The Benefits of a Specialist A&E for Over-80s 

Siobhan Harris

Disclosures

June 19, 2020

There's an emergency department in the UK dedicated solely to the care of older people over the age of 80. The facility at Norfolk and Norwich University Hospital has been up and running for more than 3 years.

Patients over 80 are taken straight to the Older People's Emergency Department (OPED) where a team of emergency consultants and geriatricians will treat them. If they need admission, they'll be transferred to a specialist ward. During the pandemic it has been used as a non-COVID area.

Hospitals usually have geriatricians working in standard A&Es and the idea of an OPED is not feasible for all NHS Trusts. Many don't have the capacity to separate younger and older patients plus there's a national shortage of geriatricians.

However, general emergency departments can be scary places with little privacy and long waits for older patients, whilst the OPED can be a calmer and quicker alternative.

Dr Sarah Bailey is clinical lead for frailty at NNUH.

Medscape UK asked her about the Older Person's Emergency Department at Norwich and Norfolk University Hospital.

Q&A

The first step on the road to OPED was in 2016 when we decided to identify those frail patients who would benefit from a multi-disciplinary review at the front door. We used an identification tool called FRAIL, which formed part of our assessment of older people, over the age of 80, in the Emergency Department (ED) and highlighted the group of patients that would benefit from a comprehensive geriatric assessment. This identification and assessment of patients proved successful. We found that the number of patients that were converted into an admission reduced, the length of stay of those patients that were admitted was shorter, and those admitted returned to their usual place of residence. Patients’ and relatives’ satisfaction improved as there was an earlier review of these patients from a consultant geriatrician lead multi-disciplinary team.

Due to this success, and the opportunity to expand the ED footprint in 2017, we were approached to develop the Older People’s Emergency Department - the first in the UK. Right from the start both nursing and medical teams were involved in the layout of OPED. The organisation recognised that to improve on current outcomes we needed an area that met the needs of the older person.

The OPED area consists of four trollies in a bay and two in side rooms - all with natural lighting. There are seats next to the trollies so that patients can be transferred to a chair as part of the assessment and for comfort, and orientation aids at hand with large print signs and large clocks on view. The toilet facilities are also in walking distance for our older patients, which again improved their experience and enabled the team to assess their abilities.

The team within OPED is varied and all have a background in dealing with the older patient. We continue to work closely with our colleagues in the Early Intervention Team which consists of occupational therapists and physiotherapists. We have seven advanced clinical practitioners, five of which are trainees. Within the team we have five consultant geriatricians and five middle grades.

We deliver a comprehensive geriatric assessment on all patients seen and the number of patients seen per month has increased since OPED began. In December 2017 we saw 191 and this has grown to 615 in December 2019. On average the number of patients we saw each month pre-Covid is 500, the conversion rate to admission is 50%, the re-attendance rate is 6% which is above satisfactory for this group of patients. Average length of stay for patients admitted has reduced to 1.4 days.

What do patients think of the OPED? It must be less distressing than a general A&E?

Patients have enjoyed the experience and are very appreciative as they see a specialist within an hour, the environment is a lot quieter, and it’s bright and airy. Facilities are close by - you can’t underestimate [the importance of] a toilet as this provides dignity, privacy, and allays anxiety.

Do you think it's feasible for this type of system to be used more widely in other hospitals?

We have received lots of interest and visits from other hospitals to see how they can establish their own Older People’s ED. We are fortunate to be able to have the space to create the department, which has six trollies including two side rooms, and a relatives’ waiting room. In addition to space, recruitment of staff is also required and the organisation was able to sanction new posts for this venture with two new consultant posts and three middle grade posts. Our close links with the University of East Anglia enabled us to develop the role of the OPED Advanced Clinical Practitioner. This may not be an option in other organisations as it is well documented that there is a national shortage of consultant geriatricians.

What are the benefits of having a specialist unit for older people over having more geriatricians working in A&E in general?

The environment is key. Many older patients often need more tests to determine a diagnosis, may be over-treated with antibiotics or miss essential medications. They need to be seen by a team that is in tune with their needs. Emergency Departments are often high acuity areas and elderly patients are prone to prolonged waits on trollies and as a result are more susceptible to develop delirium. Having an area within the ED footprint that is quieter and is run by a multi-disciplinary team, allows us to give a better service than seeing patients scattered in a busy, noisy, main ED.

Over the last 5 years, the number of attendances to our ED has increased by 25%, but the number of patients over 80 attending has increased by 35%, and this age group now make up nearly 20% of all our emergency attendances. Furthermore, while conversion rates - the proportion of emergency attendances requiring admission - have been falling, older people have a much higher likelihood of being admitted: 68% for this hospital 5 years ago. However, we have already seen this fall with conversion rates of 50% for older people seen through OPED.

At the moment, in these times of coronavirus, what's the unit being used for?

The hospital at the peak of the pandemic was split into yellow (potential COVID) and green zones (non-COVID). Therefore, we needed to double resus, rapid assessment, ambulatory majors and minors. Our OPED area became a green ambulatory majors area. We continued to work within the ED footprint, seeing patients wherever they were within the footprint.

During the pandemic, we saw a drop in ED attendances, which meant we relaxed our criteria and worked with our ED colleagues to see patients 70-years-old and above. We also increased the number of days we were in the department to cover 7 days.

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