The Front of House Team: Enabling and Supporting Discharge from the Emergency Department.

Purpose

There is an increasing strain being placed all across the NHS systems. Emergency Departments up and down the country are being widely criticised for their performance against the national targets. We also have an aging population often with multiple co-morbidities that often present to the emergency department with both health issues and social care issues. The Royal Stoke Emergency department is one of the busiest in the country. In 2018 it had 111,091 attendances. 30,074. It had a higher than national average attendance to admission rate for over the age of 70. An external body wanted to see if creating a new MDT made up of senior decision makers with a background in the care of frail patients could make a difference.

3,929
Total Number of patients seen.
3,262
(83%) Total Number of facilitated discharges.
2,710
(83% of 3,262) Discharged to usual place of residence
437
(11%) Number of re-attendances within 7 days.

Approach

On the advice of ECIST, a new team was trial of advanced nurse practitioners who specialised in frailty, advanced physiotherapists and occupational therapists, community liaison nurses and social care. The team was tasked with enhancing the journey of frail patients in the emergency department with the emphasis on discharging them directly from ED and reducing admissions which are known to be detrimental if no acute medical need. The team had no remit but were told to see if they could change the way frail older people were treated. The team see patients directly from ambulance triage as the ANP clerks the patient and investigates medically as required, they then have a therapy assessment and a plan is made for discharge with the appropriate support and safety netting as required. The team also accept referrals from ED for patients who have no medical need for admission but may need support at home to enable a thorough, safe holistic discharge plan.

Outcomes

The team was initially set up in 2016 but only the results of 2018 are used in this abstract.

Total Number of patients seen: 3,929.

Total Number of facilitated discharges: 3,262 (83%)

Discharged to usual place of residence: 2,710 (83% of 3,262)

Number of re-attendances within 7 days: 437 (11%)  

Having a specific frailty front door team based in the emergency department can promote discharges directly from ED. Physiotherapy is vital in this process and helps deliver core aspects of comprehensive geriatric assessment at the front door which is proven to prevent re-admissions. It could be argued that these patients would be sent home by ED anyway but being seen by Front of House ensures they have a holistic approach to their attendance and not a single minded accident or emergency approach.

Cost and savings

Costs were not directly calculated but al discharges were on the same day of admission which prevented unnecessary admissions. Patients were also re-directed directly to community hospitals which again prevented the unnecessary use of acute hospital beds.

Implications

Having physiotherapists as part of a frailty front door team can help encourage discharge and prevent unnecessary admissions. These team is made up of senior decision makers who are able to take the associated risks in enabling frail people to go home. Having a frailty team makes frail patients a priority, ensures holistic approach to care and can prove to be effective in getting patients to their usual place of residence directly from ED.

Top three learning points

  1. Having a multi-disciplinary team meeting patients at the front door and making them a priority enhances the patient journey and prevent unnecessary admissions and deconditioning.
  2. Physiotherapy is a key part of a frail patient’s journey through the emergency department and can prevent deconditioning and promoting movement is vital.
  3. Improving medical knowledge and working closer alongside doctors, nurse practitioners can improve clinical reasoning and improve decision making and help to encourage more thorough clinical reasoning. Improving these skills may lead to advanced practice roles or advanced clinical practitioner roles.

Fund acknowledgements

N/A. 

Additional notes

This work was presented at Physiotherapy UK 2019

Please see the attached Innovations poster below. 

 

For further information about this work please contact Ian Tyrrell.