What was the problem?
Frail older people falling at home generally phone 999. The attending ambulance crew can either leave the person at home with limited access to care, or take them to the emergency department (ED).
In 2014, 34% of all London Ambulance Service journeys to the Queen’s Hospital ED in Romford were with patients aged 75 years and over. A significant proportion were due to falls, for which patients generally stay in hospital at least one night.
As a result, ambulances were unable to attend the highest acuity calls, patient flow through ED was reduced and hospital beds were occupied unnecessarily.
What was the solution?
Using winter resilience funding, a learning collaborative of community nurses and paramedics set up a falls specialist response car, staffed by a community treatment team nurse and a paramedic, who both had additional training in treating falls.
The collaborative used plan-do-study-act (PDSA) cycles to test referral routes and acceptance criteria. It engaged stakeholders throughout to develop and evaluate the safety and effectiveness of new care pathways and understand the impact on the wider system.
What were the results?
From April 2017 to March 2018:
- 1,376 patients were attended
- 960 were safely kept at home
- 768 bed days were released (based on 80% of patients staying one night)
- £173,760 was saved (based on £181 per person cost of A&E attendance)
What were the learning points?
- Continuous measurement was essential to developing the service. The data enabled the team to understand what makes a successful referral and to continuously refine and adapt the acceptance criteria.
- Presenting the data so it is relevant to all stakeholders is important for engaging with different priorities.
- Cementing the relationship with the ambulance control room was key to keeping referral numbers up.
- Initially the team held weekly PDSA teleconferences to maintain momentum and enthusiasm and build relationships between organisations, which are now having an effect beyond the project. For example, the paramedics who worked on the project are more confident and can consider alternative care pathways when returning to their previous roles.
- Patient feedback has been overwhelmingly positive, reflecting the project's value to patients who often expect to be taken to hospital
The team continues to work on sustaining referrals, aiming for an average of 20 patients a week kept at home. It is engaging with other boroughs running similar schemes to spread the model further across LAS.
Team members are using the quality improvement methodology for other work, and it has contributed to career progression: one is now a Darzi Fellow; another has been promoted to a leadership role within the team.