Spencer Winch is a specialist paramedic in urgent care and a trainee advanced clinical practitioner in emergency care. He has a special interest in falls and care of the frail older patient and his time is currently split between the ambulance service, the local emergency department and a masters degree in advanced clinical practice. @spencerlwinch
Anna Puddy, Kate Ellis, Gill Carlill, Josie Caffrey, Claire Wiggett and Moyra Pugh are all advanced hospital based occupational therapists specialising in emergency, acute and elderly care. @TheRealAnnaPud, @OTMoyra, @CaffreyJosie
With falls in patients over the age of 65 making up 8.5% of the emergency workload locally, paramedics and the ambulance service have found themselves in a prime position to assess, treat and discharge this cohort of patients pre-hospitally. This upholds Keogh’s vision that care and treatment should be delivered closer to home without the need for hospital, and is being achieved by ambulance crews on a daily basis as highlighted in a consultant paramedic colleague’s (NWAmb_Duncan – link to BGS blog) recent blog. Higher education and degree based programmes for the paramedic profession now encourage more thorough assessment of injury and illness and thoughts around causative factors of falls, length of lie and potential for acute kidney injury. Those that are discharged on scene are then flagged to the community falls prevention teams for mobility, functionality and care assessment provided by nurse and therapists. With increasing demand on all NHS healthcare agencies, these assessments are not instantaneous and literature would suggest that those who have fallen, are likely to fall again within 24 hours without immediate intervention. New Trauma Audit Research Network (TARN) data also shows the majority of major trauma has shifted demographic to our older patients who fall less than 2 metres sustaining significant injury. With this in mind, early falls prevention assessments become imperative to prevent serious injury and admission where the frail older patient becomes disorientated, deconditioned and at risk of further falls.
A gap in the care of the elderly faller became apparent and helped form the basis of a proposal. Could these assessments be performed proactively by creating a collaborative response of specialist paramedic and occupational therapist (OT) to respond to the 999 call in place of a normal ambulance response? With access to PGD medication and enhanced assessment, wound care and catheter care skills, the specialist paramedic became the ideal clinician. Clinical assessment could then be complimented/supported by OT input with provision of equipment, aids and extra care making the patient safe and functional in their own environment.
Locally this was a new concept but nationally this was by no means a novel idea and it is at this point a ‘cap is doffed’ to all other projects nationwide who have struggled through commissioning and start up, and who justify their funding with continual supportive data. Each project is slightly different, some 5 days a week others 3 days, some with physiotherapist rather than OT, some reactive some proactive, but each unique and invaluable to the frail older patients within the communities they serve.
The idea became part of a QIP supported by Health Education England (Thames Valley) and the backfill funding of OT’s to facilitate release from a local acute trust came via a presentation to a room full of nodding local commissioners who could not believe this idea was not in place already. There was no challenge, condition or target from commissioners or ambulance directorate and the whole process refreshingly pain free. But then why would it be? This bespoke response made complete sense and met multiple NHS England high impact interventions including falls, frailty and admission avoidance. The proposal also held weight with the support and backing of local consultant geriatricians who gave the project direct access to falls clinic and a rapid access clinic for the older person appointments which were usually only afforded to the medical profession. The idea had now become a reality and a one day a week, 50-week pilot project was underway to gather data and show impact.
Since September 2015, the ‘Falls and Frailty Response (FFR)’ has been operational every Saturday between 0700 and 1900 selecting and responding acutely to incoming 999/111 calls for people over the age of 65 who have fallen in their own home. This is a primary blue lit response in place of a normal ambulance response and the project has now seen 220 patients with 150 discharged on scene. As the pilot finishes we will have probably seen 80 less patients than predicted as the complexity and time consuming nature of some of the cases had been underestimated. The project has achieved a 68% non-conveyance (or 32% conveyance rate) and overall improvement on a normal ambulance response of 15.3% (ambulance conveyance rate 47.3% for over 65’s that have fallen locally). 14,67% (22 of 150) of patients that were discharged at scene have called back within 7 days of FFR visit for another fall. This re-contact rate was initially worrying until reassured by senior colleagues that this was quite a low percentage. When dealing with the frail older patient, re-contact or readmission to hospital often occurs as solving one problem often exposes another.
For nearly a year the project has been attending frail fallers assisting them up from the floor assessing injury/illness, closing wounds, treating minor infection and then assessing mobility, function and care. Geriatrician colleagues will be pleased to know that very few urine samples were dipped, and only 2 patients of 139 were provided with antibiotic coverage for urine infection (there…I did listen to my geriatrician mentors). This may astound a very small corner of the ambulance world who still believe every older patient that falls has a uti.
From our vehicle we have been able to immediately supply new walking aids, chair and toilet raisers, commodes and grab rails to be fitted within a few hours. Time has been spent reassuring patients and their families and new care packages have been initiated and existing ones upgraded. Pendant alarms have been supplied, installed and activated for our more isolated patients providing further reassurance. Medically complex patients have been referred to outpatient clinics, rather than emergency departments, to be seen by and reviewed by specialist doctors in care of older patients. Even those patients that have needed to be admitted have benefited from this bespoke response. The OT’s have been able to commence discharge planning on scene having viewed the home environment, and with discussion with hospital based colleagues, expedite the patient journey back home.
For the FFR team, the fact that the project not only makes sense, but is now also able to show improvement on the current standard, is an absolute bonus. Our ultimate aim has only ever been to improve the patient experience and to keep our frail elderly patients as safe and as independent as possible preventing the acute, and any subsequent admission from falls. This has been achieved in no small part by the input of the occupational therapists and their partnership in this project has led to its success. The work of therapists often may often go unnoticed but their presence on this project has opened the eyes of ambulance colleagues to the important work and interventions they provide.
A bespoke emergency response to frail older falls makes perfect sense and works…Here’s hoping the funding can be found to extend and continue this front line service.