Introduction
Innovative models of service delivery are required to provide comprehensive geriatric assessment for older patients presenting to the emergency department (ED) with frailty syndromes. Out of 139,636 attendances in 2020–21 to the ED at Morriston Hospital, Swansea, 3,906 were due to falls in patients aged >65 years.
In patients aged >80 years, 41.6% of these were admitted in 2018–2020, and readmissions to ED occurred in 24%.
Method
Phase 1: In 2018, the Older Persons Assessment Service (OPAS) began a liaison service to the ED, taking referrals from the medical and ED teams for patients who presented with frailty syndromes (falls, cognitive impairment, care dependence, polypharmacy). The service saw 437 patients between April and August 2018. 76% of the patients assessed were discharged by utilising available community services, rapid access outpatient follow-up and inpatient re-ablement off the acute site. The service was estimated to avoid 50–80 admissions per month to medicine (Fig 1; Table 1), saving 17–23 beds a year, and was commissioned as a permanent service.
Emergency admissions to medicine by month.
Admissions 2017/2018
Phase 2: In 2020, a dedicated unit within the ED was allocated to OPAS, enabling the acceptance of patients directly from triage and from the ambulance service. This provided rapid access to specialist assessment and continued access to elderly care services, and avoided exposure to coronavirus-related admissions and the risks of nosocomial infection associated with admission. The service operated from 8am–4pm on weekdays.
Results
Between June 2020 and December 2021, the service saw 1,302 new patients (950 presenting with falls). 1,087 patients (83.5%) were discharged from the acute site on the day of assessment. 69 (5.3%) patients were admitted to other facilities run by the health board (eg inpatient re-ablement). The average age of an OPAS patient was 83 years and they had a Clinical Frailty Scale score >5 on average. The readmission rate at 14 days was 55 (5%). Of the 284 patients who were admitted to an inpatient setting, 35 (12.3%) contracted nosocomial COVID-19.
Conclusion
This service demonstrates the ability of consultant-led multidisciplinary services that provide comprehensive geriatric assessment in the emergency department to avoid hospital admissions and readmissions. This study has been able to demonstrate a greater measurable impact on these service metrics than has been previously published.1–3 The team has secured investment and now functions 7am–7pm on weekdays, with plans for future weekend working.
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