Frailty same day emergency care (SDEC): a novel service model or an unhelpful distraction?

Key Points

• Editorial to accompany ‘Care pathways in older patients seen in a multidisciplinary same day emergency care (SDEC) unit’.

• Emergency and unscheduled care is adapting to the needs of older people.

• Same day emergency care is one alternative to ED attendance that has been developed.

• An honest dialogue about the expectations and realities of admission avoidance is needed.

Healthcare systems worldwide are undergoing significant transformations to address the long-anticipated demographic shifts impacting service demand and delivery. There has been an increasing demand for unscheduled care, presenting challenges in patient flow within hospitals and culminating in suboptimal (and dangerous) solutions such as corridor care [1]. Predictive modelling data has further underscored the urgency of addressing future demand, highlighting the need for healthcare systems to adapt and innovate in response to these demographic realities.

People living with frailty have long been known to have longer emergency care stays, perhaps because of the inherent complexity of their presentations [2]. In the UK, a quality standard that required patients to be assessed, treated and discharged or admitted to hospital within 4 hours of attending an emergency department exacerbated barriers to providing comprehensive, multimodal assessments and creating individualised management plans. This standard, while intended to ensure prompt care, inadvertently pressurises healthcare providers to make quick decisions, often resulting in systemic inclination to admit patients on arrival at the expense of thorough patient evaluations and tailored care plans. Increased awareness of the dangers and indignity of crowded emergency care may plausibly further influence such behaviour, with professionals seeking to minimise the time people living with frailty are exposed to such settings. Up to one-third of people admitted acutely to hospital are subsequently discharged within 24 hours, suggesting that a proportion of inpatient services are assigned to admissions that were avoidable [3].

Same day emergency care (SDEC) services have emerged as a potential solution to these challenges. These services are intended to provide an alternative to the ED for a specified cohort of patients providing access to rapid assessment, diagnostic imaging and initial treatment with a goal to avoid hospital admission where care can be delivered on the ‘same day’. However, the evidence base for SDEC services is at best limited, although a scoping review is planned [4]. Nevertheless SDEC services have expanded at pace across the UK. SDEC is typically delivered by acute or general physicians and aims to reduce ED occupancy and inpatient admissions by providing services in alternative settings. How many of these patients might have been managed similarly by emergency departments is unclear. Historically, older people living with frailty have been excluded from SDEC services, despite them being at risk of having the longest hospital stays. This has led to emergence over the last decade of a range of front door frailty services. These have some empirical evidence of benefit [5], although a recent England-wide evaluation of a large-scale improvement collaborative focusing upon ‘acute frailty’ failed to show any impact on bed-days [6]. Reducing bed-days is complex, and it is likely that ‘bolt-on’ services, whether located in communities or acute hospitals, rarely achieve that intended outcome. They do, however, risk duplication, silo working and reduced opportunity to develop integrated teams and care pathways [7]. Furthermore, the multiple points of entry into acute care must be just as confusing for patients to navigate as they are for clinicians.

In their recent paper, Elias et al. [8] observe a standalone older people’s SDEC setting for attenders’ subsequent health service use. They report an early, pre-pandemic era example of SDEC, following 533 people who attended in 2015. These patients had similar frequency of frailty (46%) to current typical European emergency care settings [9]. It is therefore unsurprising that discharge pathways were highly complex, requiring flexibility to individualise escalation or de-escalation of care. A minority (9%) of attenders had no subsequent follow-up: as well as people with interventions ‘completed’ in the SDEC, these may also have included individuals with ‘ambulatory care-sensitive conditions’ who could have been managed in primary care.

The evolution of SDEC services underscores the necessity for an honest and comprehensive dialogue about the expectations and realities of prehospital, community and acute hospital efforts to avoid inpatient bed use. Success metrics for SDEC services need to be clearly defined and agreed upon, taking into account the nuanced and multifaceted goals of reducing admissions, improving patient care and efficiently utilising resources. Moreover, the cost of SDEC services and their impact on the broader healthcare system must be critically examined. In the paper by Elias et al., SDEC assessment was associated with a two-fold increase in the number of days involving any sort of healthcare interaction in the following 6 months. There is a need to contextualise these cost savings of ED avoidance within the broader framework of healthcare financing and delivery, recognising that the downstream effects of SDEC services, while potentially beneficial in reducing certain admissions, might also lead to unintended and currently unmeasured consequences such as increased demand on outpatient or community healthcare services.

Perhaps a more pressing issue is to discuss whether the perpetual search for bed-day savings is distracting from what should be the primary focus of a healthcare system, namely, to improve patient outcomes [10]. The emergence of pre-hospital triage schemes with access to ‘hospital at home’ and of single emergency care access points might help focus on getting the right care to the right person at the right time [13, 14]. Perhaps it is time for an honest conversation about moving away from heroic efforts to save bed-days, and start to focus upon what really matters to patients. We certainly do not have the right solutions at present [11, 12].

Declaration of Conflicts of Interest:

None.

Declaration of Sources of Funding:

None.

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