Read Standard 10: Sudden deterioration and immediate care

Ageing and frailty standards
Healthcare Improvement Scotland

Standard statement

Older people living with frailty who experience a sudden change in their health can access timely, coordinated and consistent support.

Rationale

Older people with frailty can deteriorate quickly and experience a sudden decline in health following illnesses or stressors. A sudden or unexpected illness can trigger a social care emergency with the need for additional support at home.

Management of a sudden deterioration should be in line with expressed wishes and any future care plan. Real-time access to clinical and care information can enable staff to understand the person’s priorities and circumstances. Older people are at higher risk of poor health outcomes when they present at urgent and unscheduled care services. Acute pathways should enable rapid assessment and treatment.100, 101

Admission to hospital should be avoided unless it is necessary. Prompt community assessments, including point of care testing, can reduce unnecessary hospital admissions.100,102 Virtual wards such as Hospital at Home provide acute care services in a person’s home, enabling people to remain independent in familiar surroundings.6 Urgent assessment and access to social care and/or community-based support may reduce the likelihood of admission to hospital.

When admission to hospital is required, treating people with frailty in a dedicated hospital frailty unit can reduce readmission and shorten the length of hospital stay.103-105 Older people in frailty units often experience better health outcomes including independence, reduced mortality and fewer complications.6

People living with dementia may have vague symptoms or be unable to report their symptoms. This can result in missed diagnoses or higher rates of invasive testing if they experience sudden deterioration in their health. People with dementia are at higher risk of delirium, infection, malnutrition, dehydration, constipation and falls when they are admitted to hospital following deterioriation.89

Delirium can be both a cause and a consequence of a sudden deterioration in health. It should be considered in all care settings. People in long-term care or in hospital are at higher risk of delirium.106 Poorly identified, assessed and managed delirium not only extends length of hospital stay. It can cause significant distress for people, their care partners and staff.107

Criteria

10.1

Older people with frailty experiencing a sudden deterioration in health can access, as appropriate:

  • an immediate and rapid response from emergency services
  • a same day response from an appropriate member of the general practice team
  • assessment in their own home or their current place of care
  • urgent social care assessment and support
  • point of care testing.
10.2

People experiencing a sudden deterioration receive care in a setting in line with expressed wishes and any future care plan.

10.3

NHS boards provide a Hospital at Home or enhanced community support service for older people with frailty which:

  • operates for a minimum of 10 hours a day, seven days a week
  • has sufficient capacity for their population.
10.4

All hospitals have:

  • a dedicated frailty unit or ‘front door’ frailty team
  • an established frailty ward or assessment area with access to a specialist frailty team.
10.5

Older people presenting to hospital are screened for frailty within one hour of admission using a consistent and validated clinical frailty score.

10.6

Older people identify as living with frailty have access to a specialist frailty team within four hours of admission to hospital (or 12 hours if presenting out of hours).

10.7

Older people with frailty receive a CGA within four hours of admission to hospital (or 12 hours if presenting out of hours).

10.8

People receive medicines reconciliation:

  • within six hours of admission to an acute care setting
  • when they are discharged from hospital or when they move between health or care settings.
10.9

People at risk of delirium receive rapid assessment and management on admission in line with current guidelines.

10.10

Proactive discharge and future care planning begins on admission and continues as a person’s health, care, choices, needs or circumstances change.

10.11

Staff are aware of the potential impact of medicines and medicine withdrawals during acute admission.

10.12

People with frailty can access:

  • life-saving treatment, including access to high dependency or intensive care at ward level, where clinically appropriate
  • specialist palliative care
  • rapid supported discharge to die at home or in a homely setting where clinically appropriate.

What does this standard mean for...

What does the standard mean for the people?

  • You can access health care and social care quickly if you become suddenly unwell.
  • If you become suddenly unwell, you will be assessed and treated in line with your preferences.
  • You will be involved in decisions about whether to stay at home or be admitted to hospital.
  • You will receive acute care in the right place for you.
  • You will receive timely access to acute care services that meet your needs.

What does the standard mean for staff?

Staff, in line with roles, responsibilities and workplace setting:

  • promote a ‘home first’ approach where appropriate
  • work collaboratively to support discharge without delay
  • can access advice and support from senior hospital clinicians when considering whether an older person living with frailty requires hospital admission
  • have access to a specialist frailty team
  • screen for frailty using validated tools
  • act in a timely manner to identify frailty.

What does the standard mean for the organisation?

Organisations:

  • regularly review and redesign urgent and acute care services
  • have plans and processes to reduce unnecessary hospital admissions
  • plan Hospital at Home services with capacity to meet the needs of their population
  • have an acute frailty unit or dedicated area for the care of older people who are living with frailty.

Examples of what meeting this standard might look like

  • Protocols and pathways for a responsive assessment of care needs following a sudden deterioration.
  • Evidence of a community-based ‘urgent care team’ who can assess people quickly in their own homes 7 days a week.
  • Audit of the proportion of requests for Hospital at Home that are accepted.
  • Evidence of a frailty unit, dedicated frailty beds or a dedicated frailty area within a hospital.
  • Audit of time taken to identify frailty in older people arriving at a hospital emergency department or acute assessment unit.
  • Evidence of a dedicated frailty unit which has enough capacity for the population it serves.
  • Audit of time taken to commence a CGA after frailty has been identified.