Blue Ribbon Patient: Do Not Transfer

Rick Strang RN is Emergency Care Improvement Lead at Isle of Wight NHS Trust in England. When not involved in all types of emergency care Rick is usually finding innovative ways to avoid household chores.

Most of us across acute care have been involved in late night bed pressures that call for that dreaded decision to need to move some patients around between wards. Typically we see the only beds available to be surgical ones whilst the demand is for acute medical beds. Moving acute medical patients directly to these outlying beds from the emergency department (ED) may present too much of a risk. Lower acuity patients from acute wards are therefore often sought out to be transferred into these surgical beds thus making way for the more acute ED demand. End of Life (EoL) patients seem particularly at risk of being moved, which can be very distressing for families, friends, the patient and the care teams.

Choosing the right care for people from nursing homes: Hobson’s Choice, Morton’s Fork or Buridan’s Ass?

Glenn Arendts is Associate Professor in Emergency Medicine at the University of Western Australia and Chair of the Geriatric Special Interest Group of the Australasian College for Emergency Medicine. He writes about his Age & Age paper. 

Hobson’s Choice: A choice where there is really only one option
Morton’s fork: A choice between two equally unpleasant alternatives
Buridan’s Ass: A hungry donkey placed equal distance from two identical bales of hay cannot use reason to choose between them, and so dies of hunger

Take a straw poll of hospital emergency department (ED) staff and you will find majority support for the following statement: “too many people from nursing homes are sent to the ED”. That your poll results may say something about the views of some hospital staff toward nursing home (NH) residents is immaterial. Acute medical care of dependent people with life limiting illness is an area of legitimate concern, and the prevailing orthodoxy is that ED is a less than ideal place to deliver it. For decades, health services have invested in a variety of programs and interventions to reduce the transfer from NH to ED.

A Bespoke Blue Light Response to Frail Older Fallers: Makes Complete Sense – But Does It Work?

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.

Systematic review of Emergency department community transition strategies

Judy Lowthian is a researcher at Monash University’s School of Public Health and Preventive Medicine. Here, she discusses a new systematic review published in Age & Ageing, which looks at various emergency department community transition strategies (ED-CTS) to determine their efficacy.

Emergency Department patients aged 65 years and over are increasing at a faster rate than the ageing population. These older individuals have longer stays in the emergency department and a higher chance of admission due to various psychosocial and medical problems. They also often need increased resources to better comprehend their reason for presentation. Clinicians are also under the strain of meeting time-based targets, managing the flow of the emergency department, maintaining adequate quality of care and accounting for appropriate resource allocation.

The 12 Days of Christmas – a hospital doctor’s lament

David Oliver is the current President of the BGS, a visiting Fellow at the Kings Fund, and a consultant in geriatrics and acute general medicine at the Royal Berkshire NHS Foundation Trust.

This time last year, I wrote the “Geriatrics Profanisaurus” – all about words and phrases which should be banned when discussing older people. It triggered plenty of  responses “below the line”, adding to the list of ageist and ignorant language regarding healthcare for older people and went a bit “viral” online. Indeed, the BGS is now being followed by Roger Melly’s Profanisaurus on Twitter, as is occasionally “sweary geriatrician” Dr Wyrko.

As I started the precedent of a festive Presidential blog, I couldn’t resist my own re-write of the old favourite “The 12 Days of Christmas”. I say this as a frontline doctor who frequently disappears into an uber-busy acute medical unit, or emergency department and has inpatients who are increasingly frail and complex and often requiring step down health and social care services which are themselves over-stretched. It’s a very challenging environment both for staff, patients and families and one that I know colleagues right across the four nations face, especially in the winter months. Its important in letting off steam on this site – mainly read by clinicians, that we are all deadly serious about trying to provide the highest quality care for patients. So no fun is intended to be at anyone’s expense.

But here goes anyway: do join in, especially with a hearty “Five Interims”.

On the twelfth day of Christmas,
My true love sent to me:
Twelve “vacant” locums,
Eleven “bed meetings”,
Ten “points of access”,
Nine winter pilots,
Eight re-admissions,
Seven day working,
Six delayed transfers,
Five Interims,
Four hour breaches,
Three Iberian Nurses,
Two Norovirus,
and  an over-crowded ED…

I also sometimes find other songs going through my head that seem strangely appropriate to the jobs we all do. Here are one or two:

“Back in Black” …”I want my bed base back”  – with thanks to Los Bravos.

Or indeed “Back to Black” by Amy Winehouse. “Black Alert” that is – when we have as many beds as Bethlehem had room at the Inn. At such times, though I am a Man City Fan, “Simply Red” would be a welcome sight for once.

Talking of Amy, if I had a quid for every patient whom I have wanted to send to intermediate care for ongoing rehab, but has preferred either to stay in hospital or to go home with no rehabilitation and support, surely “They tried to make me go to rehab, I say No, No, No” fits the bill.

Allied to this is the Beatles “Hard Day’s Night” – not only applicable to overstretched on call teams and nurses but also when patients who don’t want to stay another hour in hospital say to me “Doctor, when I’m home…” and I do feel like replying “I know…everything seems to be right”.

Sadly it’s hard for many patients to understand that hospital consultants can’t click their fingers and magic up social care or community rehab places; I can see these patients singing Gwen Stefani’s “What you waitin’, what you waitin’ for?”

When it comes to falls resulting from postural instability, then we have to acknowledge the sage words of Miss Meghan Trainor: “It’s all about that Base”

Now over to the readers of this blog, for your suggestions! Nothing disrespectful or inappropriate, please or our Digital Media Editor will be in like Flynn and remove the post,  but if you can think of any more songs for the thread or any more lyrics for those twelve days, we’d like to hear from you!

Finally, let me wish you all a very Happy Christmas. And remember, winter pressures or not, the health service is an immensely rewarding place to work: our colleagues are troupers and caring for people at their neediest is a privileged occupation, however demanding it may be. But perhaps a bit of dark humour can help through the worst two clinical weeks of the year.

Do pharmacists have a role in reducing emergency admissions?

Alyson Huntley is a Research Fellow at the University of Bristol’s Centre of Academic Primary Care. She has recently published a systematic review of pharmacist-led interventions to reduce unplanned admissions for older people.

The expansion of the pharmacist’s role as a contributor to patient’s health has been championed over the last couple of decades.  In addition to their traditional role, pharmacists contribute to the care of people with long term conditions by carrying out medication reviews, promoting healthy lifestyles, and supporting self-care.

The older people become, the more medications they are likely to be taking (both prescribed drugs and self-medication) leading to an increased risk of adverse reactions, interaction between drugs and poor adherence.

Award Winning Telehealth

Chief Executive of Airedale NHS Foundation Trust; Bridget Fletcher discusses how this Yorkshire Hospital is delivering unique, new and bespoke video consultation services to support patients in their own home and preventing unnecessary admissions to ED and inpatient beds.

Overburdened A&E departments and hospital wards full to capacity are almost daily news items currently.  It is likely that the individual human stories behind those news items involve very many people over the age of 65 living with one or more long term conditions.  In fact statisticians tell us around 70% of our NHS resources in general are spent caring for patients living with long term conditions, much of which is re-active care rather than proactive.

Only a minority of stroke victims are being seen by doctors within the recommended timeframe

Despite the recent FAST awareness campaign, just 8% of high-risk patients surveyed attended clinic within 24 hours of symptom-onset

In a study, published in Age and Ageing, of over 270 patients newly diagnosed with minor strokes or transient ischaemic attack (TIA), only a minority sought medical help within the timeframe recommended by the Royal College of Physicians. This is despite the high profile FAST campaign, which was taking place at the time that the study was conducted.

Acute care for older people – approaching consensus?

Dr Simon Conroy is Head of Geriatric Medicine, University Hospitals of Leicester, Honorary Senior Lecturer, University of Leicester and an Associate Editor for Age and Ageing journal.

Some 300 physicians (geriatricians, acute physicians, emergency physicians), and some paramedics and primary care staff gathered at the Royal College of Physicians on the 26^th June 2013, to discuss the topic de jour – acute care of older people.

The day started of poignantly with Dame Julie Mellor (Parliamentary and Health Service Ombudsman) ensuring that patients and their families remain the focus of our efforts.

The traditional Multidisciplinary Meeting: Still the Gold Standard or Losing its Lustre?

Prof David Oliver is a Consultant Geriatrician in Berkshire and a visiting Professor in Medicine of Older People at City University, London. He is President Elect of the British Geriatrics Society.

Since leaving my role as national clinical director at the end of last year, I have found myself seconded for day a week to the NHS Emergency Care Support Team and to the Kings Fund alongside my clinical day job. In this new capacity, I have gone into a number of busy acute hospitals or health economies to review care pathways for older people. It has been fascinating to meet so many hard-working colleagues and to see the similarities and differences in how older people’s services are delivered. A key focus in these visits is ensuring that – whatever the issues may be with external delays waiting for “step down” community services or social care – we do, as hospital teams whatever we can internally to minimise delays in our own care pathways.