winter pressures 2013 acute geriatric intervention service ... · winter pressures 2013 acute...

1 Phil Lumbard ECP, May 2013

Winter Pressures 2013

Acute Geriatric Intervention Service – The right response, first time in a timely manner?

Overview/Background

The Acute Geriatric Intervention service (AGIS) was established at the commissioners request to

build on the success of the Cambridge Falls Partnership Vehicle (FPV) to help manage the acute and

urgent needs of the elderly and frail elderly. It was a collaborative venture between the East of

England Ambulance Service (EEAST) and Cambridgeshire Community Services (CCS). The FPV had

previously received a National Innovation Award for the services it provided and it was felt that this

experience could be built upon. It was natural for the already established interdisciplinary team to

progress towards providing a more comprehensive approach to healthcare provision for a wider

demographic of elderly patients.

With the publication of “Quality Care for Older People with Urgent and Emergency Care needs” aka

“The Silver Book” in summer 2012, examples of current best practice and evidence based practice

were readily available, along with some national thinking on how to approach caring for the elderly.

Some key points from this publication should be considered;

Acutely ill elderly people are very sensitive to delays in care. The longer they wait for a

definitive consultation; a hospital admission becomes more likely.

Current model of acute care is unsuited to patients with complex needs; the emphasis should

be to provide evidence based decision-making and holistic management.

Specialist geriatric care improves outcomes, unfortunately illness & disability is often

normalised in the elderly and not investigated adequately.

Multidimensional assessment and multiagency management of older people leads to better

outcomes.

A multidisciplinary response should be available within 2 hours.

For any local health care system to achieve these points successfully, a change of approach and

radical reform would be required.

Locally in Cambridgeshire and Peterborough, the Office of National Statistics expects the over 65

population to increase by 66% by 2030. In the area of operation for this service, population of circa

300.000, there are around 6000 frail elderly who are at risk of acute admission and this is expected to

rise to approximately 8000 over the next 2 years.

The service started on the 9th January 2013 and ran until 31

st March 2013. It utilised two response

vehicles each with a Paramedic and a therapist working together as a team. It ran Monday to Friday

and covered the hours of 0630 to 1830. The service was supported by a Specialist Paramedic, Senior

Rehabilitation Therapist and a Community Consultant Geriatrician. Support was available via

telephone but also had the capability to respond.

The service facilitated two separate referral pathways, the first via 999 Emergency Ambulance Control

for elderly fallers (AMPDS Code 17) and the sick elderly (AMPDS Code 26). The criteria for these

patient’s was that they were over 65 years of age and at their usual place of residence. The second

referral pathway was GP direct referral, these patients were required to be over 75 years of age and

at risk of admission to an acute healthcare facility, but did not present with any red flag conditions,

e.g. stroke or chest pain.


Governance for the service was provided primarily through a virtual ward round led by the Community

Consultant Geriatrician, but also utilised case load supervision and case discussion with the patient’s

own GP. Patients GPs were informed of all patient contacts and outcomes, excluding those admitted

to an acute facility. This was either by letter following a contact or via telephone during any contact

dependent on the nature of the situation. All decisions made for GP referrals were made in

conjunction with the patients GP via telephone at the time. It is intended in the future to also hold bi-

monthly clinical governance meetings to review practice.

The service has since been commissioned to run for a further year, 1st April 2013 – 31

st March 2014

and will utilise extended hours. The service will be operational 6 days per week, 12 hours per day.

Initially it will have a single response vehicle but it is planned for a second vehicle to come online from

September, prior to winter pressures.


Aims of the Service

To respond to 999 calls for AMPDS code 26 sick, other and AMPDS code 17 falls for patient’s

aged over 65. Respond to referrals direct from GPs for the complex elderly at risk of acute

admission for patients aged over 75.

To facilitate an immediate comprehensive geriatric assessment approach to the elderly, at

risk of admission or who have fallen, who are over 65 years old and at their place of

residence.

To assess patients holistically.

To provide safe appropriate admission avoidance solutions, which promote independent living

and patient centred goals.

Assess, investigate, diagnose, treat and make appropriate referrals for a wide scope of

conditions relating to elderly health, elderly social needs and falls with in the team’s scope of

practice.

To provide immediate intervention where possible or appropriate onward referral.

Promote falls prevention.

Professional collaboration and networking

Simple and complex case management in conjunction with other healthcare professionals.

Maintain in-reach and out-reach activities relating to acute facilities

Approach

This service is an extension of the Falls Partnership Vehicle previously piloted within the Cambridge

City and South area which was fully evaluated in November 2011 demonstrating service effectiveness

and value for money.

In December 2012 CATCH and Cam Health agreed with EEAST and CCS to increase the range of

offerings of the Falls Partnership Vehicle with effect in January 2013, to include other long term

conditions interventions and the proactive case management for suitable patients, resulting in the

development of the Acute Geriatric Intervention Service (AGIS).

The service pathway was also redesigned to:

• Increase the AMPDS codes the service responds to (code 17 for falls and ambulance crew

referrals, and code 26 for sick, other patient aged 65 & over, and patients at home)

• Add a new referral route whereby GPs have direct access.

Clear criteria were developed for GP referral (appendix 1), to ensure the potential benefits of the

service are maximised with an aim to avert unnecessary hospital admissions by responding to elderly

patients who are in or at risk of imminent crisis.

The hope was that this approach would go some way to addressing high inappropriate admission rate

of the elderly to acute facilities.


What does the Service do?

The aim of the service is to avert inappropriate hospital admission for elderly patients who are

in or at risk of imminent crisis which would likely result in an acute admission.

The service will respond to 999 calls to the elderly and will accept direct referrals from GP’s

against set criteria. The team will look to initiate a comprehensive geriatric assessment which

is holistic and patient centred. This can include the patient’s physical health, functional ability,

cognitive function, nutritional status, mobility and falls, and an environmental assessment.

The service has the ability to provide many interventions at the time of contact such as

functional equipment and walking aids, wound care and provision of some medications.

Make appropriate onwards referral, be that for further assessment such as Consultant

Community Geriatrician, specialist nursing, community matrons, RADAR or START, the

implementation of care packages and use of respite beds or on-going rehabilitation such as

balance and strength classes or community therapy and referral onto other services such as

care lines or assistive technology.

It is able to access social care input via reablement and nursing skills from the local

community services.

Where it is appropriate for a patient to be transported to an acute facility, an access visit

report is provided alongside the medical assessment with any relevant information to assist

the hospital staff in ensuring a timely discharge.

As well as having a responsive element to the Consultant Geriatricians input, she also leads

the team’s weekly virtual ward round to review each patient cared for by the team and provide

telephone advice as required.

GP will receive notification that the team has visited one of their patients which will detail the

nature of the contact and any outcome from it. If the contact is via GP direct referral the team

would expect telephone contact with the referring GP to make any final decision regarding the

patient’s care jointly.


Outcomes

The service ran from the 9th January 2013 until 31

st March 2013 and did not work bank holidays. The

first vehicle started on the 9th

January and the second vehicle started on the 21st January. This meant

there was a potential of 108 working days across both vehicles. The service was in operation for 88 of

these days due to sickness and prior engagements. Unfortunately due to the short timescales it was

not possible to establish any resilience for the service.

March also saw the ambulance trust implement its rota redesign where resources were targeted

against historical need. The resultant higher number of ambulance resources coupled with a drive to

achieve response targets appears to have had a negative impact on the exposure of the service.

Monthly data in some key areas.

0

20

40

60

80

100

120

140

PatientContacts

GP Referrals 999Referrals

ApproriateAdmissions

Treated atHome

AdmissionsAvoided

Total Figures

Total Figures

0

20

40

60

80

100

120

Appropriate999

Approprite GP Appropriteadmission

Admittedwithin 14days

Step up beduse

Appropriate Calls

Appropriate Calls


This table shows the number of 999 calls (AMPDS Code 26 and 17) to the elderly, transported to an

acute facility. It shows a reduction in the number of 999 calls but also a significant reduction in

conveyances to hospital which is not mirrored in the previous year but corresponds with the

introduction of AGIS. It should be noted however that elderly care was a particular focus for the local

health care system during winter pressures.

0

20

40

60

80

100

120

January February March

Patient Contacts

GP Referrals

Admissions

Admissions avoided

Admitted within 14days

Step-up bed referral

Referral to other services

Care Packages

Interventions


The problem list at point of call for all patients was either a fall or ill/acutely off-legs. The following

table shows the teams working diagnosis following assessment and patients were treated

accordingly.

*includes faint/syncope, new ecg change etc

**includes constipation, acute abdomen, respiratory problems, polypharmacy, diabetes etc

***includes parkinsons, cognitive problems, PsP etc

****Care package, Care liaison, SOVA, Information/advice etc

*****Home adaptations, Comm OT, Comm Physio, Day Rehab etc

0

5

10

15

20

25

30

35

40

45

50

Working Diagnosis

Working Diagnosis


Conclusions

The target population for this service was the elderly over 65 years of age with particular focus on

whether they could be managed more appropriately in the community and although not covered in

this report, whether appropriate intervention earlier in their timeline of care leads to longer patient

independence. From the table below you can see this service was trialled in the area with potentially

the smallest need but still provided an impact.

Population growth forecast 2008-21 by age group and district

The 999 access to fallers and sick elderly allowed for random selection of patients within the specified

age criteria. The variation of acuity in this group was vast ranging from cardiac arrest through to

accidental activation of a call alarm with no acute need established. It was not intended that such an

array of calls would be attended, however triage is open to interpretation and varies accordingly.

GP referral allowed for a more targeted patient audience who were expected to be unwell or at least

in need. This however also provided a large variation in patient need ranging from a pure social need,

to short term medical intervention for a period of illness, to the GP having no clear diagnosis and

seeking a Second Opinion.

The premise of the service was to achieve early identification and assessment of the elderly and frail

elderly, but also to provide early intervention for medical and therapy needs to promote safe

independent living. It is also worth noting that many of the patients that this service interacts with are

first time callers and would be brought to the attention of the relevant GP practice via telephone or

letter.

The service set its own aims to be achieved and they have been met. Patient demand for the service

is ever-present however there have been some problems with supply with fluctuating numbers of

referrals from both ambulance control and GPs. This has been for a variety of reasons such as,

awareness of the service it was launched on a very short time frame and the different collaborators

having other priorities at the time.

The key aims of patient centred holistic assessment, admission avoidance solutions, assessment and

intervention are all demonstrated above with a wide array of working diagnosis and interventions. The

recognition that a large proportion of patients required multiple interventions including medical,

therapy and social support the assumption that the approach was holistic.

The value of joint decision making between Ambulance and Therapy staff at the point of need should

not be underestimated.


The ambulance clinicians are skilled at “see and treat” and dealing with patients and relatives in a

home environment during a crisis. They are also familiar with working autonomously within their

scope of practice and are prepared for all eventualities and capable of dealing with a multitude of

challenges. Therapists bring experience dealing with the elderly, problem solving around daily

activities and mobility to the decision making process, which enables a safer level of admission

avoidance activity. They actively promote independence and prevention activities, establish an inter-

disciplinary team and convey a vast knowledge of community referral pathways and experience

making use of them. It is evident that their consistent approach to enabling people plays a large part

in the low care package and interim bed utilisation. The interdisciplinary approach also reduces

duplication of services and supports appropriate referral to other support services. There has been

feedback that the Community Therapy teams are receiving fewer referrals.

We need to be clear that although skilled, the health care professionals that are part of this team are

not doctors and the ownership of its patients remains with the GP.

There were also some key points from the “Silver Book” referred to earlier as well as many more than

have not been highlighted here, these were;

Acutely ill elderly people are very sensitive to delays in care. The longer the wait for a

definitive consultation a hospital admission becomes more likely.

Current model of acute care is unsuited to patients with complex needs; the emphasis should

be to provide evidence based decision-making and holistic management.

Specialist geriatric care improves outcomes unfortunately illness and disability is often

normalised in the elderly and not investigated adequately.

Multidimensional assessment and multiagency management of older people leads to better

outcomes.

A multidisciplinary response should be available within 2 hours.

Does AGIS address these considerations of care for the elderly?

Undoubtedly it does. The 999 response alone addresses the majority of them, the team itself

comprises of professions suited to delivering elderly care. The team is based within a rehabilitation

unit and is constantly involved and exposed to caring for the elderly.

The service has a clinical governance system which is led by a Community Consultant Geriatrician via

a multi-disciplinary virtual ward round (Appendix 2) on a weekly basis during which each case is

discussed individually and the management can be agreed, altered or reflected upon. This also

provides the patient with exposure to Consultant review of their current needs and a higher level of

expertise in areas such as medication review. In addition to this case load review and one to one

supervision is also undertaken. A bi-monthly clinical governance meeting has also been established

to examine the services and individual performance as well as mortality, morbidity and admission

rates etc.

The ambulance trust has recently revealed that it naturally leaves 40% of its patients at home utilising

its normal see and treat procedures. As we know the elderly are likely to have multiple co-morbidities

or complex issues, there is also a large group which will likely be classified as frail and vulnerable to

admission.

However the following data suggests a different picture for the elderly or over 65s. It clearly shows

that the older the patients are, the greater the number of patients transported to hospital. For the over

65s, 63% of patients are transported to hospital. This is above the trust’s average figures in an area


that’s primary focus has been the elderly. Would a true reflection of this be higher without the recent

elderly care initiatives? A closer inspection of the data would be required.

Is the Ambulance Service missing opportunities to identify potential issues without a geriatric centred

assessment and therefore conveying more to hospital?

It is widely accepted that the frail elderly are subject to a 30% inappropriate admission rate, the AGIS

service has shown that it has achieved an admission avoidance rate ranging between 21% and 29%,

an average of 24% over duration of the pilot. This suggests that an approach which employs

appropriate assessment for the elderly can effectively tackle this high level of inappropriate

admissions.

The AGIS service over the 3 month period of winter pressures successfully treated 69% of its patients

at home, this is 29% above the ambulance services see and treat rate. This is for a group of patients

with complex needs that are at a higher risk of acute admission than their younger counterparts,

added to this are the patients with a higher acuity referred from GPs. The service offers other

advantages gained from collaborative working which haven’t been experienced before. The utilisation

of 999 as a referral route allows for the team to identify issues earlier and provide solutions in a single

patient contact or refer on as appropriate. Continuity of care is vital and the collaboration between

Emergency, Community and Acute services will greatly improve patient experience and care.

As a specialist service the team in the absence of any acute need during lower acuity calls is still able

to assess and provide proactive intervention providing longer term solutions. The collaboration with

the Ambulance Trust not only allows access earlier to patients via the 999 system but also ready

access to transportation requirements. This specialist service also enables other emergency double

staffed ambulances to be available to respond to more appropriate calls. The presence of the service

0

100

200

300

400

500

600

700

800

900

1000

0-2 3-9 10-17 18-64 65+ 75+ 85+ Unknown

Inci

de

nt

cou

nt

Age band

Seen And Treat Count

Seen And Conveyed Count


has also played a part in raising the profile of elderly care within the ambulance trust and we have

started to note that Ambulance clinicians not involved with the service are beginning to ask for and

record new different information around caring for the elderly.

What has proven a challenge for the service at times is the limited capacity within social care and

step-up/step-down beds in the local community. The service also currently has no provision to take

blood samples and this can be an issue in different areas, the lack of intravenous therapy in the

community has also been highlighted. All these factors can and have reflected negatively on

admission avoidance decisions.

The service will continue for the following 12 months, initially with a single vehicle but will employ a

second response vehicle prior to the winter pressure period. It will operate extended hours working

Monday to Saturday, 12 hours per day. The change in hours has already seen an increase in activity.

In the first month a single response vehicle was able to assess 71 patients, more than half the total for

the 3 months winter pressures period.

AGIS has achieved its goals of providing an appropriate service for the elderly: improving patient

experience and patient outcomes by treating more patients at home appropriately and exposing them

to Senior Clinical review at an earlier stage compared to a traditional 999 response

“The right response, first time, in a timely manner.”

Phil Lumbard ECP

Elderly Care Lead, West Sector

East of England Ambulance NHS Trust


Appendix 1

GP direct access criteria

The service is for patients over 75 who are in or at risk of imminent crisis. The services aim to avert

hospital admission, for example;

Immediate short term management of the acutely ill

Acute delirium or confusional states

Acute decline of function or mobility

An urgent or immediate medical need

A patient requiring a comprehensive multi-disciplinary approach or assessment urgently ie.

Patients with multiple needs.

Inclusion criteria

Patients over the age of 75

Patients at their normal place of residence

Acutely unwell with no red flag symptoms

(e.g. Chest pains, severe SoB, head injury with LoC, stroke)

GP is aware of patient’s premorbid state or has had contact with the patient.

GP outline of expectations

A working diagnosis of the problem.

Exclusion criteria

Patients under 75 years old

Patients not at usual place of residence

Patients with red flag symptoms

Patients who require 24 hour care

Patients experiencing a social care breakdown (e.g. Main carer is unwell and partner requires

respite)

Single need patients with no urgent requirement (e.g. Only Physio, only minor wound care –

DN’s)

Alcohol abuse/intoxication

Patients requiring IV treatment


Appendix 2

Virtual Ward Round Template

Acute Geriatric Early Intervention Service (AGEIS)

Patient Details

Surname: How was AGEIS accessed? (Please circle)

999

GP referral Forename:

DOB: M / F

Address:

Date/time visited: Number of days service:

Visited by: NHS/Hospital No:

Clinical Details

Clinical test Done? Result

Postural BP (mmHg) Y / N Lying: Sitting: Standing:

ECG Y / N Pulse:

Temperature (ºC) Y / N Comments:

Blood sugar (mmol) Y / N Comments:

Pain Y / N / 10 Abbey Pain Score / 18

Urine dipstick Y / N MSU

CSU

Chest examination Y / N Comments:

Number of medications Psychotropic meds?

Frail Elderly Y / N Comments:

Vulnerable/At Risk Y / N Comments:

Other observations of note:

Cause of fall (please circle)

Accident Slip/trip Infection Alcohol

Musculoskeletal Polypharmacy Other:

Assessment Tools Completed

CAM (Confusion Assessment method) Score: N / A CDI (ADLs and Function) Score: N / A

Cognition (GP-COG) Score: N / A Tinietti (Balance & Gait) Score: N / A

Abbey Pain Score Score: N / A Mobility (Rivermead Index) Score: N / A

Geriatric Depression scale (short) Score: N / A Pressure Areas (Waterlow) Score: N / A

MUST (Malnutrition screening) Score: N / A Medication (Stopp/Start) Score: N / A

HAD (Anxiety Scale) Score: N / A Home Environment Y / N

Falls Screen Complete Y / N


Virtual Ward Round Template … continued

Probable/Working Diagnosis

Referred to Interventions made

GP Y / N Hospital admission Y / N

Community Physiotherapy Y / N Equipment provided Y / N

Community OT Y / N Home hazards removed Y / N

Assistive Technology Service Y / N Home hazard advice Y / N

Community Matrons Y / N Discussion with consultant Y / N

District Nurses Y / N Care Package Y / N

Safer Homes Y / N Respite Care Y / N

Day Rehab Service at Brookfields Y / N Inpatient rehab @ Brookfields Y / N

Falls Clinic Y / N Consultant response Y / N

Community Pharmacist Y / N Further Information:

START Y / N

RADAR Y / N

Medication review Y / N

Specialist Nursing Y / N Nursing Discipline:

Other referrals considered if they were available:

Patient Disposal Details

Longer term benefit? Y / N Comments:

Inappropriate admission prevented? Y / N Comments:

Appropriate admission? Y / N Comments:

Inappropriate admission? Y / N Comments:

Appropriate GP referral? Y / N Comments:

Admitted within 14 days? Y / N Comments:

Additional Information

Consultant review date: Signature:

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