Presentation on theme: "Consultant in Emergency Medicine University Hospitals of Leicester"— Presentation transcript:
1Consultant in Emergency Medicine University Hospitals of Leicester Dr Jay BanerjeeConsultant in Emergency MedicineUniversity Hospitals of LeicesternhsManagers.net
2Older people: urgent/emergency care Over the next 20 years, the number of people aged 85 and over in the UK is set to increase by two-thirds, compared with a 10 per cent growth in the overall population.≥60 years account for 23% of attendances to the EDs and compared to the age group, are more likely to arrive by ambulance, have more investigations done and despite similar booking in and assessment times, spend a longer time in the ED.The admission rates for the over 60s is also higher compared to the years age group and they account for 43% of all admissions to hospitals in England and Wales.
4Annual costs: in £000’s/person with disease (UK, 2010) – burden of disease
5National reports NHSNHS must close the gap between the promise of care and compassion outlined in its Constitution and the injustice that many older people experience (Health Service Ombudsman, 2011)35% of inspected hospitals needed to improve, 25% did not meet 1 or 2 standards (Care Quality Commission, 2011)patients’ privacy not being respected – for example, curtains and screens not being closed properly (CQC)staff speaking to patients in a dismissive or disrespectful way (CQC)how often should a patient be told that “because of being unable to use the toilet… she should wet the bed”? Is that OK as long as it is only 10 times a month or 20? (Patient Association, UK, 2011)Francis report (February 2013)Berwick report (August 2013)
6Hospital outcomesNegative outcomes in hospital including HAI, falls, delirium, pressure ulcers, diagnostic errors, missed diagnosis, adverse drug reactions, deathNegative outcomes post discharge including high readmission rates, functional decline, death, institutionalisationReports of poor care, invasion of privacy and dignity, lack of compassionate care
7Increasing attendance to ED? While a substantial research literature describes general patterns of ED use, there is much less research on ED use as a function of other health service use. Gaps in the research literature result in a limited understanding of the full scope of the issue and opportunities for practice and policy intervention(Gruneir et al. Emergency Department Use by Older Adults: A Literature Review on Trends, Appropriateness, and Consequences of Unmet Health Care Needs . Med Care Res Rev April : , first published on September 9, 2010)
8Purpose of Silver BookDescribes the issues relating to older people accessing urgent care in the first 24 hours irrespective of providerDescribes the competencies required to respondRecommends urgent care standards for older people - first 24 hrs of an acute care episode
9Membership Age UK Assoc. of Directors of Adult SS British Geriatrics SocietyChartered Society of PhysiotherapyCollege of Emergency MedicineCollege of Occupational TherapistsCommunity Hospitals AssociationEmergency Nurse Consultants Assoc.National Ambulance Service Med. Dir.Society for Acute MedicineRoyal College of General PractitionersRoyal College of NursingRoyal College of PhysiciansRoyal College of Psychiatrists
10Silver Book: “Is” and “Isn’t” This document is a best practice guideline, comprising recommendations based on a review of the literature and refers to evidence where availableIt does not describe the commissioning and mode of delivery of the competencies, as these will vary according to local needs, resources and policiesThe older person’s care needs may be delivered in the emergency room, the acute medical unit or a community setting depending on local service configuration.
11Underpinning principles Respect for the autonomy and dignity of the older person must underpin our approach and practice at all times.A whole systems approach with integrated health and social care services strategically aligned within a joint regulatory and governance framework, delivered by interdisciplinary working with a patient centred approach provides the only means to achieve the best outcomes for frail older people with medical crises
12General Practice & GP OOH Community Support999EDAMU- Focus on Long Term Conditions (heart failure/frailty/dementia/ COPD)- More effective responses to urgent care needs- Advance care planning/end of Life care plans- Targeted input into Care HomesAccess to integrated services through NHS Pathways (3DN) including health & social careClear operational performance framework integrated with GP processesReady access to specialist advice when neededImproved integration with 1° & 2° responders via NHS PathwaysFront load senior decision process including primary care, ED Consultants& GeriatriciansInpatientwardsOptimise emergency care:- Evidence based management- Multidisciplinary input from PT / OT & community matrons- Access to intermediate and social care- Front line geriatrician input- Effective information sharing with primary care/ secondary care/ community- Develop minimum data set- Redesign to decrease LOS with social & multidisciplinary input using a “pull” system- Effective Date of Discharge- Ambulatory care (macro level) for falls/LTCObjective: A left shift of activity across the system as a function of time; yesterday’s urgent cases are today’s acute cases and tomorrow’s chronic cases.
13Whole system metricsProportion of urgent care encounters in primary care leading to a hospital attendance and separately hospital admission in people aged 65+/75+/85+ED attendance and re-attendance rate per 1000 population of 65+/75+/85+Emergency department conversion rate for people aged 65+/75+/85+ per populationHospital readmission rates for people aged 65+/75+/85+ and ED re-attendance rate for same groupRates of long term care use at 90 days post-discharge following ED attendance and discharge from hospital for people aged 65+/75+/85+Mortality rate per 1000 in the 65+/75+ and 85+Patient and carer satisfaction surveyStaff satisfaction survey
15Standards – eg.There must be an initial primary care response to an urgent request for help from an older person within 30 minutesThe presence of one or more frailty syndrome should trigger a more detailed comprehensive geriatric assessment, to start within 2 hours (14 hours overnight) either in the community, patient’s own home or as an in-patient, according to the patient’s needs
16RecommendationsGeneric – across all settings in first 24 hrs; including discharge planningSpecific – includePrimary careCommunity hospitalsED/UC/AMUMental healthSafeguardingMajor incident planningCommissioningTraining and development for all staff groups
17Staff competencies - generic Communication including listening skillsCompassion, empathy and respectClinical reasoning and assessment skillsTime/patience and the ability to build a rapportAwareness of community servicesRisk assessment surrounding discharge planningMultidisciplinary team working skillsPersonal care training skillsMoving and handling skillsBasic life support skillsAbility to balance contrasting needs of a complex person