South Warwickshire Frailty Flow

South Warwickshire Foundation Trust over 75s frailty pathway participated in cohort 1 of the Flow Coaching Academy, delivered in partnership with Sheffield Microsystem Coaching Academy and the Health Foundation. The key principles of the programme are - 
  • A bottom up approach including all the key front line stakeholders
  • A ‘Big room’ with weekly meetings to host the improvement work and introduce various improvement and lean tools and techniques.
  • The 5Vs (Value, inVolve, Visualisation, eVidence, Vision) - an assessment of current state information about the pathway undertaken by the stakeholders, including both data and patient stories.
  • Plan, Do, Study and Act cycles to make small changes, and use evidence to measure improvement.
  • Develop coaching support to the Big Room team with advice, guidance and facilitation

Background

Frail adults over the age of 75 are frequent attenders and service users of acute NHS trusts. They have high rates of admission due to associated co-morbidity and contribute to 50 % of the medical take.  From the point of entry into acute services they begin decompensating physically and cognitively, making them less mobile, sleep deprived, delirious, and more dependant, which in turn contributes to increased therapy needs, prolonged length of stay and increased care needs on discharge.  

The Vision

Over 75s formed approximately half of all medical admissions. The aim was to reduce the Length of Stay (LOS) in a selected proportion of the group, the frail elderly who are identified to need short stay. The aim was to
  • recognise these patients promptly on arrival
  • have them owned and managed by the frailty team, and
  • discharge appropriately and promptly to minimise decompensation associated with prolonged hospital stay.

What did the 5Vs assessment tell us?

  • The majority of this patient group arrived at the Emergency Department (ED) by ambulance
  • Self referred attendances peaked between 09:00 to 12:00 noon and GP referred patients peaked between 16:00 to 19:00
  • The average LOS for the medical admissions in the over 75s was 12.5 days

Our Stakeholders:

We had a very wide variety of stakeholders from many professional groups – 
  • The frailty team (consultants, Medical Nurse Practitioners, Occupational Therapists, Physiotherapists, Ward Nurses, junior doctors)
  • The Emergency department – consultants, nurses and other staff
  • Acute Medicine – consultants, nurses and other staff
  • The Community Emergency Response team (CERT)
  • Paramedics from West Midlands Ambulance Service (WMAS)
  • General Practitioners with special interest in frailty
  • Support from South Warwickshire CCG, GP federation and Trust management

Process mapping using patient stories

Patients were conveyed to the ED by the paramedics, seen by the ED triage nurse, the junior and senior medical team, and referred to the on call medical team. They were subsequently seen by the junior and senior acute medical team and referred to the frailty team almost a day or more after arrival. Often the management plan needed to be changed after the Comprehensive Geriatric Assessment (CGA) was done. 
Many of the patients who missed being seen by the frailty team were admitted in peripheral wards and their LOS was even longer.

Value Stream mapping & testing

The team decided to test removing the non value added steps in ED and Acute Medicine in the current pathway, and take and retain ownership of the patients from the point of nurse triage in ED.  This was tested using PDSA cycles.  Several PDSAs were undertaken. The team decided to remove the non value added steps (blocked out in white in the Figure 2 below) for the patient in ED and Acute medicine in the current pathway and take and retain ownership of the patients from the point of Nurse triage in ED for the pilot for three months.
The logic behind the test was the evidence that assesment by the frailty team has a positive impact on the quality of patient care.  The frailty team complete the Comprehensive Geriatric Assessment (CGA), which teases out the exact needs of the patients and helps implement the appropriate management. The ED and Acute Medical teams do not often have the time, expertise or the motivation to undertake this assessment.

Results

  • Time to see frailty ANP and time to see consultant decreased.  Average time to see the frailty team after arrival to ED is 1 hr. and 22 min, average time to see consultant in the frailty team is 2hrs 15 min.
  • 63% of patients were discharged from ED, AMU or Frailty to the destination they came from with an average LOS of 2 days
  • 23% whose ownership could not be retained with the frailty team and had to be moved to peripheral ward  had an average LOS of 10.5 days  
  • There was a significant reduction in the overall LOS of over 75s in medical beds (See SPC chart below)
  • Release of 14 beds across the Trust within 5 months of start of the PDSA testing

Statistical process control chart of average LOS for emergency medical admissions over 75 at SWFT


Conclusion

This work havs demonstrated that effective management of the frail older people is a high impact intervention, which does not need extra resources, but can deliver extraordinary efficiencies. Using the Flow Coaching Academy methodology was helpful in the Big Room, resulting in the team decreasing LOS and bed occupancy. The positive impact for the patient is also profound. 

Warwick Frailty Big Room Coaches

  • Dr. Jyothi Nippani, Deputy Medical Director, South Warwickshire Foundation Trust
  • Tim Morris, Practice Manager, Waterside Medical Centre

 

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