Emergency care

At University Hospital Monklands, a district general hospital in Lanarkshire, an ED in-reach pilot was set up to deliver the best possible outcomes for frail older adults by proactively reducing unscheduled admissions, thereby reducing the time they spend in the hospital.

Aim

To reduce unscheduled admissions for patients with a clinical frailty score (CFS) ≥ 6, admitted to ED between 8am – 3pm, Monday to Friday, by 50%. Method An ED Frailty MDT was formed, comprising of Acute Care of the Elderly (ACE) nurses/ Advanced Nurse Practitioners (ANP) and Consultant Geriatricians. Patients ≥ 65 years with a CFS ≥ 6 likely to be discharged on the same/next day were identified by ED staff and referred to ANP/ACE nurses. A Comprehensive Geriatric Assessment (CGA) was performed by the nursing team within 30 minutes of the referral, with the support of the consultant geriatrician. Data was collected on number of patients seen, time taken before review and patient outcomes.

Results

97 patients were reviewed at the ED by the team within a 4 – month period (October 2023 – January 2024). 53.6% (52/97) of them were discharged, either directly home(32) or with a referral to the Hospital at Home service/Home Assessment Team (20).

Conclusion

The pilot had three tests of change with variable results. The volume of calls from ED staff improved after the first and second tests of change (which involved increasing visibility of the ANP/ACE nurses in ED and having the consultants accompany them for reviews respectively) but a sharp drop was noted after the third test of change. There was also the challenge of staff shortages but despite this, the pilot was well received by the managers and staff in ED and further work is being planned on how to establish the gains of the project.

Aim: Several scores have been developed to identify SDEC patients from Emergency Department (ED) triage and acute medical intakes. Scores are designed to improve system efficiency, overcrowding and patient experience but none have been developed for older adults. Previous work has shown that existing scores e.g. Glasgow Admission Prediction Score, Sydney Triage to Admission Risk Tool and the Ambulatory Score were not able to predict admission in our population(1). We have developed a novel, frailty-focused score. Methods: The Older Person’s Assessment service (OPAS) is ED based, accepting patients with frailty syndromes aged >70 years to provide a comprehensive geriatric assessment (CGA) and is extended into medical SDEC. The databases were retrospectively analysed and interactions with age, Charlson Co-morbidity index (CCI) and Clinical Frailty Score (CFS) were evaluated alongside NEWS, 4AT, including who with and where the patient resides. Results 1011 attendances, 414 (40.9%) Male, mean age 82.3(±8.4) years, CFS 5.3(±1.2) and CCI 8.0(±1.8), 701(69.3%) discharged same-day and 629(62.2%) fallers. OPAS: 776 attendances, 306 (39.4%) Male, age 82.4(±8.7) years, CFS 5.3(±1.1) and CCI 7.9(±1.9), 540 (69.5%) discharged same-day, 557(71.8%) fallers. SDEC: 234 attendances, 108(46.2%) Male, age 81.8(±8.0) years, CFS 5.2(±1.3) and CCI 8.2(±1.7),162(69.2%) discharged same-day, 72(30.1%) fallers. There was significant difference between groups with NEWS (p<0.02), mortality (P<0.001) and presenting complaint(p<0.001). We used a cut-off Score >6.5 indicating admission(p<0.0001). Each variable’s weighing was determined using T-tests and Chi-squared analysis. Overall score Sensitivity 0.75, Specificity 0.63, Positive Predictive Value 0.65, Negative Predictive value 0.57, Area under Curve 0.65. Conclusion Frailty is an important determinant in identifying whether ambulatory care is appropriate. The efficacy of the score is comparable to the results derived in validation cohorts of existing and recommended scores. We are currently prospectively testing the score but clinical judgement, alongside a MDT providing a CGA is gold standard care.

Same Day Emergency Care (SDEC) at St James’ Hospital, Leeds provides urgent care at the interface between primary and secondary care, offering comprehensive geriatric assessment (CGA) to those living with frailty, aiming to prevent hospitalisation and delay frailty progression. Advance care planning (ACP) is a vital component of prioritising care preferences including at end-of-life, but timing often falls short in practice. This quality improvement (QI) initiative aims to proactively open ACP discussions, allowing patients to consider their care goals, ensuring our care is aligned with their priorities.

Between July 2022 and April 2023, the project involved 1039 patients. Led by Advanced Clinical Practitioners with support from consultant geriatricians and a palliative care specialist nurse, ACP discussions were encouraged through prompts in daily staff huddles and drop-in teaching sessions. ACP uptake increased from 7.8 % to 19.3%. Insights from a perception survey involving 83 healthcare professionals revealed key barriers including clinical workload, limited space, lack of experience and confidence as well as prognostic uncertainty and patient factors. Education and training, clinical supervision, patient information leaflets and a conducive environment were positively associated with ACP.

There has been a cultural shift in the department as the practitioners now routinely prompt staff to undertake ACP in safety huddles. Key catalysts for ACP initiation were found to be progression of frailty, terminal diagnoses, dementia, and recurrent hospital admissions. As a new SDEC unit is scheduled to open in the coming months, with provision of space and privacy, our aim is to improve the quality and quantity of ACP discussions with the patient at the centre of all decision-making. In line with these endeavours, parallel support within the community through our home (virtual) ward will further enhance proactive care planning in older people living with frailty.

Introduction:

Frailty is the concept of increasing vulnerability to minor stressors in the context of a reduction in physiological reserves (Clegg et Al. The Lancet 2013, Volume 381, pages 752-762). It affects 10% of people presenting to Emergency departments (ED) and around 30% of inpatients in acute medical units (NHS England and NHS Improvements. 2019). Implementing a CGA is known to result in a significant increase in your likelihood of being alive and in your own home at 6 months (Ellis et Al. BMJ 2013).
 

Aims:

To implement an ED in reach frailty service with the goal of performing a CGA at the earliest opportunity.
 

Methods:

We undertook a 3 week pilot with a small team comprising a consultant, frailty ACP, SHO and geriatric registrar. The team were based in ED and worked alongside the existing ED navigator team and in conjunction with various community teams. Data was collected assessing completion of the usual domains within the CGA and discharge data.

Results:

62 patients were seen in total. Mean age was 82.4 years with a mean CFS of 5. Each patient received a CGA. 9/62 (15%) of patients were discharged on the same day. 15/53 (28%) were discharged within 72 hours of admission. Other notable results include: 100% completion of 4AT and 70 medications de-prescribed. Feedback from patient and relatives in addition to ED and AMU doctors was extremely positive.
 

Conclusion:

We demonstrated that performing a CGA in ED resulted in higher numbers of patients being discharged on the same day or within 72 hours of admission. We were able to demonstrate a significant increase in assessment of delirium allowing earlier detection and a much higher rate of deprescribing with significant benefits for both patient and the trust.

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. The previous work highlighting drivers, but not the experiences that explain why they occur, leads this study 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 emergency clinicians from one English ambulance service in May 2023. Open questions generated qualitative data for thematic analysis³. Ethical and regulatory approvals, and informed consent, were obtained.

Findings: 81 participants completed the survey. Analysis identified three themes.

• Care Provision: Provision of hospital avoidance pathways varies throughout the region. Concerns arose from not knowing what different areas had and reduced accessibility out of hours.
• Communication: Decision-making confidence was impacted by the participants’ experiences of interactions with hospital and community colleagues; positive experiences encouraged use of hospital avoidance pathways, whilst negative experiences impeded willingness to avoid hospital for fear of repercussion.
• 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.

Conclusion: Confidence of frontline ambulance staff was impacted by the challenge of a regional and 24/7 ambulance service not having consistent pathways available. Communication with other services impacts ambulance clinician’s future decision-making and confidence. 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. (2022) Thematic Analysis: A practical guide.

Introduction:

 It is recognised that there are pressures on the NHS particularly the emergency services.  Therefore, a focus of the 21/22 Priorities and Operational Guidance was to develop community services to prevent emergency department (ED) attendance and avoidable hospital admissions.  This informed the funding of urgent community response services (UCR).  An urgent response is defined as a presentation that would likely result in hospital admission if a response were not made within 2 hours.  Quality Improvement methodology was applied to evaluate the potential impact an advance clinical practitioner (ACP) could have in providing alternatives to hospital conveyance by redirecting appropriate calls to the UCR. 

Method:

Small scale tests of change with iterations of Plan Do Study Act cycles were conducted to enable comparison and recommendation for the use of the funding.  PDSA 1.  ACP based in an ambulance station. PDSA 2 and 4 ACP based in 2 different hospital EDs at the point of triage.  PDSA 3.  ACP based in the clinical hub where 111 calls are triaged.  

Results:

These PDSA cycles enabled process mapping of the patient journey to be made and a gap analysis showed the possible interventions an ACP to make to prevent an inappropriate admission.  It was apparent that a call stack pull model where the ACP can directly respond to calls from the ambulance list, and often redirect to the UCR service, was the most effective method.  Cross organisational information governance issues were found to be a barrier to implementation.

Conclusion:

Small-scale tests of change were implemented to seek the most effective use of an ACP to support alternatives to hospital admission. To introduce this pathway, a whole systems approach is needed to collaboratively provide a seamless service and an overall better experience for all.

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.  

Background

Time critical intervention delays contribute to increased waiting times, length of stay, worsening morbidity, and mortality for the already frail patient. Evidence suggests some clinicians decide to admit whenever test results are not yet available; mistakenly believing this decreases patient risk. Within one day, this project reduced waiting times for decision makers by upgrading the blood sample processing priority so results are available sooner.

Method

Our Quality Improvement (QI) team leader spent one shift observing practices in the Emergency Department, noting ED blood samples are processed as ‘urgent’. The QI team leader discussed with the laboratory manager if capacity existed to process the frailty unit’s bloods as ‘urgent’ rather than ‘routine’. This had zero impact on laboratory resources due to limited numbers attending the frailty service daily; they supplied different colour coded blood sample bags: purple. This immediately visually indicates to staff the sample is ‘urgent’. (Previous bags: red - haematology, yellow - biochemistry, green - microbiology). A start date was arranged for the following day. Red, yellow and green bags were removed from the frailty services’ unit and replaced with purple. Staff were informed the change would start that morning.

Results

Our main outcome measure was average waiting time for a decision to admit or alternative pathway. From day one, staff achieved 100% compliance with ‘urgent’ sampling and waiting times for a decision reduced by up to 80% (from up to eight hours to less than one hour).

Conclusion

QI identified a reason for delayed decision making contributing to increased waiting times for frail patients. This sustainable change reduced risk and improved quality of care.

Introduction:

The benefits of early frailty scoring for patients over 65 presenting to emergency settings are well established. A scoping exercise in the Emergency Department (ED) at the University Hospital of Wales (UHW) identified lack of familiarity with the Clinical Frailty Scale (CFS) and time pressures as barriers to achieving frailty screening at triage. In response, the Frailty Intervention Team (FIT) at UHW developed the Self-Assessment of Frailty in the Emergency Settings Tool (SAFE-T).

Methods:

A PDSA cycle was performed to assess SAFE-T validity and the feasibility of implementation in ED and in a community intermediate care clinic. A 5-day pilot was conducted in April 2023 where all patients >65 years were asked to complete and return a SAFE-T. In parallel, blinded to the result of the SAFE-T, the FIT team completed a CFS score and the results were compared. Process feedback was collected from the FIT team, ED staff and hospital volunteers to identify implementation barriers.

Results:

Data were analysed from 58 questionnaires (50 from ED, 8 from Community Clinic). 42 participants completed SAFE-T alone, 16 completed it with support (e.g. family advocate/hospital volunteer). 7 were excluded from final analysis due to insufficient data to enable comparison. Initial results indicate that the SAFE-T is a sensitive screening tool for frailty and that sensitivity maybe improved where the patient is supported by a collateral informant. Process feedback identified problems with SAFE-T layout, resource implications and the perceived labour intensiveness of the tool.

Conclusions:

SAFE-T is a sensitive tool for the identification of frailty in different clinical settings. Process feedback suggests that further development of the tool will improve ease of use for patients and healthcare professionals. A further PDSA cycle is now underway to assess how the tool may assist in improving compliance with frailty scoring in ED

Aim: Several patient selection scores have been developed to identify patients suitable for ambulatory care from triage in the Emergency Department (ED) and from the acute medical intake. These scores are designed to improve system efficiency, overcrowding and patient experience. Studies have been conducted that compare the ability of several scoring systems; none specifically in frail older adults (1-4). This study compared the Glasgow Admission Prediction Score (GAPS), Sydney Triage to Admission Risk Tool (START) and the Ambulatory Score (Ambs). Methods: The Older Person’s Assessment service is ED based, accepting patients on the basis of the presence of frailty syndromes in patients aged >70 years. The service achieves same day discharge for >75% of patients. The service databank was retrospectively analysed for people assessed between January-December 2021. Interactions between clinical outcomes with age, Charlson Co-morbidity index (CCI) and Clinical Frailty Score (CFS) were evaluated alongside a comparison of each ambulatory score. Emergency department documentation was used to gain triage data. Results: 502 attendances were analysed of which 112 (22.3%) were admissions, 374 (74.5%) presented with falls. 185 (37.2%) were male, mean age 82.8 years, CFS 5.1 and CCI 6.6. There was a significant link between those admitted and those discharged when comparing CFS (p<.001). ambs: sensitivity 0.42, specificity 0.75, positive predictive value (ppv) 0.80, negative (npv) 0.23, area under curve (auc) 0.70. gaps: 0.15, 0.87, ppv npv auc 0.62. start: 0.09, 0.97, 0.92, 0.64. conclusion: frailty is an important determinant in identifying whether ambulatory care appropriate. however, was low for all scores and none could be reliably used as a screen suitable patients same day emergency services although the ambs score most accurate our population.