12 actions to help manage winter pressures
As winter approaches, BGS members across the country will be considering the impact that the change in seasons will have on their patients and services. Winter is traditionally a tough time in the NHS and we know that the overarching issues that continue to place pressure on our health and care services are not going to be solved before the cold weather hits. Indeed, for many BGS members the pressures are no longer seasonal. Older people use health and social care services the most, but our workforce and services remain under-prepared to meet their needs.
The 12 actions that follow are intended as a guide to focus our minds on the possible. We hope to encourage our non-specialist colleagues to join us as allies in providing the best care possible for this population in very challenging circumstances.
Across all settings
Encourage everyone in your service to equip themselves with the skills they need to care for older people with frailty, including generalist staff and those delivering other specialist services.
The BGS frailty e-learning module provides free training at Tier 3 level. Download a poster to display in a prominent area of your hospital or office to promote this to colleagues.
Frailty training for Tiers 1, 2a and 2b is available from NHS England’s elearning for Healthcare.
Optimising community care
Implement proactive care plans and advance care plans (known as anticipatory care plans in Scotland) in primary and community settings, especially care homes, to consider future health needs including end of life care. Those based in the acute setting may be able to do this as part of the discharge process.
Proactive care plans, centred around individuals' specific wishes for the future and preferred place of care, including advance care planning, can improve the use of available services. Care plans, once developed, must be shared with relevant family members and added to healthcare records to ensure that they are followed when necessary. Those updating healthcare records may also wish to ensure that next of kin details are recorded, especially for older people living on their own in the community.
Continuity of care in primary and community settings can also help to avoid admissions. For some patients who do need hospital treatment, attending hospital earlier in the day may mean that they can be treated by a Same Day Emergency Care (SDEC) service and avoid being admitted to hospital.
Resources available to support planning conversations include:
Encourage all people aged 65 and over, and all care home residents, to receive vaccinations against Flu and Covid-19.
In addition, people aged 75-79 will be offered a vaccine for RSV for the first time this year. Increasing vaccination uptake is considered to be a high priority to protect people from serious illness and support the NHS and adult social care.
Those working in the community can encourage patients to get the vaccinations that they are eligible for and share information with any patients who may be unsure. Those working in acute setting may have access to inpatient vaccination services which allow patients admitted to hospital to be vaccinated while they are there. Adding vaccination status to CGA templates or clerking proformas can help staff to identify patients who are not vaccinated and ensure that they are offered vaccinations. Health and social care staff should also ensure that they are vaccinated against winter illnesses, if they are eligible.
Resources available include:
Get to know your local social worker with the aim of developing better connections between health and social care.
Forging strong relationships can improve quality of care and enhance individualised person-centred care. Working collaboratively around a common goal can lead to better outcomes in mental, physical and emotional wellbeing. You might achieve this by inviting your local social worker to your next team meeting or arranging shadowing between your teams to enable staff from both sides to understand each other’s work better.
Make better use of technology available through social care to support people at home.
These might include smart devices that help people to carry out day-to-day tasks or devices to help healthcare professionals to monitor someone’s health remotely. Digital apps can be used to help people to record daily pulse oximeter and pulse rate readings which are then automatically transmitted to the hospital digital care hub with abnormal readings triggering an alert and prompting a follow-up with the patient. One example of such an app is the MyCare24 app, used by NHS Airedale: https://www.airedale-trust.nhs.uk/service/digital-care-hub/mycare24/.
Resources include:
Address polypharmacy and waste by asking patients to ‘show me your meds please.’
Community staff on routine home visits can ask to see a patient’s medications and, if they have any concerns, can contact the primary care team who can then follow up with a full review. Medication-related complications are thought to contribute to up to 30% of admissions in older people.1 Deprescribing reviews should be completed as part of routine inpatient care for older people. Medication accounts for 25% of carbon emissions in the NHS2 so reducing unnecessary prescribing throughout the patient journey not only reduces the risk of medication-associated harm but also contributes to reducing the carbon footprint of the NHS.
More information here.
Reducing hospital-associated harm
Seek to minimise use of temporary care environments (also known as ‘corridor care’) for older people – this includes ‘boarding.’
Ensure frailty scores are included in any Trust policies or Standard Operating Procedures (SOPs) around the provision of care in a temporary setting to allow better risk stratification. Ensure bed management teams understand that these environments increase the risk of delirium, falls and pressure area damage for older people with frailty and that low National Early Warning System (NEWS) scores should not provide false reassurance in this cohort. Wherever an older person is cared for, continue to advocate for the key components of quality care outlined below. Trusts should consider how these can still be provided in temporary care environments.
Identify patients with frailty as soon as they arrive at the hospital through proactive use of the Clinical Frailty Score in triage.
- BGS Front Door Frailty
- Acute Frailty Network CFS app – available free on Apple and Android.
- GIRFT Six Steps to Better Care for Older People in Acute Hospitals
- GIRFT Hospital Acute Care Frailty Pathway
Encourage older people in hospital to get up, get dressed and get moving to avoid deconditioning.
This is a real risk for older people in hospital – hospital inpatients have muscle strength reduced by up to 10% in the first seven days of admission.3 There may be voluntary groups locally who can support patients to move around safely in hospital. Welcoming carers and family members into the acute hospital setting can also help to avoid deconditioning as they can help their loved ones to get out of bed and mobilise.
Useful resources:
Recognise and treat delirium as a medical emergency and prioritise its prevention and recognition.
The incidence of inpatient delirium in older people is around 20%.4 Systems should use the 4AT Rapid Assessment Test to identify delirium on admission and the single question in delirium (SQiD) at Board Rounds. Patients or their carers should also be asked ‘what matters to you’ to help to guide treatment decisions and ensure that the patient’s needs are prioritised.
Useful resources:
Prioritise pressure area care for older people who are admitted to hospital.
The majority of pressure injuries are hospital-acquired and they are associated with increased morbidity and mortality.5 Hospital-acquired pressure ulcers increase length of stay by an average of 5-8 days per pressure ulcer. There should be clear pathways for identifying patients who need pressure mattresses, ordering mattresses and ensuring that pressure mattresses follow patients if they are moved within the hospital. Processes should be in place for routine skin checks for older people in emergency departments and to regularly turn patients who are at high risk of developing pressure ulcers.
More information on pressure care in hospitals care be found in the Silver Book II.
Consider whether older people could be treated in a Hospital At Home service as an alternative to hospital admission.
While hospital may be the best option for some older patients, it is a risky environment for many older people, especially when pressure on the system is at its highest. An older person who wants to go into hospital and can benefit from it should not be denied this option. However, most older people would prefer to avoid hospital admission if possible and evidence shows that for the appropriate patient population, hospital treatment can be provided in a home setting with comparable outcomes. Hospital At Home services are available in many parts of the country and provide a safe alternative to hospital for some patients.
Useful resources:
References
- Hohl CM, Dankoff J, Colacone A and Afilalo M, 200 ‘Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department’. Ann Emerg Med, Dec;38(6):666-71.
- NHS England, undated. Greener NHS – Areas of Focus. Available at: https://www.england.nhs.uk/greenernhs/a-net-zero-nhs/areas-of-focus/
- Arora A, 202 NHS Blog: Recondition the nation. Available at: https://www.england.nhs.uk/blog/recondition-the-nation/
- Gibb K, Seeley A, Quinn T, Siddiqi N, Shenkin S, Rockwood K and Davis D, 2020. ‘The consistent burden in published estimate of delirium occurrence in medical inpatients over four decades: a systematic review and meta-analysis study.’ Age Ageing Apr 27;49(3):352-360.
- British Geriatrics Society, 2021. Silver Book II: Quality urgent care for older people. Available at: https://www.bgs.org.uk/resources/resource-series/silver-book-ii