ‘Completely confident’.

No significant difference was found between the locality and confidence levels for assessing this patient population. However, there was a significant difference between confidence levels when utilising hospital avoidance pathways across localities (p-value=.0045). 

Length of experience in either frontline ambulance and overall healthcare provision was not significantly associated with different levels of confidence.

Conclusion: Locality of work had a relationship with confidence in utilising hospital avoidance pathways. In contrast, locality of work did not significantly impact confidence to assess older adults who have fallen. Confidence levels were not found to be related to the number of years providing healthcare. Online survey delivery is feasible effective method in this population.

References

1. Dewhirst. (2023). National Falls Prevention Coordination Group. https://committees.parliament.uk/writtenevidence/117837/pdf/

2. NHS England and NHS Improvement. (2019). Ambulance Improvement Programme. https://www.england.nhs.uk/wp-content/uploads/2019/09/planning-to-safetly-reduce-avoidable-conveyance-v4.0.pdf

Background: Elderly patients report less positive experience of hospital admission than younger patients¹. Targeted interventions have been shown to improve patient ability to perform activities of daily living and reduce frequency of discharges to long-term care facilities. Additionally, non-pharmacological interventions reduce incidence of delirium and prevent falls². We aimed to improve the inpatient experience on a care of the elderly ward through use of a recreation room for mealtimes and recreational activities.

Methods: We performed a quality improvement project using patient and staff surveys pre- and post-interventions, including the introduction of a poster and use of the recreation room for activities. We registered use of the recreation room to monitor attendance.

Results: Use of the recreation room increased by 175% from week 1 to week 4 (n=8 to n=22). Most visits were for mealtimes (71%) and the remainder for activities including listening to music, socialising, or playing puzzles. Patient satisfaction improved (82% to 87%) and awareness of the recreation room increased (27% to 75%). Staff satisfaction with patient experience increased (80% to 92%), and 100% of staff agreed that care was improved for patients attending the recreation room.

Conclusion: Use of a recreation room for mealtimes and activities on a care of the older person ward resulted in improved patient satisfaction and staff perception of patient satisfaction and care. Further inpatient-engagement will be sought through volunteer-run activities and a timetable of regular activity sessions.

Background: Older individuals living with frailty face a heightened risk of experiencing significant deterioration in their mental and physical well-being following seemingly minor health challenges. Our aim was to assess and enhance the practice of the Clinical Frailty Scale (CFS) during inpatient assessments within a large teaching hospital.
Methods: We conducted 2 cycles of retrospective data collection within a single centre setting, screening a total of 600 patients focussing on; age ≥65, level of frailty, location of CFS assessment - Emergency Department (ED), Medical Assessment Unit (MAU); and the health-care professionals involved in CFS practice. We compared practices amongst young-old (65-74), middle-old (75-84), and old-old (≥ 85) age groups.  
Results: The CFS documentation rate for eligible patients was 76.7% in the first cycle, involving 240 patients, and 83% in the second cycle which included 247 patients, whereas the rate for the above-mentioned age sub-groups was 13.8%, 67.7%, 98.3% respectively. The prevalence of frailty amongst the age sub-groups was 74.1%, 84.7%, and 93.9% respectively, while male-to-female prevalence was 88.9% and 89.2%. Overall, 72.7% of the CFS assessments were completed in ED. The Frailty Interface Team (FIT) significantly contributed to the CFS assessment by completing 58.1% of overall assessments.
Conclusion: The results underscore the significance of integrating frailty education into core teachings to enhance CFS practice among junior doctors. Identifying inpatient frailty in the 65-74 age group is crucial, as they are frailer than initially perceived and will further decline with aging. Interdisciplinary collaboration is essential, particularly a specialized FIT, proving pivotal in CFS practice within our hospital. Larger studies into inpatient frailty in the young-old age groups are recommended. 

Introduction  

The weekend on-call team attends ward emergencies and front door new assessments. The extra routine ward work results in delay in the new assessments and add further exhaustion for the on-call team, impacting on junior doctor’s well-being and patient safety.  

Objective  

Aim to improve patient safety by facilitating the continuity of patient care over the weekend 

Method 

Group discussions among junior doctors, nurses, pharmacists, and ward managers were done to understand the challenges that impact communication. The average time spent on a ward by on-call team was 60 minutes. Plan-do-study-act (PDSA) cycles were introduced. The key measurement used was the time taken to complete the ward task. 

Results 

Team agreed to focus on improving communication over weekends based on the number of times nurses contacted junior doctors 

Friday morning ward round was made mandatory for every patient and a check-list sticker was introduced to test the change for 15 patients. Results were assessed and showed 3 patients did not require review and saved 6 minutes of on-call team over the weekend.  

The second PDSA included 30 patients which showed 11 minutes of time saved. But change was not sustained. Awareness sessions were introduced, and the plan was to add A4 sheet titled Mandatory Friday Round (MFR). Next PDSA cycles showed saving on-call team but not all the on-call team and nurses reviewed MFR.  

The team reviewed the results of the 5th PDSA cycle and agreed to use the green colour MFR A4 sheet and included prompts for the team to complete all the usual tasks. This saved about 28 minutes of on-call team.  

Discussion  

28 minutes saved from one ward were used for the new assessment. The team feels extending the good practice to all 5 elderly care wards will save approximately 2 hours 

Conclusion  

Effective communication using MFR has enabled on-call team to assess extra new patients and have adequate rest.  

Introduction:

Around 10% of calls received by English ambulance services are for older adults who have fallen¹; with an ageing population there are significant care provision needs. Decision-making on the treatment for people who fall, can impact their future physical and mental health. Previous research in decision-making of ambulance staff found perception of role, confidence, service demands and training to be key drivers². Previous work highlights drivers, but not experiences that explain why they occur.

Aim: to determine the experiences and confidence of frontline emergency clinicians in attending older adults who have fallen.

Method:

Online cross-sectional survey of frontline ambulance staff from one English ambulance service in May 2023. Including open questions that generated qualitative data for thematic analysis³. Ethical and regulatory approvals, and informed consent, were obtained.

Results:

81 participants completed the survey. Analysis identified three themes:

Care Pathways: Provision of hospital avoidance pathways varies throughout the region. Concerns arose from not knowing what different areas had and reduced accessibility out of hours.

“Only issue does arise when it’s between 1700 and 0900, as there’s very very limited alternative pathways” P6

Shared Decision-Making: Patients, family and clinicians were all valued as part of shared decision-making, with past feedback on decision-making informing future practice. 

Communication: Decision-making confidence was impacted by the participants experiences; positive experiences encouraged use of hospital avoidance pathways, whilst negative experiences impeded willingness to avoid hospital for fear of repercussion.

"Many services are helpful and willing to assist with education for hospital avoidance.” P18

Conclusion:

Prominent themes arose from the challenge of a regional and 24/7 ambulance service, not having consistent pathways available. This variation led to concerns when responding to patients outside of the clinician’s usual area and further challenges ambulance clinicians must balance in their practice.

References:

1. Snooks, Anthony, Chatters, et al. (2017) Health Technology Assessment, 21; 1-218.

2. Simpson, Thomas, Bendall, et al. (2017) BMC Health Services Research. 17; 299.

3. Braun and Clarke. (2006) Qualitative Research in Psychology, 3; 77-101.

Introduction:

Falls in older people are associated with multifactorial risks which are often preventable. Last year there were over 220,000 emergency admissions for falls in people aged 65 years and over in the UK. Improving how we assess such patients on admission may help to ameliorate these risks and prevent future admissions.

Method:

The aim of this quality improvement project was to identify weaknesses in our acute risk assessment of multifactorial falls and to improve on these. We completed a retrospective case note review for 68 patients in their first 48 hours of admission. As an analytical framework, we adopted the NICE guideline: ‘Falls in older people: assessing risk and prevention’ which details twelve key parameters of risk assessment. For each patient we sought to determine whether these parameters were assessed or missed. After the first audit cycle, we found four guideline parameters which were commonly missed during the acute admission phase. An educational intervention was subsequently organised for medical staff at a departmental level and corroborating posters were placed around the acute areas of the hospital. Two months later a second audit cycle was undertaken which assessed the same parameters and looked for improvement.

Results:

There were notable improvements in four areas. The assessment of visual impairment increased from 32.4% to 42%. The documentation of patients’ perceived risk of falling improved from 37.3% to 60.9%. Osteoporosis risk assessment rose from 32.4% to 63.8%. The completion of Lying/Standing BP demonstrated the most significant increase, from 14.7% to 44.9%.

Conclusions:

The results suggest that a tailored educational session and a poster campaign have increased overall awareness and improved the risk assessment of multifactorial falls at a central Birmingham Hospital.