London has a higher proportion of people aged 25-34 than the rest of England – with up to one in four people in inner London in this age range.
But in Bromley the story is different. While the borough has its fair share of younger people, it also has the largest ageing population in the capital, with almost one in five – or 60,000 – over-65s.
Of these, one in 10 are considered frail, finding it difficult to care for themselves due to lack of mobility or cognitive decline. The result? Many risk ending up in the Princess Royal university hospital’s (PRUH) emergency department (ED) and face long stays in hospital. With evidence showing that 10 days of hospital stay is the equivalent of 10 years of muscle wasting, staff at the PRUH are setting up an acute frailty network aimed at identifying frail patients quickly and giving them tailored support. The network will build on the specialist stroke service already operating in the emergency department.
Stroke patients arriving at the ED are already well looked after. They are assessed by an on-call stroke team, which ensures they have a head scan and a diagnosis within 30 minutes of arrival. Once stroke is confirmed, patients are transferred to the hospital’s hyperacute stroke unit (HASU) for rapid assessment and treatment. This can entail being treated with clot-busting drugs (thrombolysis) for 72 hours, before being transferred to a hospital closer to their home for the rest of their care.
Now the hospital hopes to offer a similar rapid assessment model to frail patients who arrive at the ED in crisis. Many suffer from falls or they may come in with chest pain or breathing problems.
Debbie Akerman, a clinical frailty nurse at the PRUH, said that too often frail older people arrived at the ED, were admitted to an acute medical ward, only to then be transferred to a frailty ward. This increased their length of stay and reduced their chances of living in their own homes.
During a two-week trial of a frailty pathway, a multidisciplinary team rapidly assessed patients attending the ED, the neighbouring clinical decision unit or those in ring-fenced frailty beds on the acute medical unit.
Patients in the frailty assessment beds stayed for a maximum of 48 hours, while the team worked to discharge patients to their home with care in place or referred them to community rehabilitation services. Patients needing admission were identified for an acute frailty bed or other post-acute medical beds. Those with dementia who had ongoing medical needs were transferred to two “step down” wards at Orpington hospital. Meanwhile, more than 50% of patients, who would otherwise have been admitted, went home with support in place.
“It brought together what was available through social services and what families could do to bring patients home,” says Jane Evans, consultant physician in clinical gerontology and clinical director of post-acute medicine.
Another pilot is planned in June. However, more staff are needed if the service is to be permanent. It is hoped there will be a service seven-days a week, staffed by a multidisciplinary team including two geriatricians, two frailty nurses, a physio and occupational therapist, and a staff member from transfer of care (when the responsibility of care is transferred between different care professionals and organisations). They would work closely with a community matron, the transfer of care bureau, staff at Orpington hospital and Bromley Well – a partnership of local voluntary organisations.
None of this would be possible without Bromley integrated care hub – a network of GP practices that work together to identify patients with complex needs at high risk of hospital admission. Patients are assessed in their own homes by a community matron, who then reports her findings each week to a multidisciplinary team, made up of the gerontologist, family doctor and a representative of Age UK. Social services may also attend. There are three integrated hubs, each covering a different part of the borough. Reports may be given on the management of problems such as cognitive impairment, with patients referred to the memory clinic or receiving help from specialist Parkinson’s nurses or falls nurses. Those that are very frail may be referred to Bromley Care or St Christopher’s Hospice.
Akerman, who used to be a ward sister at the PRUH’s ED, says links with the community are very important. Working with the community matron, who has access to information on patients, has proven “invaluable”. She also works closely with a rapid response team of advanced nurse practitioners who can assist people in their own homes for up to 10 days.
“My job is not just about discharge. I can liaise with geriatricians and my judgment is trusted. From a nurse’s point of view, I can focus on the reason why the person has come to ED,” she says. “It is often a busy place and far too often there is little time to speak to families. By having more time to talk, a frail person’s care may be improved and a quicker discharge arranged. What we are doing is really exciting. I get a real buzz from my work. We just need more staff to join us now.”
