Emergency care

Introduction

It is well recognized frailty is increasing amongst the population and can impact on outcomes for patients when admitted to hospital.  Frail older adults are more vulnerable to developing complications form continued hospital admissions. National recommendations by GIRFT indicate CFS scores ought to be documented in the Emergency Department (ED) to facilitate early recognition of frailty and stream patient to the appropriate pathway and clinician. The aim of this is to ensure the correct Clinician reviews the frailer adult in the most appropriate setting and thereby reduce risk of deterioration and patient harm.  In October 2022. Bolton NHS Trust created a dedicated frailty unit staffed by Geriatricians for older frail adults.  Therefore, a method of identifying and streaming frailer older adults is crucial to effectiveness of the unit. This was embedded into Electronic Patient Record (EPR) system.

Methods

PDSA cycles were implemented. A retrospective audit was performed prior to the implementation of the CFS documentation.

A robust education programme was introduced to all clinical staff in the Emergency Department. Online modules were also available. A second audit as part of PDSA cycle was then performed to assess the intervention.

Results

Pre-intervention and EPR documentation tool only 11% of patients had CFS score. Following the intervention, 88% of medical staff included the CFS score in their assessment prior to a Frailty team referral and review. The frailty team have observed an increase in referrals.

Conclusions

Early recognition and documentation has enabled improved streaming and review of the correct patients to the frailty unit.  This has enabled Gold Standard of Comprehensive Geriatric Assessment for frailer adults to be completed.  Further PDSA cycles to the effectiveness of the unit are ongoing. Initial data indicates with correct identification and recognition of frailty; the average length of stay has reduced.

Background

North Central London Integrated Care System has invested in a pre-hospital programme where geriatricians and emergency physicians support London Ambulance Service via a telephone ‘Silver Triage’ in their clinical decision making on whether to convey an older person living with frailty to hospital. The results of the scheme are described elsewhere.

Methods

452 cases were discussed with Silver Triage between November 2021 and January 2023. Paramedics using the service were sent a survey including a free text question on how the scheme could be improved which was analysed using thematic analysis.

Results

We received 103 comments on how we could improve which fell into three key themes each with subsequent subthemes:

1. Improving access to the service – this included expanding into a 24-hour service, accessible in other areas of London, available to emergency medicine technicians and for people not living in care or nursing homes.

2. Improving information about the service – this included education for paramedics on who to refer but also increasing awareness of the scheme in local emergency departments.

3. Improving delivery of the service – this included requests for video conferencing, reported technology issues and frustrations with pathway breakdown following triage. For example if the agreed plan was not to convey and to support through rapid response or district nurse services, lack of availability led to conveyance to hospital contrary to outcome of triage.

Conclusion

Whilst the Silver Triage scheme has been well received by paramedics there are clear areas for improvement to ensure sustainable and equitable pre-hospital care for older people living with frailty.

Introduction:

The Trauma Audit and Research Network report “Major Trauma in Older People” highlighted the need to recognise falls in older patients as a mechanism leading to potentially life-threatening injuries. Reasons behind falls can be equally serious and must be addressed concurrently. A Frail Trauma Pathway was introduced in the Emergency Department (ED) of a Major Trauma Centre (MTC) and subsequent audit revealed it was underutilised. We relaunched the Frail Trauma Pathway incorporating a checklist with the aim of improving patient care.

Method:

Retrospective data was collected over one week, including patients over 65 years with a Clinical Frailty Score ≥5, a low velocity trauma and multiple injuries or isolated head injury. We then updated the Frail Trauma Pathway incorporating a checklist, re-distributed it throughout the ED, sent staff email reminders and held teaching sessions. An educational “Advent Calendar” was circulated daily in December. Following this we repeated data collection.

Results:

20 patients pre and 18 post-intervention fitted inclusion criteria. There was a reduction in admission rates, improvement in ED senior doctor review for primary survey, increase in timely administration of Parkinson’s disease medication and venous thromboembolism assessment. However, there was a decline in other parameters measured. Due to the small patient cohort, it is difficult to assess if changes in results post-intervention are statistically significant.

Conclusion:

Several aspects of the frailty pathway showed improvement, notably admission reduction. This QIP demonstrates the difficulties of instigating change in an MTC, where numerous pathways result in ‘information overload’ and staff numbers are large and constantly changing. By focusing on the frail trauma checklist and incorporating it into our electronic records system we hope to improve compliance with the pathway. Further research on a national level is required to determine how to best care for this expanding cohort of patients.