The proactive elderly care team (PECT) was introduced at Lancashire Teaching Hospitals NHS Foundation Trust in October 2012. It had two broad aims which both related to all non-elective patients over the age of 75 years who either came to accident and emergency or were admitted into hospital, irrespective of speciality.
The first aim was to screen all patients over the age of 75 years for delirium and dementia in response to the government CQUIN.
There are about 800,000 people with dementia in England and Wales but only 41% of patients with dementia have a diagnosis, and more than 400,000 are undiagnosed.1 Although screening for dementia has been recently criticised2 there is also evidence that early diagnosis and intervention can be of benefit.3
In addition there is evidence that shows both dementia and delirium lead to longer length of stay and increases morbidity and mortality.4,5 Thus early recognition of these conditions is paramount in the modern NHS.
The second aim was to identify patients over 75 years who were the most frail, and would benefit from a comprehensive geriatric assessment (CGA). The aims of doing this were to:
1. Avoid preventable admissions
2. Reduce delayed discharges (and length of stay)
3. Perform proactive case management of frail patients
4. Promote high standards with a patient-centred approach to management.
The role of PECT was to ensure high quality care at the right time in hospital and provide a smooth transition to other services including acute care, community health and social services and mental health liaison services as appropriate.
Dementia screening is a government priority outlined in the national dementia CQUIN.6 The CQUIN specifically focuses on three areas:
1. Identifying people with dementia
2. Assessing people with dementia
3. Refer on for advice—a referral would be made for further support either to a liaison team, a memory clinic or a GP.
The authors recognised that these priorities would be difficult to implement without investment in a new service, and this was one of the main reasons that the PECT was established.
A number of initiatives have been developed over the past 10 years aiming to provide a proactive service for inpatients who are elderly and/or frail. Previous studies have detailed the older person assessment and liaison service (OPAL) and frail OPAL (FOPAL) models.7 Although they have been successful, they have concentrated on patients being admitted through medical wards, whereas we included all non-elective patients in hospital, irrespective of which ward or speciality they were admitted under.
The British Geriatrics Society (BGS) recommends that the multidisciplinary team responsible for comprehensive geriatric assessment should consist of:
• An accredited senior specialist physician in medical care of older people
• A co-ordinating specialist nurse with experience
• A senior social worker, or a specialist nurse who is also a care manager with direct access to care services
• Dedicated appropriate therapists.8
We were able to secure funding from our foundation trust to create a new team with all the attributes that the BGS recommend.
We introduced a team which would have enough members to provide an effective service, but would also be able to provide seven day a week working. It was determined the team would work weekdays 09.00–17.00 and at weekends from 11.00–16.00.
The time provided by the consultants was difficult to assess initially. We felt that it would take about 30 minutes for the consultant (or staff grade) to complete a comprehensive geriatric review (perhaps longer if there was a particularly complicated case). Six patients could easily take three hours and with a team meeting beforehand we decided that four hours (including some travelling to the base hospital) would be a reasonable starting place.
This equated to one programmed activity (PA) per day, or five PAs each week.
Screening for delirium and dementia
The PECT screened all acute admissions aged over the age of 75 years for delirium and dementia, who had been in hospital for more than three days.
The reason for deciding to wait for three days was not an easy one. One could easily argue that waiting 72 hours to screen for delirium is far too long. However the screening process was over and above the care that the patient was already receiving. It was not designed to replace normal standards of care. In addition many patients would be discharged very quickly (within a few hours) if they came to A&E and logistically it would be difficult to respond to that demand, especially at night and at weekends.
Also, many elderly patients are acutely unwell when they first come to hospital. We performed a small pilot study prior to PECT starting and this demonstrated that if patients were screened too early, a large proportion of them were not suitable to talk to (life-threatening illnesses) and this would render the screen inaccurate.
Each day a list of all the new admissions over the age of 75 years was provided from the hospital database. This had details of the ward location of the patient. Each morning at 9am PECT had a meeting and patients were allocated to the members of PECT for delirium and dementia screening. Patients already known to have dementia were excluded (although the authors do appreciate the fact that they may have concomitant delirium as well).
The PECT member then goes to the ward to see each of their allocated patients. The PECT member performs a confusion assessment method (CAM). If this is positive then causes and treatment of delirium are recommended. If the CAM is negative the PECT member proceeds to ask the dementia screening question: “Have you been more forgetful in the past 12 months to the extent that it has significantly affected your life.”
If this is answered “yes” then the PECT member would perform a six item cognitive impairment tool (6CIT). We decided to use this over MMSE because of copyright issues.
The screening question is not without problems. Some patients with dementia may still answer “no” due to lack of insight. Wherever possible the patient’s relatives and/or carers were asked as well.
If the patient scored a high mark on the 6CIT and they had been more forgetful for 12 months, and delirium was deemed unlikely, they were felt to have probable dementia. Although this process is not perfect it must be emphasised that this set of patients were referred forwards (for instance to a memory assessment service) for a more specialised review and confirmation of the diagnosis.
The comprehensive geriatric assessment
The PECT team wanted to target the frailest patients over the age of 75 years, irrespective of where they were within the hospital (A&E, medical wards, surgical wards etc). A referral system was set up whereby the healthcare professionals on the ward looking after the patient could refer that patient to PECT. It was decided that any healthcare professional could complete the referral form from any ward.
The frailty markers based on the BGS definitions were used to decide which patient would benefit most from PECT:9
1. Polypharmacy (four or more drugs)
2. Decline in mobility
3. Recurrent falls
4. Cognitive change
5. Functional change
6. Low mood or anxiety
7. Continence issues
8. Nutritional concerns
9. One or more unplanned admissions in the past three months.
If a patient had two or more of these markers, a referral to the PECT would be accepted.
The referral form could be faxed or posted to the PECT team directly but we encouraged colleagues to bleep the PECT directly.
Each day a member of PECT was designated to carry the referral bleep from Monday to Friday 09.00–17.00 and weekends 11.00–16.00. Outside of these times the referral could still be faxed or posted (and collected at the beginning of the next day) or a telephone message could be left on an answer machine for collection the following day.
Once the referral was received a member of PECT went to see the patient as soon as possible. If possible the most appropriate PECT member went: for example a patient with loss of mobility and falls might best be seen by a physiotherapist (this was clearly a learning experience for all of us).
It was felt that referrals from A&E and the rapid access unit should be seen within 30 minutes (to provide the possibility of admission avoidance). Referrals from the medical admissions unit should be seen within four hours, and referrals from other wards should be 24 hours.
Some patients needed the input of a consultant geriatrician although the authors recognise this was the clinical judgement of the PECT member whether to get a consultant involved or not. As previous studies have shown this process is not perfect at the beginning, but it does improve with time.
It was decided that the consultants should provide cover Monday to Friday. The current department consists of four consultants and a senior staff grade doctor was also included so that each doctor could provide one full session each day each week.
The geriatrician went to the ward to see the patient (usually with the PECT member who asked the consultant to review the patient) and the consultant provided a CGA from a medical perspective. It must be emphasised once again that this is in addition to the patient’s normal hospital care.
Comprehensive geriatric assessment has been shown in clinical practice to reduce the length of stay significantly.10 Length of stay is one of the key indicators of productivity in the NHS, a key priority for the government.
We also made it clear from the outset that the consultant geriatrician did not to take over the care of the patient. We feel we may have become inundated if this had been the case.
Communication from PECT members
Once the patient was seen by PECT, any plan or advice had to be communicated effectively to the team looking after the patient.
This was done both verbally and in writing. The PECT members made every effort to speak to the nurse and doctor on the ward who were directly looking after the patient. In addition a written summary was provided and this was included in the patient’s case notes.
The new service began in October 2012. Results are available up to August 2013. This covers a period of about eight months. In total 4446 patients were eligible for screening. PECT managed to screen 4384 patients in total (94%). We were set a target of achieving 90% for the purposes of the CQUIN, which we succeeded in doing.
Known dementia and new delirium
The number of patients with dementia in this study is much greater than the published prevalence. However, it is recognised that large numbers of patients are undiagnosed.
This screening process identified that 11% of patients probably had previously unrecognised dementia. This proportion is broadly in line with the prediction from the Alzheimer’s Society that 50% of patient with dementia are not yet diagnosed.
It is worth noting that 13% of patients in this study had “only” delirium, which is lower than previous studies. This is probably because patients who already had a diagnosis of known dementia were not screened for delirium as well and this would explain our lower number.11,12
Length of stay reductions
It is always difficult to interpret if PECT actually helped the patients it saw. However when the individual case notes were examined it was felt that at least 153 admissions (in emergency department, rapid assessment unit or medical admissions unit) had been avoided because of direct intervention from PECT.
The average length of stay reduced from 21.92 days before PECT to 15.10 days during PECT, a reduction of 31%.
The average number of readmissions went down from 25.07 before PECT to 17.11 during PECT, a reduction of 32%.
These results are early and only represent the first 10 months of the service. Some broad observations can be made however.
867 patients were referred for a comprehensive geriatric assessment. In this cohort of patients their length of stay was reduced by 31%, in total a saving of 5913 days.
A very conservative estimate of the cost of a day in hospital might be £130, so the saving could be equated roughly to (5913 x £130 =) £768,690 over the 10 month period, or about £922,500 over one year.
This outweighs the cost of setting up the service by a factor of about three (£922,500/£281400). Thus one could argue that for every £1 pound spent setting up this service, £3 would be saved. This only includes savings from reduction in length of stay, and does not include payment from the CQUIN, reduction in complaints and readmissions, and their costs. We would like to re-screen patients who are diagnosed with delirium after they have been successfully treated. At the moment we are probably missing some patients who have both dementia and delirium combined, and this may be one reason why the number of patients with delirium (13%) may be a little lower than some other studies.
PECT has been successful so far and it has been a great learning experience for all of us involved. We would like to extend PECT into the community aiming to reduce admissions further in a safe and timely manner. We also feel that as more patients in our community are recognised as having dementia, the number of unrecognised patients should become less.
However, recognising patients with dementia is merely the beginning of the process. The largest challenge over the next 10 years will be delivering appropriate specialist care to these patients both in the community and in the hospital, a challenge that may well need more resources.
If anyone is interested in setting up a similar service, our team would be happy to help out where we can.
Conflict of interest: none declared
1. Alzheimer’s Society. Increase in number of people diagnosed with dementia: over 400,000 remain undiagnosed, according to Alzheimer’s Society. 2012. http://alzheimers.org.uk/site/scripts/news_article.php?newsID+1164
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