University Hospitals Nottingham
Hospital size: Acute take 100 patients a day.
Challenge faced: Large unselected medical takes with increasing numbers of frail older people.
Solution: Consultant geriatrician review for identified frail older people admitted, to facilitate discharge and formulate a rapid admission plan.
Local context: The geriatric department provides input on 2 sites, with all beds on 1 site and includes 2 community geriatricians.
Staffing: 20 hours of consultant geriatrician time (planning to expand to 40 hours). Strong support from the integrated discharge team (whole time equivalent band 7 nurse).
Outcome: From a local audit of 1 month’s activity: 159 medications stopped; 260 bed days saved; 6 unsafe transfers prevented; care plans altered. Patients most in need of healthcare for elderly services identified.
In their own words: One of the key things is that the service has raised the standard of care for these frail older patients in all sorts of ways. Medications that are inappropriate have been discontinued; medications that are indicated are prescribed; and we’ve given attention to appropriate prescribing. We also attend to advanced care planning. In some instances that is simply a matter of a phone call to a family to ask, ‘Are you aware your Gran is very ill? Have you talked about the immediate future for her?’ Contact with a consultant, even over the phone, is an extraordinarily powerful thing for relatives. We also perform a thorough assessment of cognition, obtaining a collateral history from the family about the duration of memory loss and consideration of alternative explanations, whether memory loss is acute, and therefore we diagnose lots of dementia. Having a consultant, rather than a trainee, documenting a clear differential diagnosis list and a care plan in the notes improves quality of care. The patient arrives on the ward and if I have made two or three entries in the notes the nurses go, ‘Oh, that’s good. We know exactly what we are doing. Let’s get the physios to see the patient, get him up and moving and home in 36 hours’. Another aspect worth commenting on is preventing unsafe ward transfers or discharges, and ensuring that the patients who will benefit most in wards for the care of older people are triaged to go there.
Older frailer patients take time and you simply can’t do them justice on an acute take round. It was nice to hear one of our colleagues describing the acute geriatrician as decompressing the take. Our specialty colleagues acknowledge that we do have a skill set and a range of experience that is more suited to looking after frailer older people.
We are also able to expedite discharges for up to 30% of frailer older people. This is partly due to the continuity we provide by seeing the patient every day. Also, we are in a strong position to put in a lot of community services, some accessible from the front door. We have community matrons, community geriatricians, our proactive intermediate care team and a crisis team who provide 6 weeks extra support. It’s a team effort: the ward manager who can point you in the direction of patients likely to be able to be discharged, the geriatricians themselves, and the interdisciplinary team with their contacts and knowledge of the services available.
This case study was first featured on the Royal College of Physicians’ Future Hospital Tell us your story web pages, where you can read a full range of case studies.