Dr Anna Folwell is a consultant community geriatrician working at the Jean Bishop Integrated Care Centre in Hull delivering proactive and reactive frailty services in the community.
Dr Shelagh O’Riordan is a Consultant Community Geriatrician at Kent Community Health NHS Foundation Trust and President of the UK Hospital at Society.
Ever wished it could be different?
You’re on call as a hospital geriatrician. Susan, who lives with severe frailty and dementia, is a resident in a local care home and has been admitted following a fall and a possible head injury. She is on anticoagulation, so you feel duty bound to scan her head. You know that even if this does show a bleed, it’s very unlikely your local neurosurgery team will suggest any intervention. If only she hadn’t been brought to hospital…
Ever wished it could be different?
You’re a paramedic. You arrive at Frank’s house following a call out for a fall. You assess him and there’s no sign of injury. You get him up, help him to the toilet and make him tea and toast. You then notice the bed has not been slept in and your heart sinks. This is going to trigger the “long lie protocol.” You will have to take Frank for blood tests and a likely stay in hospital. If only all this could be done at home…
Ever wished it could be different?
You’re a GP in a busy surgery and John, who you know well, calls to say he’s breathless again. He has severe heart failure and frequently needs admission for IV diuretics when his weight goes up and he becomes breathless. But after his last admission, he told you he doesn’t want to go back. He hates being an inpatient and he comes out feeling worse every time. If only he could have his IV treatment without going to hospital…
Well, things are changing.
Around the country, Hospital at Home services (sometimes known as virtual wards), are now working with urgent community response (UCR) services to prevent hospital admission. These teams work with their local ambulance services to directly view “the stack” and find alternatives to hospital admission. Senior clinicians are working together to balance the risks patients tell us about, the risks for clinicians and the system risk of overcrowded hospitals. Together they can reach pragmatic solutions that avoid hospital.
We have recently supported NHS England to write and publish a new document addressing exactly these sorts of clinical scenarios. We chose 15 high-incidence conditions for which there are relatively obvious alternatives to hospital. Not all are relevant to those living with frailty (such as wheezy children and hyperemesis), but these patients have the most to lose from a hospital admission and therefore the most to gain from treatment at home. We urge you to read the document and consider how your services might increase the offer for patients out of hospital. This relies on enablers including systematic advance care planning starting from when the patient is at home, to access to point-of-care testing, easy access to the right medication and equal access to investigations that would be received as an inpatient, including transport if needed.
When done well, this can have a significant impact on the delivery of care, as illustrated in the following examples.
Margaret
Margaret lives in a care home and has severe frailty and dementia. Her carers notice her becoming increasingly quiet and lethargic. With much encouragement, she is still eating and drinking, but for the past three days, she has not wanted to play snakes and ladders like usual. The carers call the local UCR team who send a nurse practitioner to assess Margaret. She is drowsy but rousable to voice, has a new cough, left basal crackles on chest examination and oxygen saturations of 94%, RR 22, temperature 38.3, BP 90/60mmHg and HR 110bpm (NEWS score 8).
Her daughter, Jill, has lasting power of attorney for health and is present when the UCR team arrive. Jill asks whether Margaret can remain in the care home because during her last hospital admission she became distressed and fell multiple times. Jill thinks Margaret would prefer to stay in the care home, and offers to sit with her during the day and keep her drinking plenty of her favourite juice.
The Hospital at Home team has capacity and admits Margaret for once-daily IV antibiotics. The cannula is bandaged to avoid repeated cannulation, with carers advised what to do if it becomes dislodged. Blood tests show a white cell count of 15 and CRP of 180. After 48 hours, Margaret is starting to improve. She has continued to drink about 1 litre per day with support, and switches to oral antibiotics.
The Hospital at Home team takes the opportunity to review Margaret’s medications and works with Jill to rationalise them, as well as updating Margaret’s advance care plan. 48 hours later, Margaret is back playing snakes and ladders and asking for biscuits. She is discharged from the Hospital at Home team. The Primary Care Network (PCN) team check on her on their next weekly ward round.
Ahmed
Ahmed lives in a bungalow with his wife. He is moderately frail and has become increasingly constipated. He has a care package twice a day to support washing, dressing and transfer to bed. He can mobilise the short distance to the toilet with minimal assistance from his wife during the day and uses a bottle by the bed at nighttime. Over 24 hours, he increasingly struggles to pass urine.
His wife calls 111 and the case is passed to the local UCR team, who send a practitioner to assess him. Examinations show a soft but distended abdomen, normal bowel sounds and hard stool in the rectum. His BP is 100/60, bladder scan shows retention with 750ml and point-of-care tests show sodium 143, potassium 4.8 and creatinine 150 (his baseline is 90).
Options of acute admission to the frailty unit or Hospital at Home are discussed with Ahmed. Ahmed wants to stay with his wife, so a plan is agreed to facilitate this. The UCR practitioner arranges for a commode to be delivered, a prescription for laxatives, and administers an enema. As this produces only a small bowel movement and he remains unable to pass urine, he is catheterised and provided with a catheter passport and night bag. He is advised to stop his ACE inhibitor for 48 hours and drink at least 2 litres of fluid daily.
The Hospital at Home team review him the next day and administer a second enema, which is more effective. Oral laxatives are continued and the catheter is removed 48 hours later. The following morning his BP remains below 120/80mmHg, so the ACE inhibitor is not restarted. During four days of support, the team also recognise that Ahmed and his wife are lonely and arrange a visit from local Age UK volunteers to explore opportunities for social engagement.
Achieving this shift requires all of us to think differently. Much of what is currently done in hospital can already be provided at home across many parts of the country. Why not everywhere? If there are gaps in your area, why not start by agreeing some pathways for long lie, head injury on anticoagulation and heart failure? Good luck!
