Preventing emergency department admissions for older people

Abstract

Older people are among the most vulnerable members of the community, so when this population attends a hospital emergency department (ED) with comorbidities and polypharmacy they require complex care planning. Every year it is estimated that 28–33% of over 65-year-olds and 32–42% of over 75-year-olds will fall, and associated mortality and morbidity threatens functional independence and quality of life (Royal College of Physicians (RCP), 2011). As the older population increases, it is imperative that ED discharge strategies be strengthened to prevent exponential default to hospital admission and to ensure the care needs of the elderly are planned well. The need to provide effective and compassionate care for older people was highlighted in the Transforming Emergency Care document (Department of Health (DH), 2004) which acknowledged that older people are more likely to have more complex medical and social needs such as dementia or isolation, and are more likely than younger people to be admitted to hospital from ED. Among other recommendations, the Health Service Ombudsman’s report (HSO, 2011) called for a strengthened falls care pathway to be established. The National Audit of Falls and Bone Health (RCP, 2011) established a two-fold focus: to prevent admission and to reduce length of stay when admitted. By linking acute and urgent care services to secondary prevention in this way, early intervention to restore independence may be fostered in a proactive approach. The NHS Practice Guide (DH, 2010a) set out eight mechanisms to improve the emergency care response to long-term management for older people, addressing areas including long-term conditions management, rapid access to intermediate care, falls services and stroke assessment units. A particularly important factor in preventing unnecessary admission involves thorough assessment and formulation of a robust ED discharge support plan in conjunction with the patient and carers. The Joint Statement on the Emergency Care of Older People (College of Emergency Medicine, 2011) highlights the need for EDs to be appropriately supported in the management of older people through multidimensional assessment and multiagency management of older patients. To do so requires intensive collaboration to strengthen primary and acute care interfaces. One helpful way is by working together to establish the root cause of a patient’s delay in ED. This will make it possible to identify clinical obstacles to discharge and formulate immediate actions to address the medical, social and operational reasons why specific patients were unnecessarily admitted. In another positive move, trusts are facilitating crossboundary working, whereby specialist physiotherapists, occupational therapists, social workers and nurses are situated in the ED using, for example, the Emergency Admission Risk Likelihood Index (EARLI) (Lyon et al, 2007) as an instrument to determine the default to hospital admission calculation of an individual. In this way, it may be possible to create better patient outcomes, reduce readmissions, reduce long-term care, foster patient satisfaction and reduce costs associated with long hospital stay. Deficiencies in injury and trauma rehabilitation services contribute to an extended hospital length of stay, which impacts on available beds. The DH (2010b) is currently addressing this issue to enable a workable solution to assure services beyond the in-hospital trauma trajectory. Specifically, Domain 3 of the Framework includes improving recovery from injuries, trauma and fragility fractures, and, helping ill or injured older people to recover their independence. The Royal College of Nursing Emergency Care Association has also developed best treatment standards for older people who present to EDs. The Silver Book contains standards for initial assessment of patients aged 65 and over, screening tools and recommendations on safe discharge, appropriate referral and the clinical environments in which older people should be treated. The contribution of nurses is significant in supporting safe ED discharge for the vulnerable older population. However, it is imperative that falls prevention assessment commences as a routine screening of older people while in the ED/admissions unit. Clinicians must continue to ensure that older people receive the compassionate care they require. BJCN