Emergency care

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.

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.

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.

Background: Data are limited on whether the causes of Emergency Department (ED) attendance and clinical outcomes vary by frailty status.

Methods: Using the Nationwide ED Sample, causes of attendance were stratified by Hospital Frailty Risk Score (HFRS). Logistic regression was used to determine adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) of ED and overall mortality.

Results: A total of 155,497,048 ED attendances were included, of which 125,809,960 (80.9%) had a low HFRS (<5), 27,205,257 (17.5%) had an intermediate HFRS (5-15) and 2,481,831 (1.6%) had a high HFRS (>15). The most common cause of ED attendance in the high HFRS group was infectious diseases (43.0%), followed by cardiovascular diseases (CVD) (24.0%) and respiratory diseases (10.2%). For the low HFRS group musculoskeletal disease was the most common cause (21.2%) followed by respiratory diseases (20.6%), and gastrointestinal diseases (18.5%). On adjusted analysis, high-risk patients had overall mortality (combined ED and in-hospital) across most attendance causes, compared to their low-risk counterparts (p<0.001). High HFRS patients with infectious diseases, CVD and respiratory diseases had an increased risk of overall mortality, compared to their low-risk counterparts (aOR 23.88 95% CI 23.42-24.34 for the infectious disease cohort, aOR 2.58 95% CI 2.55-2.61 for the CVD cohort and aOR 36.90 95% CI 36.18-37.62 for respiratory disease cohort).

Conclusions: Frailty is present in a significant proportion of ED attendances, with the cause varying by frailty status. Frailty is associated with decreased ED and increased overall mortality across most attendance causes.

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.

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: 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.

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.