Timely Access to Experts
Approach
Timely access to experts offering frailty-based care in hospital with frailty assessment, diagnostics and pathways.
Hospital care requires a caring frailty environment that allows for front door recognition of frailty, followed by Comprehensive Geriatric Assessment and best practice care for frailty syndromes (falls, immobility, incontinence, polypharmacy, delirium), together with early inter-agency planning for discharge home to optimise care and prevent hospital related complications and deconditioning.
The following are examples of what to consider when thinking about developing specialist frailty care, pathways and services within the hospital setting.
- Expert decision makers are available at the front door of the acute hospital from 8am to 8pm, seven days a week.
- Specialist assessment should be available within 12 hours of admission, seven days a week (ideally, proactive identification of frailty within 4 hours).
- The presence of one or more frailty syndromes should trigger a comprehensive geriatric assessment.
- Sufficient specialty and community hospital beds to look after all frail older patients with complex needs and enough relevantly trained staff to deliver high-quality care and assessment for them.
- Employ ‘trusted assessment’ to identify those who will benefit from intermediate care.
- Strategies to reduce avoidable unexpected mortality should be in place – warning scores, critical care outreach, regular senior review and adequate access to high dependency beds.
- Hospitals make safer care for older people a key priority – prevention and treatment of falls, pressure sores, hospital-acquired infection, medication errors, deep vein thrombosis and malnutrition, delirium and immobility as a result of bed rest.
- Minimising in-patient moves for those older people identified as frail especially those with delirium.
- Liaison and in-reach services for frail older people under other medical and surgical specialities including psychiatric services (e.g. dementia and mental health problems).
- An identified Frailty Unit/Service may be considered and desirable with staff trained in how to look after frail people focusing on rapid assessment, treatment and rapid discharge.
- Adequate and timely information must be shared between services whenever there is a transfer of care between individuals, carers (paid or unpaid) and services.
- The recognition of carers (formal and informal) as crucial parts of the team.
- Advice on appropriate housing and adaptations.
Resources
N.B. Many of the resources in the previous section are also relevant here.
- NHS Confederation, Growing old together: A report by the independent Commission on Improving Urgent Care for Older People – http://www.nhsconfed.org/resources/2016/01/growing-old-together-sharing-new-ways-to-support-older-people
- The Acute Frailty Network and is a multi-professional initiative that seeks to optimise secondary care of frail older people in England – https://www.acutefrailtynetwork.org.uk/
- Presentation from Prof Simon Conroy AFN (Acute Frailty Network) – https://www.acutefrailtynetwork.org.uk/uploads/files/1/Events/AFN%20Conference%20Presentations%202017/Professor%20Simon%20Conroy.pdf
- Silver Book. Guidelines for the emergency care of older people. https://britishgeriatricssociety.wordpress.com/2012/06/21/the-silver-book-guidelines-for-the-emergency-care-of-older-people/
- Acutely ill adults in hospital: recognising and responding to deterioration. NICE – http://www.nice.org.uk/CG50
- British Geriatric Society. BLOG discussing acute care for older people in hospital – https://britishgeriatricssociety.wordpress.com/category/acute-care/
- NHS elect. Website with access to acute frailty care and case studies – https://www.nhselect.nhs.uk/
- Toolkit – acute care of frail older people – http://www.acutemedicine.org.uk/wp-content/uploads/2016/05/4.1-Managing-Acute-Frailty.pdf
- Comprehensive care. Older people living with frailty in hospital. NIHR themed review (2018) – https://www.dc.nihr.ac.uk/themed-reviews/frailty-in-hospital-research.htm
- The Older People’s Commissioner for Wales is an independent voice and champion for older people across Wales, and 1000 Lives Improvement Falls Prevention program for Older People supports NHS Wales – http://www.olderpeoplewales.com/en/Home.aspx
- HSJ Commission on Hospital Care for Frail Older People (November 2014) – https://www.hsj.co.uk/download?ac=1292263
- The Royal College of Physicians partnered three NHS organisations across England and Wales with the specific aim of improving the care of frail older patients as part of its Future Hospital programme – www.rcplondon.ac.uk/projects/future-hospital-programme
- NHS England (2013). Bed availability and occupancy – https://data.england.nhs.uk/group/bed_availability
- Covinsky, K. Loss of independence in activities of daily living in older adults hospitalised with medical illnesses Journal of the American Geriatric Society 20013;51(4):451-458. DOI:10.1046/j.1532-5415.2003.51152.x
- NICE guideline CG103 (2010). Delirium: prevention, diagnosis and management – https://www.nice.org.uk/guidance/cg103
Evidence
- People over 85 account for 25% of total bed days in hospital. After a hospital admission, 12% of people over 70 experience a reduction in their ability to undertake activities of daily living between admission and discharge.
- Older people who saw deterioration in their balance and mobility in the first 48 hours of hospital admission had a 17-fold increase in risk of death within fourteen days.
- Older people living with frailty admitted to hospital as an emergency have an improved chance of living in their own home at up to a year after discharge if they receive specialist comprehensive geriatric assessment (CGA) and specialist inpatient care.
- Comprehensive care. Older people living with frailty in hospital. NIHR themed review (2018) – https://www.dc.nihr.ac.uk/themed-reviews/frailty-in-hospital-research.htm
- People aged 85+ are nearly 10 times more likely to have an emergency admission than those aged 20-40 years and the oldest have the highest readmission rates and long-term care use after discharge.
- A meta-analysis of studies with A&E teams identifying and supporting community discharge provides some evidence of improved outcomes.
- Acute Geriatric Units have been shown to reduce the risk of functional decline and increase the probability of returning home; such units have not been compared directly to an Acute Medical Unit (AMU) in the UK – https://www.dc.nihr.ac.uk/themed-reviews/frailty-in-hospital-research.htm
- Older Persons’ Assessment and Liaison (OPAL) teams have shown to improve outcomes in hospital for older people’s care.
- Silver book – https://britishgeriatricssociety.wordpress.com/2012/06/21/the-silver-book-guidelines-for-the-emergency-care-of-older-people/
- Effectiveness Matters: Recognising and managing frailty in primary care – Centre for Reviews and Dissemination, The University of York – https://www.york.ac.uk/crd/publications/effectiveness-matters/frailty-primary-care/
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