Frailsafe: from conception to national breakthrough collaborative.

The number of people aged over 60 years worldwide is projected to rise from 605 million in 2000 to almost 2 billion by 2050, while those over 80 years will quadruple to 395 million. Two-thirds of UK acute hospital admissions are over 65, the highest consultation rate in general practice is in those aged 85-89 and the average age of elective surgical patients is increasing. Adjusting medical systems to meet the demographic imperative has been recognised by the World Health Organisation to be the next global healthcare priority and is a key feature of discussions on policy, health services structures, workforce reconfiguration and frontline care delivery.

Timely care for frail older people referred to hospital improves efficiency and reduces mortality without the need for extra resources.

BACKGROUND: hospitals are under pressure to reduce waiting times and costs. One strategy that may be effective focuses on optimising the flow of emergency patients. OBJECTIVE: we undertook a patient flow analysis of older emergency patients to identify and address delays in ensuring timely care, without additional resources. DESIGN: prospective systems redesign study over 2 years. SETTING: the Geriatric Medicine Directorate in an acute hospital (Sheffield Teaching Hospitals NHS Foundation Trust) with 1920 beds. SUBJECTS: older patients admitted as emergencies. METHODS: diagnostic patient flow analysis followed by a series of Plan Do Study Act cycles to test and implement changes by a multidisciplinary team using time series run charts. RESULTS: 60% of patients aged 75+ years arrived in the Emergency Department during office hours, but two-thirds of the admissions to GM wards were outside office hours highlighting a major delay. Three changes were undertaken to address this, Discharge to Assess, Seven Day Working and the establishment of a Frailty Unit. Average bed occupancy fell by 20.4 beds (95% confidence interval (CI) -39.6 to -1.2, P = 0.037) for similar demand. The risk of hospital mortality also fell by 2.25% (before 11.4% (95% CI 10.4-12.4%), after 9.15% (95% CI 7.6-10.7%) which equates to a number needed to treat of 45 and a 19.7% reduction in relative risk of mortality. The risk of re-admission remained unchanged. CONCLUSION: redesigning the system of care for older emergency patients led to reductions in bed occupancy and mortality without affecting re-admission rates or requiring additional resources.

Corrigendum: Staring into the crystal ball.

[This corrects the article on p. 90 in vol. 6.].

Discharge to assess: transforming the discharge process of frail older patients.

The 2012 Royal College of Physicians report Hospitals on the edge is clear that 'decisions about service redesign must be clinically led and clinicians must be prepared to challenge the way services - including their own service - are organised'. This paper describes a service redesign in which we have gained learning and experience in two areas. Firstly, a description of measured improvement by the innovation of redesigning the traditional hospital-based assessment of frail older patients' home support needs (assess to discharge) into their own home and meeting those needs in real time (discharge to assess). In combination with the formation of a collaborative health and social care community team to deliver this new process, there has been a reduction in the length of stay from completion of acute hospital care to getting home (from 5.5 days to 1.2 days for those patients that require support at home). Secondly, the methodology through which this has been achieved. We describe our translation of a Toyota methodology used for the design of complex cars to use for engaging staff and patients in the design of a healthcare process.

Introducing quality improvement as an intrinsic part of healthcare.

Healthcare systems worldwide face the challenge of recognising and improving safety, timeliness, quality and productivity. The authors describe how the COM-B model, developed by Michie et al in 2011 to explain and change criminal behaviour, is useful in identifying what skills and capabilities healthcare providers require to improve their systems. These skills include the intellectual capability to understand, design and improve healthcare processes; the opportunity to do this in their daily work; the motivation to do this - in particular recognising the reasons not to change; and finally unlearning the behaviours based on historical system beliefs that are now invalid. Individual self-awareness and organisational leadership are required to give staff the time and resources to reflect, experiment and learn.

Improving self-efficacy in spinal cord injury patients through "design thinking" rehabilitation workshops.

Advances in surgical and medical management have significantly reduced the length of time that patients with spinal cord injury (SCI) have to stay in hospital, but has left patients with potentially less time to psychologically adjust. Following a pilot in 2012, this project was designed to test the effect of "design thinking" workshops on the self-efficacy of people undergoing rehabilitation following spinal injuries. Design thinking is about understanding the approaches and methods that designers use and then applying these to think creatively about problems and suggest ways to solve them. In this instance, design thinking is not about designing new products (although the approaches can be used to do this) but about developing a long term creative and explorative mind-set through skills such as lateral thinking, prototyping and verbal and visual communication. The principles of "design thinking" have underpinned design education and practice for many years, it is also recognised in business and innovation for example, but a literature review indicated that there was no evidence of it being used in rehabilitation or spinal injury settings. Twenty participants took part in the study; 13 (65%) were male and the average age was 37 years (range 16 to 72). Statistically significant improvements were seen for EQ-5D score (t = -3.13, p = 0.007) and Patient Activation Measure score (t = -3.85, p = 0.001). Other outcome measures improved but not statistically. There were no statistical effects on length of stay or readmission rates, but qualitative interviews indicated improved patient experience.

Colonic stenting: an alternative to surgery in the elderly.

This case report describes the management of a frail older patient presenting with a rare case of an obstructing right-sided colonic lesion, combined with complex co-morbidities. The report briefly discusses use of colonic stenting in right colonic lesions as well as palliative management of colonic tumours in general.

A randomised controlled trial of warfarin versus aspirin for stroke prevention in octogenarians with atrial fibrillation (WASPO).

BACKGROUND: atrial fibrillation (AF) is the commonest chronic arrhythmia with a prevalence of 9% in octogenarians and accounts for 24% of the stroke risk in this population. Although trials demonstrate reductions in stroke with warfarin, audit data show that it is still underused. However, anti-coagulation in the very elderly is not without risk. METHODS: randomised open labelled prospective study of primary thromboprophylaxis for AF. Patients aged >80 and <90 were randomised to receive dose-adjusted warfarin (INR 2.0-3.0) or aspirin 300 mg. All patients had permanent AF, were ambulant, had Folstein mini mental score >25 and had no contraindications to either treatment. Follow-up was for 1 year with 3 monthly visits. The primary outcome measure was a comparative frequency of combined endpoints comprising death, thromboembolism, serious bleeding and withdrawal from the study. RESULTS: seventy-five patients (aspirin 39; warfarin 36) were entered (mean age 83.9, 47% male). There were significantly more adverse events with aspirin (13/39; 33%) than warfarin (2/36; 6%), P = 0.002. 10/13 aspirin adverse events were caused by side effects and serious bleeding; there were three deaths (two aspirin, one warfarin). CONCLUSION: dose-adjusted warfarin was significantly better tolerated with fewer adverse events than aspirin 300 mg in this elderly population. Although aspirin 75 mg may have been better tolerated, there is no evidence for efficacy in AF at this dose.

Bio-available testosterone levels fall acutely following myocardial infarction in men: association with fibrinolytic factors.

The effect of acute myocardial infarction on plasma levels of testosterone in men is unclear. No previous studies have evaluated the bio-available fraction of testosterone. Low plasma testosterone levels have been associated with several risk factors for myocardial infarction, including an unfavorable fibrinolytic profile. In a prospective, case control study, we examined changes in plasma levels of sex hormones, including bio-available testosterone, in patients with acute myocardial infarction and in control subjects. In addition, changes in hormone levels in patients were compared with alterations in the fibrinolytic profile. Thirty male patients admitted with chest pain were studied. Twenty two had acute myocardial infarction and eight had non-specific chest pain. Plasma levels of total and bio-available testosterone, 17beta-estradiol, sex hormone binding globulin and insulin were measured at baseline and throughout admission. In addition, fibrinolytic factors (plasminogen activator inhibitor-1 (PAI-1), tissue plasminogen activator (tPA) and fibrinogen) were measured in patients who received fibrinolysis. Height and weight, and the subsequent development of heart failure or myocardial dysfunction were also recorded. Patients had lower levels of bio-available testosterone (2.07 +/- 0.75 nmol/L vs. 5.3 +/- 1.7 nmol/L, p < 0.05) and higher levels of 17beta-estradiol (87.9 +/- 39.5 pmol/L vs. 48.1 +/- 18.4 pmol/L, p < 0.001) than controls. Total and bio-available testosterone levels fell acutely following myocardial infarction (11.9 +/- 3.8 nmol/L to 9.7 +/- 3.3 nmol/L, p < 0.05; 1.95 +/- 0.76 nmol/L to 1.55 +/- 0.67 nmol/L, p < 0.05). This reduction was associated with elevation of PAI-I activity and reduction of tPA activity, independent of changes in plasma insulin levels. Patients with lower baseline levels of testosterone and higher levels of 17beta-estradiol had a relatively pro-thrombotic fibrinolytic profile and increased risk of complications. In conclusion, total and bio-available levels of testosterone fall following acute myocardial infarction in men, in association with adverse changes in fibrinolytic profile. It is not clear whether this association represents a direct effect of testosterone on thrombotic tendency but warrants further investigation.