2-year impact of an Older People Short Stay Unit team working across emergency areas in the over-75s
Aims
It is recognised that the older person, once admitted to hospital, frequently has a longer length of stay (LOS) and occupies more bed days than other patients, so we focused on reducing the LOS for the over-75s.
Methods
We set out to reduce LOS for over-75s using plan–do–study–act (PDSA) cycles that involved amalgamating the existing older persons’ assessment and liaison (OPAL) team with the acute therapy team with senior therapy presence in emergency areas, forming the Older People Short Stay Unit (OPSSU) team (November 2015); created an OPSSU with 13 beds (December 2015) expanding to 29 beds (October 2016), patient information leaflets emphasising the ethos of the importance of getting patients home, developed a ‘time to move’ culture in the unit (February 2016), a sense of urgency with the red to green management system (March 2017) and continuity of care with junior staff across 7 days (April 2017).
A monthly frailty dashboard was created which focused on LOS for the over-75s, A&E conversion to admission rates, readmissions and mortality to ensure that these quality markers were not significantly influenced.
Results
See Table 1 below.
Using under-75s as control, the LOS reduced from 3.79 (December 2014 – November 2015) to 3.54 days (December 2015 – November 2016) – only a 6.6% reduction in LOS; there was therefore reduced impact for the under-75s, but also a knock-on effect as excellent care for the over-75s released staff to focus on the care of the under-75s. 29,240 bed days were saved.
Mortality, readmission and conversion rates remained relatively stable, as shown below.
Mortality
April 2014 – March 2015, 8.5%
April 2015 – March 2016, 8.6%
April 2016 – March 2017, 8.5%
Readmission (30 days)
April 2014 – March 2015, 23.4%
April 2015 – March 2016, 25.0%
April 2016 – March 2017, 25.8%
A&E conversion to admission rates
April 2014 – March 2015 57.1%
April 2015 – March 2016 55.8%
April 2016 – March 2017 57.2%
98.8% (330 patients) mentioned that they were extremely likely or likely to recommend the service.
Weekday and weekend discharges from OPSSU after April 2017 (continuity of care):
Pre-intervention medical cover November 2016 – February 2017 (4 months): weekdays: four FY2 doctors with random on-call commitments; weekend: one locum senior house officer (SHO) and one locum geriatrician.
Post-intervention medical cover April – July 2017 (4 months): weekdays: improved continuity of care with four OPSSU-based SAS doctors with no on-call commitments, two SAS doctors covering other geriatric wards; weekend: one in six SAS doctors on rotation.
OPSSU all discharges (n): 468 vs 528
Control all discharges (n): 519 vs 437
OPSSU weekend discharges (n): 76 vs 91
Control weekend discharges (n): 84 vs 55
Conclusion
The OPSSU team working across all emergency areas reduced the LOS for the over-75s. It was challenging but crucial to have engagement with partners from the early stages to support the smooth transition of care for patients.
Continuity of junior and therapy staff into the weekend is key for success and we would have done this at an earlier stage instead of having locum cover, as this ensured improved weekday and weekend discharges.
Our intervention is now routine practice which is sustainable long term, as going forward we are now linking OPSSU with our community locality hub.
Conflict of interest statement
None declared.
- © Royal College of Physicians 2019. All rights reserved.
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