Acute Frailty Network A Compilation of “Best Practice ... ?· “Best Practice” Case Studies ...…
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Acute Frailty Network
A Compilation of Best Practice Case Studies
Nurses and therapists across the network have worked with us to compile this collection of case
studies, sharing their experiences and stories of improving services for frail older people.
1. Kettering General Hospital
2. Leicester Royal Infirmary
3. Norwich and Norfolk University Hospitals
4. Portsmouth Hospitals
5. Royal Cornwall Hospital
6. Wirral University Teaching Hospital
Acute Frailty Network2
Kettering General Hospital NHS Foundation Trust had no dedicated frailty service in 2012. The hospital a medium-sized district general with 574 beds - is based in Northamptonshire, which already has a greater percentage of older people than many other regions and is facing a 19% increase over the next 10 years. The number of over 85s is expected to rise the fastest.
Pilot projectA baseline audit showed poor quality data collection for frail older patients. The hospital began a three-month nurse-led pilot to explore ways of improving the identification and management of frailty. It developed a comprehensive geriatric assessment (CGA) process using the Royal College of Physicians acute care toolkit and the Silver Book. The team identified particular frailty markers to identify suitable patients, including falls, confusion (acute or known), dehydration and patients in receipt of care packages. It began carrying out CGAs in urgent care wards, conducted by a single nurse working fixed times.
Nurse-led frailty teamAfter three months, the pilot scheme demonstrated a 40% reduction in length of stay for patients who met its frailty criteria. This was enough to convince the hospital to create a full-time Acute Frailty team. The team began as one full-time post (Lauren Rothwell, a former deputy sister in urgent care). Between 2013 and 2017, four former urgent care nurses joined the Acute Frailty team, as well as a senior nurse.
Working with the resources they haveKettering General Hospital
A Compilation of Best Practice Case Studies 3
One of the factors that made this such a successful project was the fact that it was nurse-led and that all of the nurses had previous urgent care experience. Lauren explained:
We already had good relationships with the acute physicians. In common with many hospitals, we have a shortage of geriatricians so the clinicians were very appreciative of our support and open to our input. In return, we adopted a very purposeful, collaborative approach. We all had a willingness to challenge assertively but from a place of professional enquiry; we respected their perspectives and they respected ours. We have built on these good relationships from the start and encouraged a collaborative mentality between our team and the teams we work with.
Easy-to-use CGAThe CGA process was reviewed at the end of the pilot programme and amended in response to nurse and therapist feedback. The layout was amended to make it easier to use and they added new sections relating to medical reviews and functional assessments. This process of reviewing and refining has continued since the CGA was introduced. Lauren added:
We are now up to version 12 but, despite adding more sections and making revisions, we have kept the documentation to the same five-page format. Any longer becomes unmanageable for staff. Weve avoided duplicating any information that is already gathered during our emergency department (ED) clerking process. Our aim is for every patient over 75 to have a CGA when they come through the front door and to get them where they need to be as quickly as possible. It is vital that the form is short and easy for nurses to use.
An expanded teamThe Acute Frailty team, with the support of the Trust Therapy Lead, expanded in 2016 to include dedicated therapy time. At the same time, it moved into ED. This proved to be a pivotal moment in the development of the service as Lauren explained:
Originally we were based in urgent care but this meant patients had already been admitted by the time we saw them. Relocating ourselves into ED means we see patients earlier in their journey and even these few hours can make all the difference. We have reduced length of stay still further since moving into ED.
Nurses within the team are developing their skills by undergoing Advanced Practitioner and Clinical Assessment training. Such is the relationship between the Acute Frailty team and ED colleagues that Advanced Clinical Practitioners from ED provide mentoring support to Acute Frailty nurses undergoing training.
Look for the LilacThe Acute Frailty team launched an awareness-raising campaign called Look for the Lilac to coincide with the expansion of the team in 2014/15. All of our frailty documentation has lilac-coloured branding, said Lauren, we created a poster campaign and attended forums and MDT meetings across the hospital to let people know about the Acute Frailty service and to encourage them to look out for our documentation which contains a wealth of information on caring for frail patients. The Acute Frailty services credibility and awareness has been boosted by sharing within the Trust the regional and national recognition it has received.
Acute Frailty Network4
Improving safeguardingThe Acute Frailty team has made a positive impact on the number of frail patients being admitted and length of stay. It is also impacting patient safeguarding through closer examination of psychosocial circumstances. Lauren said:
One of the areas we are making a difference is in assessing treatment plans. We have time to gather more information about a patients history and background than staff in other areas of the hospital and this helps us to improve patient safety. For example, in this way we have identified patients who have been put on IV fluids due to suspected acute kidney injury, but they actually have chronic kidney disease and the presenting results are normal for them. We have liaised with clinicians to ask for the patients treatment to be amended. It is not about apportioning blame, it is all about working together to provide the best possible care for the patient.
Frailty Assessment UnitKettering recently opened a new 10-bedded Frailty Assessment Unit, open 24 hours a day, seven days a week with lengths of stay of up to 72 hours. It has also recruited a registrar and geriatrician.
This project is no longer being funded by the clinical commissioning group, but it still has access to the Intermediate Care Team, through referral, for community-based reablement.
ChallengesThe biggest challenge for Kettering General Hospital was a lack of sufficient resources to support the kind of Acute Frailty service it aspired to. Executives were keen to create an Acute Frailty Unit earlier in the process but without the geriatricians to support it, it proved too challenging at that time. There was a risk of staff becoming disengaged at the start because we simply didnt have the resources to deliver what was being asked of us. But rather than give up we decided to do what we could do with the resources wed got. That would be my one piece of advice to other organisations doing similar work to us work with what youve got, dont wait. We have achieved a lot with very few resources, said Lauren, and now a few years down the line more resources are being made available to us.
Success factorsThe main factors that were identified as contributing to the success of the Acute Frailty service in Kettering were:
There were good working relationships between the Acute Frailty team and other teams in the hospital. The Acute Frailty teams collaborative mentality and an approach based on assertively challenging helped to strengthen these relationships.
The Acute Frailty team had good credibility as it was staffed by nurses with urgent care experience. The team has built on this by upskilling nurses and expanding to include more therapists and geriatricians. Other teams in the hospital have witnessed the difference the Acute Frailty team makes to patients, which further strengthens the teams credibility.
The CGA model was created by the Acute Frailtys lead nurse, senior Physiotherapist and Occupational Therapist, general manager (a nurse by background) and a geriatrician. They used gold standard documentation from the Royal College of Physicians and the silver book. The model has been reviewed and refined many times but the team has kept it short, succinct and manageable.
The Acute Frailty team ran a Look for the Lilac campaign to raise awareness of its services to staff across the hospital.
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Nearly a quarter of older people in acute hospitals suffer from dementia. University Hospitals of Leicester NHS Trust has taken proactive steps to improve the wellbeing of dementia patients in its hospitals, typically around 120 people a day. Such patients are vulnerable to illness, accidents and falls, all of which can impact on their wellbeing and extend length of stay.
For all frail older patients admission to hospital can be detrimental, leading to a loss of everyday skills and mobility. However, for patients with dementia this deconditioning can be irreversible as they may be unable to relearn lost skills. While in hospital they may struggle to eat and drink, and the loss of routine, change in environment and other medical causes can trigger delirium.
In 2013, Leicester ran a pilot project to deliver meaningful activities to patients with dementia. These activities ranged from simply chatting, which helps both to calm patients and provides hospital staff with an opportunity to find out about them