Plan to keep frail A&E patients out of hospital saves almost 4,000 bed nights

An initiative aimed at keeping frail older patients attending emergency departments out of hospital and supported at home has saved almost 4,000 bed nights in its first 18 months of operation at Dublin’s St James’s Hospital.

The programme is one of several in the State’s biggest hospital aimed at relieving pressure on its overstretched emergency department (ED) while ensuring that patients are looked after at home, where most of them want to be.

Together with other initiatives designed to ensure that well patients in the hospital are discharged promptly, it helps to explain why St James's, despite its size, has relatively low trolley numbers. A similar frailty intervention team is in place at Beaumont Hospital, another facility with a relatively good record on trolleys.

These so-called Frailty Intervention Teams are a key part of the HSE’s winter plan this year, and have the aim of minimising unnecessary admission to hospitals, thereby freeing up much-needed beds for other patients.

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‘Divert them’

"The aim is to get the patient home, if this is at all possible. Hospitals are not always the best place for the kinds of patients we see to find themselves in," advanced nurse practitioner Aoife Dillon explains of the four-strong Home First team. "We'll be trying to divert them from admissions if possible."

The Home First team sees patients aged over 70 only. Many will have suffered falls, or are experiencing problems with pain management, and end up in the hospital ED seeking help.

Over half of these patients will need follow-up in the community after they receive treatment in hospital. In the past, they were generally referred back to their GP’s, where they would then have to wait along with everyone else for physio or further assessment etc. The result was a “revolving door” situation where frail patients kept returning to the ED as the only place they could get prompt treatment.

" With Home First, when a frail patient arrives, they're assessed by a multidisciplinary team the moment they walk in the door," says ED consultant Paul Staunton. "It's not just about their medical health; we're looking at the social situation, their background, what supports they have in the community. It's about providing more holistic care."

Practical benefits

There are practical benefits for the patient: access to a comprehensive geriatric assessment, regarded as the gold standard for care of the elderly; and access to the day hospital in St James’s, where rehabilitation programmes are available.

On occasion, families can be suspicious about efforts to encourage loved ones not to enter hospital, Dillon acknowledges. “Families are the unsung heroes in terms of providing care, so this is understandable sometimes. But often it’s no-one ever had a conversation with them, and once you do everything changes. Often, they just want an acknowledgement that what they are doing is the right thing.”

The lack of home help hours and the fragmented nature of primary care services are drawbacks, but overall the initiative has helped ease overcrowding the hospital’s ED while meeting the needs of patients.