It has been known both locally and nationally that frail elderly patients are inappropriately
admitted to acute hospitals, that such facilities are likely not to offer optimal care and that
outcomes can often be adverse. This cohort often has significant co-morbidities and
requires complex co-ordination of local out of hospital health & care services when well. It
has always been assumed that significant illness precipitated an emergency medical
response but analysis of local data (reported later) would suggest that often the initial
contact can be for a minor event (such as a recurrent fall with no injury) but that the
unscheduled care delivered often leads to prolonged hospitalisation-with good evidence for
potential harm including:-
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Loss of social networks
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Loss of muscle mass and subsequent mobility
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Loss of independence
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Generally reduced ability to cope with activities of daily life
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Increased confusion (and deterioration) if suffering with Dementia
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Inappropriate investigations
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Hospital Acquired Infection
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Premature admission to long term care
Significant work has been undertaken within the acute hospital locally to improve standards of care, ensure a focus on the overarching concept of frailty and ensure as effective a discharge as possible. In parallel both primary and community services work closely together in trying to keep such individuals within their chosen domestic circumstance but nationally the 111 service, regionally the local ambulance service (NWAS) and locally the UHMB ED departments appear to work to strict protocols but in relative isolation (although things are slowly starting to change). Work is ongoing locally to provide effective co- ordination and cross organisational working (which will help) but there appears to be a need for a comprehensive approach to the patient group in question. When these individuals enter the system (from whatever source) we should be able to screen them efficiently and safely for any correctable pathology whilst respecting their autonomy and decision making and offer a holistic approach to care.
Detailed analysis of work within East Integrated Care Community suggested that approx. 1/3 of admissions (17/50) in any age range were either definitely or probably avoidable. This finding led to a more detailed piece of work within UHMB looking at admissions in the 70+ population via the Emergency Department (ED) at the Royal Lancaster Infirmary which among other things concluded that only 16% (7/43) were appropriately admitted. This is
backed up by the finding that in 81% of cases (35/43) the NEWS2 score on admission was 4 or less (not significant illness) suggesting a limited clinical justification for admission. In broad terms the current pathway appears to be that the individual lives at home (84%), not the Regulated Care Sector, that a 111 or 999 call is made and NWAS transport the patient to the ED at RLI (74%) where a junior doctor with limited out of hospital experience admits the individual with limited review as to their existing medical or functional record and expressed wishes-irrespective of patient competence. Currently there are 150 of these admissions to the RLI site alone per month with over 750-900 associated bed days (average stay 5-6 days).
On a small scale and with certain staff members a different approach is being used in the ED at RLI the screen this patient group with good feedback and appropriate outcomes utilising a nurse delivered approach assessing the current functional ability, the degree of acuity, the out of hospital medical record and seeking out the patients pre-existing and current wishes. In more extreme cases suggesting the final illness-again nurse led screening may well be appropriate, all leading to a community service discharge rather than an acute hospital admission. With the above evidence we should be able in due course to reduce emergency admissions in this cohort by at least 50% if the process can be systematised and scaled up to cover all ED attendances for the 168 hours in the week. Scoping of the support requirement by community services is underway (including provision of medical support removing any additional workload on the GP Practice) and it is not obvious that addition resource is needed as a rapid community discharge means that both health and care can provide continuity-always less challenging than when starting afresh with a patient who has significantly deteriorated following a recent 5 -6 day admission.
With reference to the published literature and best practice a Comprehensive Frailty Decision Tool (CFDT) is being developed which will be available electronically to facilitate a standard of assessment, decision making and effective audit. Whilst initially targeted for use in the ED the tool will be made available for others to use once it has been refined to ensure that only questions of added value are asked. It will work both embedded in clinical systems or stand alone and can even be used outside the NHS e.g. in the regulated care sector. The CFDT will work without access to the GP or Community Record including Care Plan and NEWS2 score when well, but it will be of more use if such information is available (pending Q2/Q3 2018/9).
It is hoped that by adopting in a systematic way the approach above will provide a safe,
caring, effective and empowering methodology for all to stop admitting frail elderly
patients to acute hospitals and causing harm.
Reference Articles
https://www.england.nhs.uk/wp-...
https://www.acutefrailtynetwor...
http://www.eolc.co.uk/uploads/...
https://www.thelancet.com/jour...
https://academic.oup.com/agein...
https://www.bmj.com/content/35...
William Lumb
Alison Nicholson
Dianne Smith
September 2018