Sending somebody over 75 into an ED isn't something we should be doing flippantly

Dr Harnedy set up the Rapid Access Clinic at St Finbar's Hospital about a year ago. It is aligned with the Integrated Care Programme for Older Persons (ICPOP), a model of care whereby services are brought into the community.

Every day, Dr Harnedy triages referrals from the emergency departments (EDs). "During weekdays, there's a clinic for individuals that need to be seen rapidly by a consultant, a registrar, a physiotherapist, an occupational therapist and a specialist nurse. We have a nurse whose special interest is Parkinson's Disease. She provides support for patients who've had a stroke. There's also a memory clinic at St Finbar's and there's an advanced nurse specialist that provides support for patients who have dementia."

Network in community

Before the pandemic, older patients were referred to day centres but because of Covid, these services have been put on hold. Dr Harnedy says they are hugely missed as they were an important part of older people's networks in the community.

But there is an outreach team, based on physiotherapy, occupational therapy and advanced nurses' aides going out into the community and into people's home. "It is being done in line with Covid restrictions with risk assessments carried out and the wearing of PPE."

Essentially bringing the ED to the patient is how the clinical lead at CUH in emergency medicine, Dr Conor Deasy describes the alternative pre-hospital pathway (APP) in collaboration with the national ambulance service.

"The APP was introduced in early 2020 with a view to responding to low acuity calls coming through the NEOC (National Emergency Operation Centre). "We felt there was a good chance we'd be able to reduce the need to come to the hospital and into a busy ED which can be a very confronting environment for the over 75's. That change in environment can precipitate them developing delirium. We are aware that sending somebody over 75 into an ED isn't something we should be doing flippantly. There's a need to explore other alternatives."

Treat patients at home

The APP team comprises an emergency medicine registrar with a member of the national ambulance service and an emergency medicine technician. The team is activated by the control centre of the ambulance service or by a paramedic team that is at the scene who think the patient might be able to be kept at home safely. A doctor and the APP team will come out and see the patient.

"The doctor will interface with the GEMS (geriatric emergency multi-disciplinary service) if needs be. Sometimes, there's no need for that. It could be something easily remedied like a catheter blockage. There are simple things and there are more complex problems that require a deeper level of response."

Dr Deasy says the APP service responds to all age groups "but about 33% of its activity is in the over 75's. Within that group, it manages to achieve a 68% non-conveyance rate. But bear in mind, if anybody calls an ambulance, the paramedics are obliged to bring the patient to the ED."

Being able to treat elderly people in their homes make a lot of sense, particularly in the pandemic. 

"Also, it gives us an insight into people in their own homes. When a patient is brought in an ambulance to hospital, they'll be on a trolley and they'll look very different to what they look like sitting on their couch. In an older person's living room, you'll have an instant appreciation of whether the person is vulnerable or not, whether they're well supported or not, whether there's fresh food in the fridge and whether the house is cold and full of slip hazards."

If things are not good in the house, the patient will be taken to hospital. "Other times, we can activate community services to intervene. The public health nurse will help address some of the risks in the house, in collaboration with community services and geriatric services."

The right care at the right time

As Dr Deasy points out, Sláinte Care is all about trying to deliver the right care in the right place at the right time. "Our APP is inspired by that model of care where we can deliver care at home. Inevitably, there will be some patients that need to come to hospital. Then, it's about having hospitals that are attuned to our ageing population so that the patient can get back to their communities. A proportion won't be able to get back to their community and will need long term care. What we want is to try and prolong their duration of independent living as much as possible."