Introducing ‘the CARE tool’: a simple tool to improve general surgery documentation and understanding of key aspects of frailty

Introduction

Increased frailty is associated with increased post-operative morbidity and mortality in older patients undergoing emergency laparotomy. NELA recommend documentation of frailty in surgical patients over 65.

Using QI methodology, we introduced a ‘CARE tool’ for surgical doctors aiming to improve their documentation of an older person’s medical history (including CFS and delirium).

Method

A collaborative team representing geriatric medicine, anaesthetics and surgery devised the acronym CARE (Cognition, Assistance at home, Record the CFS, Exercise tolerance).

The tool was tested using QI methodology over 2 PDSA cycles. Cycle one introduced the tool into electronic patient records (EPR) and presented it at the surgical faculty meeting. Cycle two introduced the tool specifically to surgical FY1 doctors during induction.

The EPR surgical clerkings of patients over 65 years old admitted to general surgery were sampled weekly over seven weeks to assess CARE tool completion.

Post-intervention, we surveyed the surgical doctors assessing their understanding of frailty and perceived value of the CARE tool.

Results

At baseline: 12% of confusion, 92% dementia status, 0% CFS, 30% assistance at home, 8% exercise tolerance were documented.

Following PDSA cycle one, use of the CARE tool was 40%. There was an increase in the documentation of confusion (40%) and CFS (40%). Dementia status and assistance at home were documented in similar frequency pre and post-cycle.

During cycle two, CFS documentation increased to 55% but identification of confusion dropped to 25%. The survey demonstrated that frailty, CFS scoring and delirium screening were better understood by junior doctors than Consultants and registrars.

Conclusions

Our project showed mixed success in improving documentation using the CARE tool. The survey demonstrated a good understanding and knowledge of frailty in surgical FY1s. Ongoing frailty teaching is planned for the surgical department.