Emergency 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.

Introduction: Emergency departments are increasingly seeing more older adults living with frailty. Between 5% and 10% of all those attending EDs and 30% of acute medical units are older adults living with frailty. The consequences of this on the system manifests as increased patient length of stay, poorer patient experience and clinical outcomes, such as mortality and morbidity, are measurably worse.

Aim: The Acute Frailty team aimed to move and expand its resource to provide a service to frail, older adults in both the Acute Medical Unit and the Emergency Department. This aligns with a key National objective that recommends all type 1 EDs have 70 hours access to a Acute Frailty Service. The team are a liaison service and therefore work alongside the ED and medical teams.

Method: Quality improvement methodology was applied utilising multiple PDSA cycles. An incremental increase in provision of an Acute Frailty service within the ED. A stakeholder group was set up, KPIs were set. The team worked alongside the ED team to improve early CFS scoring for over 65s and embedded the Nationally agreed same day frailty criteria of CFS/4AT, EWS and the presence of a frailty syndrome to identify appropriate patients for the service within the ED. The CGA was initiated in parallel with the ED assessment.

Results: Time between admission and CGA decreased by an average of 30 hours, Time between CGA and dc from hospital decreased by an average of 1.6 days. The Acute Frailty team activity increased in the ED and decreased in the AMU and there was no increase in re-admission rate.

Conclusion: A CGA initiated in the Emergency Department had a positive impact on length of stay and the earlier dc did not increase readmission rates.

Background 

Frailty Same Day Emergency Care (FSDEC) is a service designed to identify and manage frail older people at the hospital front door with a view to provide early Comprehensive Geriatric Assessment, implement management and where appropriate support a same day discharge home. 

Introduction 

In September 2023 the FSDEC service opened with 6 assessment spaces adjacent to A&E. This project aimed to quantify the rate of re-admission for patients seen in FSDEC and explore approaches to improve performance.  

Methods 

This QIP utilised a PDSA approach. Baseline re-admission data was collected from a 2 week period in October 2023. Notes were reviewed for all patients seen in FSDEC during this timeframe and reviewed for evidence of any 30 day emergency re-attendances. Cases were then reviewed to identify any links between the 2 attendances and any preventative measures that could have been taken. Following PDSA cycle 1 frailty nurse telephone follow up was implemented. PDSA cycle 2 was a stress test of this (limited) service during winter pressures. PDSA cycle 3 followed expansion of Community Integrated Response Hub (CIRH) and discharged patients being able to self-refer for support once discharged. 

Results 

FSDEC 7 day re-attendance reduced from 10% to 5% after introduction of frailty nurse follow up. This was not sustained over challenging winter months with variable staff availability but did recover in Summer 24. There has also been a gradual improvement in 30 day re-admission by PDSA cycle 3 following roll out of self-referral to CIRH. 

Conclusion 

Emergency re-admissions have reduced following implementation of frailty nurse telephone follow up and expansion of community services including patient access to CIRH for help following discharge from FSDEC. Addressing staffing model could allow for a more consistent follow up service. There is scope to trial this approach on geriatric ward discharges.  

Introduction:

It is very often observed in clinical practice that older patients with frailty stay in the A&E for long periods under the Therapy Assisted Discharge Service (TADS) team without an appropriate referral to the medical/Frailty team. There are many potential risks identified such as missed opportunity for early geriatrician/frailty input, incomplete clinical assessment, missed opportunity for CGA, critical medications omitted, missed VTE assessment, and delay in receiving care.

Methodology:

A retrospective study of 50 patients was conducted through EPR notes at East Kent Hospitals University NHS Foundation Trust.  We collected data from the A&E list daily for patients >75 years old with Rockwood scores 5 or more, who have been in A&E for >12 hours under TADS/A&E without referral to any specialty. We also looked for referrals to the medical/Frailty team, Comprehensive Geriatric assessment (CGA), regular medicine prescription, advanced care plan, successful discharge, and percentage of patients readmitted in 7 days. Following the first cycle, awareness was raised through meeting with the TADS team, educating front-door doctors to refer patients to the Frailty/Medical team within <12 hours who met the inclusion criteria. 

Results:

After interventions, we demonstrated an improved result compared to the initial cycle. We achieved patient referral to Medics/ Frailty from 45 to 59% within 12 hours, Comprehensive Geriatric assessment (CGA) done 15% to 45%, medications charted within 12 hours 50% to 75%, advanced care plan 45 to 64%, successful discharge 38% to 60%. Interestingly, there was a significantly reduced percentage of patients re-admitted within 7 days which is 30% to 10%.

Conclusion:

It is unsafe to admit older patients with frailty under the A&E/TADS for more than 12 hours without any referrals to the medical or Frailty team because of many potential risks. Following a limited awareness campaign, we witnessed some improvement in some of the standards. However, there are still areas of potential improvement. To attain 100% compliance with the first recommendations of this QIP, a re-audit with increased awareness and actions is planned in a few months.

Reference:

https://www.england.nhs.uk/urgent-emergency-care/same-day-emergency-care/acute-frailty/

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.

Introduction

Emergency department (ED) frailty screening is recommended in guidelines for its potential to trigger earlier and more appropriate comprehensive evaluation and intervention for the most vulnerable patients. Post-implementation studies of the Clinical Frailty Scale (CFS) typically observe around 50% concordance with screening. Little is known regarding the characteristics of those people omitted.

Methods

The Frailty in European Emergency Departments (FEED) cohort study observed prevalence of frailty, administering the CFS to consecutive attenders over twenty-four hours. Retrospective “normal day” data from two weeks prior were also collected, where sites used retrievable electronic health records. Age, sex, ethnic group, mode and time of arrival and departure, NEWS2 score, and use of resuscitation areas were recorded. CFS missingness was assessed for distribution and dependency with other variables using chi-squared tests. The frailty distributions in prospective and retrospective data were compared with the Kruskal-Wallis test.

Results

Only five of sixty-two sites collected CFS scores in retrievable electronic records. The cohorts included 368 individuals prospectively and 399 retrospectively. At these sites, 14% prospective and 55% retrospective CFS observations were missing. CFS entries were more frequently missing in people with non-white ethnic group (p=0.007) and self-presentation (p<0.001). The distributions of CFS differed significantly (p=0.009); on the retrospective day, no individuals were assigned CFS scores 1 or 9, and CFS scores 4 and 6 were over-represented.

Conclusion

Acknowledging the limited participation and use of snapshot data, these findings alert the presence of systematic, non-random missing data in routine CFS screening. Systematic missingness in frailty data has critical implications for research in geriatric emergency medicine, presenting real limitations in validity where studies seek to analyse routinely collected data to reach representative inferences. Screening practices and retrievability of data warrant further study and improvement.

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.