Frail safe

In the rush to hit the A&E four-hour jackpot, minds are focusing on how to reduce emergency admissions among frail older people.But how to ensure that it is not at the cost of quality care?

Mary-Louise Harding reports

As the January 2005 accident and emergency target to deal with 98 per cent of patients within four hours looms ever closer, attention is once again focusing on frail older people who repeatedly show up at their local hospital accident and emergency departments.

At a recent Royal College of Physicians conference aimed at tackling the problem, emergency care czar Professor Sir George Alberti and older people's czar Professor Ian Philp led the debate on how to reduce admissions and improve the quality of care for this age group.

There was plenty of attention on efforts to improve and increase intermediate care provision.However, while some believe that much of what can be done within A&E to reduce waits has been achieved, both czars stressed that for older people specialist intervention at the emergency gateway is desirable to complement work in the community to prevent admissions in the first place.

But what are the consequences when two different policy agendas collide? Is there a danger that in the rush to hit the A&E four-hour jackpot - and there are considerable financial rewards for those that do - appropriate, patient-centred care of older people will take a back seat?

Professor Graham Mulley, consultant geriatrician at St James'University Hospital's department of medicine for the elderly in Leeds, can see where improvement might lie: 'If attempts to provide a solution that benefits the patient results in a frail older person being diverted to a specialist team, led by a consultant geriatrician in the medical assessment unit, for a comprehensive assessment that has the time and facilities it needs at its disposal, then that would be a very good thing.'

Professor Mulley says that, as a part-time community geriatrician, this is a very topical issue for him: 'I think the elegant solution would be that when an elderly person arrives at A&E with complex morbidity, as the majority do, they ought to go straight into an adjacent ward manned by all disciplines to be seen by a consultant who has access to their records.'

'If when they arrive It is clear that they have multiple pathology and are generally not robust, then they need urgent specialist assessment as there will be a large number of diagnostic possibilities. But most junior doctors are not trained to handle such cases.'

He adds that the intermediate care team and a hospital-based rapid response team with links to the community, together with a physiotherapist, occupational therapist and social worker, should be on hand to ensure a comprehensive geriatric assessment.He argues that there is scientific evidence that a rapidly deployed, consultant-led assessment is 'highly effective in improving health and social outcomes'.

'This system would offer a number of advantages. For a start it would abolish trolley waits at a stroke, and it would perhaps address the issue that is causing concern among geriatricians at the moment: older people getting prematurely diverted into intermediate care - where there is no on-site geriatrician - and subsequently deteriorating, ' he adds.

But one of the problems is that geriatricians are in short supply. Despite the increasing popularity of geriatrics as a specialism among junior doctors (a recent paper from the British Geriatrics Society reported an increase of 7 per cent a year) in some parts of the country hospitals are having difficulty filling posts.

Meanwhile, many geriatricians point out that any specialist system will fail to rise to the challenge with any finesse until the elusive electronic patient record system - promised but not yet delivered - is in place.

'When an old person comes through the door, It is important to know their history, from any special needs to their support network, ' explains East Kent Hospitals trust honourary consultant geriatrician Dr Iain Carpenter. 'If they'd had a comprehensive assessment before they arrived at the emergency door, then the triage could be done normally before handing on to the next level if a more complex referral were needed.'

Sir George agrees that shared records 'will make an enormous difference', but argues that until that point there are several factors that need to be put in place.

'We are trying to produce a better whole-system model of what should go on across the board, ' he says.

'Hospitals need to recognise that they need to provide the resources in A&E for multidisciplinary assessment at the front door, with a view to getting the majority the hell out of there.

'But the big job is stopping people arriving in the first place, by providing appropriate community-based treatment.Older people tend to be admitted because noone is sure how to treat them at home. This needs wholesystems planning and working - much better use of emergency care networks would be a tremendous help.'

A strong community care infrastructure has been essential to the success of an emergency care pilot at University Hospitals Coventry and Warwickshire trust's Walsgrave Hospital. Its rapid emergency assessment team, REACT, was celebrating recently after convincing its commissioners to make it permanent.

In 2003, in the run-up to the introduction of 'bedblocking' fines , Walsgrave Hospital's poor record on delayed discharge had attracted the attention of the Department of Health's change agent team. The REACT pilot was set up to help reduce unnecessary admissions.

However, it was different to other pilots in that the trust placed its multidisciplinary team at the front door of its emergency medical assessment unit. This is where fallers and people with chest pains or neurological problems, for example, are taken, rather than to A&E.

Although the H-grade nurse, social worker, senior occupational therapist and registered mental health nurse who make up REACT can and do deal with younger patients, nearly half of their caseload is aged over 65. Between April and December last year, more than 40 per cent of over-65s arriving at the MAU and screened by REACT (677 patients) were discharged either into intermediate care or back home with a community rehabilitation plan in place.

'Our pilot could not have worked without the excellent intermediate care infrastructure in the area, ' says project co-ordinator nurse Julie Hewitt. 'We have 24-hour district nursing services and access to beds in the community.

'In terms of quantifying our success, a lot of people ask how many more patients would have been admitted if we were not in situ.

However, a better question is how many would have been readmitted? We have a strict screening process and, initially, We are looking for signs like acute confusion, reoccurrence of falls, chest infections or urinary tract infections.

Then, for those who have more complex needs, we do the same assessment process and then expedite early referrals to other agencies such as the stroke assessment team.'

Ms Hewitt admits it would 'be lovely' to have a consultant geriatrician on hand as well, but they manage to get by with an A&E consultant who is available to them every day, and who can liaise with specialty colleagues if necessary.

Development plans include deploying a similar team within A&E, which is moving to the Walsgrave Hospital site later this year, and designing a system whereby antibiotic and intravenous therapy can be administered at home.

To contribute articles to HSJ's clinical management section, please e-mail ann. dix@emap. com

Key points

Hospitals need to strive to reduce admissions and improve quality of care for frail older people.

Dedicated units within accident and emergency offer the best hope of reducing demeaning trolley waits.

Community-based care and home treatment needs to be better co-ordinated to reduce the burden on hospitals.