High Impact Change Area C: Managing presentations in the Emergency Department – case studies

Plan

Front door frailty services ensure that older people living with frailty are identified at the earliest opportunity when presenting to the emergency department. This service enables specialist review, triggering an early Comprehensive Geriatric Assessment (CGA) and either redirection to the most appropriate ward or if safe to do so, discharge home on the same day. St Georges Hospital front door frailty service has demonstrated a positive impact, improving patient flow and outcomes. 

Implementation

The team comprises of specialised consultant geriatricians, one band 8b, two band 8a and four band 7 frailty practitioners. Additionally, they have one admin staff member and a band 3 technician. The service is based within the Emergency Department (ED) and operates across the Acute Medical Unit (AMU), between the hours of 8.00am – 6.00pm, Monday to Friday. 

The front door frailty team utilise the following criteria to see patients at the front door: Clinical Frailty Score (CFS) of 5 and above, age 65 years+ and frailty syndrome as the admission criteria to the service. All patients have a NEWS2, and those with suspected delirium have a 4AT completed at the front door. 

Every patient who is seen by the service has a collateral history taken, a thorough note review (including some GP records), which helps ascertain their baseline. A holistic approach is adopted for assessment, identifying the needs of patients, enabling a 360-degree view and understanding of each patient case.  

Patients are supported to return home, ideally on the same day if safe to do so. There may be some barriers to this, including inability to implement the correct care package within the community, e.g. virtual ward capacity (for patients requiring acute-level care).

In this instance, patients are directly admitted to a senior health ward where possible, including Heberden and Dalby wards which are designed to be dementia friendly. If patients are deemed to only require a stay in hospital of less than 72hours, they will be admitted to an acute space such as the acute senior health unit, the medical short stay ward or AMU. This further reduces the risks of long hospital stays, which are generally associated with poor outcomes. 

Outcomes

This service has shown substantial improvements for patients including: 

• A reduction in length of stay from 22 days to 10.8 days for patients admitted from ED. 
• Approximately 25 per cent of patients seen in ED are discharged the same day. 
• They are currently in the process of considering the launch of a Frailty SDEC. 

Contact

Dr Gaggandeep Singh Alg, Consultant Geriatrician and General Physician

Email: [email protected] 

Plan

The Acute Liaison and Frailty Assessment (ALFA) Team was formed by merging the existing ED liaison team with the front door frailty service. The aim for this team is to ensure patients receive integrated care across acute frailty pathways, relevant departments and services including Frailty SDEC (FSDEC). The Croydon Frailty SDEC is equipped to efficiently manage patients with dementia, adopting a dementia friendly environment. 

Implementation 

The Acute Liaison and Frailty Assessment team is a service based within the Emergency Department at Croydon University Hospital. The team consists of trainee advanced clinical practitioners from both allied health professions (AHPs) and nursing along with physiotherapists and nurses working beyond their traditional scope of practice at their banding. Thus, the service is utilising a large skill set to enable an efficient and seamless response to those presenting to ED with frailty. 

The FSDEC pilot ran between November 2023 to January 2024, where a bay within the acute care of the elderly ward was utilised. The admissions criteria included: age 65 years and above, Clinical Frailty Score (CFS) of 5 and above and possibility to discharge home on the same day. The service was operational between 9am-5pm Monday to Friday and had the capacity of 4 trolleys. The FSDEC team consisted of a dedicated frailty consultant Geriatrician, existing front door frailty team staff, band 5 nurse, HCA and pharmacist. Following the pilot, FSDEC continued to demonstrate significant improvements in patient flow, along with positive feedback from patients and carers, some of which can be seen below.

FSDEC is accommodating for patients with dementia, providing a quieter, calmer and more comfortable and spacious environment, to support their needs for orientation, promoting their recovery and discharge from hospital. Having a separate space, away from the busy and noisy ED area additionally enables easier communication with the person and their families/carer. 

Outcome

The initial pilot: 

• 86 patients were seen over 26 days
• 72 per cent were discharged home. This was an improvement from the average discharge rate of 65.3 per cent
• 8.1 per cent re-admitted within 72 hours
• Discharges earlier in the day 
• Positive feedback from emergency department (ED) team, as this released ED capacity, including from the London Ambulance Service (LAS) corridor 
• Noted challenges included limited time, process bottlenecks, learning on the shop floor, lack of IT processes and locum nursing staff. 

Frailty SDEC July 2024: 

• 74 patients seen
• 78 per cent discharged on the same day 
• 6.9 per cent re-admitted within 72 hours 

Frailty SDEC August 2024:

• 67 patients seen
• 73 per cent discharged on the same day
• 14.3 per cent re-admitted within 72 hours

Feedback from patients and family/carers has been significantly positive: 

...once transferred the team offered expert 360 degree feedback on how to best support mum in the short (while at hospital) medium (once returned to her home) and longer term (through a bone scan assessment).”

I was allowed outside visiting times to encourage my mum to eat”

Everyone in this unit is so supportive of the patient and all findings are explained using plain language. Nothing is done in a hurry and the staff very friendly. We had been referred to this unit via A&E before and on our first visit we were impressed. Always attentive but not claustrophobic.  Once every avenue had been explored a plan for moving forward was explained and implemented with ease whilst including the patient’s wishes and understanding at all times”

A game changing addition to the service with excellent staff knowledge support and care quality and efficiency”

Contact

Dr. Towhid Imam, Consultant Geriatrician, [email protected]