WHY FOCUS ON OLD PEOPLE?

1. QUALITY STANDARDS FOR THE CARE OF OLDER PEOPLE WITH URGENT & EMERGENCY CARE NEEDS ‘Silver Book’DR JAY BANERJEE, Consultant in Emergency Medicine University Hospitals of Leicester NHS Trust

2. 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 >85 yrs set to increase by two-thirds, compared with a 10% growth in the overall population.

3. ED ATTENDANCES

4. FRAILTY MAPPING EXERCISE • How does one code “frailty”? • Local mapping – 27,000 >65yrs/year • Acutely confused, care home resident, fragility fracture, Waterlow>25 • 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

5. EMERGENCY DATA BY AGE GROUP: Leicester, 2009

6. 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.’

7. 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’).

8. 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.

9. 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 don’t think they can respond quickly, they have so much to do, they do their best”.

10. 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?

11. 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 • …………………

12. 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

13. 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

14. 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

15. 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

16. STANDARDS

17. STANDARDS • There should be primary care–led 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, patient’s own home or as an in-patient, according to the patient’s 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

18. 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

19. 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

20. T&D 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 people’s 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.

21. 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/Physician 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

22. 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 everyone’s business • Agree on care standards & commission right care • Address staff learning needs, monitor performance • Create a movement • jb234@le.ac.uk