‘Silver Book’
Jay Banerjee FRCS FCEM MSc(Ed Res)
(on behalf of the multi-disciplinary group)
Consultant in Emergency Medicine
University Hospitals of Leicester NHS Trust, Leicester, UK
Health Foundation Quality Improvement Fellow 2012-13,
Institute for Healthcare Improvement, Cambridge, MA, USA
THE FUTURE IS PREDICTABLY GREY…..
World
• Older people will outnumber children by 2018
• By 2038, over-65s > 1.3 billion (506 million in 2008) – a leap from
7% of the world's population to 14%
• Europe is the greyest continent, with 23 of the world's 25 oldest
countries
UK
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Patients over 70 years of age account for more than 15% of
attendances (Hospital Episode Statistics)
Represent 40% of the 5 million people admitted to hospital in 2008/9 –
and increasing
Next 20 years, people >85 yrs set to increase by two-thirds, compared
with a 10% growth in the overall population
Most patients are admitted to hospital via the Emergency Department
which is one of the key points in the health and social care system.
ED ATTENDANCES
THEY ARE COMING..….SILVER TSUNAMI?
EMERGENCY DATA BY AGE GROUP
NATIONAL REPORTS ON OLDER PEOPLES
CARE IN THE NHS
• THE HEALTH SERVICE OMBUDSMAN, UK
CARE & COMPASSION? Feb 2011
• CARE QUALITY COMMISSION, UK. DIGNITY AND
NUTRITION FOR OLDER PEOPLE. Mar 2011
• PATIENT ASSOCIATION, UK. LISTEN TO PATIENTS.
SPEAK UP FOR CHANGE. Oct 2011
SOME FINDINGS….
• NHS must close the gap between the promise of care and
compassion outlined in its Constitution and the injustice that
many older people experience (Ombudsman)
• 35% of inspected hospitals needed to improve, 25% did not
meet 1 or 2 standards (100 inspected, CQC)
• 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)
CAN THE FUTURE BE A BRIGHTER SHADE
– “SILVER” ?
• Prof Matthew Cooke
NCD Urgent & Emergency Care
• Prof David Oliver, NCD Older People
• Prof Alistair Burns, NCD Dementia
QUALITY CARE FOR OLDER PEOPLE
WITH URGENT & EMERGENCY CARE
NEEDS: SILVER BOOK
An intercollegiate body of work describing care
standards for older people over the first 24
hours of an urgent care episode, with the
specific remit to:
• help decrease variations in practice
• influence the development of appropriate services
across the urgent care system
• identify and disseminate best practice
• influence policy development
SILVER BOOK MEMBERSHIP
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Age UK
Association of Directors of Adult Social Services
British Geriatrics Society
Chartered Society of Physiotherapy
Community Hospitals Association
College of Emergency Medicine
College of Occupational Therapists
National Ambulance Service Medical Directors
Royal College of General Practitioners
Royal College of Nursing
Royal College of Physicians
Royal College of Psychiatrists
Society for Acute Medicine
- 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
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
• Contextualises health & social care for older people &
at the interface
• Aimed to improve satisfaction and outcomes for older
people in urgent care & satisfaction amongst staff
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.
• All older people have a right to a health and social care
assessment and should have access to treatments and
care based on need, without an age-defined restriction to
services
• 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
STANDARDS:
All older people accessing urgent care should
be routinely assessed for (based on priorities)
pain
delirium, dementia
depression
nutrition/hydration
skin
sensory loss
falls & mobility
activities of daily living
continence
vital signs
safeguarding
end of life care issues
STANDARDS
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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
Health and social services should be
commissioned such that they can contribute to
early assessment of older people, including
mental health assessments.
Older people who present with intentional selfharm should be considered as for failed suicide
RECOMMENDATIONS
• Generic – across all settings in first 24 hrs; including
discharge planning
• Specific – include
- Primary care
- Community hospitals
- ED/UC/AMU
- Mental health
- Safeguarding
- Major incident planning
- Commissioning
- Training and development for all staff groups
EMERGENCY DEPARTMENT
• The assessment area for older people should be located in a
quieter, preferably separate, area of the department where
observation is possible but noise, interruptions and over
stimulation is minimised. However, it should not be close to an
exit.
• Food and drink should be readily available; helping with
nutrition should be provided when necessary
• Clinical equipment should be kept to an absolute minimum
and where possible create an ambience consistent with the
age of the patient
• For selected older people, comprehensive geriatric
assessment should commence within 2 hours (14 hours
overnight) of access to a hospital
SUMMARY
• The ED represents a key point in the health and social
care system where older people with health & social
crises can be managed
• Create a “frailty friendly front door”
• Focus on the needs of the patient, respond to the needs
• Think outside the box – challenges are new, traditional
way of thinking would not solve it
• Commissioning the right model relevant to the needs of
the local population
• jb234@le.ac.uk