Sister Arlene Wellman,
RACOP, Royal Berkshire and Battle
NHS Trust, United Kingdom
Email: [email protected]
The Royal Berkshire and Battle Hospitals NHS Trust was originally based across two geographical sites and was consolidated onto one site in 2005.
The Elderly Care Day Hospital (ECDH) transferred to the consolidated site in May 2005.
The EDCH had been established in the late 1970’s, in an attempt to free up acute hospital beds, by providing day hospital care for older people. The initial focus of the day hospital was treatment. However, over the years, patients started to attend daily, received some physiotherapy and/or occupational therapy input in the morning, and spent the afternoon undergoing diversional therapy, such as playing bingo or scrabble.
Meetings with staff revealed that they had already tried various methods to increase the efficiency of the service, with little success. Similar informal discussions with patients and relatives also identified issues around transport as well as other concerns. A SWOB analysis (Ansoff, 1965) was done, with the involvement of the staff, to identify possible ways to improve the service. Included in this analysis was a literature review.
What the Literature Says
The literature review was conducted to establish the efficacy of day hospitals and obtain research evidence on improving its efficiency. Two large studies were found. The study done by Sui et al (1994), a retrospective cohort comparison study, found that many aspects of the day hospital were beneficial to patient care.
However, this study was unable to demonstrate better outcomes from assessment in a geriatric day hospital, when compared to such assessments received in a clinic without a day hospital. The more recent study, conducted by Forster et al (1999), was a systematic review of day hospital care for the elderly.
In this study, the authors had also concluded, that while day hospital care seemed to be an effective service for older people, it had no clear advantage over other forms of comprehensive care. They also highlighted the fact that seventy-five percent of the trials that had reported cost information had indicated that day hospital care was more expensive than the alternative treatment.
Standard 3 of the National Service Framework for Older People (DOH, 2001), stresses the need for intermediate care services to focus on responding to or averting a crisis. Barton and Mulley (2002) have criticised the concept of not admitting elderly patients to hospital, but acknowledged the benefit that these patients might gain from a comprehensive geriatric assessment.
After reviewing the available literature, Rubin (2000) concluded that a multidisciplinary team, with rapid access to services such as radiology, pathology and skilled geriatric personnel, was needed. Hanger et al (2004) have in fact proposed that older people prefer to ‘age in place,’ if at all possible. The government has already documented its plan to bring healthcare services closer to people’s homes. (DOH 2006)
The British Geriatrics Society (BGS) (2003) also advocates that access to comprehensive non inpatient assessment, should be a key element of specialist services for older people. In this document, the BGS stipulated that any illness or change in health of an older person should trigger an assessment and investigation, where they could be expected to be seen within one week, if the problem requires urgent attention.
Tanaka (2003) therefore advocated that the multidisciplinary team assessment and intervention should play an increasingly important role in the management and care of elderly patients. He suggested that this assessment could be done in specialist clinics, such as rapid assessment clinics. A search of the national literature revealed that a few Rapid Assessment Clinics had already been implemented.
A joint medical and nursing proposal was taken to the trust board of directors, for approval to close the day hospital and transform the service into a Rapid Assessment Clinic for Older People.
When the proposal was accepted, a communication strategy and dedicated paperwork, were devised, which included the design of a process flow diagram for the new service. The EDCH closed its doors on 25 November and the RACOP was opened on 28 November 2005.
How the Service Works
There is a set of criteria for referral to the unit which has been communicated to all general practitioners in the area. Patients who have been living at home and are developing problems requiring rapid assessment and intervention to prevent admission to hospital, can be referred by GPs and community matrons. Referral is by fax to a dedicated fax number. Patients that are referred to the clinic can expect to be seen within 24-48 hours.
All patients are assessed by a nurse and a senior doctor in consultation with the consultant geriatrician of the day.
The patients also have access to occupational/ physiotherapy and speech and language therapy assessments if required. There is also the facility for investigations such as x-rays, blood tests and CT scans, the results of which are reviewed before the patient leaves the department.
The outcome of the attendance is communicated to the GP via an electronic discharge letter system, ensuring that the GP is up to date with the progress of their patient and the outcome of the specia list assessments. This information is also available should the patient subsequently require further attendance or admission.
This ultimately means that the patient has a full specialist elderly care assessment, can have treatment started and return to the comfort of their own home by the end of the day. This prevents attendance in the clinical decision unit and/or the accident and emergency depart ment for these patients and frees up beds for the patients that need to be admitted.
To date there have been in excess of 900 patient visits to this service.
The service operates and is staffed from an acute elderly care medical ward. This ensures that elderly patients who would have traditionally required admission for an intervention such as a blood transfusion or ascitic tap for example can now have this done as a day case.
Patients can come to the department in the morning, have their blood transfusion or other procedure done and return to their own home in the evening.
There is also no added pressure on the staff of the clinic to work beyond a defined ‘closing time’ of the clinic. If the transfusion is still in progress at the close of the clinic the patient can be monitored and cared for in their designated area on the ward, by the ward staff who are there 24/7. The same applies if the patient is awaiting collection by ambulance transport or a relative.
The development of this service required the closure of another unit, and the management of a period of rapid change in the working practices of a number of doctors, nurses, therapists and clerical officers.
In order to accommodate the service there was also the need to close two inpatient beds on an adjoining ward and transform these into consultation rooms.
There was also the added challenge to transform a riser room where ‘excess equipment’ was being stored into a room that is now used for nursing and therapy staff to assess patients.
All this was done within 6 weeks with a budget of less than £500 and minimum disruption to the wards and departments involved.
This service is an excellent example of delivery of services in a patient focused manner. The benefits of this service are highlighted by the excellent feedback from patients and GPs and the wide interest in the unit that has been expressed by other acute trusts in the south of England.
This clinic has revolutionised the way that older people living in the community can access comprehensive assessment and multidisciplinary management by elderly care specialists.