Abstract

Silver phone service evaluation: a service providing consultant-led telephone advice to pre-hospital clinicians for patients over the age of 80 years.

Background: The purpose of the Older People’s Emergency Department (OPED) is to provide access to an Older People’s Medicine (OPM) consultant at the front door of the hospital. The Silver Phone Service (SPS) was established in order to extend this access to an expert decision maker to pre-hospital clinicians via telephone.

Methodology: This included thematic analysis of pre-hospital clinician (service user) and OPM consultant questionnaire (service provider). Data collation and analysis of all engagements with the SPS between 1st November 2019 and 30th April 2020 to determine the advised admission avoidance rate. Using the eAudit tool of Symphony ED software, cross-matching attendance to the emergency department seven days following advice for all patients advised to avoid admission was performed to allow calculation of ‘true’ admission avoidance.

Results: Pre-hospital clinician questionnaire: The feedback from the pre-hospital clinician questionnaire showed a positive trend in all questions with the lack of longer operating hours was viewed as a barrier to access.

OPM consultant questionnaire: ‘Interruption’ was commonly cited as a potential risk when overseeing clinical decision making in OPED.

‘True’ admission avoidance rate: The admission avoidance rate advised vs ‘true’ admission avoidance rate was consistent over the six month period. The mean for each was 76.2% and 62.6% respectively.

Discussion: Patient outcome and risk have not been considered as part of the service evaluation and would be challenging to undertake. Preliminary data of neighbouring ambulance service localities is suggestive of reduced conveyance rates of older people within the host organisations catchment area.

Conclusion: The Silver Phone Service, as an adjunct to the OPED, will contribute to a reduction in admissions to the emergency department which is known to carry risk for older people.

 

 

Introduction

The Older People’s Emergency Department (OPED) was first established at the Norfolk and Norwich University Hospital NHS Trust (NNUH) in 2016, with operating hours having gradually increased since that time. The purpose of the OPED is to provide access to an older people’s medicine (OPM) consultant at the front door of the hospital.

The OPED still falls under the emergency department footprint and is subject to national targets regarding discharge or decisions to admit within four hours of arrival, differentiating it from a frailty assessment unit. The OPED has specifically tailored its environment to cater for older people with dementia-friendly assessment cubicles, corridors and toilets. The Silver Phone Service (SPS) supplements the OPED by offering a long-armed support mechanism for pre-hospital clinicians.

The ‘silver phone’ is a service delivered by the OPM consultants leading the OPED, whereby they provide telephone advice to pre-hospital clinicians (ambulance service personnel and GPs) relating to patients over 80 years of age. The service aims to support clinical decision making around admission/admission avoidance by remotely extending access to the expertise of an OPM consultant.

It is hoped that this will reduce inappropriate admissions, thereby aiding with capacity issues within the emergency department and reduce exposure to unnecessary risks that hospital admission brings for patients, particularly those patients classified as frail. The Silver Phone Service (SPS) follows the same operating hours as the OPED (08.00-17.00 Monday-Friday, 08.00-18.00 weekends).

Background

There are numerous facets that contribute to older people being more susceptible to avoidable harm in the acute setting than younger people. Medication errors are thought to be more likely due to polypharmacy1 with timing issues specific to Parkinson’s medication also noted to have led to harm.2

Medication omission errors are highly prevalent during admission to hospital.3 Falls contribute to the risk of harm for older people with 50% of those over 80 years old suffering falls annually.4 Clegg (2013) speaks of a “vulnerable” and “fragile” system of care for older people,5 which has potential to cause harm with NHS England (2014) echoing these thoughts by stating that it is well established that patients admitted to the acute setting can unnecessarily come to harm.6

Admission to an emergency department is not a benign intervention. Numerous studies around overcrowded emergency department have been carried out which evidence alarming mortality rates for older people, Guttman’s 2011 study being a typical example that concluded that the longer the wait to be seen for the patient, the higher the seven-day mortality rate for the patient.7

Whilst access to expert decision makers within the emergency department offers a degree of mitigation to the risks outlined and reduces the likelihood of admission to the hospital, it doesn’t prevent unnecessary attendance to the emergency department. The SPS aims to positively impact the use of alternative pathways and safe discharge of care at home or in the community, as attendance at the emergency department is accompanied by an increased likelihood of hospital admission. The OPED aligns to commissioner guidance wherein they outline that acute hospital care should include access to expert decision makers at the front door of acute hospitals.6

The author can find no evidence relating to other initiatives providing a directly comparable service to the SPS. A similar type of service was established by Airedale NHS Foundation Trust in 2015, whose ‘Telehealth Hub’ provides access for nursing homes and prison to a team of clinicians, led by senior nurses.8 Within this service, they also have access to advice from acute consultants. The service is provided via video-link and outlines the importance of viewing detailed patient history during consultation, a feature that has evolved to be key for consultants providing the Silver Phone Service.

Incidents relating to falls, suspected urine tract infections, chest infections, pain management and medication queries featured in their top ten reasons for calls and these topics are synonymous with older people’s medicine. Analysing their care home data over the first two years of implementation, they evidence an impressive 35% decrease in emergency admission and 50% decrease in emergency department admissions.

The ‘Doctor First’ model is a less comparable service as it is employed in primary care, ensuring that the first patient contact is via telephone.9 However, significantly this mode of consultation is associated with a 20% decrease in emergency department admission.9 These schemes represent examples of successful services, centred around telemedicine, that have had a positive impact on the wider NHS by reducing admissions to the emergency department. Acknowledgment is made to the fact that evidence surrounding patient outcome and safety is less clear.

Methodology

The specific measures for this service evaluation were as follows:

Process measure: pre-hospital clinician questionnaire

The questionnaire was distributed via email using the SurveyMonkey platform to all staff within central Norfolk, giving 28 days to complete. The first 50 respondents were analysed using thematic analysis to determine experience.

Process measure: OPM consultant questionnaire

The questionnaire was distributed via email using the SurveyMonkey platform to all OPM consultants delivering the Silver Phone Service, giving 28 days to complete. All (seven) respondents were analysed using thematic analysis to determine experience.

Outcome measure: ‘True’ admission avoidance rate

Data was collated and recorded by OPM consultants to determine admission avoidance rate advised using Microsoft Excel spreadsheet. Using the eAudit tool of Symphony ED software, attendance to the emergency department was checked seven days following advice for all patients advised to avoid admission. Admission avoidance rate was calculated based on those advised to avoid admission and with no attendance in the seven days subsequent to advice.

The majority of questions for both questionnaires were unipolar in design. The author also included open questions so there was an element of free text. Allowing free text enables the responder to capture specific details and examples of experience, although these responses are more difficult to code and score.10 Demographic questions were included to allow
scope for more detailed analysis of certain characteristics such as experience, clinical grade and role.11

Results

Questionnaire analysis (closed questions)

The author calculated the response percentage for each closed question (bipolar/unipolar) to allow illustration in graph form. The mean of each closed question, attributing the highest number to the most positive response, is detailed below. A satisfaction percentage has been included to highlight positivity of respondents (Table 1 and Table 2).

 

Question

Mean

Satisfaction (%)

From your experience, how accessible have you found the Silver Phone Service?

3.23/4

81%

From your experience, how supported have you felt in your clinical decision making when accessing the Silver Phone Service?

3.52/4


88%

To what extent do you agree/disagree with the following statement: ‘When dealing with patient’s over 80 years old, I feel more supported in my clinical decision making during the operating hours of the Silver Phone Service’.

4.14/5

83%

Overall, how useful do you think the Silver Phone Service is in providing support to clinical decision making for pre-hospital clinicians?

3.67/4

92%

 

Table 1. Pre-hospital clinician Questionnaire, closed questions mean results with satisfaction percentage.



Question

Mean

Satisfaction (%)

How well supported by the department do you feel to provide the Silver Phone Service?

3.57/4

89%

Generally, what degree of impact does provision of the Silver Phone Service have in your ability to manage your OPED workload? (i.e. do frequent interruptions reduce your effectiveness in your OPED Consultant role)

2.42/4

61%

How frequently do you receive inappropriate calls from pre-hospital clinicians? (i.e. calls which you do not consider appropriate for support relating to safe discharge of care art home)

2.42/4

61%

When providing advice to pre-hospital clinicians via the Silver Phone Service, how confident do you feel in signposting to community services?

4.00/5

80%

How accurate do you feel data recording has been since the service began?

1.86/4

47%

How accurate do you feel data recording has been recently? (i.e. the last three months)

3.28/4

82%


Table 2. Consultant Questionnaire, closed questions mean results with satisfaction percentage.


Pre-hospital clinician questionnaire

With regards to the qualitative data, there was an overwhelming experience of ease of access to the current service but enthusiasm for the services operating hours to be extended. There are multiple requests for the service to operate 24 hours a day, seven days a week and a preference of using the service for advice, over the 111 out of hours service. Whilst the limited hours of service were viewed as a barrier to access, the craving for an extended service time should be considered a positive sign regarding the perceived value of the service. The qualitative data revealed experiences relating to consultant attitude to be mixed, with quite marked variation.

The incidence of ‘negative’ versus ‘positive’ perceived consultant attitude is equal and one example highlights the disparity by stating that “most consultants are extremely helpful but others seem resistant to discussing patient cases”. Perceived poor attitude by healthcare professionals has long been a theme of complaints with the national health service, with 72% of complaints in UK hospitals involving an element of insensitivity or perceived poor attitude.12

Overall service perception was also a theme that was mentioned frequently with pre-hospital clinicians seemingly taking the questionnaire as an opportunity to heap praise on the availability of the service. Whilst there was negative feedback relating to the approachability and attitude of the consultants, there was no negative feedback about the service as a concept. This may be influenced by the demographic that chose to engage with the questionnaire with unintentional administration bias, i.e. professional and personal traits of respondents engaging with a questionnaire disseminated electronically may not represent the workforce as a whole.13

Consultant questionnaire

Whilst feeling supported to deliver the SPS, both the quantitative and qualitative data highlights that there is a degree of impact on the consultant’s working day. The frequency of inappropriate calls to the service was a risk highlighted on the original service charter at the time of inception and the quantitative data shows the “quite frequent” option as the most common response to the questionnaire. This highlights an opportunity to provide education to the pre-hospital clinicians around when the service should be accessed. Anecdotally, phone calls are sometimes made whilst the clinician is already conveying the patient to hospital and this is supported by comments within the qualitative data.

Retrospective data

The admission avoidance rate advised vs ‘true’ admission avoidance rate was consistent. The Mean for each was 76.2% and 62.6% respectively. There have been no parameters set to quantify what is deemed as successful/appropriate. The quality indicator within the OPED standard operating procedure states that failed discharges (those that return to hospital in seven days) should not exceed 5% but it would be remiss to view those patient’s that had been advised to remain at home that were subsequently admitted to hospital as a “failed admission avoidance” in the same way that we view failed discharges. The purpose of highlighting failed discharges relate to unsafe practices, with insufficient social assessment/support one factor that may affect older people.14 An “unsuccessful admission avoidance” may be a more appropriate term in the context of this service evaluation.

Discussion

The impact on the OPM consultants working day was evident from the qualitative data. In 2019, a systematic review carried out by Stehman et al. found that emergency department physicians are particularly affected by the intensity of clinical practice and risk of litigation.15 Whilst the review also included disrupted circadian rhythms (not a factor for the OPED consultants) as a contributing factor to the risk of ‘burnout’ for clinicians, there is a strong case to argue that delivery of this service further increases this risk.

Whilst the questionnaire results can in no way be used as a tool to identify a psychological syndrome such as ‘burnout’, it does give an opportunity to acknowledge the stresses taken on by the consultants in delivering the service whilst already in a role which is emotionally exhausting.16 In view of this, it is perhaps no surprise that at times, the attitude of the consultants is perceived as hurried and dismissive as per the thematic analysis of the open qualitative data.

Although call volume was not included in the measures for this service evaluation, it is prudent to note that call volume increased significantly following communication relating to the expectation of data recording and the importance of this element to accurately evaluate the service. This was also demonstrated in the quantitative data, which shows a clear perceived increase in accurate data recording more recently.

It is also note-worthy that April 2020 saw a spike in use of the Silver Phone Service, a time when social lockdown measures were at the highest in light of the Covid-19 pandemic. Nationally, emergency department attendances fell by 57% compared to April 201917 so increased use of the service could be attributed to a combination of both clinicians and patients/family members increased desire to avoid hospital.

An aspect that has not been considered as part of this service evaluation is patient outcome and patient risk. In view of the majority of patient’s not being admitted to the hospital, undertaking analysis of patient outcome would be challenging. Those patient’s that were admitted to the hospital in the seven days following advice to remain at home, could represent a group from which more data can be drawn. Interpreting clinical information/presentation from the admission and how this relates to the advice given via telephone would be difficult due to the limited information recorded by consultants relating to their telephone discussion.

The brief nature of details being recorded could represent a risk to the hospital, should a complaint or serious incident arise from advice given by the OPM consultant. However, to date, no serious incidents have been attributed to the service which has been operating for a considerable time, so this in itself is reassuring when considering the level of risk.

Quantitative data from the pre-hospital clinician questionnaire showed a positive trend in all questions. Completion rate was poor with just 21 respondents, which falls significantly short of even the lower range of recommended completion rates for a 10 question survey. Improved engagement with the local ambulance service may have resulted in higher completion rates and identifying senior figures that can appropriately disseminate and influence staff members to complete would be beneficial.

Due to the organic nature of the evaluation, the author also collected preliminary data from the local ambulance service trust regarding conveyance rates of neighbouring localities to the emergency departments of their designated acute hospital. Although not an agreed measure as part of this review, data over a six month period showed a consistently lower ambulance conveyance rate for patients over 80 years old to the NNUH, from which the Silver Phone Service operates. The mean conveyance rate over the six month period for the host organisation was 53.79%, compared to 58.14% and 56.74% for the neighbouring hospitals. Data collection was not sufficiently valid to include as part of this literature but does represent a ‘snap-shot’ for possible future research.

Limitations

Completion rate was poor with just 21 respondents, which falls significantly short of even the lower range of recommended completion rates for a 10 question survey. Improved engagement with the local ambulance service may have resulted in higher completion rates and identifying senior figures that can appropriately disseminate and influence staff members to complete would be beneficial.

Efforts should be made for any future service evaluation to include feedback from primary care clinicians as their experiences have not been captured and are likely to represent a different picture to ambulance staff.

Conclusion and recommendations

The admission avoidance rate advised vs ‘true’ admission over the six-month period was consistent. The mean for each was 76.2% and 62.6% respectively. The Silver Phone Service, as an adjunct to the OPED, will contribute to a reduction in admissions to the emergency department which is known to carry risk for older people. There does not appear to be a truly comparable service.
The only common theme generated from the qualitative data relating to the consultant questionnaire was the difficulty in delivering the service whilst working in an acute setting, with ‘interruption’ cited as a potential risk when overseeing clinical decision making in OPED. Whilst feeling supported to deliver the Silver Phone Service, both the quantitative and qualitative data highlights that there is a degree of impact on the consultant’s working day.

Improving stakeholder engagement with the local ambulance service’s lead operations management team may help improve ambulance staff engagement with questionnaire’s in the future. Education for ambulance staff surrounding appropriate use may also help in building relationships and show-casing the service, with an advanced practitioner being capable of delivering such sessions. Covid-19 social distancing measures may hinder the ability to deliver sessions in the immediate future.

Although not part of the agreed measures for the service evaluation, data collected from the local ambulance service shows a persistent trend of lower conveyance rates to the NNUH as the provider of the Silver Phone Service, when compared with surrounding hospitals possessing similar patient and clinician demographics. Whilst the data collection process requires refinement for this particular aspect, it has potential to provide evidence for other acute hospital trusts to develop a similar service, with the Silver Phone Service having the capability to act as a ‘blue-print’ for such future service development.


Dale Gedge, Advanced Clinical Practitioner, Norfolk and Norwich University Hospital NHS Trust and PhD Student at the University of Hertfordshire

d.a.gedge@herts.ac.uk


References

  1. Koper D, Kamenski G, Flamm M, Bohmdorfer B, Sonnichsen A. Frequency of medication errors in primary care patients with polypharmacy. Family Practice. 2013;30(3):313-9
  2. Fialová D, Onder G. Medication errors in elderly people: contributing factors and future perspectives. British Journal of Clinical Pharmacology. 2009;67(6):641-5
  3. Rostami P, Heal C, Harrison A, Parry G, Ashcroft DM, Tully MP. Prevalence, nature and risk factors for medication administration omissions in English NHS hospital inpatients: a retrospective multicentre study using Medication Safety Thermometer data. BMJ Open. 2019;9(6):e028170
  4. National Institution for Health and Care Excellence. Falls in older people: assessing risk and prevention 2013. https://www.nice.org.uk/guidance/cg161 (Accessed March 2021)
  5. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752-62
  6. NHS England. Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commisioners, providers and nursing, medical and allied health professional leaders. 2014.
    https://www.england.nhs.uk/wp-content/uploads/2014/02/safe-comp-care.pdf (Accessed March 2021)
  7. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ. 2011;342(jun01 1):d2983-d
  8. NHS England. The Atlas of shared change. The implementation of Airedale NHS Foundation Trust. 2019. https://www.england.nhs.uk/atlas_case_study/implementation-of-telemedicine-at-airedale-nhs-foundation-trust/ (Accessed March 2021)
  9. NHS England. High quality care for all, now and for future generation: Transforming urgent and emergency care services in England. The Evidence Base from the Urgent and Emergency Care Review 2013.
    https://www.england.nhs.uk/wp-content/uploads/2013/06/urg-emerg-care-ev-bse.pdf (Accessed March 2021)
  10. Tsang C, Boulton C, Burgon V, Johansen A, Wakeman R, Cromwell DA. Predicting 30-day mortality after hip fracture surgery: Evaluation of the National Hip Fracture Database case-mix adjustment model. Bone Joint Res. 2017;6(9):550-6
  11. NHS England. The Change Model Guide. 2018.
    https://www.england.nhs.uk/publication/the-change-model-guide/
    (Accessed March 2021)
  12. Friele RD, Sluijs EM. Patient expectations of fair complaint handling in hospitals: empirical data. BMC Health Serv Res. 2006;6:106.
  13. Choi BC, Pak AW. A catalog of biases in questionnaires. Prev Chronic Dis. 2005;2(1):A13
  14. Ombudsman PaH. Care and compassion? Report of the Health Service Ombudsman on ten investigations into NHS care of older people. Fourth report of the Health Service Commissioner for England. 2011.
    https://www.ombudsman.org.uk/sites/default/files/2016-10/Care%20and%20Compassion.pdf (Accessed September 2020)
  15. Stehman C, Testo Z, Gershaw R, Kellogg A. Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I. Western Journal of Emergency Medicine. 2019;20(3) :485-94
  16. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. The Lancet. 2016;388(10057):2272-81

Ethics approval

Full ethical approval was not required as this service evaluation does not meet the criteria for ‘research’ but the chair of the ethical committee for the University of East Anglia (UEA) was required to authorise the project as this was the institute the author was studying with at the time.
Consent for Publication: Consent gained from the Norfolk and Norwich University Hospital NHS Acute Trust, to be provided in writing prior to publication.

Competing interests: None

Funding: None

Acknowledgments

With thanks to the Norfolk and Norwich University Hospital NHS Acute Trust for supporting me to undertake this work and the local ambulance service for assisting in questionnaire dissemination.

Datasets

Data not for public access due to confidentiality. Data collected and stored by the Norfolk and Norwich University Hospital NHS Acute Trust in line with information governance policy.