Currently frail older patients are being held overnight for FIT review on the following day by the ED team. While this has reduced risk for this vulnerable population ie being discharged inappropriately during the night this adversely prolongs the PET and delays access to an inpatient bed if necessitated. This has been flagged by nursing, management and medical staff as an issue.
A solution is for identified suitable patients to be admitted under the care of the EM consultant on call, Sunday to Thursday. Cases for admission should be discussed with the on-call EM consultant by the EM doctor until 9pm. After this time the senior EM registrar should be consulted to assess suitability using the inclusion/exclusion criteria. It is the responsibility of the accepting EM registrar to ensure that these patients are safe to be admitted overnight under the EM team. It is expected that the registrar should review the patients prior to admission. Patients who clearly require hospital admission should not be admitted on this pathway.
An order form for HOLD overnight for FIT must be completed as well as a drug Kardex. This is available on the Mater FIT folder on patient centre. This highlights the onus on the referring EM doctor to have reviewed pertinent investigations and developed a plan of care for the patient. This should be shared on the Siilo ED handover group by the referring EM doctor. The ED CNM should be informed of the admission. Ideally this should occur early in the patients ED journey once that decision has been made.
The patient will be handed over to the GEM registrar/Frailty ANP/GEL consultant at handover the following morning. This will mandate that the GEM registrar/Frailty ANP or GEL consultant be present at ED handover. If the patient is not deemed suitable for acceptance by the FIT service the clinical care will rest with the EM team for a care plan and further management. The responsibility for further care will rest with the night shift EM doctor who accepted their care in consultation with the EM consultant.
An option to transfer the patient to the AMAU the following morning for further care is at the discretion of the GEL consultant/GEM registrar once agreed at senior nursing level. Clinical governance of this patient is then under the AMAU consultant. Consideration should be made with regard to the number of patient transfers/transitions in this vulnerable group. (increases risk of delirium)
This group of patients should only be admitted to AMSSU beds rather than outlying wards if a bed becomes available after hours as the FIT service does not operate outside of the acute floor.
This makes another care pathway admission under the EM service to add to the existing Head Injury, Cellulitis, and Stable UGIB pathways in existence.
There remains provision of an outpatient Mater FIT rapid review clinic Monday to Friday at 10am for suitable patients and other outpatient pathways (Smithfield Rapid Review Clinic, SMH Falls Clinic etc)
Criteria for suitability:
Ø >65 years old
Ø Agreement by EM consultant on call or EM senior at night
Ø Patients who do not require Level 4 hospital admission but may benefit from in-patient Level 1 rehabilitation or rehabilitation at home.
Ø Critical illness
Ø Patient requiring admission by another service
Ø Patient requiring ongoing surgical specialty input eg ENT, plastic surgery, General surgery
Ø Patients requiring prolonged Level 4 care.
Ø Pending investigations requiring input of ED or other specialities (e.g. orthopaedics)
On behalf on the MMUH EM consultants, Mater FIT and the Department of Medicine for the Older Person