Emergency care

Same Day Emergency Care (SDEC) at St James’ Hospital, Leeds provides urgent care at the interface between primary and secondary care, offering comprehensive geriatric assessment (CGA) to those living with frailty, aiming to prevent hospitalisation and delay frailty progression. Advance care planning (ACP) is a vital component of prioritising care preferences including at end-of-life, but timing often falls short in practice. This quality improvement (QI) initiative aims to proactively open ACP discussions, allowing patients to consider their care goals, ensuring our care is aligned with their priorities.

Between July 2022 and April 2023, the project involved 1039 patients. Led by Advanced Clinical Practitioners with support from consultant geriatricians and a palliative care specialist nurse, ACP discussions were encouraged through prompts in daily staff huddles and drop-in teaching sessions. ACP uptake increased from 7.8 % to 19.3%. Insights from a perception survey involving 83 healthcare professionals revealed key barriers including clinical workload, limited space, lack of experience and confidence as well as prognostic uncertainty and patient factors. Education and training, clinical supervision, patient information leaflets and a conducive environment were positively associated with ACP.

There has been a cultural shift in the department as the practitioners now routinely prompt staff to undertake ACP in safety huddles. Key catalysts for ACP initiation were found to be progression of frailty, terminal diagnoses, dementia, and recurrent hospital admissions. As a new SDEC unit is scheduled to open in the coming months, with provision of space and privacy, our aim is to improve the quality and quantity of ACP discussions with the patient at the centre of all decision-making. In line with these endeavours, parallel support within the community through our home (virtual) ward will further enhance proactive care planning in older people living with frailty.

Introduction:

Frailty is the concept of increasing vulnerability to minor stressors in the context of a reduction in physiological reserves (Clegg et Al. The Lancet 2013, Volume 381, pages 752-762). It affects 10% of people presenting to Emergency departments (ED) and around 30% of inpatients in acute medical units (NHS England and NHS Improvements. 2019). Implementing a CGA is known to result in a significant increase in your likelihood of being alive and in your own home at 6 months (Ellis et Al. BMJ 2013).
 

Aims:

To implement an ED in reach frailty service with the goal of performing a CGA at the earliest opportunity.
 

Methods:

We undertook a 3 week pilot with a small team comprising a consultant, frailty ACP, SHO and geriatric registrar. The team were based in ED and worked alongside the existing ED navigator team and in conjunction with various community teams. Data was collected assessing completion of the usual domains within the CGA and discharge data.

Results:

62 patients were seen in total. Mean age was 82.4 years with a mean CFS of 5. Each patient received a CGA. 9/62 (15%) of patients were discharged on the same day. 15/53 (28%) were discharged within 72 hours of admission. Other notable results include: 100% completion of 4AT and 70 medications de-prescribed. Feedback from patient and relatives in addition to ED and AMU doctors was extremely positive.
 

Conclusion:

We demonstrated that performing a CGA in ED resulted in higher numbers of patients being discharged on the same day or within 72 hours of admission. We were able to demonstrate a significant increase in assessment of delirium allowing earlier detection and a much higher rate of deprescribing with significant benefits for both patient and the trust.

Introduction: Around 10% of calls received by English ambulance services are for older adults who have fallen¹; with an ageing population there are significant care provision needs. Decision-making on the treatment for people who fall, can impact their future physical and mental health. Previous research in decision-making of ambulance staff found perception of role, confidence, service demands and training to be key drivers². The previous work highlighting drivers, but not the experiences that explain why they occur, leads this study aim to determine the experiences and confidence of frontline emergency clinicians in attending older adults who have fallen.

Method: Online cross-sectional survey of frontline emergency clinicians from one English ambulance service in May 2023. Open questions generated qualitative data for thematic analysis³. Ethical and regulatory approvals, and informed consent, were obtained.

Findings: 81 participants completed the survey. Analysis identified three themes.

• Care Provision: Provision of hospital avoidance pathways varies throughout the region. Concerns arose from not knowing what different areas had and reduced accessibility out of hours.
• Communication: Decision-making confidence was impacted by the participants’ experiences of interactions with hospital and community colleagues; positive experiences encouraged use of hospital avoidance pathways, whilst negative experiences impeded willingness to avoid hospital for fear of repercussion.
• Shared Decision-Making: Patients, family and clinicians were all valued as part of shared decision-making, with past feedback on decision-making informing future practice.

Conclusion: Confidence of frontline ambulance staff was impacted by the challenge of a regional and 24/7 ambulance service not having consistent pathways available. Communication with other services impacts ambulance clinician’s future decision-making and confidence. This variation led to concerns when responding to patients outside of the clinician’s usual area, and further challenges ambulance clinicians must balance in their practice.

References:

1. Snooks, Anthony, Chatters, et al. (2017) Health Technology Assessment, 21; 1-218.

2. Simpson, Thomas, Bendall, et al. (2017) BMC Health Services Research. 17; 299.

3. Braun and Clarke. (2022) Thematic Analysis: A practical guide.

Aim:  Several patient selection scores have been developed to identify patients suitable for SDEC from triage in Emergency Departments (ED) and the acute medical intake. Scores are designed to improve system efficiency, overcrowding and patient experience.  Studies have been conducted that compare these; none in frail older adults. This study compared the Glasgow Admission Prediction Score (GAPS), Sydney Triage to Admission Risk Tool (START) and the Ambulatory Score (Amb). 

Methods: The Older Person’s Assessment service (OPAS) is ED based, accepting patients with frailty syndromes aged >70 years with same-day discharge for >75% of patients. The OPAS databank was retrospectively analysed and interactions with age, Charlson Co-morbidity index (CCI) and Clinical Frailty Score (CFS) were evaluated alongside each ambulatory score. ED documentation was used to gain triage data.   

Results: 748 attendances, 274(36.6%) Male with mean age 82.8(±8.5) years, CFS 5.2(±1.4) and CCI 6.7(±2.6) with 584(78.1%) discharged same day.  Mean Amb 4.2(±1.7), GAPS 21.4(±5.8), START 23.5(±4.7) scores all within admission range with 29.1% Mortality within 12 months. There was a significant difference between those admitted and discharged with CFS (p<0.001) and mortality (p<0.001).

Conclusion:  Frailty is an important determinant in identifying whether ambulatory care is appropriate. No score could be reliably used as a screen for suitable patients for SDEC services although the Amb score was the most accurate when assessing each individual variable. We are developing our own SDEC score for older, frailer adults which is currently being validated in the OPAS and SDEC settings. 

Background

Time critical intervention delays contribute to increased waiting times, length of stay, worsening morbidity, and mortality for the already frail patient. Evidence suggests some clinicians decide to admit whenever test results are not yet available; mistakenly believing this decreases patient risk. Within one day, this project reduced waiting times for decision makers by upgrading the blood sample processing priority so results are available sooner.

Method

Our Quality Improvement (QI) team leader spent one shift observing practices in the Emergency Department, noting ED blood samples are processed as ‘urgent’. The QI team leader discussed with the laboratory manager if capacity existed to process the frailty unit’s bloods as ‘urgent’ rather than ‘routine’. This had zero impact on laboratory resources due to limited numbers attending the frailty service daily; they supplied different colour coded blood sample bags: purple. This immediately visually indicates to staff the sample is ‘urgent’. (Previous bags: red - haematology, yellow - biochemistry, green - microbiology). A start date was arranged for the following day. Red, yellow and green bags were removed from the frailty services’ unit and replaced with purple. Staff were informed the change would start that morning.

Results

Our main outcome measure was average waiting time for a decision to admit or alternative pathway. From day one, staff achieved 100% compliance with ‘urgent’ sampling and waiting times for a decision reduced by up to 80% (from up to eight hours to less than one hour).

Conclusion

QI identified a reason for delayed decision making contributing to increased waiting times for frail patients. This sustainable change reduced risk and improved quality of care.

Introduction:

The benefits of early frailty scoring for patients over 65 presenting to emergency settings are well established. A scoping exercise in the Emergency Department (ED) at the University Hospital of Wales (UHW) identified lack of familiarity with the Clinical Frailty Scale (CFS) and time pressures as barriers to achieving frailty screening at triage. In response, the Frailty Intervention Team (FIT) at UHW developed the Self-Assessment of Frailty in the Emergency Settings Tool (SAFE-T).

Methods:

A PDSA cycle was performed to assess SAFE-T validity and the feasibility of implementation in ED and in a community intermediate care clinic. A 5-day pilot was conducted in April 2023 where all patients >65 years were asked to complete and return a SAFE-T. In parallel, blinded to the result of the SAFE-T, the FIT team completed a CFS score and the results were compared. Process feedback was collected from the FIT team, ED staff and hospital volunteers to identify implementation barriers.

Results:

Data were analysed from 58 questionnaires (50 from ED, 8 from Community Clinic). 42 participants completed SAFE-T alone, 16 completed it with support (e.g. family advocate/hospital volunteer). 7 were excluded from final analysis due to insufficient data to enable comparison. Initial results indicate that the SAFE-T is a sensitive screening tool for frailty and that sensitivity maybe improved where the patient is supported by a collateral informant. Process feedback identified problems with SAFE-T layout, resource implications and the perceived labour intensiveness of the tool.

Conclusions:

SAFE-T is a sensitive tool for the identification of frailty in different clinical settings. Process feedback suggests that further development of the tool will improve ease of use for patients and healthcare professionals. A further PDSA cycle is now underway to assess how the tool may assist in improving compliance with frailty scoring in ED

Aim: Several patient selection scores have been developed to identify patients suitable for ambulatory care from triage in the Emergency Department (ED) and from the acute medical intake. These scores are designed to improve system efficiency, overcrowding and patient experience. Studies have been conducted that compare the ability of several scoring systems; none specifically in frail older adults (1-4). This study compared the Glasgow Admission Prediction Score (GAPS), Sydney Triage to Admission Risk Tool (START) and the Ambulatory Score (Ambs). Methods: The Older Person’s Assessment service is ED based, accepting patients on the basis of the presence of frailty syndromes in patients aged >70 years. The service achieves same day discharge for >75% of patients. The service databank was retrospectively analysed for people assessed between January-December 2021. Interactions between clinical outcomes with age, Charlson Co-morbidity index (CCI) and Clinical Frailty Score (CFS) were evaluated alongside a comparison of each ambulatory score. Emergency department documentation was used to gain triage data. Results: 502 attendances were analysed of which 112 (22.3%) were admissions, 374 (74.5%) presented with falls. 185 (37.2%) were male, mean age 82.8 years, CFS 5.1 and CCI 6.6. There was a significant link between those admitted and those discharged when comparing CFS (p<.001). ambs: sensitivity 0.42, specificity 0.75, positive predictive value (ppv) 0.80, negative (npv) 0.23, area under curve (auc) 0.70. gaps: 0.15, 0.87, ppv npv auc 0.62. start: 0.09, 0.97, 0.92, 0.64. conclusion: frailty is an important determinant in identifying whether ambulatory care appropriate. however, was low for all scores and none could be reliably used as a screen suitable patients same day emergency services although the ambs score most accurate our population.

Background

Up to 17.5% of admissions for older adults with frailty may be Preventable Emergency Admissions (PEAs). PEAs are costly and expose patients to complications including deconditioning, delirium, malnutrition and nosocomial infections. Royal Derby Hospital (RDH) has 1159 beds and cares for a population of around one million. The Frailty Emergency Assessment Team (FEAT) operates within the Emergency Department (ED) and Medical Assessment Unit. FEAT is multi-disciplinary, comprising nurses, physiotherapists and occupational therapists.

Aim

To reduce the number of PEAs for older adults presenting to RDH.

Design

We integrated a Geriatrician into FEAT with the aim of reducing PEAs through early medical reviews. Suitable patients were identified through referral from ED and routine screening of the patient information system. To support consistent medical reviews and automate data collection we created an e-form embedded within the Electronic Patient Record. This captured details and outcome of medical reviews including Clinical Frailty Score (CFS), problem list, medication review and ‘Medically Stable for Discharge’ (MSFD) status.

Results

Between 7th February 2022 and 20th February 2022 68 medical reviews were collected on the e-form. 72% were assessed first by an ED clinician. 81% had a CFS of 5-7 and 7% had a CFS of 8. The most common presenting complaint was ‘fall(s)’ (25%) followed by ‘clouded consciousness’ (13%). 66% of FEAT physician reviews resulted in planned discharge from ED, 13% of which avoided an admission planned by ED. Of 68 patients reviewed 42 (62%) were MSFD. Of these 29 (69%) were discharged home, 11 (26%) were admitted to a ward to await interim beds or new care package, one (2%) patient was discharged to a care home and one (2%) to another health care facility.

Conclusion

Our intervention reduced PEAs for older adults presenting to RDH. The e-form automated data collection successfully.

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.