Leigh Jenkins is Assistant Project Manager at the NHS Benchmarking Network. Dr. Gill Turner is a consultant geriatrician and Vice President, Clinical Quality for the British Geriatrics Society.
Wouldn’t it be great if you could benchmark the acute services provided for older people in your hospital, against others trying to do similar things? Might this be the start of a quality improvement process, allowing you to seethat other hospitals do things differently and possibly better?
This month saw the publication of a report which moved us closer to that ideal. The NHS Benchmarking Network have completed the first phase of a national benchmarking project looking at the care of older people in acute settings. Developed in conjunction with the British Geriatrics Society, the project explores the pathways that older people take through hospital by looking at four key areas of the acute pathway; admission avoidance in A&E, assessment units, inpatient care and supported discharge.
Over the course of the summer of 2014 the Network collected data from 47 Trusts and Local Health boards on a range of metrics. Within each area of the pathway the service models, activity, workforce and finance data was explored. A number of key quality and safety indicators were also collected, and participating trusts were encouraged to share any good practice and innovation that is happening locally. The findings of the first phase of the project provide a robust, up-to-date picture of the care of older people in acute settings in the UK.
We were keen to explore the availability of different teams in A&E who are dedicated to admissions avoidance. The results show that 24% of the Trusts who participated in the project have a dedicated geriatric team located in the A&E department, typically available for 9 hours per day during the week, reducing to 6.5 hours at weekends. Nearly two thirds of the 47 participating trusts have rapid access to social workers in the ED to support early turnaround and admission avoidance – whilst commendable – this means that over a third don’t have this facility- already an important comparator and a stimulus to discussion in those trusts.
We collected data on assessment units, with a particular interest in the use of Comprehensive Geriatric Assessment (CGA). 29% of participants have a frailty unit, and 90% are using CGA on the frailty unit. Senior medical cover on the frailty unit averages 13 hours per weekday, and 10hrs at weekends. It is perhaps disappointing that more than 10 % of specialist geriatric units do not provide CGA- again food for further discussion in those trusts.
77% have a short term assessment unit (up to 12 hrs expected LoS), with 44% of these performing CGA on this unit. Senior medical cover is available 17hrs per day during the week, and 6hrs at weekends. Finally, 85% report having an ‘other’ assessment unit (12 to 72 hrs expected LoS), with around a third of these units performing CGA. Senior medical cover availability averages 15.4hrs on weekdays and 14.4 hrs at weekends.
It was also found that 87% of elderly care wards deliver Comprehensive Geriatric Assessment, which reduces to just 23% of speciality wards delivering CGA, suggesting that outlying patients are not receiving CGA.
We were also interested in the staffing skill mix at each element of the pathway, particularly the nursing staffing ratio. We found a richer nursing skill mix is available at the front and back end of the hospital, with the use of unregistered nurses significantly higher within assessment units and care of the elderly wards. In the admissions avoidance teams in A&E the ratio of nurses was 80% registered and 20% unregistered, compared to 55% registered and 45% unregistered on the elderly care wards.
Excitingly the Network has already made the decision to repeat the audit this summer, and we anticipate increasing momentum with a greater number of trusts and health boards getting involved. The BGS Clinical Quality group are working alongside the project team to develop the measures of quality in several domains – we are keen to see how routinely collected data can help to assess efficiency, effectiveness and safety. We are looking at developing a Patient Reported Experience Measure (PREM) and examining how this could practically be incorporated into the project.
Data collection will open on 3rd August 2015, and is open to all member organisations of the NHS Benchmarking Network. To find out if your Trust is a member or for more information on the project please contact Leigh Jenkins of the NHS Benchmarking Network on leigh.jenkins@nhs.net, 0161 266 2113.
We don’t have all the answers – but we are starting to understand what questions we should ask. Please get involved and take a look at the report and contact us if you have things to say. We really want to hear from you.
Hundreds more metrics can be found in the full report, which can be accessed here.
British Geriatrics Society 