Emergency care

Introduction

Older patients admitted to the emergency department (ED) do not have a pharmacist-led medication review within the comprehensive geriatric assessment (CGA), yet the presenting complaint can be attributed to overprescribing and problematic polypharmacy. Taking ten or more medications increases the risk of hospital admission by 300% due to adverse drug reactions (ADRs)1, therefore a medication review can reduce this outcome by optimising current therapy2. Responsibility of safely transferring this medication information between care settings is a healthcare professional's duty, as the rate of error is 30 - 70%3.

Method

Patients were identified by the ED Frailty Team according to local frailty criteria, including patients > 65 years presenting with delirium, a fall and/or multi-morbidities. Medicines reconciliation was carried out by the frailty pharmacist, and medications optimised to reduce future harm with investigations prompted where needed. Interventions were categorised. A summary plan was written to the General Practitioner (GP) and each patient was followed up after 4 weeks to assess if received and actioned appropriately.

Results

73 medication reviews were conducted for patients (mean age 84.4 years) from June to September 2022, majority presenting with fall (69%). High-risk medication review was most common intervention (90%), followed by counselling (50%). 92% patients required a pharmaceutical intervention (n=208). GP plans were actioned for 65% patients in Primary Care.

Conclusion

ED frailty pharmacist's input reduced inappropriate polypharmacy and optimised medication for this patient cohort, with majority of care plans carried out appropriately following discharge. A future study could examine re-admission rates of patients in comparison to those without a frailty pharmacist's input.

References

1. Payne RA et al. British Journal of Clinical Pharmacology 2014; 77: 1073 – 1082.

2. Department of Health and Social Care, 2021. Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf. Accessed 19/1/23.

3. Department of Health, 2011/2012. Available at: www.wp.dh.gov.uk/healthandcare/files/ 2011/01/outcomesglance.pdf. Accessed 19/1/23.

Introduction: Musculoskeletal (MSK) injuries are a common factor in acute presentations to the emergency department (ED). Effective pain management is crucial for patient comfort and recovery, yet pain control for MSK injuries admitted under the medical team often falls short of optimal standards. This quality improvement project aims to evaluate and enhance the prescription practices for pain relief in elderly patients with MSK injuries at the Wrexham Maelor Hospital (WMH) ED. Methods:  A two cycle project was completed in which patients with MSK injuries were identified and reviewed regarding any pain relief they may have been prescribed (regular or PRN). Following cycle 1, interventions were put in place and prescribing practices were reassessed. Inclusion criteria: >60 years of age, MSK injury described in notes. Each cycle of data collection lasted a week, with a sample size of 17 and 14 patients respectively. Results: Cycle 1 No pain relief- 33% PRN Only- 6% Regular Only- 50% Both- 11% A significant number of patients were not receiving adequate pain relief, highlighting the need for improved pain management protocols. Interventions Educational posters were displayed around the emergency department and the frailty hub, and a presentation was given to the frailty team. Cycle 2 (post intervention) No pain relief- 14% PRN Only- 29% Regular Only- 21% Both- 36% Post-intervention results showed a marked improvement in pain management, with fewer patients receiving no pain relief and an increase in the combined use of PRN and regular pain relief. Conclusion: The quality improvement project highlights the necessity for targeted interventions to enhance pain management for elderly patients with MSK injuries in the ED. Preliminary results suggest that increased awareness and education among medical staff can potentially improve pain relief prescription rates.

Category one – clinical effectiveness 

Category two- Innovation 

Background 

The Older Person’s Same Day Emergency Clinic (OSDEC) at Portsmouth Hospitals University NHS Trust is an acute admission unit for older people. 

Introduction 

The aim of this quality improvement project was to design and deliver a teaching programme to improve understanding of key OPM topics and the complexity of older patients on OSDEC.  This would facilitate rapid holistic assessment and effective communication within the multidisciplinary team (MDT) and with other services, improving patient flow through OSDEC, which improves patient experience and hospital pressures.    

Method 

We developed a survey to identify the learning needs and team members who could share their knowledge. We created a teaching curriculum and sourced educators from the OSDEC and the wider hospital team.  Twice weekly 10 minute “bite-sized” teaching sessions were scheduled following the MDT board rounds and feedback was collected.  We conducted a review at 3 months to assess the reception and impact of the teaching. 

Results 

Average confidence scores before and after teaching improved by 0.91 on a 5-point scale.  Staff rated the topics and the bite-size model positively on the feedback survey.  17 teaching sessions were delivered, with the main challenge being identifying educators.   

Conclusion 

In the busy environment of OSDEC, our bite-sized teaching is a sustainable teaching model for the MDT. The programme increased staff confidence in a range of key OPM topics, showing that the bite-size model was effective, while building the teaching skills and confidence of team members.  Going forward we aim to formalize a cyclical OSDEC curriculum. 

Introduction: Emergency departments are increasingly seeing more older adults living with frailty. Between 5% and 10% of all those attending EDs and 30% of acute medical units are older adults living with frailty. The consequences of this on the system manifests as increased patient length of stay, poorer patient experience and clinical outcomes, such as mortality and morbidity, are measurably worse.

Aim: The Acute Frailty team aimed to move and expand its resource to provide a service to frail, older adults in both the Acute Medical Unit and the Emergency Department. This aligns with a key National objective that recommends all type 1 EDs have 70 hours access to a Acute Frailty Service. The team are a liaison service and therefore work alongside the ED and medical teams.

Method: Quality improvement methodology was applied utilising multiple PDSA cycles. An incremental increase in provision of an Acute Frailty service within the ED. A stakeholder group was set up, KPIs were set. The team worked alongside the ED team to improve early CFS scoring for over 65s and embedded the Nationally agreed same day frailty criteria of CFS/4AT, EWS and the presence of a frailty syndrome to identify appropriate patients for the service within the ED. The CGA was initiated in parallel with the ED assessment.

Results: Time between admission and CGA decreased by an average of 30 hours, Time between CGA and dc from hospital decreased by an average of 1.6 days. The Acute Frailty team activity increased in the ED and decreased in the AMU and there was no increase in re-admission rate.

Conclusion: A CGA initiated in the Emergency Department had a positive impact on length of stay and the earlier dc did not increase readmission rates.

East Kent has 38,101 people over 80 years, 39, 021 living with moderate or severe frailty and 304 care homes. This population have high levels of unplanned admissions which can put them at risk of long hospital stays, reduced mobility and increased delirium.

East Kent Ambulance services (SECAMB), Acute hospitals (EKHUFT) and Community Services (KCHFT) have piloted a single-point of access consisting of an ED consultant, community frailty clinician, Urgent care senior nurse, advanced paramedic practitioners. They sit together at the ambulance bases, 10am-6pm Monday to Fridays. This team reviews all patients awaiting ambulances to assess whether there are alternative services to ED which would meet the individuals' needs.

Method

The MDT assesses all patients listed as awaiting an emergency ambulance. Clinical records can be accessed from all services including GP records. If patients would benefit from treatment by alternative services, rather than conveyance, the paramedics are asked to call the MDT. This allows clinical assessment, history and investigation results to be taken into account in planning care. Patients and Carers are involved in deciding how they would like to receive medical care via a video or phone link with clinicians.

Results

Conveyance to hospital pre pilot - 62% post pilot less than 50%

Ashford catchment: admissions save weekly 27.3, bed days saved weekly 179.2

Thanet Catchment: admissions saved weekly 19.1, bed days save weekly 106.9

Conclusion

Many people can be treated effectively without conveyance to hospital through pre-hospital triage, consultation and planning by senior clinicians in a multi-disciplinary team.

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.

Background:

OPAL Team cares for elderly patients arriving at hospital front door. 80% of referrals to OPAL team are related to Falls. Early assessment and intervention reduce future risk of falls improving health outcomes. OPAL assessment proforma used for falls assessment varies widely depending on local resources. In our trust Multifactorial risk assessment (MFRA) is included in OPAL proforma to assess any patient presenting with a fall or has had two or more falls in the past six months or needs hospitalisation due to fall. Our MFRA includes assessment of Vision, Continence, Cognition, Footwear, Medication review, Lying Standing Blood Pressure (LSBP), Range of Movement (ROM), Strength, Gait, Balance, and Functional assessment.

Methods:

A retrospective review of health records of 100 patients seen by OPAL in June 2022 assessed compliance with MFRA. This revealed 100% compliance in documenting patients falls history but only 20% had vision assessment, 17% Footwear assessment and 40% has LSBP checked. Emphasis on adherence to proforma and regular departmental teaching targeted toward components of MFRA was held every month during this study period (June 2022-June 2023). The retrospective audit was repeated in June 2023 after these interventions.

Result: Visual assessment improved from 20% to 66%, footwear from 17% to 60%, LSBP increased from 40% to 53% but there was decrease in assessment of ROM 67% to 38%, Strength 71% to 44%, and Balance 71% to 60. While other components assessment was around average 75%.

Conclusion: Reduction in some MFRA risk factors is relating to time and space constraints in ED environment. A dedicated OPAL assessment area in ED is anticipated to improve these parameters. Reinforcement in MDT meetings, buddy system for fresh staff and adherence to proforma for documentation will help in achieving 100% in all components.

Introduction: Falls remain the leading reason for elderly people to attend emergency department (ED), which in 2023 led to 250,000 hospital admissions in the UK. A seemingly large number of geriatric patients undergo CT head as an initial workup in ED which might not be necessary, especially in minor head trauma. NICE (National Institute for Health and Care Excellence), recommended risk stratification to reduce unnecessary head scanning which may potentially reduce ED length of stay, hospitalisation and medical expense. Our study evaluated the current practice of adherence to NICE guidance on Head Injury: assessment and early management for performing CT head scans in elderly admitted to Basildon hospital.

Methods: Two cycles of retrospective data collection were undertaken across three elderly care wards. Elderly patients admitted with falls who had CT head scans were identified. Indication for scanning were evaluated to determine adherence with NICE guidelines for head injury. Between cycles, formal educational sessions were provided to Junior Doctors by departmental teaching and distributing leaflets/posters explaining NICE guidance for indication of CT head scans in head injury.

Results: Following the interventions implemented, patient compliance to the NICE guidance for undergoing CT head with a history of falls, rose from 77.33% to 93.99%. No significant difference in abnormal CT head findings were demonstrated between cycles. In addition, mortality observed between cycles was near equivalent, 12% and 11.67% respectively. The mean time for CT head scans performed also improved, from 13 hours to 4 hours.

Conclusion: We demonstrated education regarding the indication for CT head scans in elderly with falls improved the appropriateness of scans performed in accordance with NICE guidance. CT head scans performed which more robustly met NICE guidance demonstrated no difference in adverse findings or patient mortality and may have contributed to reduced mean scan time, thus improving resource allocation.

Introduction:

Older patients attending the Emergency Department (ED) and discharged home are at higher risk of adverse outcomes. Geriatric Ambulatory ED services were developed with the aim to deliver goal-directed care of older patients from ED using onward referral to Community Providers.

Method:

A retrospective review was undertaken from 13th January 2022 to 23rd December 2022 in older patients discharged from the ED following a targeted geriatric assessment and recommended community follow-up interventions. Demographic information, functional ability, hospital utilisation and mortality (up to one year), and any post-visit fragility fractures were reviewed. Data collection included identification of osteoporosis or osteopenia during or following the index ED visit.

Results:

108 patients were assessed, of whom, 74% were female, average age 76 years, range 61-93 years. 65% of patients were CFS scored, 9% were CFS 6 or 7, 15% CFS 4 or 5 and 41% CFS 1-3. GP review was advised for 76% of patients and 61% attended and therapy interventions were recommended for 9.3%, of whom, 3% attended. The majority presented with falls (82%) and half of those who fell, sustained a fracture. Osteoporosis or osteopenia was newly identified in 30% but in 44% of patients bone health remained unevaluated and only 8% had newly initiated anti-resorptive and 9% existing treatment. 4% experienced fragility fracture following their ED visit. Uptake was low for therapy (30%) and nursing interventions (14%). Following the index ED visit, 7% patients attended ED within 7-days, and 5% admitted to hospital within 30-days. 35% of patients re-attended ED and 22% were hospitalised within one year. One year mortality was 5%.

Conclusion:

ED targeted geriatric assessment can identify patients with falls and fragility fractures but better collaboration and communication between primary and secondary care is needed. Recommended bone health assessment occurred in a relatively small proportion of patients.

Introduction

Emergency department (ED) frailty screening is recommended in guidelines for its potential to trigger earlier and more appropriate comprehensive evaluation and intervention for the most vulnerable patients. Post-implementation studies of the Clinical Frailty Scale (CFS) typically observe around 50% concordance with screening. Little is known regarding the characteristics of those people omitted.

Methods

The Frailty in European Emergency Departments (FEED) cohort study observed prevalence of frailty, administering the CFS to consecutive attenders over twenty-four hours. Retrospective “normal day” data from two weeks prior were also collected, where sites used retrievable electronic health records. Age, sex, ethnic group, mode and time of arrival and departure, NEWS2 score, and use of resuscitation areas were recorded. CFS missingness was assessed for distribution and dependency with other variables using chi-squared tests. The frailty distributions in prospective and retrospective data were compared with the Kruskal-Wallis test.

Results

Only five of sixty-two sites collected CFS scores in retrievable electronic records. The cohorts included 368 individuals prospectively and 399 retrospectively. At these sites, 14% prospective and 55% retrospective CFS observations were missing. CFS entries were more frequently missing in people with non-white ethnic group (p=0.007) and self-presentation (p<0.001). The distributions of CFS differed significantly (p=0.009); on the retrospective day, no individuals were assigned CFS scores 1 or 9, and CFS scores 4 and 6 were over-represented.

Conclusion

Acknowledging the limited participation and use of snapshot data, these findings alert the presence of systematic, non-random missing data in routine CFS screening. Systematic missingness in frailty data has critical implications for research in geriatric emergency medicine, presenting real limitations in validity where studies seek to analyse routinely collected data to reach representative inferences. Screening practices and retrievability of data warrant further study and improvement.