Karen Goudie: Older people in acute care improvement programme

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Karen Goudie

Speaking at our event on delivering integrated care for older people with frailty on 15 March 2016, Karen Goudie, National Clinical Lead of Healthcare Improvement Scotland, shares lessons from the older people in acute care improvement programme.

Karen Goudie: Older people in acute care improvement programme

Transcript

Back in 2012 when we started off we were commissioned for two years to look at what were the key areas to improve all care for older people in acute hospitals. The identification and management of delirium is one aspect of the programme, the other huge aspect of the programme is identification of frailty.  This figure, I think, is astounding, that 2% of the population use about 50% of acute hospital and community prescribing resource and about 77% of bed days.  Now, frailty is right through the middle of this figure.  So to put it simply we wanted to ensure that any over 75 year old that presented to an acute hospital was absolutely assessed for frailty syndromes and then that the care was directed that they would have a comprehensive geriatric assessment within 24 hours. 

So NHS Fife have taken quite a creative approach to frailty, frailty is absolutely a hot topic from the leadership down to the workforce delivering the care that all people that arrive in the acute hospital in NHS Fife have a frailty assessment so that age is not a component of the frailty screen at all. So all patients that enter the acute medical receiving unit within this hospital have the screen. There's also some early testing of this screening, all over 65s presenting to the emergency departments.  If there's one key think that you need in your toolkit, you need a network of clinicians that are willing to share and learn from each other.  So we have been very lucky that the clinicians have been absolutely accepting of the programme.

The scrutiny part of older people’s care in Scotland has been a driver, I have to say that it’s not the be all and end all of improvement but it has certainly got the attention of leadership. And in Scotland we have very much taken a quality improvement approach and using improvement science as our methodology.  How will we know that change is an improvement if we don’t have the data to support that.

So in Scotland were trying to train and educate as many staff as possible with an equation which Jason Leach here has very often … that no member of staff should be two steps away from someone that has expertise in QI. So in NHS Fife we’ve tried to really work around frailty as our key topic within that acute hospital.  We measured the amount of patients that were frailty positive and around 68% of all medical admissions were positive for frailty syndromes.  So we wanted to organise the team around those individuals that they would receive the right rapid assessment with the right expertise from the multi disciplinary team.

We have a frailty huddle every day at 11 am and half past two. Staff hated that initially but we use a QI approach, we started to measure things, we introduced something where staff that were involved in the delivery of care for older people actually stood together and spoke to each other about what they planned to do for their patients.  We don’t have bed managers within this team at all, we’ve been given permission, if you like, to utilise the bed base within the acute hospital and we’ve also been given permission to utilise the community hospital bed base.  So the one tells us where the patients are going, we make the decision based on the clinic assessment and the pathway that's correct for that patient.

We can also access in palliative care environments, we can also step down our patients to hospital to home where acute care delivery is delivered by nurse practitioners and geriatricians out in the community. So in NHS Five we’ve taken a bit of a risk over the last few months and used the winter capacity wards to try something new.  So we didn’t open a winter capacity ward but what we did have was a support for discharge model whereby the frailty team could access support for discharge packages not home care, but reablement packages to get people back to their own home that may well have been teed up with some hospital at home but the aim of the package was to make sure that individuals got back home with the right delivery of care in their own care setting.

What we have done is have saved an efficiency saving of around 265,000 and real savings from not opening the winter capacity wards at all. So that has created quite a lot of interest in NHS Scotland around how we deliver this elsewhere.

The average length of stay for over 65s that are transferred to medicine for the elderly that have been seen by the team, there has been some reduction in length of stay for those individuals within the specialist geriatric bed base within the hospital and the complete average length of stay for older people has come down. So our theory is that the right patients are getting to those beds rather than patients waiting for packages of care, waiting for in support in the community, or otherwise.

So I think it’s about really shifting the balance of care to what matters to that person and designing care with the person in mind and with their family in mind and what’s important to them instead of us designing care around conditions and really thinking about frailty as a whole person approach, a whole family approach.

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