Bristol South and West Primary Care Trust - Acute Response Team (ART)

The Acute Response Team (ART) is one of the initiatives designed to free-up hospital beds. It comes under the overall heading of intermediate care. The specific objective of the ART is firstly to prevent hospital admission and secondly to expedite discharge from hospital of patients who are already in hospital.

There are 6 or 7 people in the teams. They include the following disciplines nursing, physiotherapy, occupational therapy and social work. There is one full-time equivalent for each. The team works closely with the Community Rehabilitation Team and it is hoped that the 2 teams will be based in a single building in Knowle West shortly. The ARTs can prescribe antibiotics and give chest physiotherapy at home. They are normally involved for about 10 days at a time.

The report covers the period October 2002 to March 2003. It is a follow-on document and does not give much in the way of background information and there is no discussion section. At the time of writing the editor of the website has not seen any other reports.

During the study period 366 referrals were received. This represents an average of 61 per month and compares with 43.2 per month during the same period the previous year. Thus, it is clear that the number of referrals is increasing.

Approximately equal numbers of patients were referred by general practitioner and consultant teams about 37% from each source. Nine percent were referred by the Discharge Assessment Team (DAT) and a further 15% were referred from miscellaneous sources. Forty-six percent of all referrals were early discharges from hospital and 54% were for the prevention of admission to hospital. It should be noted that the number of discharges from A&E was included in the early discharge figures (26 patients). It could be argued that these patients should fall under the category of admission preventions.

Community referrers tended to request assistance within 2-4 hours. Hospital referrers, on the other hand, were within 24 hours. This may reflect the fact that patients in hospital are perceived as being in a safe environment not always needing rapid access. On the other hand patients at home require a rapid response time to prevent unnecessary hospital admission. Referrals were received from a total of 26 wards.

Visits occurred throughout the day but there was a particular peak between 12 midday and 1 pm. The majority of visits lasted between half an hour and 1-2 hours. (No more specific information given.)

The average number of visits per patient during the 6 month period under study was 15.57. This compared with 15.72 for the same period 12 months earlier.

The average number of days on the \"caseload\" decreased from 6.82 to 5.91 days over the same period. (RLH notes The report does not define the term caseload. This point requires clarification.)

The number of face to face visits for the 6 month period was 4469.

There are 4 \"safe haven\" beds which are in a residential setting. At risk patients can be supervised 24 hours per day whilst the ART are providing care. (RLH notes Further information required.)

The report claims that a total of 2176 bed days were saved during the 6 months study period. The figure was apparently calculated using the length of time in \"caseload\" for discharged patients for each of the referring teams. The consultant team and discharge assessment team the referrers were asked to estimate how many days they might be saving. (RLH notes This is a crucial figure because the whole exercise appears to depend on the number of bed days saved. A further explanation of the calculations is required.)

At the time of referral to the ART 25% were referred for social reasons, 20% because they had had falls, 16% for respiratory problems and 10% for intravenous therapy. There were a considerable number of miscellaneous diagnoses given.

The diagnosis on discharge from the ART was given as immobility in 20%, inability to cope in 14%, COPD in 13% and fractures in 12%. A range of other less frequent diagnoses was given.

The largest number of inappropriate referrals were for patients who were judged more appropriately managed by another service. Thirteen percent of all referrals to the service during the reporting period were judged inappropriate. It was to be hoped that once a single point of referral is achieved this percentage would decrease.

This is an interesting report but it has to be seen in context with the previous reports that have been produced. RLH would like to see copies of these particularly the rationale for the team.

There seem to be a considerable number of alternative teams/resources. These include the district nurse, health visitor, and the community rehabilitation team. In the document there is mention of the Discharge Assessment Team (DAT) but the nature of this is not explained. It is unclear as to what resources they command if any.

The report says nothing about the types of intervention that are deployed by the ART. This is really essential information particularly when it is noted that the team includes a physiotherapist and an occupational therapist who would presumably be involved with rehabilitation. The criteria for referral to the ART as opposed to the Community Rehabilitation Team is unclear. The term caseload (page 8 of the report) is not explained.

I am unconvinced about the claim regarding saving of bed days. This needs to be further explored. Ideally this project should be subjected to independent analysis/audit. Is this being done? It would be a valuable academic exercise.

Overall I felt that this was an exciting, probably worthwhile project, but I would like to know more of its history and whether or not other people throughout the UK are undertaking similar work. Information is required from the consultant geriatricians as to how they perceive the service. The report would be greatly improved if there was some practical examples of exactly what the team does. )

RLH