Dr Jay Banerjee
Consultant in Emergency Medicine
University Hospitals of Leicester
nhsManagers.net
Older people: urgent/emergency care
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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 21-59 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 2159 years age group and they account for 43% of all admissions to
hospitals in England and Wales.
Hospital bed use
Annual costs: in £000’s/person with disease
(UK, 2010) – burden of disease
National reports NHS
 NHS must close the gap between the promise of care and compassion
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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)
Hospital outcomes
 Negative outcomes in hospital including HAI, falls,
delirium, pressure ulcers, diagnostic errors, missed
diagnosis, adverse drug reactions, death
 Negative outcomes post discharge including high
readmission rates, functional decline, death,
institutionalisation
 Reports of poor care, invasion of privacy and dignity,
lack of compassionate care
Increasing 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 2011 68: 131155, first published on September 9, 2010)
Purpose of Silver Book
 Describes the issues relating to older people accessing
urgent care in the first 24 hours irrespective of provider
 Describes the competencies required to respond
 Recommends urgent care standards for older people -
first 24 hrs of an acute care episode
Membership
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Age UK
Assoc. of Directors of Adult SS
British Geriatrics Society
Chartered Society of Physiotherapy
College of Emergency Medicine
College of Occupational Therapists
Community Hospitals Association
Emergency Nurse Consultants Assoc.
National Ambulance Service Med. Dir.
Society for Acute Medicine
Royal College of General Practitioners
Royal College of Nursing
Royal College of Physicians
Royal College of Psychiatrists
Silver 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 available
 It does not describe the commissioning and mode of
delivery of the competencies, as these will vary according to
local needs, resources and policies
 The 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.
Underpinning 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
- 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 Homes
-Access to integrated services through NHS Pathways (3DN) including
health & social care
Clear operational performance framework integrated with GP processes
Ready access to specialist advice when needed
Improved integration with 1° & 2° responders via NHS Pathways
Front load senior decision process including primary care, ED
Consultants& Geriatricians
General
Practice &
GP OOH
Community
Support
Objective: 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.
999
ED
Optimise 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
AMU
Inpatient
wards
- Redesign to decrease LOS
with social & multidisciplinary
input using a “pull” system
- Effective Date of Discharge
- Ambulatory care (macro
level) for falls/LTC
Whole system metrics
 Proportion 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 1000
population
 Hospital readmission rates for people aged 65+/75+/85+ and ED re-attendance
rate for same group
 Rates 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 survey
 Staff satisfaction survey
Comprehensive assessment
Standards – eg.
 There must be an initial primary care
response to an urgent request for help from
an older person within 30 minutes
 The 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
Recommendations
 Generic – across all settings in first 24 hrs; including discharge
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planning
Specific – include
Primary care
Community hospitals
ED/UC/AMU
Mental health
Safeguarding
Major incident planning
Commissioning
Training and development for all staff groups
Staff competencies - generic
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Communication including listening skills
Compassion, empathy and respect
Clinical reasoning and assessment skills
Time/patience and the ability to build a rapport
Awareness of community services
Risk assessment surrounding discharge planning
Multidisciplinary team working skills
Personal care training skills
Moving and handling skills
Basic life support skills
Ability to balance contrasting needs of a complex person
Delivery
Some practice points
 Assessment of needs - individual/population
 Develop system-wide competencies - to deliver CGA
 Tailor services locally - resources, cost, availability
 Consider workforce implications
 Foster multi-disciplinary collaborative at micro, meso-
and macro- level
Moving on….
• “Acting our way into a different way of
thinking”……the Silver Book can serve as a useful
guide