Therapy

increased social worker staffing for three months, reducing the number of delayed discharges;

extended the hours of the medical assessment unit (MAU) to screen some elderly patients from GPs and from the accident and emergency department;

developed the rapid-response nursing team enabling them to support high- dependency patients in the community who otherwise would have required an inpatient stay.

The aims were to:

enhance social worker presence during peak periods of demand, to cope with the increase in referrals to this service;

reduce inappropriate admissions by creating a gatekeeper service, which would identify patients with social and nursing needs who did not require the ongoing support of a specialist clinician;

ensure rapid access to 24-hour nursing support in the community, providing support for high-dependency patients discharged from the MAU back into their own home.

During the winter, delayed discharges and increasing admissions from accident and emergency result in cancelled surgical operations and an increase in elderly frail patients developing hospital-acquired infections. The hospital cannot accommodate more than 20 patients with a delayed discharge awaiting placement in a nursing or residential home if emergency admissions are to be managed and cancelled operations avoided.

South Essex health authority supplied pounds10,000 from the Department of Health's winter pressures money, covered increased social worker and administrative staffing during Christmas, and funded a full-time social worker for the 10-week project. This brought the hospital's social worker complement to 13 whole-time equivalents. Medical and nursing staff at ward level and other members of the multidisciplinary team commented on the ease of access and availability of the social workers.

The high referrals from January to March did not result in a delay in the provision of care packages. Before the project, the average time between a patient being allocated to a social worker and community care being provided was 16.6 days. This dropped to 13.8 days during the project.

The MAU, previously open from 9am to 5pm Monday to Friday, was open from 8am to 9pm during the project. A locum registrar was employed for the duration of the project, and the nursing staff increased from seven to eight whole-time equivalents. A geriatric consultant provided assessments with physiotherapists, social workers and nurses.

In the 10 weeks of the project an additional 109 patients, all elderly, were screened. Approximately 43 per cent were referred by GPs and 57 per cent came via accident and emergency. Of these, 71 per cent were discharged, 23 per cent needed follow-up by the MAU, 4 per cent received support services in the community from therapists, 9 per cent required district nursing support, 17 per cent required support from a rapid-response team, and 15 per cent required support from social services.

The range of diagnoses varied. Collapse, cardiothoracic problems and cerebro-vascular accident would appear to be the commonest diagnoses (see box 1). Forty of the patients were suffering from falls/collapse, pointing to the need for a special falls clinic. This would involve developing proper protocols for gait/balance and providing a screening service for carotid sinus hypersensitivity.

The second most common diagnosis was congestive cardiac failure. A service using an outreach nurse to check drug compliance and follow-up symptoms might prevent these admissions.

An audit of patients discharged from the MAU identified that 11 were readmitted, seven of whom had unrelated diagnoses. Only one had the support of the rapid-response team.

Therapy services provided support to 18 per cent of patients admitted to the unit, 17 per cent received follow-up support in the community, averaging 2.5 one-hour home visits, and 20 per cent of the rapid-response team's patients also required support from this service.

The demand for care from the rapid-response team of community nurses providing 24-hour support was not as high as initially envisaged. We thought at least five patients a week would require support, but this did not prove to be the case (see box 2). Seven of the 20 patients shown above did not have any next of kin. There were several reasons for the low level of referrals to the community team. Many patients with an acute illness who met rapid-response team criteria were discharged into residential or nursing homes. Some, although acutely ill, were discharged home with extra social back-up such as meals on wheels or help with washing and dressing, provided by the hospital social work discharge team. A small number were referred to the district nursing service for wound care etc, requiring minimal support.

Patients recovered rapidly, and said they felt this was due to being at home rather than in hospital. Schemes such as the rapid-response team may be of major benefit to patients' mental and social well being, as well as saving the hospital money by preventing admission. Patients requiring care after the withdrawal of the rapid-response team were handed to social services, district nursing or the rehabilitation team. More than a third (37 per cent) of the patients were provided with hospital transport. The cost of this was pounds4,000.

If all patients were screened by the MAU, more could be returned to the community and nursed by the rapid-response team.

It is very difficult, perhaps impossible, to calculate the likely length of stay of the 77 patients who were discharged. But if the 11 patients readmitted during the 10-week project are excluded, calculations can be made.

Seventeen of the patients were supported by the rapid-response team. The project clinician envisages they would have been admitted to the hospital's department of medicine for the elderly with an average stay of 14.5 days. So the bed days released are 246.5, an average of 3.5 a week.

The other 49 patients might have been admitted to other departments with an average length of stay of 2-6.5 days. So the bed days released are 98-318.5, an average of 1.4-4.5 a week.

This shows that five to eight beds a week may have been released by this project. If the project is developed, clinicians from across the directorates will be asked to assess assumed length of stay.

The bed days released helped the hospital deal with rising emergency admissions and with delayed discharges. The criteria used will have to be developed further to allow a full evaluation.

The project has been extended to cover this winter. The MAU has been expanded to allow an additional four to 10 patients to be screened daily, increasing the average number of patients to 24 a day. In addition, the unit is now open seven days a week. The cohort of patients will increase by 100, making fuller evaluation possible. In the first eight weeks of this year's project we have screened 250 patients, of whom 55 (22 per cent) have been admitted and 195 discharged.

The possibility of using a nurse to improve drug compliance in elderly people is being developed. We are also developing a falls service and have designed questionnaires to test GPs', patients' and carers' satisfaction with the scheme.