Avoiding hospital associated harm for older people this winter

Dr Ruth Law is BGS Deputy Honorary Secretary and a Consultant in Geriatric Medicine at Whittington Health NHS Trust. She tweets @Ruth_E_Law

As we pass the winter solstice and the days start to lengthen, it feels hard to believe we will ever leave ‘winter’ in the NHS. Back-to-back ‘crises’ for health and social care, a perfect storm of a continuing pandemic/pandemic recovery, a chronically under-funded and under-staffed health service and social care sector and a cost of living crisis mean that our patients are going to struggle even more than usual this winter. As healthcare professionals working with older people, it’s easy to feel helpless and it’s true that as individuals, we can’t do much about the above issues. However, those of us working in hospitals can help to ensure that we don’t make things worse for older people admitted to hospital this winter and it is with this in mind that I offer this blog.

The three themes of this blog will be familiar or maybe even stating the obvious to many BGS members but of course, the majority of people working in hospitals are not specialists in older people’s healthcare. So I hope what I write may be useful, to structure conversations with senior leaders in your hospital who are considering winter escalation plans or perhaps to share with colleagues in non-geriatric specialty wards who may be experiencing higher volumes of older patients over the winter.

1. Avoid unnecessary admissions

The most obvious way to avoid hospital-associated harm for older people is not to admit them to hospital in the first place. Front door teams should consider whether the patient definitely needs hospital care before admitting and consider what services are available in the community that could better support the patient. The BGS report Right Time, Right Place details some of the services that might be available to support patients that don’t need to be admitted such as Urgent Community Response (UCR) or Same Day Emergency Care (SDEC). If the patient definitely needs hospital care, it’s worth considering whether there are services in place that can provide hospital-level care at home, such as a Virtual Ward or Hospital at Home service.

2. Avoid meaningless labels

As the system becomes near-paralysed, the cohort of older people in hospital who have completed their acute episode of care continues to grow. Across the four nations, hospitals are filling up with patients who could be managed in the community. ‘Medically fit for discharge’... ‘Medically optimised (MO)’… ‘Clinically stable’…these terms have many pitfalls. A quick glance around the ‘MO’s currently under my care gives some clues why. Two patients have complex dementia with BPSD (behavioral and psychological symptoms of dementia) and require 1:1 supervision. One is receiving specialist palliative care as they await their fast track discharge to a care home. Several have precarious long-term conditions which will require specialist nursing support in the community - and that is just in bay one!  As was pointed out at the BGS autumn meeting, labelling these patients ‘fit’ detracts from the layers of complexity around their long-term health and care needs and minimises the presence of sometimes severe comorbidity. They will not be leaving hospital to return to independent living: they will be moving to ongoing healthcare support in a different environment. Our community frailty services can manage these cases, but we do everyone in the system a disservice by over-simplifying matters with outdated labels . These patients are individuals with unique needs and personalised care plans – that is the essence of geriatric care and it should not be erased by the term ‘MO’. Whilst coding may be needed at a systems level, reducing our patients to abbreviations introduces a confirmation bias to our clinical assessments that blinds us to recognising their needs, facilitates cohorting and ultimately I believe increases the likelihood of hospital-associated harms.

3. Avoid  hospital-associated harm

Of course, hospitals do save lives. Hospital admissions can’t and shouldn’t be avoided for everyone and for many of our patients, hospital is absolutely the best place for them to be. There are however practical things we, as healthcare professionals across the multidisciplinary team, can do to reduce hospital associated harm.

Skin – Pressure injuries are common in older patients coming through Emergency Departments and the majority are hospital-acquired. Pressure injuries lead to prolonged pain and discomfort, reduced quality of life, increased risk of infection and increased length of stay. They can however be prevented through simple measures such as a full-body skin check upon admission, moving the patient to a hospital bed from a trolley as soon as possible, and basic care in the ED such as turning high risk patients every 2-3 hours, keeping skin dry and improving nutrition and hydration. More information about reducing pressure injuries can be found in the Silver Book II.

Delirium – Patients with delirium can be easily agitated in a hospital environment and every effort should be taken to minimise interventions that can cause or exacerbate agitation. Pain should be addressed promptly and tethers such as cannulae, lines and monitoring devices should only be used when absolutely necessary. More information about delirium in an ED environment can be found in the Silver Book II and more resources about delirium can be found in the BGS Delirium Hub.

Falls – Fall-related injuries are a leading cause of mortality and morbidity worldwide and account for 17% of all ED presentations in older people. We know that people admitted to hospital are at risk of falls while in hospital, which can lead to a longer stay. All adults aged 65 and over being admitted to hospital should be assessed for falls risks and tailored education programmes to prevent falls implemented with those at high risk. More information about the prevention and management of falls can be found in the World guidelines for falls prevention and management for older adults.

Deconditioning – One of the biggest risks for older people in hospital is deconditioning – the loss of function due to long periods of immobility. Patients should be encouraged to get out of bed and get dressed each day if possible, to walk to the toilet and to eat meals sitting up in a chair. More details about preventing deconditioning in hospital can be found in this blog by BGS Vice President for Workforce, Dr Amit Arora.

Continence management – Incontinence is a major concern to older people and is frequently neglected, with many older people embarrassed by it and not likely to volunteer information. Acute and reversible causes of incontinence should be identified and healthcare professionals can work with patients and carers to establish a management plan for incontinence. More information can be found in the Silver Book II.

It’s going to be a tough winter for all of us working in older people’s healthcare and it’s going to be tougher for many of our patients. I hope this helps BGS members in having conversations with colleagues about caring for older people over the winter. Are you doing something else to support your older patients over the coming months? How do you feel about the term ‘medically optimised?’ BGS would love to hear about it. Please get in touch with our Policy Manager Sally at s [dot] greenbrook [at] bgs [dot] org [dot] uk.