Despite concerns that some seriously ill people may be staying away from A&E because of the coronavirus crisis, Frederick Smith, 81, who has heart failure and asthma, was rushed to the emergency department at his local hospital in March because his breathlessness had reached crisis point.
Smith and his wife, Edna, who live in a bungalow on the outskirts of Norwich, had to dial 999. It was the fourth time this year.
On each previous occasion, they have been taken straight to the older people’s emergency department (Oped) – a special unit at the Norfolk and Norwich university hospital that provides emergency care for patients over 80.
“When we call the ambulance, I always ask if they can get us into the Oped,” says Edna. “ It’s such an excellent service.”
Launched in 2017, the unit, just down the corridor from A&E, has six beds, two in side rooms and no waiting room. Normally, it admits patients identified as frail and usually with multiple conditions that need a lot of care (such as cognitive impairment, incontinence or reduced mobility). They are brought straight in by ambulance or trolley from other parts of the hospital and seen by a consultant geriatrician within two hours.
A team of nurses with experience in both emergency care and care of the elderly, pharmacists and physiotherapists are on hand to support patients much more quickly than A&E to get patients out of hospital and back home within the same day wherever possible. For patients who need to stay longer after treatment there is an adjacent ambulatory ward.
This unique model is showing results. The proportion of the specialist department’s patients admitted to the hospital is 50% compared with 68% for the same age group of emergency patients coming to the hospital five years ago, when they were treated at the normal A&E. When Oped patients are admitted, their average length of stay is 1.2 days less.
“It’s just what we want for old people,” says Dr Sarah Bailey, the department’s lead consultant geriatrician. “We get the experts in straight away because we recognised that’s the best thing for [them]”.
With the number of patients aged over 80 attending A&E at the hospital up 30% from 2015 levels, the unit is popular and, until the pandemic, had been treating over 600 patients a month.
Smith’s breathing problems meant that on this visit he had to be treated as a potential coronavirus case and had to wait in A&E, without his wife, before being admitted to a respiratory ward with patients of all ages and tested for the virus. It turned out he had ordinary flu. He was treated and returned home after four nights.
During the pandemic, the unit is helping to keep those who do not have coronavirus symptoms, such as those with injuries from falls and some stroke patients, away from the main A&E ward, providing a degree of shielding not normally possible.
But for most NHS trusts, providing a separate unit like Oped is not feasible. “Hospitals are working to separate emergency patients with respiratory problems from those with other conditions,” says Dr Jay Banerjee, who leads the Royal College of Emergency Medicine’s work on emergency care for the elderly. “But most just do not have the capacity to also try to separate elderly patients with other conditions from younger patients.”
Well before the coronavirus pandemic, the Royal College of Nursing has described A&E as a “place of terror” because it is noisy and impersonal, there is little privacy and there can be long waits for care, during which frail, older patients can rapidly deteriorate.
“It was very frustrating seeing a 101 year-old on a trolley in A&E when we think we could sweep them up and sort them out,” says Bailey, who has worked for the past five years to “pull” patients from other parts of the hospital to develop the Oped model of care.
But it is yet to become commonly used. While popular with its Norfolk patients, the model is not easy to replicate. It requires space next door to A&E, which Norwich happened to have, and a budget for extra staff, unless existing staff are able to cover the new service –as Norwich’s did initially. And in cities with high numbers of older residents such a unit would need to be much larger.
With 8.8 million over-70s and 3.3 million over-80s, it is no surprise that in many hospitals, geriatricians have begun working within normal A&E departments in recent years. And many hospitals have created so-called “frailty units” , but not all are as active in seeking out potential patients – Oped liaises with paramedics, GPs and care home staff to identify patients who need its services.
Zoe Wyrko, the vice-president for workforce at the British Geriatric Society, questions the need for a separate A&E. “The current situation is reflective of our societal ageism,” she says. “Building a separate emergency department for older people risks further perpetuating this.”
Instead, she wants emergency services and buildings to be built or adapted to meet the needs of the growing numbers of older people.
That is the approach being taken by Banerjee, who is also a consultant in emergency medicine at the Leicester Royal Infirmary. He argues that specialist emergency units for old people are just not feasible. “Older people are going to be the biggest chunk of our future patients,” he says. “Already 65% of ambulance patients are old. If you start pulling older people out of the emergency department, you won’t have an emergency department left.”
Norwich’s Oped is advertising for more geriatricians to expand its service, but with a national shortage meaning half of all consultant geriatrician posts go unfilled, Bailey says it may be hard to find the consultants the unit needs to expand.
Instead, “we need to make all the staff in every emergency department competent in managing older people”, says Banerjee. Leicester Royal Infirmary, which has the largest A&E department in the country, has rebuilt it with older patients in mind. And Banerjee is leading efforts to train consultants and nurses in emergency care for the elderly. “We are building a system that’s going to be future-proof,” he says.
With colleagues he has also set up a so-called “frailty network” to advise and support hospitals around the country to adapt their entire systems – not just emergency departments. “There needs to be a system-wide change. Everyone, except perhaps paediatricians, needs to know how to care for older people,” says Banerjee.
Back in Norwich, Smith now has oxygen at home when his breathing gets really bad and says he feels a lot better. Self-isolating with his wife, he has nothing but praise for the Oped. “They were wonderful. I got in quickly, they sorted me out,” he says. “They are so kind and they will come and hold your hand, you know.
“They seem to treat you special. You don’t get that kind of care on the other wards. It makes such a difference.”