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Nurses use video link to keep older people out of hospital

Telehealth is enabling nurses to triage older people in care and nursing homes, avoiding unnecessary emergency department presentations

Telehealth is enabling nurses to triage older people in care and nursing homes, avoiding unnecessary emergency department presentations

  • Nurses take about 30 calls a day, assessing nursing and care home residents via video link
  • Team has helped to prevent 3,500 unnecessary visits to emergency departments
  • Homes can link with nurses to have patients checked, avoiding need to wait for a GP visit
Picture shows Peter Grace, clinical lead for the digital health team, taking a call. A video link is enabling nurses to triage older people in care and nursing homes, avoiding unnecessary admissions to the emergency department.
Peter Grace, clinical lead for the digital health team

A nurse-led digital health service is using video technology to provide faster care for older patients, preventing avoidable visits to a hospital emergency department.

The scheme was launched in Tameside, Greater Manchester, in November 2017 with the aim of tackling the high number of avoidable emergency department attendances by residents of nursing and care homes.

Latest figures up to July 2019 show that the nursing team based at Tameside General Hospital has helped to prevent 3,500 unnecessary visits to the emergency department.

‘The homes no longer have to wait for a GP to visit, they can link in with us and we will look at patients and prioritise the response’

Peter Grace, clinical lead for the digital health team

The nurses take around 30 calls a day from nursing and care homes, assessing and triaging residents via video link. They are also on hand to offer guidance, advice and reassurance.

The pioneering service has been highlighted by NHS England as an example of innovation and best practice in urgent and emergency care.

Emergency nurse practitioner Peter Grace, who is clinical lead for the digital health team, says the service ensures people in care homes receive the right response at the right time.

‘The homes no longer have to wait for a GP to visit, they can link in with us and we will look at patients and prioritise the response,’ Mr Grace says. ‘Being able to see the patients via video link gives us reassurance. It also gives us a level of concern when we need to sometimes say, “No, this patient must be seen today.”

‘If they need a GP, we have access to some healthcare professionals directly. This frees up the staff to focus on caring for the residents and getting them ready for the day’s activities.’

The service has also helped care and nursing home staff to improve their skills. As part of their introduction to using the tablet device that links homes directly to the digital health team, they are trained in observations, including how to check blood pressure, temperature, oxygen levels and respiratory rate.

Proud to be in this team

Picture of emergency nurse Louisa Bardsley, a member of a digital health team that uses a video link to triage older people in care and nursing homes, avoiding unnecessary admissions to the emergency department.

Louisa Bardsley is an emergency nurse who joined the digital health team in July 2018.

‘What attracted me to the role was being able to help older patients avoid coming into A&E unnecessarily,’ she says. ‘The biggest impact we’ve had is on reducing the number of avoidable A&E attendances as a result of falls and head injuries.

‘An amazing idea’

‘We always adhere to NICE (National Institute for Health and Care Excellence) guidelines and carry out head injury observations. If patients can be managed at home, the beauty of our service is that the staff can keep us informed with regular updates and we can provide advice whenever they need it.

‘I'm proud to be part of this team. It’s an absolutely amazing idea.’

 

‘When we are talking to staff at the homes about why we need to check something, they are learning from us. They will come through to us at times and say, “I’ve been pushing fluids with Doris for the last two and a half hours and she still hasn’t improved,” or, “Her blood pressure’s a little on the low side.” It is definitely improving their knowledge and skills. It’s been great to see them progress and grow in confidence,’ says Mr Grace.

When a call comes in, the team triage to check there is no immediate risk. The nurses have access to general practice and hospital records, plus the outcome of any recent investigations.

‘A&E avoidances are validated, so we know our decision-making is accurate’

‘We have a wealth of information at our disposal to help us make a good decision around what we think is going on with a patient and who will be best to respond,’ explains Mr Grace.

‘We also have strict avoidance criteria and all A&E avoidances are validated at the end of each week, so we know our decision-making is accurate.’

In addition to linking up with residential care and nursing homes in Tameside and Glossop, the team works closely with the community response service to help people to continue to live safely and independently in their own homes.

This includes warden-controlled sheltered housing where residents have a pendant that triggers an alarm when pressed. If a patient has had a fall, the community response service will Skype the digital health team so the patient can be assessed before an attempt to move them.

If there is a severe bleed, the team can provide advice on what to do while waiting for an ambulance to arrive.

Picture of members of a nurse-led digital health service who use a video link to triage older people in care and nursing homes, avoiding unnecessary admissions to the emergency department.
Members of the nurse-led digital health service

Another aspect of the team’s work is telehealth monitoring of patients living at home who have chronic obstructive pulmonary disease (COPD) and heart failure.

Equipment in the patient’s home records their oxidation levels and this information is sent via Bluetooth to the team. If the readings are outside of set parameters, the system will alert the team by triggering a red flag on their dashboard.

‘We can then contact the patients and provide advice, start steroids or rescue packs or get the right people out if they are known to the team,’ says Mr Grace. ‘We’re able to provide a timely response to prevent deterioration and the need to come into hospital.’

Team to pilot video consultations for patients with long-term conditions

The team is due to pilot a new telehealth plus model at the end of 2019 that will enable patients with these long-term conditions to receive video consultations.

The digital health service takes all medical referrals, including those coming into the hospital’s resident medical officer and the ambulatory care area. This helps the hospital to manage patient flow in the emergency department.

‘We take a clinical handover from the referring doctor and apply the triage process to assess the risk of diverting the patient to a ward and avoiding A&E,’ says Mr Grace. ‘On average per month, we take about 300 referrals from doctors and around 270 go direct to the receiving ward.

‘Patient flow has improved dramatically in A&E and length of stay has also come down’

Peter Grace

‘The majority of the time we can move patients through the system in this way. It is beneficial for patients, as they are being seen by the right clinician at the right time. We have nurses on the receiving ward that begin triage as soon as patients arrive.

‘Patient flow has improved dramatically in A&E and length of stay has also come down. We also have an escalation ward, which in the year before this programme was open from late October to February. For the period up to the end of 2018 we opened the escalation ward for just two days.’

The hospital’s head of patient flow, Grace Wall, says the impact of the service can be felt across the whole system. 'While supporting patients to remain safely in their own home, our digital health service not only improves patient experience, it also reduces the demands on our emergency department,' she explains.

'The service positively impacts on patient flow as when a patient no longer needs to be cared for in an acute hospital setting, they can be discharged in a timely manner. Our local care homes have further assurance that they can contact the digital health service if they need any further advice, guidance or support.'

The digital health team also has access to the Tameside and Glossop 111 and 999 call stack for the North West Ambulance Service (NWAS).

Team members assist the ambulance service by providing a clinical triage and urgent care practitioner response service. If they identify lower priority patients, the team can take over their care.

Team has backgrounds in emergency, primary, respiratory and critical care, and cardiology

Mr Grace says: ‘We will triage them and if we think we can prevent them from coming into A&E, we will either go out to see them or we will arrange a GP appointment.

‘Alongside this, we also provide the acute patient assessment service where NWAS pushes patients to us and we will contact them to triage. In the past month, we saw 111 patients and prevented 75 ambulance call-outs.’

The digital health team includes nurses with backgrounds in emergency care, primary care, respiratory, critical care and cardiology. Sharing their knowledge and skills benefits the whole team.

For example, some of the patient issues are well known to nurses who have worked only in the community.

‘We sometimes see patients with symptoms of bullous pemphigoid (a rare skin condition that causes itching, redness and blisters) and it’s a condition I’ve never seen or heard of as my background is in emergency care,’ says Mr Grace.

‘My team are exceptional and they’re constantly coming to me with new ideas. It’s really refreshing, and I think that’s due to them feeling motivated because they can see the difference they’re making daily.’

Solutions to local health and social care issues

As part of Greater Manchester’s devolved health and care approach, Tameside has integrated its combined £1 billion NHS and local council budget over the past three years to develop solutions to local health and social care issues.

The Tameside and Glossop Care Together integrated system includes NHS Tameside and Glossop Clinical Commissioning Group, Tameside and Glossop Integrated Care NHS Foundation Trust and Tameside Metropolitan Borough Council.

The service links the nursing team with all but one of the care homes and nursing homes in Tameside and Glossop via video technology. The only home that is not included, due to poor Wi-Fi, liaises with the digital health team via phone.


Picture of health writer Julie Penfold, whose article describes how a video link is enabling nurses to triage older people in care and nursing homes, avoiding unnecessary admissions to the emergency department.Julie Penfold is a health writer

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