Keeping older people out of hospital: the emergency crews who make house calls

Seeing frail, older people lying on trolleys in corridors of acute hospitals is one of the most shocking images of modern healthcare systems.

Now– partly due to the Covid-19 pandemic – emergency medicine consultants and other healthcare professionals in Ireland are assessing frail older people in their own homes instead and discovering that many of them don’t need to be admitted to hospital at all.

“I think it’s the way forward. We need more connection between community and hospital – particularly for frail, older people,” says Dr Rosa McNamara, emergency medicine consultant at St Vincent’s University Hospital Dublin. It is widely understood that when older people attend emergency departments, they increase their risk of picking up an infection, having a reaction to medication, suffering from cognitive decline or delirium – any of which can result in an increased length of time in hospital and ultimately shorten their lives.  So finding ways to assess and treat them at home is crucial.

Dr McNamara explains how during the Covid-19 crisis, some older people were fearful of coming into hospital and declined to come by ambulance after a fall in their home.

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A weekend home assessment service for older people in Wicklow set up in February was extended to cover the entire catchment area of St Vincent’s Hospital.   The emergency medicine team also went see many nursing homes residents during the pandemic instead of these frail older people being sent to the emergency department of an acute hospital.

“We find we are better able to plan person-centred care from people’s homes.  Often when older people come into the hospital, they are stuck on a trolley, it gets late and the person is admitted and is kept for three to four days,” explains Dr McNamara.

With this new approach, a hospital-based doctor and occupational therapist assesses patients referred to the hospital by their GP in their own homes.  Potential injuries or illnesses that might have precipitated the fall are checked out.  Wounds are cared for. Blood tests are checked and electrocardiograms or ultrasounds given if necessary. Intravenous antibiotics or other medications are administered.

“You have a much better sense if the person will be fine or not when you see him/her in their own context. In a hospital, you are trying to imagine them in their home,” says Dr McNamara.

If the patient needs an X-ray or if they need to see another specialist, these appointments are arranged just as promptly from home as from the emergency department of the hospital.

Occupational therapist, Kerri Donnelly is part of the St Vincent’s University Hospital team who see older people in their homes.  She believes home visits are better for frail older patients.

“Many older people can seem worse when they come to an emergency department.  You can make a wrong assumption that they aren’t safe at home but you get a true picture of how they are coping when you see them at home,” says Donnelly.

An occupational therapist can observe the placing of furniture and rugs or see if older people are keeping their medicines safely and if they have a list of key people to call next to their phone.

“We can also see how they use a stick or a walking frame at home, how they manage getting washed, dressed and making dinner. Cocooning has had a massive impact on older people with many of them not able to go to day centres, men’s sheds or to play bridge or see their grandchildren. Some are still anxious about returning to these things or even walking outside yet not walking increases the risk of a fall,” explains Donnelly.

Being part of the assessment team for frail older people means that hospital-based occupational therapists also get to see patients earlier which can also prevent an inappropriate admission to a large acute hospital such as St Vincent’s University Hospital.

“We can also link in with the public health nurse or their GP or admit them to St Columcille’s Hospital or St Michael’s Hospital where they will have access to physiotherapist and occupational therapists on the wards if they need that,” says Donnelly.

Follow-up team

Patrick McCann (92) was seen by the St Vincent’s Hospital team recently.

“I had two falls which undermined my confidence in walking.  I didn’t want to go into hospital so I was happy to be seen by the doctors in my home,” he says.

Over 500 patients have been seen at the St Vincent’s Hospital frailty service since it began in early April and only 6 per cent of these patients have needed to go to hospital, according to figures provided by the hospital. Staff are rostered into the service as required.

St Vincent’s University Hospital is not the only hospital looking to improve the way they care for older people. Pathfinder is a service run by Beaumont Hospital and the National Ambulance Service in North Dublin. With this service, low risk older people are treated by an advanced paramedic and an occupational therapist or physiotherapist rather than bringing the person to the emergency department.

A follow-up team of occupational therapists and/or physiotherapists then support patients who remained at home, providing equipment and linking them into community health and social care services.

A similar service is also run from Cork University Hospital. Dr McNamara says: “The entire system is trying to find a better way for older people.  Sometimes people will still need to come into the hospital – mostly for diagnostics – but even then, we can organize for them to see consultants and go straight home or be promptly admitted if that’s what’s needed.”