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Thinking outside the box: ‘Reducing length of stay makes a massive difference to patients’

Dr Nicholas Coles is a consultant in care of the elderly at Glangwili hospital (GGH) in Carmarthen. In this blog, taken from our recent report on innovation in west Wales, Thinking outside the box, he discusses how setting up a frailty unit at the front door has improved patient care.

I’ve been a consultant geriatrician at GGH for around four years. We’re a small hospital and we struggle to recruit, although we’re all doing our best. When I first arrived, there was no acute frailty service here. I had recently come from Morriston where I’d set one up from scratch, knocked the length of stay down by at least a week, and in some cases a month, which made a massive different to patients. Our data told us that patients were less likely to come back into hospital, and more likely to live longer with an acute frailty service at the front door.

We’re trying to replicate the model here. It’s slow going, but we now have an advanced nurse practitioner and we're linking with intermediate care in Carmarthenshire. On a daily basis I see patients in A&E or in the back of an ambulance, then we’ll work our way towards the admissions unit. We use surrogate frailty markers to identify patients who have come in with immobility, confusion, delirium, dementia, incontinence, Parkinson’s disease, and those who have a package of care or are living in a care home. The multidisciplinary team will then carry out a comprehensive geriatric assessment.

As well as a consultant and an ANP, we have access to occupational therapists, physiotherapists, a social worker, and the Delta Wellbeing team who screen patients for social services. (They can provide short-term care while waiting for a longer-term package). We have a pharmacist who joins us from time to time. The key member of the team is the frailty nurse. They pull everything together; they manage all the communications between different members of the team, and they make sure that everybody is working together to speed up discharge.

We’re also developing a frailty pathway in our SDEC units with consultant support, nurses and healthcare assistants. The idea is to move our frail patients out of A&E, treat them as quickly as possible and refer them into intermediate care – we want to get the patient home with support.

Dr Nicholas Coles
RCP college tutor for Glangwili Hospital
Consultant in care of the elderly medicine
Hywel Dda University Health Board