The emergency department (ED) is not a suitable place for the assessment and treatment of older patients. It has high intensity, periodic and disease-oriented activity and there is general consensus that these patients with complex medical, social and psychological needs cannot be catered for in the ED.
Most emergency physicians have not been trained or educated in specific geriatric approaches, and many report being less comfortable when dealing with older patients.1,2 Despite many investigations and staying longer in the ED, the diagnosis can still be unclear due to polypharmacy, multiple diagnoses and lack of a clear history from delirious older patients. Often interventions done in the ED are not communicated to the community or to the primary care physician in a timely manner.3
These older patients are at increased risk of multiple or return ED visits, multiple medical problems, serious illnesses, being hospitalised more, longer length of stay and poor outcomes (such as dissatisfaction with ED), functional decline or death.2,4 Usually 12–24% of these frail older patients attend the ED and in the US, the ED annual attendance in patients older than 65 years was 49 out of 100 and 60 out of 100 in patients older than 75 years compared with an overall rate of 41 out 100 persons.5
In the UK patients over the age of 85 years have increased by two-thirds compared to only a 10% increase in the overall population and they account for about 15% of ED attendance.6
Yeovil District Hospital NHS Foundation Trust is a district hospital with 345 beds and provides acute care, including maternity services, for a growing population of 180,000, mostly in South Somerset, North and West Dorset and parts of Mendip. Over the next decade the core catchment will increase by 6% in terms of headcount but, in composition there will be a 33% increase in the over 75 years age groups and a significant decline in working age adults. By the end of the decade, the over 75s will increase as a proportion of the population from 10% to 13%. The additional demographic demand is 30,200 bed days or 83 beds at today’s performance. In 2013, 2356 patients aged 80 years or over were admitted through the ED.
It is important that these frail older patients are seen and attended in the ED by a geriatrician and provided with holistic care so as to prevent unnecessary admissions to the hospital.
A geriatrician-led team was appointed in the ED for five days a week 9am–5pm reviewing frail, older patients. The team comprised of an occupational therapist, a physiotherapist, staff nurse, a consultant geriatrician and a junior doctor. The junior doctor belonged to the ED but worked under the instruction of the geriatrician. The initial age limit was 80 years or above but younger patients were seen by the geriatrician if the patient was considered to be frail.
The Trust clinical decision unit adjacent to the ED was taken over by this team. Patients with acute coronary syndrome, stroke, fractures and severe sepsis were excluded because they would need admission to the hospital. This project was carried out for two months and data was collected. The primary outcome was reduction in admission and the secondary outcomes was seven days ED reattendance and readmission rate within and after 30 days.
In the two months 84 patients were seen and assessed by the geriatric team. 33 patients were 90 years or above. 34 between 80–89 years and 14 patients were between 70–79 years. Three patients were younger than 70 years (Box 1). 12 patients (14%) were admitted as they were found to have either acute coronary syndrome or fractures needing interventions and operations. They were admitted directly to speciality wards and bypassed the medical assessment unit. 45 patients (53%) were sent home after assessment with at least a third with new care packages through the independent living team (a community team consisting of a occupational therapist, physiotherapist and social worker in south of Somerset), 23 (27%) to community hospitals for further rehabilitation and four patients (5%) were transferred to a care home as a placement (Box 2). 26 patients (about 30%) were given follow up in geriatric outpatients for further investigations.
The admission rate from the ED showed that 55% (on average) of these older patients were admitted in 2012 and 46% (average) in 2013 during this project. After the project the admission rate went up to 68%. One week during the project because of hot weather the admission rate was 65% but it settled quite quickly to the above mentioned average.
The seven day ED reattendance rate was seven patients (8%). The readmission rate was 11 patients within 30 days (13%) and 13 patients after 30 days (15%). Most of these patients were admitted with a different complaint and presentation.
The King’s Fund report in 2012 stated that among over 65s, the average length of stay (LOS) varied from seven days (for those aged 65–74) to 11 days (for those aged 85 and over).7 In our trust LOS for these patients was about 12 days but the patients admitted by the geriatrician during this project stayed less than three days in the hospital. If 10–12 admissions are avoided per week then approximately 500–600 admissions can be avoided per year and with an average LOS of 8.5, this is about 4488 bed days.
The comprehensive geriatric assessment (CGA) is a multidimensional and multidisciplinary process that assesses the medical, psychiatric, functional and social needs of frail older patients in order to provide a long-term integrated plan for their care as well as follow up. Medication, cognition and nutrition, vision, footwear review and osteoporosis risk assessment should be included in this standard medical review.
CGA has been shown to improve the outcome of older patients.8,9,10 As shown in a recent large trial a CGA can be embedded in the ED to improve older patients’ care and also create a significant reduction in the admission and readmission rate.11 This will allow ED doctors to attend other emergencies such as trauma and severe sepsis.
According to the King’s Fund, men and women under 65 years use approximately one-fifth of a bed day, whereas men and women over 85 years use more than five bed days per annum.7 In view of the increase in the ageing population and constraints on the ED, it is important that change in the operating systems is introduced. The benefit of incorporating a CGA to an ED setting will serve multiple purposes especially in a district general hospital setting. This project has showed that the admission rate from the ED has decreased with reduced length of stay and readmission rate. These improvements will lead to cost reductions and will help in redirection of the resources available.
This project’s strengths were its ability to achieve primary outcomes of reduction in admissions from ED and the secondary outcomes of seven days ED attendance and readmission rate. In addition, a CGA was delivered to older patients as an added benefit. There were several weaknesses as this project was done by one geriatrician working only week days and for two months only. There was no control group. Also these patients were not followed up in community to see the effect of these interventions.
However, the results of this project strengthened the basis of a frail older patient assessment service in our Trust with a dedicated space and staff for the assessment and it is up and running now. Time will tell us how this service is going to provide an integrated holistic care for the older patients.
Conflicts of interest: none declared
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