Welcome to the emergency department exclusively for the over 80sBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m931 (Published 11 March 2020) Cite this as: BMJ 2020;368:m931
The corridors are wide, and there’s an atmosphere of calm. The space is full of natural light and designed with long, clear lines of vision to reassure the patients—all of whom are over 80. There are six beds, some in single rooms; an adjacent ambulatory ward; and a “therapy room” where patients, relatives, and staff can have private conversations. Hot meals and cups of tea are served regularly, and nurses take the time to chat and help people get to the toilet, of which there are a generous three.
Yet this is not a geriatric ward or palliative care unit. It’s the Older People’s Emergency Department (OPED) at the Norfolk and Norwich University Hospital, where older patients needing urgent or emergency care are seen by a consultant geriatrician, given a comprehensive geriatric assessment within two hours of arrival, and treated and cared for by a multidisciplinary team.
Compared with the hospital’s windowless (and often hectic and noisy) 16 bay emergency department only 20 metres down the corridor, with its sometimes drunk and distressed patients all sharing a single toilet, this is a haven of tranquillity.
“It’s great. It’s just what we want for old people,” says Sarah Bailey, OPED’s lead consultant geriatrician. Bailey helped set up the unit, which opened in 2017, to provide specialised care for the growing number of elderly emergency patients at the hospital.
Since its opening OPED has proactively sought out patients in the emergency department or elsewhere in the hospital who could benefit from its services. Increasingly, the unit also advises Norfolk’s GPs, care homes, and paramedics by phone to help them assess potential patients and admit them directly to the department, avoiding the emergency department altogether. All patients are over 80 and are identified as frail, using a simple screening tool (see box).
“It’s about intervening at the front door so we’re not duplicating and prolonging the patient pathway,” Bailey explains.
Many OPED patients have reduced mobility, altered cognition, and comorbidity and need lots of care. Some may simply be dying, and OPED’s geriatricians help them to die in a peaceful and dignified way. The unit also works closely with the emergency department to care for trauma patients.
“Lots of patients come in with falls and head injuries, so the A&E [accident and emergency] team have taught us how to collar and block,” says Bailey. “But stitching heads—we’re not surgeons, so they come over and do that. They do FAST [focused assessment with sonography in trauma] scans for us too.” The unit doesn’t take patients with conditions that already have clear pathways, such as acute strokes, acute abdomens, or single organ diseases such as pulmonary fibrosis or primary biliary cirrhosis.
Since the unit opened it has achieved a conversion rate (the proportion of emergency patients who are admitted) of 50%, compared with the hospital’s conversion rate of 68% among this age group five years ago, and it has cut their average hospital stay by 1.2 days. Over time, as the department has established itself, it has dealt with increasing numbers, seeing 600 patients in December 2019, up from 200 in the same month in 2018.
“The big issue for most older people is time,” says Rachel Burridge, an advanced clinical practitioner who helped set up the department. “Time in the back of an ambulance, time in A&E waiting to see someone, time waiting to see a senior decision maker. We’ve condensed that to within an hour sometimes.”
OPED can also provide support after patients are discharged, booking them into a clinic within 48 hours, rather than the usual 6-8 week booking process for outpatient follow-up appointments.
Burridge says it also helps that OPED’s nurses, and those in the neighbouring ambulatory ward, are all people who are keen to work with old people, who are not fazed by incontinence, who help patients stay mobile (to avoid muscle wastage caused by long periods in bed), and who take the time to chat. The team also includes physiotherapists and pharmacists. “To the best of my knowledge, we’ve only had two complaints,” says Burridge. “We’ve got boxes of ‘thank you’ notes.”
One patient wrote, “Such a brilliant idea to have a facility aimed at ‘we oldies.’ Your team were first class and so very thorough, plus no long delays as in previous visits.”
The UK population has aged in recent years and, with it, the number of elderly patients with multiple morbidity needing emergency admission has grown dramatically. Some 59% more patients aged over 85 required emergency admission in 2017-18 than in 2006-07, in an analysis by the Health Foundation.1 And from 2017 to 2040 the number of over 85s is projected to almost double, from 1.4 million to 2.7 million.2
Norfolk has a larger elderly population than most UK counties, and over the past five years the number of patients aged over 80 attending the emergency department at the Norfolk and Norwich University Hospital has increased by 30%. What’s more, nearly 20% of its emergency patients are in this age group, compared with a national average of 10%.3 The hospital’s overall emergency department attendance has risen by 25%, and the number of four hour waits in the department has more than doubled in the past year. On one day last December, every bed was full and 35 patients were waiting to be admitted as emergencies.4
This, then, was fertile ground for a new service that both relieved pressure on the emergency department and provided better care for the growing numbers of older emergency patients. The hospital was fortunate to have the space to create a new unit physically close to its emergency department. Yet the new unit is open only on Sunday to Friday from 8 am to 8 pm and is unable to serve the many patients who could benefit but who are under 80.
Shortage of applicants
The Norfolk and Norwich University Hospital Trust is advertising for more consultant geriatricians to expand its service, but geriatricians are in short supply. From 2013 to 2018, reports the British Geriatrics Society (BGS), half of all consultant appointments advertised in acute internal medicine and geriatric medicine went unfilled because of a shortage of suitable applicants.5
This shortage, says Jay Banerjee, consultant in emergency medicine at University Hospitals of Leicester and an expert in healthcare improvement for older people, means that the Norwich model may not be suitable or feasible for other hospitals. “I do not see a role for the geriatric emergency department at the NHS, simply because we will never have the number of geriatricians needed to deliver it,” he says.
Zoe Wyrko, vice president for workforce at the BGS, comments that “there is no ‘one size fits all’ model for the delivery of acute care to older people.” Around the country, she explains, different models are being explored. “Some are ‘frailty’ services,” she says, whereas “others do not discriminate on frailty but see patients with complex needs, and others are age based.
“Many have their own physical space where they move patients away from the emergency department or acute medical unit, and others are fully integrated with the emergency and acute medicine teams.”
In many services, geriatricians are working “at the front door” alongside emergency and acute medicine colleagues, Wyrko explains.
“The bottom line,” says Banerjee, is that “we need a system-wide change,” so that all staff in every emergency department are competent in managing older people. Efforts are under way to achieve that, he explains. The BGS has published guidelines on care of older people with urgent and emergency care needs, known as the Silver Book.6
The acute frailty network set up by Banerjee and Simon Conroy, professor of geriatric medicine at Leicester University, aims to help emergency departments “geriatricise” themselves and for them to support all specialties (except, perhaps, paediatrics and obstetrics) in understanding the principles of frailty.
Wyrko argues that the very buildings in which healthcare is provided need to be geriatricised, not just the services. “Emergency care, and the environment it is delivered in, should be appropriate for those who are most in need of it,” she says. “These are likely to be people with complex needs and multiple comorbidities, very many of whom will be older and some of whom will be living with frailty.
“Therefore, the ideal situation would see hospitals and emergency departments built with this cohort of people in mind, rather than being ideally suited to otherwise fit 40 year olds with single pathology.”
Norfolk and Norwich University Hospital’s simple screening tool to identify frailty
Patients who are living in a care home (residential or nursing) or are aged over 80, with one or more of the following:
Falls (history of)
Reduced mobility (from usual)
Altered cognition (confusion or memory problems)
Several medicines and/or lots of care from family, friends, or professional carers
Competing interests: I have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.