Leading change

An Advanced Nurse Practitioner (ANP) in Older Persons’ Medicine (OPM) piloted and subsequently embedded a new frailty pathway within the Emergency Department at The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust (RBCH). This has decreased waiting times, supported a reduction in length of stay and improved admission avoidance.

Where to look

In 2014-15, a fifth of people admitted to hospital in England were aged 75 years and over, accounting for around 40% of all days spent in hospital. For some older people, hospital admission is associated with an increased risk over and above the presenting clinical condition (Hubbard et al, 2017). Furthermore, hospitalisation can be the initial event that heralds an intensive period of health and social care use, especially for ‘older people with frailty’, a distinctive late-life health state in which seemingly minor stressor events are associated with adverse health outcomes.

Older people living with frailty are at risk of rapid decline, deconditioning, increased risk of delirium and loss of reserve when admitted to hospital (Ellis et al., 2014, Craswell et al., 2016). Admissions for this group are associated with poorer outcomes, multiple returns, higher mortality and increased lengths of stay (Grief 2003, McCusker et al., 2013). The implementation of a complex geriatric assessment (CGA) has been shown to improve outcomes in the ED (Conroy et al., 2014, Cooper et al., 2010).

Focusing on frailty is an exercise in risk stratification – identifying a cohort at especially high risk of adverse outcomes (NHS Improvement). Turner (2014) suggests the Comprehensive Geriatric Assessment (CGA) is a key assessment process for the management of frailty in older people as it involves a holistic, multidimensional, interdisciplinary assessment of an individual and has been demonstrated to be associated with improved outcomes in a variety of settings.

What to change

Within the Emergency Department (ED) at RBCH, older patients are assessed by a medical clinician before then formally being referred to the OPM team for assessment and intervention by the multi-disciplinary team (MDT).

The OPM Advanced Nurse Practitioner identified unwarranted variation in the time for referral across the ED. Supported by the OPM and ED managers, an audit (May-September 2018) demonstrated that a patient would wait between 25-45 minutes to see an ANP and 2.5-3.5 hours to see an ED clinician, due to a range of factors.

The nurse identified that on arrival at the department, frail older patients were often triaged as being of a lower level of acuity, despite them presenting with complex co-morbid conditions, polypharmacy and requiring comprehensive assessment by a multi-disciplinary team.

This provided an opportunity to change practice, to address the unwarranted variation in practice and ensure frail older patients presenting at the department were assessed as a part of a pathway which provided appropriate advice, support and treatment.

How to change

Following discussions with managers and clinical teams it was agreed for the ANP to begin working under the governance of ED consultants as part of the initial assessing and clerking team. The ANP would assess patients with frailty at the earliest opportunity with the aim of expediting admit/discharge decisions and completing a CGA with the Older Persons’ Assessment and Liaison (OPAL) team.

The ANP led a pilot of a new ‘frailty pathway’ over a 3 month period, with regular review intervals by key stakeholders and involved close working with Older Persons’ Assessment and Liaison team. The evidence based inclusion criteria meant patients who meet the criteria for the frailty pathway included:

• Patients over 85 or 75 years old with frailty syndromes including Dementia, Parkinson’s Disease, Multiple Sclerosis (MS);
• Patients over 75 living in residential care, or with home social care packages.

To ensure safe practice the exclusion criteria were agreed as:

• Critically ill patients
• Patients without frailty syndromes, who would be referred through an alternative discipline specific pathway
• Frail patients with surgical conditions/ailments

The new service was established available weekdays, with the ANP supported and overseen for all patients by an ED consultant, to ensure safe and evidence-based clinical reasoning and decision making. The ANP identified those patients that met the frailty pathway criteria, assessed, examined, ordered investigations, interpreted results and prescribed treatment in accordance with best practice guidelines. Admission and discharge decisions were acted on accordingly.

Data collection methods were identified with the engagement of RBCH Quality Improvement and Information Team and focused on identifying:

• Time to be assessed;
• Number of patients seen by OPM ANP;
• Outcome for the patient,
• Time of referral to appropriate discharge
• Admission avoidance.

Adding value

• Better outcomes – The programme has shown a number of successes including that overall waiting times for older frail patients to be seen by a clinician in ED has decreased by approximately 2 hours 11 minutes. The OPAL team and Social Services have been able to assess patients sooner, which has decreased overall length of stay in hospital as discharge plans were implemented from the point of presentation. Furthermore, the inpatient admission length of stay has decreased by approximately 75%. Collaborative MDT practice that caters for the complex needs of the older person has also been shown to improve outcomes for those being cared for. Unnecessary admission avoidance has increased by over 50% in comparison to the same timeframe in 2017. Collaborative practice with the MDT and community colleagues enabled the ANPs to achieve more safe and effective discharges from the ED, meaning patients can return home with services and support readily available to them which they may have not had before the change.

• Better experience – Throughout the trial period there has been a decrease in the waiting time for patients with frailty to be assessed within the emergency department. This has resulted in a streamlined service for patients and ensured that they are assessed and managed with a CGA approach. Positive feedback has been received from ED staff in terms of the impact the service improvement has had; positive feedback has also been received from patients and relatives with regards to the care and treatment they have provided to older adults living with frailty presenting to the emergency department.
• Better use of resources – MDT working and liaison with community services has improved to ensure patients are adequately reviewed and supported after discharge to promote independence; to reduce the likelihood of re-attendance; and to highlight potential problems that could lead to future ED attendances. Staff have been able to support and signpost relatives to relevant services such as Dementia and Delirium Services, Social Services, Community Therapy and Voluntary Services. The reductions in inpatient lengths of stay, unnecessary hospital admission avoidance as well as streamlining of services is expected to have positive resource implications including but not limited to financial and time savings.

Challenges and lessons learnt for implementation

Some challenges included overcoming governance issues with regards to roaming prescribing rights, radiological requesting rights and referring to other specialities if patients did not meet the criteria for the frailty pathway. The APNs had to negotiate inclusion/exclusion criteria for patients that would be appropriate for them, ensuring this was communicated to all levels of staff. This required the APNs to produce, agree with key stakeholders and circulate a standard operational policy describing their working practice.

The APNs also had to learn new software and manage the time constraints associated with working in the emergency department, and integrate into a well-established team, quickly building effective and trusting relationship with all levels of staff. Through perseverance the APNs overcame these issues and integrated into the department well.

Due to the success and efficacy of the pilot, the service has now become permanent working practice within the ED, significantly improving the services for older adults.

Find out more

For more information contact:

• Nikki Dacosta – Older Persons Medicine Advanced Nurse Practitioner, The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, nikki.dacosta@rbch.nhs.uk
• Peter Keen – Older Persons Medicine Advanced Nurse Practitioner, The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Peter.keen@rbch.nhs.uk