Same day acute frailty services

Transcription

1 Ambulatory emergency care guide Same day acute frailty services Published by NHS Improvement, NHS England, the Ambulatory Emergency Care Network and the Acute Frailty Network June 2018

2 Contents Introduction... 2 Background... 2 Patient presentation... 3 Acute frailty service provision the mandate... 4 Identifying frailty... 4 Clinical Frailty Scale... 5 Assessing frail patients... 6 Geriatric syndromes... 6 STOPP START criteria... 7 Same day acute frailty metrics (for patients with moderate to severe frailty CFS 7-9)... 8 Service redesign... 8 Further information... 9 Next steps Contents

3 Introduction This document has been created by the Ambulatory Emergency Care Steering Group in collaboration with NHS Improvement, NHS England, the Ambulatory Emergency Care Network and the Acute Frailty Network as part of a series of publications supporting secondary care providers to deliver ambulatory emergency care (AEC)/same day emergency care (SDEC). This guide describes acute frailty services and supports recent publications including the AEC guide, Managing increased demand from winter illness, and as the Guide to reducing long hospital stays. Acute frailty service redesign is crucial to deliver high quality, sustainable healthcare. Rising patient demand across urgent and emergency care services means increasing admissions impact on patient flow in emergency departments (ED), increased bed occupancy and outlying patients across the hospital with an inevitable negative impact on patient outcomes and experience and increased length of stay. Trusts need support to improve quality, effectiveness and productivity across acute frailty care pathways. Background Between 5% and10% of all people attending ED and 30% of patients in acute medical units (AMU) are older people with frailty. 1 Frailty is a consequence of cumulative decline in many physiological systems over a lifetime, and is a state of vulnerability to poor resolution of homeostasis after stressor events : 2 a state of impaired resilience and recovery. Even small challenges such as a minor infection or a change in medication can have a disproportionate, sometimes catastrophic impact, on a frail person. 1 Conroy S, Dowsing T. (2013) The ability of frailty to predict outcomes in older people attending an acute medical unit. Acute Medicine 12(2):74-6. Basic D, Shanley C (2015) Frailty in an older inpatient population: using the clinical frailty scale to predict patient outcomes. Journal of Aging and Health 27: Ferguson C, Woodard J, Banerjee J, et al (2010) Operationalising frailty definitions in the emergency department - a mapping exercise. Age and Ageing 39(S1):i7. 2 Clegg A, Young J, Iliffe S, et al (2013) Frailty in elderly people. The Lancet 381: Ambulatory emergency care guide: acute frailty services

4 Not all older people are frail but the cohort with moderate to severe frailty accounts for the majority of issues and use of resource for reasons that include falls, delirium, disability, hospital readmission and care home admission. 3 In the over-75 age group, approximately 20% of patients account for 80% of such events (including patient deaths) and bed day use in that age group. 4 Identifying and targeting this high-risk cohort provides an opportunity to improve quality of care and optimise patient and service outcomes for a vulnerable population. Patient presentation People with frailty may present differently to other patients. They often have nonspecific symptoms, such as delirium, reduced mobility and falls, without the usual textbook diagnostic indicators. This should not be interpreted as a lack of seriousness or urgency it is related to underlying pathophysiological processes emerging across several bodily systems simultaneously and to communication challenges. Frail older people may also prioritise different outcomes, such as functional recovery or, in some cases, comfort over cure. Their preferences should be documented and should influence onward management. Frail patients with acute care needs are especially vulnerable to harm from delays in hospital, and to deconditioning. 5 For example, a failure to identify delirium 3 Clegg A, Young J, Iliffe S, et al (2013) Frailty in elderly people. The Lancet 381: Fried L, Tangen C, Walston J, et al (2001) Frailty in Older Adults: Evidence for a Phenotype. Journal of Gerontology: Medical Sciences 56A(3):M Boyd C, Xue Q, Simpson C, et al. (2005) Frailty, hospitalization, and progression of disability in a cohort of disabled older women The American Journal of Medicine 118(11): Covinsky KE, Pierluissi E, Johnston C (2011) Hospitalization-associated disability: she was probably able to ambulate, but I m not sure. Journal of the American Medical Association 306(16): Romero-Ortuno R, Wallis S, Biram R, et al (2016) Clinical frailty adds to acute illness severity in predicting mortality in hospitalized older adults: An observational study. European Journal of Internal Medicine 35: Wallis SJ, Wall J, Biram RW, et al (2015) Association of the clinical frailty scale with hospital outcomes. QJM 108(12): Gilbert T, Neuburger J, Kraindler J, et al (2018) Development and validation of a hospital frailty risk score focusing on older people in acute care settings using electronic hospital records. The Lancet (in press): The Lancet-D R2. 5 Platts-Mills TF, Owens ST, McBride JM (2014) A Modern-Day Purgatory: Older Adults in the Emergency Department with Nonoperative Injuries. Journal of the American Geriatrics Society 62(3) Carter EJ, Pouch SM, Larson EL (2013) The Relationship Between Emergency Department Crowding and Patient Outcomes: A Systematic Review. Journal of Nursing Scholarship 46(2): Ambulatory emergency care guide: acute frailty services

5 leading to poor oral intake and reduced mobility can result in harm such as dehydration and pressure sores which add to the primary presenting problem. Frail patients should be seen by a senior clinical decision-maker as soon as possible to improve outcomes, avoid unnecessary admissions and reduce the length of time the patient spends in hospital. Patients should be managed holistically and proactively, and transferred back to the community as soon as it is safe to do so that they do not lose the ability to care for themselves. Wherever clinically appropriate, AEC/SDEC should be provided for frail older patients. Acute frailty service provision the mandate As part of the 2018/19 ambitions set by NHS Improvement earlier in 2018 it is expected that by 31 December 2019 all Type 1 EDs trusts will provide an acute frailty service for at least 70 hours per week. This service should include input from physiotherapists, occupational therapists, case managers (typically a nurse specialist) and pharmacists to provide multidisciplinary (MDT) assessment. Regional management teams and commissioners are aware that by March 2019 the expectation is that 75% of trusts with Type 1 EDs will be delivering this service. Identifying frailty Identifying frailty must become an embedded part of the acute assessment of people aged over 65. This will enable earlier targeted assessment and intervention using Comprehensive Geriatric Assessment (CGA, see below). Assessment of frailty should involve all multiprofessional teams across an organisation. Bernstein S, Aronsky D, Duseja R, et al. (2009) The effect of emergency department crowding on clinically oriented outcomes. Academic Emergency Medicine 2009;16(1):1-10. Pines J, Pollack C, Diercks D, et al (2009) The association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain. Academic emergency medicine 16(7): Gill TM, Allore HG, Holford TR, et al (2004) Hospitalization, restricted activity, and the development of disability among older persons. Journal of the American Medical Association 292(17): Kortebein P, Symons TB, Ferrando A, et al (2008) Functional impact of 10 days of bed rest in healthy older adults. Journals of Gerontology A: Biological Sciences and Medical Sciences 63(10): Ambulatory emergency care guide: acute frailty services

6 Clinical Frailty Scale The Clinical Frailty Scale (CFS) is a quick and simple tool describing degrees of frailty based on symptoms and functional status. Patients scoring 1 are very fit, active and independent during a hospital admission their aggregated risk of death is 2%. Patients scoring 4 6 are vulnerable but with a mortality risk of less than 6%. Patients scoring 8 are very severely frail and completely dependent, with an aggregated risk of death of 24% during that hospital admission. Patients scoring 9 are terminally ill with a life expectancy of less than six months. Such scores are insufficiently precise for individual prognostication but can help in identification and risk stratification. Figure 1 Suggested uses of CFS in clinical and disposition decision-making Category CFS score Clinical considerations Robust 1-3 Usual care pathway, including specialist care referrals if indicated Mild frailty 4-6 Screen for presence of geriatric syndromes, refer onwards if identified (usually as outpatient) Moderate to 7-9 Geriatric syndromes severe frailty highly prevalent, ensure holistic care available, end-of-life scenarios common Disposition considerations Driven primarily by primary presenting problem Consider case management in discharge planning to reduce the risk of readmission Services able to deliver Comprehensive Geriatric Assessment (in hospital or at home) 5 Ambulatory emergency care guide: acute frailty services

7 Assessing frail patients Isolated medical interventions alone do not optimise outcomes for older people with frailty a more holistic, multidimensional care model is required. Comprehensive Geriatric Assessment (CGA) is a structure for the thorough assessment of a person s medical, psychological, functional, social and environmental circumstances and needs. It has been shown to improve patient and service outcomes, 6 and increase the likelihood that patients survive and are in their own homes at 3-12 months after discharge. 7 CGA is no longer the province of geriatricians only, increasingly acute and emergency physicians are developing geriatric competencies. Geriatric syndromes Geriatric syndromes are clinical presentations particularly common in moderate to severely frail people. They include falls, immobility, delirium, dementia, depression, and incontinence. These syndromes must be managed proactively from the start to prevent them contributing to morbidity, prolonged hospitalisation or even the patient s death. Frail older people usually present with a range of issues, not just medical, and require a thorough, multidisciplinary management plan. They will often have pre-existing functional impairment which will be further affected by acute illness, particularly if there has been a delay in presenting to ED or after enforced bed rest. A period of rehabilitation will often be needed, ideally in the patient s own home. 6 Baztan JJ, Suarez-Garcia FM, Lopez-Arrieta J, et al (2009) Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis. British Medical Journal 338(jan22_2):b50-. Silvester KM, Mohammed MA, Harriman P, et al (2014) Timely care for frail older people referred to hospital improves efficiency and reduces mortality without the need for extra resources. Age and Ageing 43(4): Ellis G, Gardner M, Tsiachristas A, et al. (2017) Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2017(9):CD Ambulatory emergency care guide: acute frailty services

8 STOPP START criteria The Screening Tool of Older People s Prescriptions (STOPP) is used in older people to identify potential medication-related patient safety incidents, for those patients on multiple medications (polypharmacy) or with long term conditions (LTCs). The Screening Tool to Alert doctors to the Right Treatment (START) address potential errors, omission or underutilisation of medication. Frail patients often, though not invariably, have multiple comorbidities, with the consequent iatrogenic (illness caused by medication, examination or treatment) risks of multiple medications. Always consider opportunities for de-prescribing: you may find the STOPP-START criteria a useful tool: 8 STOPP criteria medications are significantly associated with harm, eg adverse drug events. [vi] STOPP/START criteria as an intervention applied at a single time during hospitalisation for acute illness in older people significantly improve medication appropriateness [vii], an effect that is maintained six months after the intervention. STOPP/START criteria as an intervention applied within 72 hours of admission significantly reduces adverse drug reactions (ADRs) (with an absolute risk reduction of 9.3%; number needed to treat = 11; which means that for every 11 patients assessed and managed using the tool, one ADR will be avoided). It also reduces average length of stay by three days in older people hospitalised with unselected acute illnesses. As well as rendering the person vulnerable to minor stresses, the altered homeostasis (regulation of functions of body systems) of frailty affects drug handling. When introducing new medications, start low, go slow. 8 O Mahoney D, O Sullivan D, Byrne S, O Connor M, Ryan C & Gallagher, P (2015) STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age and Ageing 44 (2): Ambulatory emergency care guide: acute frailty services

9 Same day acute frailty metrics (for patients with moderate to severe frailty CFS 7-9) Metric 1: Identification. Older people (65+) presenting to acute services (ED, AMU, AEC/SDEC) by ambulance should be identified using the Clinical Frailty Scale within 30 minutes of arrival (to align with the start time for the four-hour A&E standard). Metric 2: Response to Identification. Frail older people (65+) presenting to acute services should be screened for geriatric syndromes within an hour of being identified as having a CFS of 7 or above; documented consideration of end-of-life care should also be routine. Metric 3a: Action response during core hours. An MDT capable of assessing and managing geriatric syndromes should be available 10 hours a day, 7 days a week. This will promote same day emergency care and reduce time spent in hospital. Metric 3b: Action response outside core hours. Frail older people presenting and admitted outside acute frailty service hours should be reviewed by the frailty team by noon the following day. Metric 4: Decision-making. The MDT input should be recorded in the clinical management plan, incorporating all five domains of the Comprehensive Geriatric Assessment (medical, cognitive/psychological, functional, social and environmental problems). Service redesign Assessment and treatment areas should be frail-friendly. Environmental adaptations should include: non-glare lighting access to visual and hearing aids and large print signage and information non-skid flooring and handrails when and where possible a calm environment with reduced background noise staff trained and geriatric medicine champions appointed to promote goldstandard care. 8 Ambulatory emergency care guide: acute frailty services

10 Further information The British Geriatric Society has developed: a commissioning guide to support the design of services, which can be found on the website. an interactive service-level self-assessment toolkit available soon on the website. More information on frailty is available from: Acute Frailty Network: British Geriatric Society: Next steps We want this guide to develop and reflect best practice nationally share your examples with: england.urgentcarereview@nhs.net. 9 Ambulatory emergency care guide: acute frailty services

11 Contact us: NHS Improvement Wellington House Waterloo Road London SE1 8UG improvement.nhs.uk This publication can be made available in a number of other formats on request. NHS Improvement June 2018 Publication code: IG 23/18