Last year I travelled back to one of my old haunts in the UK. I worked in Leicester for about 5 years in various capacities last century. One role was at the Royal infirmary as a co-admitting acute admission consultant. I knew they had moved on a lot and become very influential in Frailty pathways in Acute care. It is a big hospital of around 1,000 beds, and they have a couple of unitis / wards supporting acutely unwell frail older people. below is an abstract about the service. It is planning to evolve again with a specially built part of the ED unit. While this example is beyond the needs of most NZ hospital (it's an economy of scale issue) the principles and processes are generic to making things more suited to the frail older patient. After 7 years of various alterations etc it is still very much an integral part of the Hospital and has a very stable staff.

Leicester, UK: In early 2011, a 12 bed “Emergency Frailty Unit” (EFU) was established within the ED of the Leicester Royal Infirmary, focusing on older patients who were likely to be discharged home within 24hrs, by embedding a comprehensive geriatric assessment pathway within the ED [4]. The business case for the EFU was predicated on reducing the proportion of elderly patients presenting to ED who go on to be admitted for on-going hospital care (the ED ‘conversion rate’). Geriatricians provided complete medical cover for the service from 8am-6pm, 7 days a week. Secondary/primary/community care pathways were developed and strengthened; for example, the EFU assessment was able to be used as the admission assessment and management plan in community rehabilitation facilities.
A historical cohort evaluation of the impact of the EFU over its first 2 years, showed a significant reduction in the number of older people aged >85yrs requiring hospital admission (ED conversion rate falling from 69.6% to 61.2%). This was despite an 18% increase in the number of >85 yr old patients attending the ED during the intervention period (rising from 638 per month in 2010 to 753 per month in 2012). The 90 day readmission rate following discharge from the ED also fell from 26.0% to 19.9%. However, the mean length of inpatient stay was increased (from 8.9days to 11.1 days); possibly explained by only the sickest of elderly patients being admitted to hospital. ED conversion rates fell across all age groups and are thought to be related to the time freed up for emergency physicians to care more comprehensively for younger patients

In respiratory we have a wider perspective on what 'frailty' is, and who fits the definition. Often they're younger than who we typically label 'frail'. Easy to forget other factors in frailty in lieu of advanced age.  

Hi Phil

Julie Nitschke mentioned the Long-term Conditions network site to me. With great interest, I read your contribution and study the diagram that you posted. I like to add two more suggestions to consider for developing

1. Recently the Dutch Government approved to finance an experiment where elderly that still live at home and are "care dependent" on the presence of their partner or family member, can stay 2-3 night a week at what they call a " Care Hotel". This is a section of an existing aged care facility that is specially designed for these weekly guest. The aim is to offer structural relief on a weekly basis to the partner and family of the 24 hourly care they usually provide to their family member. The two to three days the partner is in the Care Hotel they can use to re-energise by meeting again with friends or attend clubs they otherwise had difficulty to do so. It is suggested that it will reduce the isolation of the caring partner/family. This is different from respite care but could be seen as structural respite care.

2. In June the University Hospital Amsterdam has opened a special wing of a nearby aged care facility that admits frail elderly. They are not admitted via the ED department but go directly to this unit. You find more details on this innovative projects in our July newsletter.

Jan Weststrate