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Innovative RBCH nurses share success nationally

10 October

Two nurses who improved patient care for older people by cutting emergency waiting times by up to four hours have been invited to share their work nationally.

Frail older patients could spend an average of four hours 54 minutes before they were seen and triaged by ED consultants. But as a result of changes led by specialist frailty advanced nurse practitioners (ANPs) Nikki Dacosta and Pete Keen, ANPs now decide whether to admit or discharge patients before getting approval from an ED consultant.

The waiting time is now estimated between 30 minutes and one hour 30 minutes with ANPs able to provide more focused treatment for older patients, further improving patient outcomes.

The pair won a prize to share their success nationally after presenting their work to the Geriatric Society South West Regional Conference in September.

The improvements have made a tangible difference to patient experience, with one daughter of a dementia patient saying: "Compared with a fall three years ago, I have been impressed by how quickly she [my mother] has been assessed and given a quiet space to rest. Everything has been so well explained and mum feels confident in her treatment - very important with dementia when confusion can be so distressing."

Another daughter of a frail older patient said: "She [my mother] normally gets very anxious, upset and angry, and it is very difficult for me to see my mother in an uncontrolled manner. As Nikki and Pete approached I was preparing myself for an afternoon of upset and uncomfortable situations.

"I am glad to say I was wrong. As Nikki and Pete approached my mother they seemed very calm, smiling and immediately introduced themselves to my mother and me. Please convey my gratitude and thanks to them both, they are a credit to the NHS."

Nikki and Pete began a three month trial of the new practice in October 2018 and it was implemented in January 2019.

Nikki said collaborative working with ED consultants and their Older Persons Assessment and Liason (OPAL) therapy colleagues had led to significant improvements in the care of frail older patients in the ward.

She said: "The outcome has been a significant reduction in the number of admissions, a reduction in the length of stay for those that do require admission and better communication between ED and older person’s medicine directorate. Older people present to the ED with multiple problems and require a multi-disciplinary approach to their care. We are able to streamline these patients either to the frailty pathway, or to outside agencies to provide support, care and further assessments in the community.

"The Emergency Department is not the right environment for older adults with cognitive impairment due to the noise and activity and therefore we aim to assess and treat them at the earliest opportunity. This allows us as much time as possible to ensure that any discharges from the ED are safe and supported, and in the patients' best interests. Admitting patients with frailty considerations can result in a further complications and an increased frailty level upon discharge, so we are therefore proactive at preventing unnecessary admissions.

"We have great job satisfaction from our role in ED and are very proud of the positive impact we have had on patients and their relatives."

The previous process was for all patients to be assessed by an ED clinician and then formally referred to the frailty ANP for intervention. The frailty ANP now works under joint governance of ED and Older Person's Medicine so they are able to make admission and discharge decisions accordingly.

The change has resulted in patients not having to wait for three or more hours before being referred to the frailty ANP.

The improvement came after Pete and Nikki Quality spotted an opportunity to improve patient care and were supported by the hospital's dedicated Improvement Quality team to design, test and implement the change.

ED nurse, Elizabeth Hurdidge, said: "Pete and Nikki have made an incredible impact on the care and pathways relating to our older patients. This level of accessibility has had a huge impact on the timeliness and appropriateness of referrals. They have enabled us to discharge many patients who otherwise may have required admission if the service was not in place.

"We feel proud and privileged to have them as part of our diverse team, and hope we can continue to utilise their skills and knowledge in order to make the journey of our older patients a smoother one."

ED nurses

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