NHS Fife: getting it right for our most vulnerable patients

Report on improvements by Fife's Victoria Hospital of facilities and care for frail patients, following the Cochrane Review of geriatric care.

The Integrated Assessment Team ( IAT)

The newly formed Integrated Assessment team consists of
a team lead physiotherapist, specialist frailty nurse practioners, static specialist occupational therapist and physiotherapists, frailty staff nurses and Assistant Frailty Practioners. The pioneering post of the assistant frailty practioners has been a great success of the improvement work and this new role can support all professions within the team and is generically trained.

Key successes are the team’s enhanced service delivery which has enabled a seven-day service for all front door areas which is available from 7.00am until 7.30pm, 365 days a year, and is inclusive of all public holidays.

The hospital created a new pathway to identify frailty at the
front door.

Frailty @ Front Door Pathway

Frailty @ Front Door Pathway

The Integrated Assessment Team was located in the 40-bedded Medical Assessment Unit ( MAU) and developed a process of frailty screening in MAU, the Emergency Department and the Surgical Assessment Unit. Nurses within both the assessment units now screen all patients regardless of age for frailty syndromes including: reduced mobility; falls; cognitive impairment and delirium. Patients that are flagged up as having potential frailty indicators are referred to the Integrated Assessment Team for a Comprehensive Geriatric Assessment ( CGA). Each morning Monday to Friday the IAT will triage the patients screened positive for Frailty and identify 10 patients to be seen by the Consultant Geriatrician doing the Frailty Ward Round. Priority is given to patients with delirium, patients from Nursing/Care home, and patients likely to be suitable for early supported discharge with Hospital at Home. It is well recognised that the earlier CGA is started the better the outcomes for patients and by introducing the Frailty Ward round these patients are seen by a Consultant Geriatrician as early as possible in their admission and a comprehensive plan is made. We are able to take a holistic approach with our specialist skills to ensure the correct pathways for patients that would otherwise be different or delayed if seen instead by colleagues from other medical specialities first.

Back Row (L to R): Gordon Ellis (Frailty ANP), Karen Goudie (Nurse Consultant), Alex Bann (Frailty ANP), Rona Young (Frailty SN), Rhona Lyttle (Frailty SN), Nicola Weir (Assistant Frailty Practitioner) Front Row (L to R): Loretta Comer (OT), Ailsa Williams (Specialist OT), Lauren Stenhouse (Specialist PT), Louise Kellichan (Team Lead)

Back Row (L to R): Gordon Ellis (Frailty ANP), Karen Goudie (Nurse Consultant), Alex Bann (Frailty ANP), Rona Young (Frailty SN), Rhona Lyttle (Frailty SN), Nicola Weir (Assistant Frailty Practitioner)
Front Row (L to R): Loretta Comer (OT), Ailsa Williams (Specialist OT), Lauren Stenhouse (Specialist PT), Louise Kellichan (Team Lead)

Within the Emergency department, the screen sits on TRAKCARE (our IT system) and is carried out by both the medical and nursing team for patients over 65 years. Using the model for improvement the team has carried out a number of PDSA cycles to bring this process to triage where by the team is alerted to the patient at the earliest time possible in their journey.

A response time of 30 minutes is adhered which enables the specialist team to guide the decision-making to optimise patient care and lead referrals to the established community teams. This enhanced service has opened up referral routes for patients which enable the team to ensure the right care at the right time, for example discharges with Fife’s established Hospital @ Home services. Previously these patients would have been admitted, but can now often be discharged directly home.

The team provides liaison advice to all front door areas which is hugely valued and the nurse consultant supported by the Frailty NPs provide outreach delirium support and advice.

On average, the team sees 20 patients a week within the ED and 75% of these are discharged directly home. If patients attend ED out with IAT team times they will be frailty screened and if positive an out-of-hours referral is completed which the team triage next working day and identify appropriate follow up e.g. Day hospital, MOE clinic, Hospital@Home and community rehab teams. The team receive on average 20-30 Out of Hours ( OOH) referrals each month.

The feedback from the ED teams includes:

“From the ED perspective, it is very useful getting patients seen in the period from 4-7pm”.

“Referring to IAT is streamlined – phone referrals are accepted with professionalism and grace without millions of questions”.

IAT have a quick response time in coming to see patients”.

“The extended service provides a rapid response, and does aid the ED in discharging patients that might otherwise have been admitted”.

IAT team members work together to optimise outcomes for patients”.

Additionally, Dr Andrew J Kinnon who is consultant and Clinical Lead in Emergency Medicine ( NHS Fife) reports “The frailty IAT team have become an integral part of the ED team. They provide expertise in assessing those patient groups who may not need admission but need additional support or would benefit from specialist clinic follow up in the community. They can also access hospital at home if needed. The team is available to us seven days a week. They will follow up on ED referrals that were made during the OOH period on patients who were deemed fit for discharge overnight from the ED but may need some frailty input. The team members are approachable and always willing to offer support and advice in a timely fashion. They work with us to help achieve the governments and hospitals targets”.


Email: Jessica Milne, unscheduledcareteam@gov.scot

Phone: 0300 244 4000 – Central Enquiry Unit

The Scottish Government
St Andrew's House
Regent Road

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