Our research journey began with an appraisal of the evidence for comprehensive geriatric assessment (CGA) for frail older people assessed and discharged from acute medical settings (defined as the first 72 hours of an urgent care episode). In parallel to the research journey, a range of service developments with accompanying evaluations were being undertaken, aimed at improving urgent care of frail older people.
In the first instance a ‘mini’ acute frailty unit (AFU) was developed, using a series of plan, do, study, act (PDSA) cycles to try and determine the optimal structures and processes for an embedded service delivering CGA for frail older people in an acute medical unit. This service started in 2008 and early evaluation found the following:
• The initiative was successful in highlighting the importance of frailty and establishing relationships and frailty pathways with the Emergency Department.
• There was reassurance that length of stay on the AMU did not increase following the AFU being established, as this had been a concern (only 6/91 (7%) of patients for more than 48 hours).
• Benchmarking data were used to indicate sub-optimal performance in comparison to a similar hospital in the region (eg 30-day readmission 18% vs. 10% elsewhere).
• The main barriers include ensuring appropriate bed occupancy, recording admission, readmission and mortality outcomes, a relative paucity of geriatric input, the absence of a dedicated therapy team, the absence of robust links with community services and the absence of a clinical strategic voice for the unit.
Following the initial work on an AFU, a more robust liaison service was developed, supported by additional resources. This involved geriatricians working closely with therapists supporting the acute medical team in the care of frail older people. The primary aim of this service was to focus on ambulatory care (ie those patients that could be safely discharged), rather than the totality of urgent care for frail older people. There was a significant emphasis on the service being as much educational as it was about service delivery, with the explicit aim of enhancing the assessment of frailty amongst all staff. With that in mind, the geriatricians (‘experts’) fed-back on management to their colleagues, rather than simply providing a ‘take-away’ service. However, a number of tensions emerged and it was not clear whether the service was successful as an educational intervention as there was significant pressure on the liaison service to take on the care of frail older people.
This led to the next stage of development – a larger dedicated service for the care of frail older people. The Emergency Frailty Unit profiting from the relationships already established with the emergency department team and a broader trust change from a three-site acute medical take to a two-site medical take, it was possible to establish a dedicated service for frail older people in the emergency department. The core components were:
• robust pathways directing the care of frail older people throughout the 24-hour period
• dedicated area for assessment ‘off the clock’
• dedicated team – geriatricians, nurses, ‘primary care coordinators’, therapists including strong collaboration with emergency physicians
• liaison providing education, training and direct clinical support for the care of frail older people throughout the emergency department
• robust pathways out of hospital formed on mutual trust with community provider and social care.
A wide range of additional service developments took place, including the development of a larger AFU (for acute care more than ambulatory care – the primary function of the EFU), as well as the Emergency Frailty Unit, changes to the community hospital model of care (involving advance nurse practitioners supported by geriatricians replacing hospital practitioners to deliver CGA, the introduction of an in-patient psychiatric liaison service for older people, and improvement in the acute medical service more generally – meaning that none of the findings above can be considered generalisable, but indicate local acceptance of the concept of delivering CGA to frail older people to provide sustainability for the services. However, the ideas, backed up by a strong understanding of the evidence base, helped inform the policy context.
These efforts and others – notably work from Sheffield and the British Geriatrics Society – led to the commissioning of the Acute Frailty Network by NHS England, to disseminate good practice in urgent care more broadly (see: http://www.acutefrailtynetwork.org.uk/).
Reflections from the urgent care journey
The combination of evidence-based medicine that defined the principles and service development that addressed the practicalities resulted in at least some policy influence that appears to have gained traction (the benefits of co-production are the lesson learnt here). Whether this has improved care for older people with urgent care needs is uncertain, but an area for future enquiry!
Dr Simon Conroy – Consultant geriatrician, University Hospitals of Leicester NHS Trust @GERED_DOC