Acute Frailty Pathway Royal Berkshire Hospital Dr Paul Wearing Consultant Interface Geriatrician Royal Berkshire NHS Foundation Trust “Working together to provide outstanding care for our community” Approx 500,000 patients in Berkshire and South Oxfordshire. 5 different Unitary Authorities & at least 6 CCGS Average of 1200 patients over the age of 75 attend ED every month. 130 Elderly Care beds across 6 wards. Approx 30 new elderly care admissions every twenty-four hour period. 2 Acute Frailty at the Royal Berks Emergency Department New Frailty Service & ED OT Team ECPOD Interface Geriatrics RACOP (& RACU) FFR RRAT Elderly Care wards Hip fracture unit & HFESD 3 RBH Acute area Emergency Department (27++) Ambulatory Emergency Care Unit ED Obs Ward (8+) Short Stay Unit (22) Acute Medical Unit (39) HMU (4) Older people in E.D. at RBH >300 patients per day 60 patients in ED at one time every day Only 27 bed spaces Priority to critically unwell, trauma, sepsis, stroke, chest pain Older patients attending ED increased by 25% in 4 years • Conversion rate >80% E.D. Obs ward – supposedly low risk patients only • Difficult to achieve • Admission rate 20% 5 RBH E.D. Clinical champion leading service improvement – Increased cognitive assessments – Enhanced medication in Parkinson’s disease – (identification & administration) New Frailty Friendly Front Door – Frailty screening/identification – Frailty Practitioners 6 The Frailty Friendly Front Door has gone live! Frailty Practitioners are now in the Emergency Department Bleep 579 8am – 8pm, 7 days a week The team will be carrying out parallel assessments alongside the Emergency Department doctors, to expedite prompt discharge home and/or referral to alternative pathways, for patients living with frailty. 7 THINK FRAILTY ON ARRIVAL IN ALL over 65s EDOT Emergency Department Occupational Therapy RRAT RACU Rapid Response and ED Rapid Access Treatment in Care Unit Care Homes Emergency Department RACOP Falls Rapid Access Clinic Clinic for the Older Person THINK 5 TO GET HOME FIRST 8 What has been achieved? BEFORE AFTER ED (USING FRAILTY FLAG from 14th Dec) VARIANCE 14th Dec to 7th Jan 8th Jan to 8th March Attendances (ave day) 22.1 22 -0.1 Re-attendances (ave day - within 72 hours) 5 2.5 -2.6 Re-attendance Rate (within 72 hours) 22.8% 11.2% -11.6% Average Length of Stay in ED (mins) 272 237 -35 9 Frailty Practitioner Activity Number of patients seen 10 12 14 16 18 0 2 4 6 8 02/01/2018 04/01/2018 06/01/2018 08/01/2018 10/01/2018 12/01/2018 14/01/2018 16/01/2018 18/01/2018 20/01/2018 22/01/2018 24/01/2018 day per seen Patients Practitioners: Frailty 26/01/2018 28/01/2018 30/01/2018 01/02/2018 03/02/2018 05/02/2018 07/02/2018 09/02/2018 11/02/2018 Date 13/02/2018 15/02/2018 17/02/2018 19/02/2018 21/02/2018 23/02/2018 25/02/2018 27/02/2018 01/03/2018 03/03/2018 05/03/2018 07/03/2018 09/03/2018 11/03/2018 13/03/2018 15/03/2018 17/03/2018 19/03/2018 21/03/2018 23/03/2018 25/03/2018 27/03/2018 29/03/2018 31/03/2018 10 Emergency Department Occupational Therapy Team (EDOT) ➢ Occupational Therapy cover 9am – 9pm, 7 days/week ➢ Physiotherapy cover 8am – 4.30pm, Monday to Friday (AMU/SSU) ➢ Review 10 – 18 patients daily ➢ Work closely with Frailty Practitioners ➢Along with ECPOD & Interface teams ➢ Access to home & bed based intermediate care ➢ Approx170 admissions per month avoided EDOT Activity by Type ED OT Total Patients Discharged (admissions avoided) Unable to Discharge (no community capacity) Unable to Discharge (no SS capacity) Referrals to Community Services Referrals to Social Services 0 20 40 60 80 100 120 140 160 180 Average per Month Acute Medical Unit (AMU) 39 bedded admission unit o With HMU (4 beds) Alongside Short Stay Unit (SSU) Integrated unit with Acute Physicians & Geriatricians Dedicated therapy team Daily MDT board round Daily specialty visits o Cardio, Resp, Gastro, Oncology, Neuro Elderly Care Physician Of the Day (ECPOD) 8am – 8pm every day See all new Elderly Care admissions Advice & guidance for ED & GPs Review RACOP patients Provide senior cover to elderly care wards at weekends Medical admissions allocated to Elderly Care Physician on basis of need – triaged by admitting juniors Interface Geriatrics Daily consultant led input to AMU & SSU Support & enhance ECPOD service Liaison with ED, downstream wards, community CGA etc Signpost & liaise with community teams/services/geriatricians Introduction of service associated with LOS reduction Expansion of service limited by recruitment Number of Patients (over 85) Avg Los 500 11 UCL=10.923 1 UCL=466.6 450 s 10 t n e i t _ a s P X=9.206 y f 400 a 9 _ o D r X=384.8 e b m u N 350 8 LCL=7.490 LCL=303.1 300 7 4 6 8 0 2 2 4 6 8 0 4 6 8 0 2 2 4 6 8 0 /0 /0 /0 /1 /1 /0 /0 /0 /0 /1 /0 /0 /0 /1 /1 /0 /0 /0 /0 /1 4 4 4 4 4 5 5 5 5 5 4 4 4 4 4 5 5 5 5 5 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 FinMnth FinMnth Seeing more patients, and they stay less time… Rapid Access Clinic for the Older Person (RACOP) 4 clinics per week (15 patients) MDT approach: – Registrar led with Consultant review – Nursing, physio & OT input Telephone/bleep referral introduced Transport limits access to clinic Weekly dedicated MDT Falls Clinic New RACU set up in Community Hospital in Henley Falls and Frailty Response Service (FFR) Joint initiative with South Central Ambulance Service. Blue light response service, working Sat/Sun/Mon 7am-7pm. OT and Paramedic working together to assess older patients who have fallen at home. Pre-hospital assessments and functional/cognitive assessments. Equipment/pendant alarms provided. Care packages adjusted. Onward referrals to community services, voluntary sector, RACOP, Falls Clinic, GP/OOH. 18 FFR Aim to reduce unnecessary conveyance to A&E and treat older people living with frailty in their own home. Between October 2017 and March 2018 attended 169 patients with a non-conveyance of 74% (26% of patients conveyed to hospital). Therefore 125 patients being seen, assessed and treated at home 44 patients required transport to hospital • reasons included sepsis, ? #NOF, fall with long lie, head injury on warfarin RAPID RESPONSE AND TREATMENT (RRAT) FOR CARE HOMES Initial attempt to set up “Hospital at Home” Aim to reduce admissions or LOS 7 day service: 8 am to 8 pm Initial care home inclusion of the 15 highest for calls, conveyance, A&E & admissions MDT (with Pharmacy) & Community geriatrician specialist input Pilot: Reduced ambulance calls & admissions Now all care homes in Berkshire West RRAT CGA and ACP in the Care Home “Admission avoidance” with iv therapy Capped rise in 999/A&E/Non-elective admissions 984 patients seen by RRAT team Meds management is a saving of £100 per patient – 37 care homes reviewed – Estimated regional saving approaching £400,000 21 Elderly Care wards Dementia friendly wards Daily MDT board rounds Open Visiting Enhanced Recovery programme Dedicated Hip Fracture Unit With new Early Supported Discharge Orientation Before & After Day rooms Hip Fracture Unit 24 bed unit created following bed remodelling Improved pathway in which patients are admitted direct to the unit from ED Raised awareness with bed management, ED and throughout the hospital Reduction in LoS from 19.4 to 15.2 days A successful business case for a new Specialty Doctor for the unit Winning the 2016 HSJ Value Award 26 Hip Fracture Early Supported Discharge CEO’s Transformation fund 2017 Targeting DTOCs on Hip Fracture Unit Outreach Service to ‘Bridge the gap’ in patient’s homes until community services commence First month launch – 20 patients, total of 47 bed days and 80 community care calls saved Aiming for 3 day ↓ in NOF# LOS (currently 13.2) The future ?Expand the service across clinical areas – include more members of the MDT Future plans in Reading ➢ Review of Acute Medical Pathway ➢ Digital Hospital Programme ➢ Enhanced Pharmacy support ➢ Expanding Interface Geriatrics ➢ Connected Care Portal ➢ OPAL for medical wards ➢ Telephone advice – GP/ED 28 Questions? 29.