ACCIDENT and emergency departments feel like “war zones”. So say a large number of senior doctors in the UK, according to Cliff Mann of the College of Emergency Medicine in London.
Then last week, waiting times hit the headlines too, prompting the government to announce a £500-million “bailout” for A&E units. Last winter, the proportion of people waiting longer than 4 hours to be seen hit its highest level since 2003 (see “Are there more emergencies?“).
Healthcare is of course a complex issue, and the reasons for the crisis are manifold. But there are ways that science could help. Recent research shows that a simple change in the way medical services are provided could improve the experience for everyone, and even cost less overall. The idea could be applied in other countries too.
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In the UK, nearly a quarter of the people arriving at A&E are over 65. And once there, they are more likely to be admitted for a prolonged stay than any other group. But often this is because A&E units do not have the resources to deal with the complex problems an older person may have. “The complexity of what needs to be done to an older person in A&E is much greater than what would be done to a younger person, and that can often result in inappropriate admissions to hospital,” says at UK health charity . “If you’ve got a pressure on waiting times and that person is clocking up hours in A&E, the easy option is to admit them.”
But pilot studies in British hospitals are pointing towards a different path. The key is to provide immediate access to a specialist service for older people arriving at A&E. This frees emergency units to deal with more straightforward cases, and reduces the number of older people who are admitted while they wait to see a specialist.
The change would also vastly improve the experience for older people who, unless seriously ill, would often rather be at home than idling in a hospital bed waiting to be seen. Patients over the age of 65 account for 80 per cent of emergency admissions still in hospital two weeks later.
“Geriatric patients are the most important group in the emergency department, but these departments often don’t have the competence, the resources, the knowledge or the ability to solve the complex social issues some of them present,” says Jay Banerjee, an A&E consultant at Leicester Royal Infirmary.
The Royal Free Hospital in London has been piloting a scheme to try to change this. In September 2010, its A&E department was joined by a specialist geriatric team consisting of a senior doctor, a physiotherapist and an occupational therapist, linked to a community team to follow up patients after they are discharged.
“The idea is to cherry-pick patients who would do well with a same-day discharge,” says Pandora Wright at the Royal Free London NHS Foundation Trust, who led the study. “The patient sees a specialist straight away, rather than being transferred to a ward and then being referred to a geriatrician.”
In the year after the scheme launched, the number of patients aged over 70 who were discharged the same day increased by 38 per cent, while the median length of stay in hospital went down by two days (). “We think this would impact everyone attending A&E as it frees up staff to process the other admissions, speeding up the waiting times for these patients,” says Wright.
“The number of older patients who could go home the same day went up by 38 per cent”
A similar scheme is being trialled at the Northern General Hospital in Sheffield. The hospital also worked with local government and transport services to support patients on their way to and from hospital. Now, older people are discharged on the same day 37 per cent more frequently. In many cases, specialist attention can involve nothing more than prescribing medication or arranging for social care.
“Freeing up beds and relocating services such as diagnostics to where they are needed most made all the difference,” says Jane Jones of UK charity the , which sponsored the scheme in Sheffield.
Importantly, there has been no increase in the readmission rate, suggesting that people are not being harmed as a result of being assessed and sent home faster.
The scheme could even save money. In Sheffield it was done without hiring extra staff, though geriatricians at the hospital had to adjust their working hours so that they were on call in the evenings and at weekends. As a result, the hospital could potentially save around ÂŁ3 million a year. The Royal Free employed just one extra nurse.
Of course, providing specialist care up front is only a small fix for a much larger problem, and will only work in hospitals with available geriatricians and those with significant proportions of older attendees.
But Jones thinks the model could have much wider applications. For example, the Northern General is now trying the approach in respiratory units, too, and bringing forward cardiologists as well as geriatricians.
Are there more emergencies?
Last winter saw a leap in the proportion of people waiting longer than 4 hours to be seen by a doctor in UK accident and emergency departments. But A&E departments have been under strain for years. Are attendance numbers really increasing?
It’s complicated, says John Appleby, chief economist at UK health charity The King’s Fund. Between 1989 and 2004, the number of people visiting A&E departments stuck at a more or less steady 14 million a year. Then the figure jumped to 16.5 million and by April this year to 22 million – a 50 per cent increase in a decade.
But around the time of that initial jump in 2004, new types of A&E departments were introduced to handle non-emergency patients. Attendance numbers for the walk-in centres and minor-injuries units were added to the A&E figures. “The extra demand actually seems to be minor injuries units, not the big A&E departments,” says Appleby. Take these patients out of the equation and attendance numbers fall back to pre-2004 levels ().
Thomas Cowley at Imperial College London agrees that these changes account for most of the increase, but says there is more to it. Many of the new units were built physically in front of existing A&E units, he says, so people might end up going to those even though they intended to visit A&E. This may mask an increase in A&E attendance.
Another factor is that, in 2010, the government relaxed the target for the number of people waiting over 4 hours to be seen, dropping it from a 2 per cent maximum to no more than 5 per cent. As a result many more people started waiting longer ().
But the British Medical Association does not believe the case has been overstated. “There is clearly increasing pressure on out-of-hours care across the board,” said a spokesperson. Douglas Heaven and Linda Geddes
This article appeared in print under the headline “Solving an age-old problem”
