nhsManagers.net

Dr Jay BanerjeeConsultant in Emergency Medicine

University Hospitals of Leicester

Older people: urgent/emergency care

• Over the next 20 years, the number of people aged 85 and over in the UK is set to increase by two-thirds, compared with a 10 per cent growth in the overall population.

• ≥60 years account for 23% of attendances to the EDs and compared to the 21-59 age group, are more likely to arrive by ambulance, have more investigations done and despite similar booking in and assessment times, spend a longer time in the ED.

• The admission rates for the over 60s is also higher compared to the 21-59 years age group and they account for 43% of all admissions to hospitals in England and Wales.

Hospital bed use

Annual costs: in £000’s/person with disease (UK, 2010) – burden of disease

NHS must close the gap between the promise of care and compassion outlined in its Constitution and the injustice that many older people experience (Health Service Ombudsman, 2011)

35% of inspected hospitals needed to improve, 25% did not meet 1 or 2 standards (Care Quality Commission, 2011)

patients’ privacy not being respected – for example, curtains and screens not being closed properly (CQC)

staff speaking to patients in a dismissive or disrespectful way (CQC)

how often should a patient be told that “because of being unable to use the toilet… she should wet the bed”? Is that OK as long as it is only 10 times a month or 20? (Patient Association, UK, 2011)

Francis report (February 2013) Berwick report (August 2013)

National reports NHS

Negative outcomes in hospital including HAI, falls, delirium, pressure ulcers, diagnostic errors, missed diagnosis, adverse drug reactions, death

Negative outcomes post discharge including high readmission rates, functional decline, death, institutionalisation

Reports of poor care, invasion of privacy and dignity, lack of compassionate care

Hospital outcomes

While a substantial research literature describes general patterns of ED use, there is much less research on ED use as a function of other health service use. Gaps in the research literature result in a limited understanding of the full scope of the issue and opportunities for practice and policy intervention

(Gruneir et al. Emergency Department Use by Older Adults: A Literature Review on Trends, Appropriateness, and Consequences of Unmet Health Care Needs . Med Care Res Rev April 2011 68: 131-155, first published on September 9, 2010)

Increasing attendance to ED?

Describes the issues relating to older people accessing urgent care in the first 24 hours irrespective of provider

Describes the competencies required to respond

Recommends urgent care standards for older people - first 24 hrs of an acute care episode

Purpose of Silver Book

Age UK Assoc. of Directors of Adult SS British Geriatrics Society Chartered Society of Physiotherapy College of Emergency Medicine College of Occupational Therapists Community Hospitals Association Emergency Nurse Consultants Assoc. National Ambulance Service Med. Dir. Society for Acute Medicine Royal College of General Practitioners Royal College of Nursing Royal College of Physicians Royal College of Psychiatrists

Membership

This document is a best practice guideline, comprising recommendations based on a review of the literature and refers to evidence where available

It does not describe the commissioning and mode of delivery of the competencies, as these will vary according to local needs, resources and policies

The older person’s care needs may be delivered in the emergency room, the acute medical unit or a community setting depending on local service configuration.

Silver Book: “Is” and “Isn’t”

Respect for the autonomy and dignity of the older person must underpin our approach and practice at all times.

A whole systems approach with integrated health and social care services strategically aligned within a joint regulatory and governance framework, delivered by interdisciplinary working with a patient centred approach provides the only means to achieve the best outcomes for frail older people with medical crises

Underpinning principles

General Practice & GP OOH

Community Support

999 ED AMU

- Focus on Long Term Conditions (heart failure/frailty/dementia/ COPD)- More effective responses to urgent care needs- Advance care planning/end of Life care plans - Targeted input into Care Homes-Access to integrated services through NHS Pathways (3DN) including health & social care

Clear operational performance framework integrated with GP processesReady access to specialist advice when needed

Improved integration with 1° & 2° responders via NHS Pathways

Front load senior decision process including primary care, ED Consultants& Geriatricians

Inpatient wards

Optimise emergency care:- Evidence based management- Multidisciplinary input from PT / OT & community matrons- Access to intermediate and social care- Front line geriatrician input- Effective information sharing with primary care/ secondary care/ community - Develop minimum data set

- Redesign to decrease LOS with social & multidisciplinary input using a “pull” system - Effective Date of Discharge- Ambulatory care (macro level) for falls/LTC

Objective: A left shift of activity across the system as a function of time; yesterday’s urgent cases are today’s acute cases and tomorrow’s chronic cases.

Proportion of urgent care encounters in primary care leading to a hospital attendance and separately hospital admission in people aged 65+/75+/85+

ED attendance and re-attendance rate per 1000 population of 65+/75+/85+

Emergency department conversion rate for people aged 65+/75+/85+ per 1000 population

Hospital readmission rates for people aged 65+/75+/85+ and ED re-attendance rate for same group

Rates of long term care use at 90 days post-discharge following ED attendance and discharge from hospital for people aged 65+/75+/85+

Mortality rate per 1000 in the 65+/75+ and 85+ Patient and carer satisfaction survey Staff satisfaction survey

Whole system metrics

Comprehensive assessment

There must be an initial primary care response to an urgent request for help from an older person within 30 minutes

The presence of one or more frailty syndrome should trigger a more detailed comprehensive geriatric assessment, to start within 2 hours (14 hours overnight) either in the community, patient’s own home or as an in-patient, according to the patient’s needs

Standards – eg.

Generic – across all settings in first 24 hrs; including discharge planning

Specific – include - Primary care- Community hospitals- ED/UC/AMU- Mental health- Safeguarding- Major incident planning- Commissioning- Training and development for all staff groups

Recommendations

Communication including listening skillsCompassion, empathy and respectClinical reasoning and assessment skillsTime/patience and the ability to build a rapportAwareness of community servicesRisk assessment surrounding discharge planningMultidisciplinary team working skillsPersonal care training skillsMoving and handling skillsBasic life support skillsAbility to balance contrasting needs of a complex

person

Staff competencies - generic

Delivery

Assessment of needs - individual/populationDevelop system-wide competencies - to

deliver CGATailor services locally - resources, cost,

availabilityConsider workforce implicationsFoster multi-disciplinary collaborative at

micro, meso- and macro- level

Some practice points

Moving on….

• “Acting our way into a different way of thinking”……the Silver Book can serve as a useful guide