This provides a unique service allowing frail older patients presenting to the ED to receive integrated and multidisciplinary care in an appropriate environment from the moment they arrive. Care is initiated within the main department by medical and nursing staff with a specific interest in Geriatric Emergency Medicine, which can then be continued by another team working within the Emergency Frailty Unit (EFU).
There are a variety of training opportunities and we are always developing new educational resources for staff wishing to further their knowledge in caring for frail patients in urgent and emergency care, and the department has a strong record of research publications and quality improvement within the field of geriatric emergency medicine.
Looking to start an OOPE in Geriatric Emergency Medicine? Click here to find out more!
Developing your skills in geriatric emergency medicine? Click here to register for our training course.
Interested in making your own department more frail friendly? Click here to view of geriatric emergency medicine for managers page.
Want to know more about Geriatric Emergency Medicine in a national and international context? Visit our news and general resources page to see what is going on in the rest of the world.
The keep up to date: Follow us on Twitter… or join our mailing list to keep abreast of upcoming events and research opportunities.
Meet The Team
Simon Conroy: Consultant Geriatrician interested in GEM
Richard Wong: Consultant Geriatrician, Head of Service for Geriatrics
Khawar Ansari: Consultant in Emergency Medicine with interest in GEM
Sarah Turpin: Clinical and QI Fellow in Geriatric Emergency Medicine
Tomoaki Hayakawa: Clinical Fellow in Geriatric Emergency Medicine
Wendy Allibone: Ward Sister EDU
Elaine Newton: Deputy Sister EDU
Mary Stretton: Occupational Therapist
Raj Pothini: Clinical Specialist Physiotherapist
ED website, Geriatric Medicine, UHL, Age UK, RVS, Better Care Together, CCGs & Social Services
- AHSNs, CLARHCS & CRN
A Frail-friendly front door
We have been working on developing services for older people in the Emergency Department (ED) for many years, building towards establishing the UK’s first ‘frailty friendly’ Emergency Department, coming on line in 2016/17.
We are currently working on developing frailty identification systems that are quick and simple to use in the ED setting, with a view to directing clinical care. We try to ensure that all older people with frailty who are identified in the ED undergo Comprehensive Geriatric Assessment. This is achieved through emergency physicians working with a team of frailty nurses (Locally known as ‘Primary Care Coordinators’), therapists and geriatricians – either in the ED or in our Emergency Frailty Unit, collocated in the ED.
We are well aware that ‘successful’; urgent care requires a whole systems approach, exemplified by our Leicester, Leicestershire & Rutland collaborative system leadership (‘Interface Geriatrics’), which lead to the development of national, inter-collegiate, inter-disciplinary guidance for the care of older people with urgent care needs (Silver Book).
Our learning has influenced the wider NHS, e.g. site visits from more than 30 UK hospitals, international visits (New Zealand, Ireland), visitors from the Royal College of Physicians’ Future Hospitals Commission and the Royal College of Nursing. Our work has been disseminated in a range of national websites, e.g. Future Hospital Commission and ‘Fab NHS stuff’, was shortlisted for the HSJ efficiency awards 2012, highly commended by NHS Innovations in 2012 and won the UHL ‘caring at its best’ award in 2013. Our work was cited by the Health Select Committee in 2013.
The hospital is in the process of building a new emergency department, to include our Acute Frailty Unit (AFU) as well as the Emergency Frailty Unit (EFU). The new building plans underwent extensive consultation with clinical leaders in the field of geriatric and emergency medicine and nursing to ensure they were appropriately designed to provide care for frail older patients. Click here to view the new floor-plans of our specially designed frail friendly Emergency Department.
The Emergency Frailty Unit (EFU):
The EFU is an 8 bedded unit within the Emergency Department where frail older patients can be assessed and managed for up to 24 hours. The aim of the EFU is to provide Comprehensive Geriatric Assessment in an emergency care setting to older people with frailty.
The service focuses on those patients likely to be able to return home the same day or the next day (ambulatory care), through care provided in the EFU but also through in-reach to the rest of the ED. Patients likely to need a longer admission are directed to the AFU. Below is a typical experience in the EFU:
THE ACUTE FRAILTY UNIT (AFU):
This is an acute admissions unit for frail patients who require admission to secondary care. It is an environment specifically designed to provide care for frail patients with acute illness. There are three rapid run down MDTs per day to facilitate efficient and effective interdisciplinary communication.
PRIMARY CARE COORDINATORS:
These are a team of registered healthcare professionals who work within the Emergency Department, EFU and AFU. Their role is to identify and arrange care for patients who could be cared for in the community.
Defining and identifying frailty in the ED
Frailty is a distinctive late-life health state in which apparently minor stressor events are associated with adverse health outcomes. The two established international models are the frailty phenotype  and the cumulative deficit model , both of which have been validated in large population studies. The models identify people at increased risk of a range of adverse outcomes including dependency, institutionalisation and premature death.
However, there is limited evidence for the discriminant ability of frailty scales in the urgent care context: although most scales perform better than chance in predicting a range of poor outcomes, none of them performed adequately, and most perform either poorly or very poorly [2, 4, 14].
When defining a population for intervention in clinical practice, acceptability and ease of use are important considerations as well as discriminant ability . Until more accurate tools become available, it is recommended that simple, clinically acceptable criteria are used to identify a large proportion of frail older people (sensitivity); the risks are that some older people without frailty will be included (specificity – usually inversely related to sensitivity).
A frailty service will usually be able to manage non-frail older people, or at least identify them and re-direct if appropriate (whilst the converse does not always apply). Studies are underway that will help develop automated frailty identification systems with higher discriminant properties; these should be available in 2017.
An example for frailty identification criteria can include the following:
Age 65+ AND presenting with one or more frailty syndromes (confusion, care home residents, Parkinson’s disease, presenting with fragility fractures and/or falls AND ≥3 falls in the last three months) OR people aged 85+
Moderate or severe frailty (grade 6-9) using the Canadian Frailty Scale (Appendix 1)
The Canadian Frailty Scale is derived from the Rockwood frailty index and has been tested in a number of studies and found to be a moderately accurate predictor of adverse outcomes for older people in the acute care context [5, 22, 23].
Education and Training
We established the first UK training programme in GEM, which involved emergency physicians (trainees and consultants) taking time out to spend up to a year training in geriatric medicine. During this period, the emergency physicians learn the core principles of geriatric medicine through working in geriatric ward teams and in the various subspecialty services (psychogeriatrics, falls/syncope, Parkinson’s, stroke and so on).
GEM fellows also spend time working across the frailty pathway, including not only urgent care, but community services and a wide range of other learning opportunities. To date we have worked with seven GEM fellows, two of whom have gone onto be appointed locally as consultants in GEM.
Our GEM team are well-regarded and have delivered extensive local, national & international presentations and GEM. Members of our team are involved in developing GEM at the European level and are founding members of the European Union GEM Special Interest Group, which is a collaboration between the European Union Geriatric Medicine Society and the European Union Society of Emergency Medicine. An early output of this collaboration is the development of the European Union GEM curriculum.
Leicester offers 1 year tailored clinical and quality improvement fellowships in Geriatric Emergency Medicine for registrars in Emergency Medicine or Geriatric Medicine wishing to develop their skills at managing frail patients in the ED. Trainees who have undertaken these fellowships have progressed to consultant posts with a specialty interest in GEM.
Interested in working in Leicester as a consultant with an interest in GEM?
Previous fellowship testimonials:
Dr Sarah Vince, ED Consultant at Northampton General Hospital:
"I was the first trainee through the UHL fellowship in Geriatric Emergency Medicine and have nothing but praise for my time there. I was trained by an enthusiastic and knowledgeable team who welcomed the new post.
I enjoyed hospital placements learning the basics of the 'Geriatric Giants' on a base ward and on the Medical Admissions Unit. I also spent time in two community hospitals and the local hospice which were very valuable experiences. I attended numerous out-patient clinics including falls, dementia, vertigo and incontinence.
The two most inspiring experiences of my year, which I still talk about when I deliver teaching, were observing one of the consultants as they took part in Advanced Care Planning at a local nursing home and taking part in the Falls Prevention Program.
There were plenty of opportunities to take part in and lead on quality improvement projects and research. I designed pocket reference cards for junior doctors in geriatric medicine and helped design admission documentation for frail elderly people on the Medical Admissions Unit. I also presented at a national conference.
The skills I learnt in my fellowship year helped me secure a consultant post in my first choice hospital and I have gone on to develop award winning services based on the foundations built during my GEM Fellowship in Leicester."
There are now 6 posts in geriatric emergency medicine which exist within a 1 year academic emergency medicine foundation training scheme. Trainees rotate through the EFU and community hospitals are provided with weekly tutorials and access to QIP within the ED specifically relating to improving care standards for frail older patients in the emergency department.
All nursing staff are encouraged to progress and mentoring has been embedded in the culture of the department. This has improved the staff morale and has led to a high staff retention rate. As a consequence improved nursing performance has been achieved, resulting in a better patient experience.
Register for our training course in GEM
Editorials, blogs, websites and more...
Editorials, Blogs, Websites and More...
Cleveland Clinic: Geriatric Emergency Medicine Online
Emergency Medicine Cases: Geriatric Emergency Medicine (Episode 34)
Articles and Editorials:
Harvard School of Public Health: The Ageing Game
EPi (Emergency Physicians International): Why the World Needs Geriatric Emergency Medicine
The John A. Hartford Foundation: Geriatric Emergency Medicine – The Time to Act is Now
International Collaboration in GEM:
EU Task Force on GEM (ETGEM) – The EUSEM Geriatric Section and the European Geriatric Medicine Society (EUGMS) have established a joint task force with the following objectives: To develop a European Curriculum on GEM; To propose a draft for a European Course on GEM; To develop European Research on GEM; To organise scientific joint sessions at EuSEM and EUGMS congresses; To submit two papers on the GEM curriculum and GEM research in the European Journal of Emergency Medicine. Production of a European Text Book on GEM; To set a strategy for getting finances to support Task Force activities; To set quality indicators and guidelines.
EU Society Emergency Medicine (EuSGEM) – The mission of this new EUSEM section is to develop GEM with collaboration between emergency physicians and geriatricians involved in two different societies, European Society for Emergency Medicine (EuSEM) and European Union of Geriatric Emergency Medicine
European Union Geriatric Medicine Society’s Special Interest Group on Emergency Geriatric Medicine (EuGMS SIG EGM) – The mission of this new SIG is to develop GEM with collaboration between emergency physicians and geriatricians involved in two different societies, European Society for Emergency Medicine (EuSEM) and European Union of Geriatric Emergency Medicine.
Quality Improvement Work
List of projects On-going/available
Link to other QIP in the field (Frailsafe etc.)
Link to IHI for training and methodology
Patients & Carers
What to expect
Links to support sites: AgeUK, Carer UK
In Leicester, our ambition is to improve outcomes for frail older people by embedding evidence based medicine into clinical practice (‘campus to clinic’ translational research), with a focus on emergency and acute care.
Much of our work is health services research, looking at how to deliver more efficient and more effective services for older people with frailty in the ED and the Acute Medical Units. Some of our key projects are listed here:
£1,038,561 – NIHR HSDR, (2014-17); acute hospital care for frail older people.
£10,000 – British Geriatrics Society, (2015-16); the use and abuse of urine testing in older people.
£386,751 – NIHR SDO, (2012-14); establishing and implementing best practice to reduce unplanned admissions in those aged 85+ through system change.
£2,200,000 – NIHR programme grant, (2008-13); medical crises in older people.
SOME KEY OUTPUTS:
- Tanajewski L, Franklin M, Gkountouras G, Berdunov V, Edmans J, Conroy S, et al. Cost-Effectiveness of a Specialist Geriatric Medical Intervention for Frail Older People Discharged from Acute Medical Units: Economic Evaluation in a Two-Centre Randomised Controlled Trial (AMIGOS). PLoS ONE 2015;10(5):e0121340.
- Gladman J, Harwood R, Conroy S, Logan P, Elliott R, Jones R. Medical Crises in Older People: final report. Programme Grants Appl Res 2015;3(4).
- Craven E, Conroy S. Hospital readmissions in frail older people. Reviews in Clinical Gerontology 2015;25(02):107-16.
- Conroy S, Chikura G. Emergency care for frail older people-urgent AND important-but what works? Age Ageing 2015;44(5):724-5.
- Wilson A, Baker R, Bankart J, Banerjee J, Bhamra R, Conroy S, et al. Establishing and implementing best practice to reduce unplanned admissions in those aged 85+ through system change (ESCAPE 85+): a mixed method, case study approach. Health Serv Deliv Res 2014.
- Franklin M, Berdunov V, Edmans J, Conroy S, Gladman J, Tanajewski L, et al. Identifying patient-level health and social care costs for older adults discharged from acute medical units in England. Age Ageing 2014;43(5):703-7.
- Conroy, S & Parker, S. Acute care for frail older people: time to get back to basics? Age Ageing 2014.
- Anderson ES, Pollard L, Conroy S, Clague-Baker N. Forming a new clinical team for frail older people: can a group development model help? J Interprof Care. 2014 Mar;28(2):163-5.
- Edmans J, Bradshaw L, Franklin M, Gladman J, Conroy S. Specialist geriatric medical assessment for patients discharged from hospital acute assessment units: randomised controlled trial. BMJ 2013;347.
- Conroy SP, Ansari K, Williams M, Laithwaite E, Teasdale B, Dawson J, et al. A controlled evaluation of comprehensive geriatric assessment in the emergency department: the 'Emergency Frailty Unit'. Age Ageing. 2014 Jan;43(1):109-14.
- Conroy S, Dowsing T. The ability of frailty to predict outcomes in older people attending an acute medical unit. Acute Medicine 2013;12(2):74-6.
- Conroy SP, Dowsing T, Reid J, Hsu R. Understanding readmissions: An in-depth review of 50 patients readmitted back to an acute hospital within 30 days. European Geriatric Medicine 2013;4(1):25-27.
- Edmans J, Bradshaw L, Gladman JRF, Franklin M, Berdunov V, Elliott R, Conroy S. The Identification of Seniors at Risk (ISAR) score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units. Age Ageing. 2013 November 1, 2013;42(6):747-53.
- Wou F, Gladman JR, Bradshaw L, Franklin M, Edmans J, Conroy SP. The predictive properties of frailty-rating scales in the acute medical unit. Age Ageing. 2013 Nov;42(6):776-81 [50%].
- Banerjee, J, Conroy, S, & Cooke, MW. (2012, December 18). Quality care for older people with urgent and emergency care needs in UK emergency departments. Emergency Medicine Journal. doi:10.1136/emermed-2012-202080.
- Vince, S, Conroy, S, & Banerjee, J. (2012, October 1). Developing a frail friendly front door: a Fellowship in Geriatric Emergency Medicine. Emergency Medicine Journal, 3-4.
- Conroy S, Dowsing T. What should we do about hospital readmissions? Age and Ageing 2012.
- Gladman J, Kearney F, Ali A, Blundell A, Wong R, Laithwaite E, et al. The role of the interface geriatrician across the acute medical unit/community interface. Medical Crises in Older People. Discussion paper series. 2012(9).
- Conroy S, Dowsing T, Reid J, Hsu R. Understanding readmissions: An in-depth review of 50 patients readmitted back to an acute hospital within 30 days. Eur Geriatr Med 2012.
- Baker R, Bankart MJ, Rashid A, Banerjee J, Conroy S, Habiba M, et al. Characteristics of general practices associated with emergency-department attendance rates: a cross-sectional study. BMJ Qual Saf. [10.1136/bmjqs.2010.050864]. 2011;20(11):953-8 [15%].
- Bankart MJ, Baker R, Rashid A, Habiba M, Banerjee J, Hsu R, Conroy S. Characteristics of general practices associated with emergency admission rates to hospital: a cross-sectional study. Emerg Med J. [10.1136/emj.2010.108548]. 2011;28(7):558-63 [15%].
- Conroy SP, Stevens T, Parker SG, Gladman JRF. A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: ‘interface geriatrics’. Age Ageing 2011;40(4):436-43 [40%].