A project aiming to improve the care of older people in emergency departments (EDs) in the UK has found ‘room for improvement’ nationally, the Royal College of Emergency Medicine (RCEM) has announced.
The ‘Care of Older People’ RCEM National Quality Improvement Programme – now in its second of three years – has compared the performance of 118 participating EDs against a set of RCEM standards of care for patients aged 75 and older.
Published in its Year 1 interim report, the results show a need for ‘room for improvement across the board, in all standards’, and highlight ‘the first areas where change should be taking place‘.
As such, the report includes recommendations for the second and third years of the project to enhance the experience and outcomes for older people receiving ED care and help to achieve the required standards, which includes engaging pharmacists in EDs to screen for polypharmacy and support prescribing for older people.
Dr Adrian Boyle, President of RCEM said the project ‘provides a valuable opportunity to gain the first insights into the level of care being given to older and frail patients on a national level‘ and thanked the participating emergency departments for their collaboration.
Key findings from the ED
A total of 9,155 Type 1 ED attendances for older patients meeting inclusion criteria for the National Quality Improvement Programme were included, with a Type 1 ED being defined as one that provides a 24-hour, consultant-led service with full resuscitation facilities.
The report captured a ‘baseline’ level of care of older people presenting with a Version 2 National Early Warning Score (NEWS2) of 4 or under from May 2023 to October 2023. It then measured the percentage of participating EDs that carried out a range of assessments including tests for delirium and risk of falls.
In relation to RCEM’s Standard 1, that all people aged 75 years and older in ED should be screened for delirium using the 4AT tool, assessed for falls risk, and screened for frailty, the results showed that 21.5% of patients (n=1997) were screened for delirium using any tool, and only 68.3% of these were screened using the 4AT tool.
As such, only 14.98% of patient care met the standard, while 31.7% failed to meet the standard because of the screening tool used.
A total of 43.79% of patients received the falls risk assessment and 53.06% of patients were screened using a recognised frailty scoring system.
Standard 2 requires that action is taken based on the findings of screening processes. This includes a delirium management plan, post-fall assessment, falls mitigation and comprehensive geriatric assessment (CGA) being initiated where appropriate.
The report revealed that of the patients found to have delirium (n=467), 28.76% had a complete delirium management plan initiated.
When it came to falls, 37.25% of patients presenting after a fall had a dedicated post-fall assessment, and 32.58% of patients identified as being at risk of falls had a full falls mitigation plan put in place.
On average, 35.5% of patients had a CGA initiated if indicated from their frailty score. The control limits showed that the process is relatively stable but unlikely to reach beyond 50% compliance unless there is a change in the system.
Standard 3 requires that patients should have their basic care needs met whilst in the ED via a safety round. The report found that 55.8% of all patients had an ED length of stay of more than six hours, and of these, 31.5% had a full safety round initiated.
RCEM recommendations
Comprehensive training for all relevant ED staff was the most common recommendation outlined in the report, with education encompassing the identification of delirium, falls and frailty in patients, the tools that should be used to assess and screen patients and the next steps that should be taken being included.
Standardising care was also highlighted as a priority, with recommendations around developing clinical pathways, departmental policies and documentation protocols, as well as including alerts, prompts and mandatory fields on patient records to ensure screening is undertaken and appropriate next steps are widely understood and actioned.
The RCEM also noted organisational audit recommendations, including that all participating EDs should perform an organisational scorecard two to three times a year to review performance and make targeted plans for improvement.
It also flagged that pharmacists should be engaged in EDs to screen for polypharmacy and support prescribing for older people, and that concise discharge summaries should be available to give to patients.
Valuable insights to improve ED outcomes
Commenting on the report, project leader Dr Anu Mitra, consultant emergency physician at Imperial College Healthcare NHS Trust, said: ‘Older people constitute a cohort of emergency department patients which is growing in size, complexity and care needs and reflects a continuing demographic trend in all four nations.
‘As a specialty whose workload reflects issues in the wider health and social care landscape, emergency medicine must accordingly meet the challenges of caring for older people at the front door.
‘This national QIP has set a broad range of standards which cover both individual care and system design, to improve experience and outcomes for older people from the moment they enter the emergency department, using recognised quality improvement methodology and sharing of best practice.’
The RCEM said it plans to share this report widely with stakeholders within the immediate departments, and added: ‘As we embed this in our routine practice, we seek to get the support that EDs require to help them in their QI activities… If all teams share their thoughts and feedback, we would have a wealth of learning to share with each other and improve future programmes.’
