QUALITY STANDARDS FOR THE CARE OF OLDER PEOPLE WITH URGENT

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QUALITY STANDARDS FOR THE CARE OF OLDER PEOPLE
WITH URGENT EMERGENCY CARE NEEDS Silver
BookDR JAY BANERJEE, Consultant in Emergency
Medicine University Hospitals of Leicester NHS
Trust
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WHY FOCUS ON OLD PEOPLE?

• Increasing number of older people are accessing
  urgent care services age ?lower thresholds
• Hospital Episode Statistics indicate that
  patients over 70 years of age account for more
  than 15 of attendances
• Represent 40 of the 5 million people admitted to
  hospital in 2008/9 and increasing
• Next 20 years, people gt85 yrs set to increase by
  two-thirds, compared with a 10 growth in the
  overall population.

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ED ATTENDANCES
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FRAILTY MAPPING EXERCISE

• How does one code frailty?
• Local mapping 27,000 gt65yrs/year
• Acutely confused, care home resident, fragility
  fracture, Waterlowgt25
• 3 of total attendance, 11 of breaches in 4 hr
  target, 15 of admissions to medicine
• Spent average of 3 hrs 45 min in ED
• 93 had delirium/dementia

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EMERGENCY DATA BY AGE GROUP Leicester, 2009
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THE HEALTH SERVICE OMBUDSMANCARE COMPASSION?
Feb 2011

• The NHS must close the gap between the promise of
  care and compassion outlined in its Constitution
  and the injustice that many older people
  experience.
• Every member of staff, no matter what their job,
  has a role to play in making the commitments of
  the Constitution a felt reality for patients.

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CARE QUALITY COMMISSION. DIGNITY AND NUTRITION
FOR OLDER PEOPLE. Mar 2011

• 100 hospitals inspected
• 45 hospitals met both standards (they were fully
  compliant).
• 35 met both standards but needed to improve in
  one or both (they were fully compliant, with
  improvements suggested).
• 20 hospitals did not meet one or both standards
  (they were non-compliant, with improvements
  required).

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CQC KEY FINDINGS

• patients privacy not being respected for
  example, curtains and screens not being closed
  properly.
• call bells being put out of patients reach, or
  not answered soon enough.
• staff speaking to patients in a dismissive or
  disrespectful way.
• patients not being given the help they needed to
  eat.
• patients being interrupted during meals and
  having to leave their food unfinished.

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CQC 1 hospital visited

• On both wards we visited, people felt that staff
  did not respond to their needs quickly enough and
  one person said she can wait for up to an hour to
  have her call bell answered.
• One person said,
• I dont think they can respond quickly, they
  have so much to do, they do their best.

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LISTEN TO PATIENTS. SPEAK UP FOR CHANGE. Patient
Association. Oct 2011

• Exactly how many times is it acceptable for a
  patient to be left in their own faeces and
  urine until relatives ask for them to be
  changed?
• 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?
• How many times is it satisfactory for night staff
  to squeal and giggle while confused patients
  wander around semi naked and staff pass them in
  the corridor without a care?

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WHAT ARE THE REASONS?

• Knowledge on special consideration for managing
  older people
• Skills and competencies
• Lack of integrated working primary V secondary,
  health V social
• Cost effectiveness V clinical effectiveness
• Specialised V holistic care

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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
• guide commissioning of services for older people
  in urgent and emergency care
• support providers to deliver the highest quality
  of care for older people in emergency settings
• support development and implementation of quality
  care standards for older people
• identify and disseminate best practice
• influence policy development proactively at
  national level

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SILVER BOOK MEMBERSHIP

• Age UK
• Ambulance Services Medical Directors Association
• Association of Directors of Adult Social Services
• British Geriatrics Society
• Chartered Society of Physiotherapists
• College of Emergency Medicine
• College of Occupational Therapists
• Royal College of General Practitioners
• Royal College of Nursing
• Royal College of Physicians
• Royal College of Psychiatrists
• Society for Acute Medicine

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SPECIALIST ADVISORS

• Matthew Cooke, National Clinical Director for
  Urgent Emergency Care
• David Oliver, National Clinical Director for
  Older People
• Alistair Burns, National Clinical Director for
  Dementia

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UNDERPINNING PRINCIPLES

• 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

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STANDARDS
All older people accessing urgent care should be routinely assessed for All older people accessing urgent care should be routinely assessed for
pain delirium, dementia
depression nutrition/hydration
skin sensory loss
falls mobility activities of daily living
continence vital signs
safeguarding end of life care issues
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STANDARDS

• There should be primary careled management of
  long term conditions
• There must be a primary care response to an
  urgent request within 30 minutes
• The presence of one or more frailty syndrome
  should trigger a more detailed comprehensive
  geriatric assessment, within 4-12 hours either in
  the community, patients own home or as an
  in-patient, according to the patients needs.
  This should be carried out in an appropriate area
  in the ED, which is visually and audibly distinct
• Geriatric and psychogeriatric services should be
  commissioned such that they can contribute to
  early Comprehensive Geriatric Assessment and
  mental health assessments including self-harm

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STANDARDS

• Older people coming into contact with any
  healthcare provider or services following a fall
  with or without a fragility fracture should be
  assessed for immediately reversible causes and if
  appropriate, subsequently referred for a falls
  and bone health assessment
• Discharge to the normal residence should take
  place within 24 hours following an appropriate
  risk assessment including mobility, and risk of
  self-harm unless continuing hospital treatment is
  necessary
• A 24/7 single point of access (SPA) including a
  multidisciplinary response within 12 hours should
  be commissioned. This should be coupled to a live
  directory of services underpinned by consistent
  clinical content (NHS pathways).
• Older people who present with intentional or
  unintentional self-harm should be assessed for
  on-going risk of further self-harm in any setting
  and during transportation
• Major Incident Plans and Disaster Preparedness
  Plans need to include explicit contingencies for
  the management of multiple casualties of frail
  older people

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TRAINING DEVELOPMENT STANDARDS

• Healthcare professionals managing older people,
  irrespective of clinical setting, need the
  following mandatory skills as minimum standards
• Communication skills, often under challenging
  conditions e.g. to take a relevant history from
  the patient, listen attentively, explain things
  in more than one way, give encouragement and be
  patient
• Clinical reasoning and assessment skills in
  respect of complex co-morbidities, poly-pharmacy
  and altered physiological response to trauma and
  illness
• Risk assessment/management skills surrounding
  discharge planning with knowledge of community
  services
• Multidisciplinary team working skills
• Cultural awareness
• An understanding of relevant mental health
  legislation and guidance
• Training in safeguarding skills

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TD CONTD.

• Healthcare professionals, irrespective of
  background are also expected to display behaviour
  characterised by
• Compassion, empathy and respect for privacy and
  dignity
• Patience and the ability to build a
  rapport/therapeutic relationship quickly
• Avoiding ageism and prejudice
• Clinical champions of older peoples care need to
  be established as part of a network to facilitate
  the implementation of educational change
  management to drive sustainable whole systems
  improvement in older peoples care.

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EMERGENCY DEPARTMENT

• Post-registration modules for emergency care
  doctors, nurses and allied health professionals
  should include sessions on the needs of the older
  person accessing emergency care which includes
  the aging process, dementia, delirium, falls and
  frailty
• Emergency Nurse Practitioner/Advanced Nurse
  Practitioner/Advanced Clinical Practitioner/Physic
  ian Assistant/Consultant Allied Health
  Professional awards should also include the
  content outlined above this is especially
  important as they may be the only clinician to
  assess, plan and implement care for the older
  patient
• Clinical advocates for the older patient in
  emergency care should provide clinical updates to
  ED staff as and when necessary for instance
  following the publication of relevant guidelines.
• There should be an emergency care network of such
  clinical advocates in order to share information
  and develop new initiatives
• Universities and Emergency Departments should
  consider asking older service users to provide
  input to any education and training provided

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SUMMARY

• There is a silver tsunami on the way
• Create a frail friendly environment
• Care for older people needs to be exactly that
  and it is everyones business
• Agree on care standards commission right care
• Address staff learning needs, monitor
  performance
• Create a movement
• jb234_at_le.ac.uk