Learning points

  • To assess the discharge rate of patients with a Comprehensive Geriatric Assessment from A&E and same-day emergency (SDEC) unit
  • To assess the re-admission rate by day seven and day 30 from A&E and SDEC
  • To assess the average length of admission from patients admitted from SDEC.

 

 

Background

Frailty is defined as a state of increased vulnerability to poor resolution of homoeostasis after a stressor.1 It is important to identify frail patients early as acute frailty syndromes (e.g. falls, delirium) may result from a relatively minor insult leading to a higher risk of acute hospital admission, care home admissions, and even death.1

Older patients can be triaged to assess frailty by their Clinical Frailty Scale (CFS) score. This is a judgement-based frailty tool that evaluates specific domains including comorbidity, function, and cognition to generate a frailty score ranging from 1 (very fit) to 9 (terminally ill).2

This is useful to identify patients who are very frail on admission to A&E. Once elderly, frail patients have been recognised, it is important to do an early Comprehensive Geriatric Assessment (CGA), which is comprised of a number of steps. Initially, a multidimensional holistic assessment of an older person considers health and wellbeing and leads to the formulation of a plan to address issues which are of concern to the older person (and their family and carers when relevant).

Interventions are then arranged in support of the plan. Progress is reviewed and the original plan reassessed at appropriate intervals with the interventions reconsidered accordingly.3

This is important to get a holistic picture on admission, which can then be managed with the aim of reducing hospital length. Thus, the role of the frailty team is to facilitate the CGA, try to increase discharge rates, reduce the length of stay, and ultimately give the best care for frail older patients.

The frailty team also have an outreach role in A&E to provide a multidisciplinary specialist service providing high quality rapid CGA to frail older adults presenting to the emergency care areas. This is aimed at avoiding unnecessary hospital admission and improving outcomes.

There should also be a same-day emergency (SDEC) unit for provision of acute same day care for patients who would otherwise be considered for emergency admission to hospital.

This service aims to maximise access to rapid clinical assessment, diagnosis and treatment with same day discharge home where safe to do so. The frailty team is managed by a care of the elderly consultant, with a MDT comprising of a senior house officer, a physician associate, a physiotherapist, frailty practitioners who are senior nurses, and a healthcare associate.

This multi-disciplinary team allow holistic care of the patient for both the outlined roles above. Patients who are suitable to come to SDC from A&E have to be CFS >3, no significant injuries, NEWS score <3, or with acute myocardial ischaemia/ respiratory issues.4

This quality improvement project (QiP) was done to assess the discharge rates, re-admission rate by day seven and day 30, and for those admitted from the SDEC to see the average length of admission. This is important to see the effect of the CGA and to see the benefit of appropriate patients coming to SDEC.

Aims

  • To assess the discharge rate of patients with a CGA from A&E and SDEC
  • To assess the re-admission rate by day seven and day 30 from A&E and SDEC
  • To assess the average length of admission from patients admitted from SDEC.

Methods

This QiP was undertaken in two cycles of three-weeks in length, with an intervention in between. The first cycle was 1-22 July 2021, and the second cycle was 22 September - 18 October 2021.

A paper record by patient hospital ID was created for each patient, excluding those who had no CGA on the EPRO system. There were 61 patients in July and 85 in September to October.

The project looked at how many were discharged or admitted. If patients were discharged, the numbers who were re-admitted within seven days or 30 days were recorded. The length of stay in hospital for those admitted from SDEC was also recorded. This data was inputted into an Excel sheet and converted into graphs to compare.

Intervention

During the project, several educational sessions took place within the frailty team as well as outreach to care of the elderly and acute wards. This was to ensure skills were being improved that would lead to better care.

Firstly, all patients that were seen by the frailty team had a CGA. This was implemented in the end of August to ensure patients were not just screened, but also had a full CGA done.

Secondly, the frailty team ran drop-in teaching sessions whereby they would go onto the ward and show a poster regarding the role of frailty and use of the CGA. This had information on how to refer to the frailty team, how to work out a CFS score, recording the CFS score on EPRO, and how to attend the teaching drop-in sessions. These sessions were educational for the frailty team, the nurses on the wards, and the doctors on the wards.

Thirdly, Northwick park hospital had a ‘safer September’ initiative ongoing whereby the trust would send emails with ways of
improving patient care, patient flow whilst maintaining patient safety. This would be discussed within the team where these trust-wide measures could be implemented.

Results

Figure 1: Number of patients seen in A&E and SDEC in cycle 1 and cycle 2. In cycle 1, 41 patients were seen in A&E and 29 in SDEC. Whilst in cycle 2, 20 were seen in A&E and 56 in SDEC.

 

 

Figure 2: Shows the % of discharges of the patients with CGAs done. In A&E, cycle 1 had 51.2% discharge rate vs 62.1% in cycle 2. In SDEC, cycle 1 had 75.0% discharge rate vs 73.2% in cycle 2.

 

Figure 3: This graph compares re-admission rates looked at within seven days, A&E had 14.3% in cycle 1 vs 11.1%
in cycle 2; SDEC had 13.3% in cycle 1 vs 4.9% in cycle 2.
Within 30 days, A&E had 27.7% in cycle 1 vs 12.5% in
cycle 2; SDEC had 7.7% in cycle 1 vs 10.3% in cycle 2.


Analysis

Figure 1 shows that more patients had a CGA done in the 2nd cycle compared to the 1st cycle. This is likely because the frailty team implemented the idea of doing a CGA rather than giving a verbal advice from end of August.

Additionally, the ratio of patients seen in SDEC compared to A&E significantly changed; this is likely due to a combination of patients coming to hospital who met the criteria to move to SDEC.  Teaching sessions in A&E also led to more referrals, and actively seeking patients earlier to come to SDEC. Being in SDEC allows patients to be reviewed by a care of the elderly consultant and get a full work-up compared to just a CGA in A&E, and thus leads to better outcomes for the patient.

Figure 2 shows that the discharge rates in A&E have increased from cycle 1 to cycle 2 by 10.9%. This highlights the effect of frailty practitioner input, which helps to facilitate discharge. This is done by setting up support using the STARRS rapid response or getting equipment delivered or starting packages of care, which would otherwise need medical admission to organise.

It also shows that discharge rates from SDEC were similar with a 1.8% decrease despite seeing an additional 36 patients in SDEC. At the time there was a bed crisis in the hospital so the frailty team were forced to take medical patients awaiting a bed or likely to be admitted to help bed flow through A&E.

Figure 3 shows readmission rates within 7 days and 30 days. Looking at within 7 days firstly, there was a reduction in re-admission rate from cycle 1 & 2 from A&E (reduced by 3.2%) and SDEC (reduced by 8.4%). This shows that the discharges were safe and that the improved teaching and safer September helped facilitate safe discharges. It also highlights the role of rapids and referring to them would help manage discharges in the community to prevent early re-admission.

Patients who were re-admitted within 30 days from A&E reduced from cycle 1 to 2 by 15.3%, but SDEC had a marginal increase by 2.6%. This was a big decrease for A&E showing implementing a CGA and better awareness of managing frailty leads to better outcomes.

 

Figure 4: This graph demonstrates the average length of stay of admitted patients from SDEC.

 

In cycle 1, patients stayed on average 5.6 days. In cycle 2,
patients stayed on average 3 days.

Unfortunately, there was a slight rise for SDEC for re-admitting within 30 days. This could because more patients were seen so the likelihood of a fall or other medical issues are inevitable. It would be useful for future QiP’s to investigate the cause of re-admission, as it may be completely different and thus could not have been prevented.

Finally, looking at the average length of stay of admitted patients from SDEC, the average length reduced from 5.6 to 3 days from cycle 1 to 2. This is a large decrease, showing that even though more may have been admitted marginally, their length of stay has reduced greatly.

This is likely multifactorial due to early CGA, more patients coming to SDEC, and education on the wards on managing frail patients. This is of great benefit to patients as reducing length of stay has been known to reduce mortality, maintain independence, reduce loss of muscle mass, as well as saving money on reduced inpatient stay. This is something that is important to continue for the wellbeing of frail patients that require an admission.

Conclusion

This QiP demonstrated the role of educating other ward teams and A&E staff, as well as the initiative of safer September, on reducing admission and re-admission rates. With a reduced length of stay of those admitted, it showed the interventions have been effective.

Further QiPs can incorporate a 3rd cycle to ensure the improvement is kept up and if it can be further improved upon. It would also be useful to do another QiP on re-admissions and the cause for re-admissions to see if the frailty team can improve any specifics of management to prevent this or if it was unavoidable/ unrelated to the first admission.

Recommendations

  1. Continuing drop-in sessions and educational sessions for all staff.
  2. Third cycle of QiP to assess ongoing improvements.
  3. Evaluate cause of re-admissions to see if they could have been avoided.

References

  1. British Geriatrics Society. (2018). Frailty: what's it all about?. Available:
    https://www.bgs.org.uk/resources/frailty-what%E2%80%99s-it-all-about. Last accessed
    22nd Nov 2021
  2. Church, S. et al. (2020). A scoping review of the Clinical Frailty Scale. BMC Geriatrics. 20, 393
  3. British Geriatrics Society. (2020). Comprehensive Geriatric Assessment Toolkit for Primary Care Practitioners. British Geriatric Society. 4-5
  4. Ali, S (2022). Acute Frailty Collaborative SDEC. LNWH Intranet. 1-17.