Autumn Speaker Series: Exercise during periods of decompensation. What is the current evidence?

Stephen Lim is a Clinical Research Fellow and a Specialist Registrar in Geriatric Medicine in Academic Geriatric Medicine at the University of Southampton. His research interest is in physical activity and deconditioning in hospital. He will be speaking at the upcoming BGS Autumn Meeting in London. He tweets at @StephenERLim

Hospital-associated deconditioning is high on the agenda across hospitals in the UK and many hospital trusts have jumped on the ‘endPJparalysis’ bandwagon to encourage patients to get up and get moving, – and rightly so! It is encouraging to see that healthcare professionals and non-clinical staff members are increasingly aware that prolonged bedrest and immobility is bad medicine.

During an acute illness, older people are at risk of worsening sarcopenia and consequently a decline in physical function. The hospital environment, altered mental state, physiological stresses and poor nutrition (as a sequelae of the acute illness), are some of the important risk factors contributing to a loss of function. Continue reading

Dying with dementia – we need to measure more than the place of death

Katherine Sleeman is an NIHR Clinician Scientist and Honorary Consultant in Palliative Medicine at the Cicely Saunders Institute, King’s College London. In this blog she discusses her paper Predictors of emergency department attendance by people with dementia in their last year of life: Retrospective cohort study using linked clinical and administrative data. She tweets @kesleeman

Over the past decade there has been a strong policy focus in the UK and elsewhere on dying out of hospital as a marker of good quality of end of life care. We have previously shown that, for people with dementia, hospital deaths have fallen over this time period, possibly as a result of these policies.

However, it is increasingly recognised that the place of death is an imperfect proxy for the quality of end of life care, providing little more than a snap shot of where a person was in their last moments. Continue reading

Autumn Speakers Series: A glimpse into the future of acute care for older people; innovation, connectivity, transformation

Professor Roger Wong is Executive Associate Dean, Education in the Faculty of Medicine, University of British Columbia (UBC). He is a consultant geriatrician at Vancouver General Hospital, where he founded the Acute Care for Elders (ACE) unit that is replicated across Canada and internationally. He tweets at @RogerWong10 and is a key opinion leader in geriatrics and ageing. In this blog article he discusses the determinants that can transform the future of acute care for older people. He will be speaking at the upcoming BGS Autumn Meeting in London.

For all of us who work with seniors in the hospital setting, we often wonder what the future holds for acute care for older people. While our crystal ball may appear blurry on some of the exact details, we can certainly take a sneak preview now on three determinants that can change and shape the future of acute care geriatrics.

First, disruptive innovation in the medical sciences has already begun to transform the delivery of healthcare in seniors. Take cancer for example, which affects a significant number of older people every year. Continue reading

Do attitudes toward older patients even matter?

Rajvinder Samra is a Lecturer in Health and Social Care at The Open University. She is interested in healthcare professionals’ attitudes towards older patients. If you’re interested in this topic at all, get in touch with her at Rajvinder.samra@open.ac.uk

doctorDoes it matter if doctors like older patients? Is there any point in working out if doctors have positive or negative attitudes towards older patients? Surely it’s irrelevant because doctors are professionals that can separate their personal and professional feelings. Maybe they can, but that’s not the point as to why these questions are important.

The US has a long history of looking at medical students’ and doctors’ attitudes towards older patients and seeing if this is related to their likelihood of working in specialties like geriatrics. It seems like you are more likely to consider geriatrics if you have more positive attitudes towards older patients than people with more negative attitudes. Well, that seems obvious, doesn’t it? Continue reading

Patients don’t just have dementia

Beverley Marriott is Birmingham Community Healthcare Foundation Trust Nurse Practitioner – Community Matron based at Heart of England Good Hope Hospital. She is currently undertaking a Fellowship in Older People at Kings College London. Here she reminds us that we need to see the whole person when looking at someone with dementia.

medical-pillsMany of us work within dementia care on a daily basis. As a community matron on an AMU department supporting safe and timely discharges for patients with dementia, I understand the importance of getting it right and what happens when we get it wrong.

Dementia has reached a critical point – over recent years the government has seen improvements in diagnosis, raising public awareness and promoting dementia friendly settings. However to deliver this level of improvement requires, time, resources and focus.  Continue reading

Benchmarking Older People’s Care in Acute Settings

Lindsey Ashley is the Communications Manager for the NHS Benchmarking Network and is a strong advocate for benchmarking our NHS services.

acuteIt is recognised in the NHS and the media that older people are a major service user cohort for health and social care services, both in hospital (the acute setting) and in the community. It is well described that the population is ageing, as people are living longer, and as a result, there are more older people as a proportion of the overall population. Whilst overall life expectancy is rising, there are also significant inequalities across the country in terms of life expectancy. Continue reading

Why rehabilitation must be part of acute care

Kenneth Rockwood is Professor of Medicine (Geriatric Medicine & Neurology) and consultant geriatrician at Capital Health in Halifax, Nova Scotia, Canada and Honorary Professor of Geriatric Medicine at the University of Manchester.

Many older people leave hospital frailer than when they started. Some of that is preventable, but much of the damage done by acute illness is baked in to how frailty works. Some of it is reparable. That is why rehabilitation must be part of acute care: if we cannot prevent damage, we should at least treat it, especially damage that we inflicted unnecessarily.

The gist of it is easy enough. When frail patients are unwell enough to come to hospital, they typically are not thinking, functioning and moving like they were before they became ill.  That is usually why they come. That, and whatever other symptoms (breathlessness, pain, something red or swollen) signal a problem.  Even when fixing the precipitants, modern care often does nothing to address the worse thinking / mobility / function in which the problems were packaged.  Such complexity of need defines frailty.

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The contribution of intermediate care to crisis response and acute admission avoidance in Catalonia

Inzitari Photo carnetMarco Inzitari is a geriatrician and Director of Healthcare, Research and Teaching at Parc Sanitari Pere Virgili, Barcelona, and Associate Professor of Medicine at Universitat Autònoma de Barcelona. Here he descibes “Subacute Care Units” which have been set up in Catalonia. He tweets @marcoinzi

An “unbelievable pressure on acute hospitals, with winter on its way…the rapidly ageing population and the increasing number of people with complex long-term conditions, frailty or dementia” describes the English healthcare situation, according to David Oliver’s recent post for The Kings Fund.

This scenario perfectly fits the reality of Catalonia, Spain. A predominantly bed-based intermediate care system is well established in Catalonia: aside from the traditional aim of facilitating early discharges from acute wards, new pathways have been implemented to reduce the pressure on acute hospitals and avoid unnecessary hospitalisation for older patients.

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NHS Benchmarking Network publish older people in acute settings results

7382c36aab90e284dc2b6bbbb705b0f0_400x400Leigh 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.

Identifying health and social care costs for older people

queueRachel Elliott and Matthew Franklin are reporting on behalf of the Medical Crises in Older People (MCOP) research team at the University of Nottingham.

As part of a programme developing and evaluating care in older people, our team wanted to know the distribution of health and social care costs of older adults discharged from Acute Medical Units (AMU) in England across six care services (primary care, hospitals, intermediate care, mental healthcare, social care, and the ambulance service). This is the first study to do this in England.

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