The Royal London Hospital (RLH) is a major trauma centre and home to the London Air Ambulance. About 60 per cent of patients admitted to the RLH live in Tower Hamlets.
It had become clear that there was an issue at the RLH with frail older patients being unnecessarily admitted into acute beds, for social admission reasons.
We also knew that there was clear evidence showing elderly patients, in particular, have poor outcomes when admitted to hospital without a medical reason – 10 days in a hospital bed leads to the equivalent of 10 years ageing in the muscles of people over 80 (Gill et al 2004).
The social work service based at the RLH hospital operated a 9-5 Mon-Fri service and was not set up to prevent unnecessary hospital admissions. Based around the transfers of care, it responded more to the sections 2s and 5 referrals to arrange the efficient and safe discharge of patients deemed to be medically from the acute wards.
To tackle this problem - we developed a new service that would operate a preventative service linked to the A&E, Acute Assessments Unit (AAU), and Clinical Decision Unit (CDU).
The Out of Hours Social workers within the Acute Assessment Unit (AAU) and ED now respond to referrals within the hour, commission support and discharge patients who do not have a clinical need to be in hospital.
By commissioning community services that allow patients to return home, we are able to join up services seamlessly and discharge patients safely.
Tower Hamlets CCG has worked closely with the local authority to develop this service and funded it through the Better Care Fund.
At its heart, the service ensures that patients have a better experience of hospitals by rapidly assessing their needs and providing the right intervention to prevent unnecessary admissions in the first place and allow them to be safely and quickly discharged. Patients who do not need to be admitted on medical grounds are identified faster, and the issues that mean they would be able to return home are dealt with quickly.
The service believes that individualised assessments, early referrals, effective communication, flexibility and joint working are instrumental in meeting their aims.
The scheme reduces hospital stays for patients, by facilitating speedier discharges.
In its first year of operation, he Royal London Hospital Social work Out of Hours Service November 2013 prevented about 703 admissions, the second year about 800 admissions and in the last 12 months till date 958 admissions.
Hours of Operation/ Referral Process:
Hospital Staff working in the Emergency Department, Acute Admission Unit and Clinical Decision Unit do not need to issue a discharge notification and are able to bleep or call social workers (referrals can also be picked up at the daily MDT meeting).
Staff can call anytime between 9 am to 8pm and 10am to 8pm at weekends. 9am to 5pm on all Bank Holidays except Christmas Day.
Social workers respond within an hour to carry out a needs assessment for safe discharge, preventing social admission to acute wards, and also preventing dependencies, muscle wastage, risk of infections and deconditioning to elderly frail patients
Case Study:
Mrs E arrived by ambulance to the A&E department at about 4pm on a Friday with a case of vomiting and diarrhoea. After treating her, the Doctor assessed that she did not need to be admitted to an acute hospital bed. Following this assessment, the out of hours social worker quickly provided the appropriate interventions, i.e.a referral to the Reablement Service for short term care and support. Reablement officers (RO) visited in the mornings for the first 6 weeks to provide care and support and to help Mrs E regained her independence. This enabled her to return to her home and avoid being admitted unnecessarily to an acute bed.
Without the out of hours service, Mrs E would have been admitted to an acute ward, kept in, and would not have been assessed for discharge until after the Bank holiday weekend. Mrs E, who was, of course, keen to get home, would then have possibly been put at risk of hospital acquired infection, muscle wastage, de-conditioning, and also would have been in a bed needed for other patients.
INTERGRATED WORKING/ Links with Other Schemes:
The Royal London Hospital Social work Out of Hours Service has continued to develop over the past two years. We work in an increasingly integrated fashion with our partners and stake holders, such as the Admission Avoidance Team, Reablement, Age UK, Tele- Care as well as the Community Equipment Service( CES )who are also operating a 7 day service. The Royal London Hospital Out of Hours Service also works closely with, GP surgeries; District Nurses and the Incontinence Service.
Benefits of the Out of Service:
- The service manages discharges in a seamless fashion through appropriate interventions to facilitate a safe and timely discharge.
- Prevents admission for those without acute medical need as well as dealing with inappropriate delayed discharges for people who require short term admission.( AAU)
- Reduces pressure on acute beds by preventing unnecessary hospital admissions.