CGA

Background

The Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary tool, designed to promote holistic care of elderly patients and provide a framework for intervention. There is evidence that the CGA reduces mortality and slows progression of frailty. Performing such interventions in the acute setting can be complex and time-consuming.

Introduction

The Older Person’s Assessment Unit (OPAU) at Weston General Hospital allows early identification of frailty and prompt intervention. We aimed to promote elements of the CGA by providing a tool for utilisation throughout the patient’s admission to coordinate patient care.

Methods

This was a prospective pre-post intervention study on OPAU. We reviewed medical records in a 5-day period analysing documentation of elements of the CGA. The primary intervention was introduction of a ward-round proforma prompting delirium screening. Following analysis and re-evaluation, a an updated proforma with an additional bone-health prompt was circulated. The completion of proformas was re-assessed.

Results

Baseline data of 20 patients showed that common presenting complaints were falls and confusion. Only 14% of those who presented with a fall had a documented bone-health screen. 0% of patients with confusion had a delirium screen. After cycle 1, 0% had bone-health screening and 20% had delirium screening. Following cycle 2, 89% of patients who had a fall had completed bone-health screening.

Conclusion

Implementation of a CGA-orientated ward-round proforma encourages consistent documentation. It demonstrated successful increased uptake of delirium and bone-health screening. The future aim is to introduce a full CGA proforma that encourages opportunistic assessment by all members of the multi-disciplinary team.

Introduction:

It is very often observed in clinical practice that older patients with frailty stay in the A&E for long periods under the Therapy Assisted Discharge Service (TADS) team without an appropriate referral to the medical/Frailty team. There are many potential risks identified such as missed opportunity for early geriatrician/frailty input, incomplete clinical assessment, missed opportunity for CGA, critical medications omitted, missed VTE assessment, and delay in receiving care.

Methodology:

A retrospective study of 50 patients was conducted through EPR notes at East Kent Hospitals University NHS Foundation Trust.  We collected data from the A&E list daily for patients >75 years old with Rockwood scores 5 or more, who have been in A&E for >12 hours under TADS/A&E without referral to any specialty. We also looked for referrals to the medical/Frailty team, Comprehensive Geriatric assessment (CGA), regular medicine prescription, advanced care plan, successful discharge, and percentage of patients readmitted in 7 days. Following the first cycle, awareness was raised through meeting with the TADS team, educating front-door doctors to refer patients to the Frailty/Medical team within <12 hours who met the inclusion criteria. 

Results:

After interventions, we demonstrated an improved result compared to the initial cycle. We achieved patient referral to Medics/ Frailty from 45 to 59% within 12 hours, Comprehensive Geriatric assessment (CGA) done 15% to 45%, medications charted within 12 hours 50% to 75%, advanced care plan 45 to 64%, successful discharge 38% to 60%. Interestingly, there was a significantly reduced percentage of patients re-admitted within 7 days which is 30% to 10%.

Conclusion:

It is unsafe to admit older patients with frailty under the A&E/TADS for more than 12 hours without any referrals to the medical or Frailty team because of many potential risks. Following a limited awareness campaign, we witnessed some improvement in some of the standards. However, there are still areas of potential improvement. To attain 100% compliance with the first recommendations of this QIP, a re-audit with increased awareness and actions is planned in a few months.

Reference:

https://www.england.nhs.uk/urgent-emergency-care/same-day-emergency-care/acute-frailty/

Introduction:

CGA is the gold-standard intervention for older adults living with frailty. A challenge is providing person-centred, time-efficient CGA. The CGA-questionnaire (CGA-Q) aims to facilitate person-centred CGA, allowing patients/carers to highlight concerns. We describe a two-site multi-cycle QIP implementing the CGA-Q.

Methods:

CGA-Q is a 19-item questionnaire covering seven CGA domains. It was adapted from the validated CGA-GOLD questionnaire. Between March 2023-June 2024, CGA-Q was established in a London and Scottish NHS Trust using ‘Plan-Do-Study-Act’ methodology. Cycle 1-3 involved designing and establishing CGA-Q at one London geriatric clinic. Cycle 4 assessed feasibility in multiple London geriatric clinics. Cycle 5 examined implementation of CGA-Q in a Scottish day-hospital. Person-centredness refers to inclusion of person-selected concerns in clinic letters, and not including person-excluded concerns.

Results:

Across cycles, cohorts were comparable in age, sex, frailty and cognitive status. In cycles 1-3 (n=174), CGA-Q completion rates improved from 39% to 83%. More CGA-Q questions were addressed especially cognition, mood, continence and falls. Inclusion of person-selected concerns increased from 60% to 70%; exclusion of person-excluded concerns remained ~70%. In cycle 4, completion rates varied by clinic: renal-CGA 100% (12/12); CGA 42% (13/31); bone-health 14% (10/60). >50% of questionnaires were completed by patients, except in bone-health where two-thirds were completed by staff. Staff feedback highlights CGA-Q is a useful discussion prompt. In cycle 5 (n=41), a similar breadth of CGA-Q questions were addressed among respondents compared to baseline. With CGA-Q, continence and pain were addressed more frequently. Inclusion of person-selected concerns was 62%; exclusion of person-excluded concerns was 71%.

Conclusion:

CGA-Q has been successfully implemented across multiple sites and clinics. It can improve person-centeredness and breadth of CGA, but early results vary across subspecialty geriatric medicine clinics with their unique processes. Ongoing work will determine the experience of patients and carers of this approach.

Introduction

Global estimates indicate over half of individuals aged 85 and older are frail (1), costing the UK healthcare system approximately £5.8 billion annually(2). Locally, over 6,500 patients aged 65+ are admitted to West Middlesex University Hospital (WMUH) every six months. The proposed frailty team aims to implement early comprehensive geriatric assessments (CGAs) through a multidisciplinary approach. Timely CGAs can increase the likelihood of patients remaining in their own homes at 6 and 12 months(3), reduce length of stay (LoS), and lower healthcare costs, contingent upon available community infrastructure. WMUH serves multiple boroughs, necessitating coordination with various community services to support discharges. These services include Hospital at Home and Integrated Care Response Services.

Objective

To gather baseline data on frail patients admitted before the introduction of a 'Front Door Frailty' team.

Methods

Data were collected for all medical admissions to WMUH from 1st to 14th July 2022, including:

• Patients aged ≥65 years

• Numbers with a frailty syndrome

• Clinical Frailty Score (CFS)

• Admissions in the previous year

• Length of stay

• Mortality at 5, 9, and 12 months

Results

From 459 admissions over 2 weeks, 278 patients (61%) were ≥65 years old. Among these patients:

• 54% had a CFS ≥ 6

• 44% presented with a frailty syndrome

• 83%, 72%, and 67% were alive at 5, 9, and 12 months respectively

• Mean LoS was 11.0 days

• 37% had ≥1 admission in the following 6 months

• Of those with a CFS ≥ 6, 63% had ≥1 admission in the previous year

Conclusions

A high percentage of acute admissions at our hospital are characterised by frailty. Through early identification, multidisciplinary management, and improved links with local community services, the new acute frailty team aims to decrease length of stay and improve patient experience.

Introduction

Older people living with frailty are core users of health and social care. Services attuned to the needs of people with frailty afford better outcomes, help avoid harm and improve the experience for people and those who care for them. Such services can also help with flow and capacity. The Glasgow Royal Infirmary (GRI) Team aimed to advance services in order to enhance the quality and provision of care for older people with frailty.

Methods

As part of the Health Improvement Scotland Focus on Frailty Programme, the GRI Team developed processes for early identification of people living with frailty, using an electronic Frailty Assessment Tool. Processes were designed to streamline patients with frailty to specialist areas of care in order to initiate early Comprehensive Geriatric Assessment (CGA). A Frailty Assessment Proforma was created to swiftly identify the priorities, concerns and goals of patients and carers and to gather key collateral information promptly. Daily CGA Huddles were commenced which include participants from various different health and social care services. Work is now being done towards the development of a dedicated Frailty Assessment Area and a trial of Rapid Access appointments at the Assessment and Rehabilitation Centres is being undertaken.

Results

There has been an improvement in frailty identification. 79% patients over the age of 75 years, who are admitted through the Acute Medical Receiving Unit, are being screened for frailty. There has been improvement noted in terms of access and time to a specialty bed. Further, there has been a reduction in length of stay for people with frailty, coupled with a reduction in readmissions at 7 and 30 days.

Conclusion

Frailty attuned acute services help patients receive timely, specialist care. They help reduce time spent in hospital and readmissions which, in turn, can contribute to improved flow and capacity.

There is a 35-week waiting time to be seen in a gastroenterology clinic for investigations such as UGI endoscopy and colonoscopy for a condition such as low Hb, weight loss, dysphagia and so on. Most of the time without adequate initial workup and ruling out iron-deficient anaemia and differentials as per the British Gastroenterology Society. The hospital is witnessing an exponential influx of patients, reflecting in long waiting times to accommodate clinic patients.

The current established low Hb referral pathway via GP to gastroenterologists does not consider the co-morbidities and frailty. Hence the main aim of the pilot project is to create parameters and filter patients who are 75 and above with co-morbidities and 85 and above, who would benefit from a comprehensive review, whose outcome might involve invasive gastroenterology investigation. The patients will be able to address their GI problems and other concerns where a Geriatrician will provide the expertise in a personalised care plan.  The Gastroenterology triaging secretaries will filter the suitable patients based on established parameters following referred to an Elderly Care consultant in comprehensive assessment clinics. In the clinic, the patient will have a thorough workup for causes of low Hb or GI causes, assess the level of frailty, and discuss with the patient if they want to go for invasive investigations or manage their condition conservatively. The project will provide holistic, patient-centred care and prevent delays in care plans.

Furthermore, help conserve endoscopy resources where the patient chooses not to have further invasive procedures—resulting in overall patient satisfaction.

Introduction

Falls are a common cause of morbidity and mortality in frail patients, with visual impairment doubling the risk of falls. NICE advises a multifactorial approach to identify risk factors to be treated, improved and managed. This includes sensory/visual assessment, which is poorly done in practice. The aim is for 50% of relevant patients admitted with fractures following falls to have a vision assessment within 5 days of admission.

Methods

A modified RCP ‘Look out! Bedside vision check for falls prevention’ aid for healthcare professionals was utilised. Patients excluded were those with significant delirium/dementia or medically unwell. We regularly collected data on how many patients had a vision assessment performed whilst implementing interventions such as Teaching Sessions, Posters and including visual assessments in the Comprehensive Geriatric Assessment(CGA).

Results

Initial results demonstrated poor rate of visual assessments in patients. With implementation of the modified tool, rates of visual assessments improved from 11%(n=1) to an average of 22%(n=4). Further interventions increased the overall average to 80%(n=36). The most effective intervention was including a visual assessment checkbox in the CGA. This improved rates of visual assessment in a subgroup of patients considered to have had falls due to visual impairment, from 33% to consistent rates of 100%. Additionally, the average days to assessment greatly reduced from 10.2 days to consistently under 5 days.

Conclusion

Identification of visual impairment reduces recurrent falls and hospital admissions. The project demonstrated the clinical significance of vision assessments - aiding the diagnosis of PSP, prescribing eye drops, and optician follow-up. Utilisation of the modified ‘Look Out’ tool is a simple way to assess vision on the ward. Posters and teaching sessions improved clinicians’ confidence. However implementing sensory impairment in the CGA proforma proved the most sustainable effort. Next steps include implementation in other Geriatric wards and Falls clinics.

Aim: Several scores have been developed to identify SDEC patients from Emergency Department (ED) triage and acute medical intakes. Scores are designed to improve system efficiency, overcrowding and patient experience but none have been developed for older adults. Previous work has shown that existing scores e.g. Glasgow Admission Prediction Score, Sydney Triage to Admission Risk Tool and the Ambulatory Score were not able to predict admission in our population(1). We have developed a novel, frailty-focused score.

Methods: The Older Person’s Assessment service (OPAS) is ED based, accepting patients with frailty syndromes aged >70 years to provide a comprehensive geriatric assessment (CGA) and is extended into medical SDEC. The databases were retrospectively analysed and interactions with age, Charlson Co-morbidity index (CCI) and Clinical Frailty Score (CFS) were evaluated alongside NEWS, 4AT, including who with and where the patient resides.

Results 1011 attendances, 414 (40.9%) Male, mean age 82.3(±8.4) years, CFS 5.3(±1.2) and CCI 8.0(±1.8), 701(69.3%) discharged same-day and 629(62.2%) fallers. OPAS: 776 attendances, 306 (39.4%) Male, age 82.4(±8.7) years, CFS 5.3(±1.1) and CCI 7.9(±1.9), 540 (69.5%) discharged same-day, 557(71.8%) fallers. SDEC: 234 attendances, 108(46.2%) Male, age 81.8(±8.0) years, CFS 5.2(±1.3) and CCI 8.2(±1.7),162(69.2%) discharged same-day, 72(30.1%) fallers. There was significant difference between groups with NEWS (p<0.02), mortality (P<0.001) and presenting complaint(p<0.001). We used a cut-off Score >6.5 indicating admission(p<0.0001). Each variable’s weighing was determined using T-tests and Chi-squared analysis. Overall score Sensitivity 0.75, Specificity 0.63, Positive Predictive Value 0.65, Negative Predictive value 0.57, Area under Curve 0.65.

Conclusion Frailty is an important determinant in identifying whether ambulatory care is appropriate. The efficacy of the score is comparable to the results derived in validation cohorts of existing and recommended scores. We are currently prospectively testing the score but clinical judgement, alongside a MDT providing a CGA is gold standard care.

Introduction

Information-sharing between primary and secondary care is vital for patient safety and reducing duplication. The Electronic Discharge Summary (EDS) enables this but is often incomplete due to time pressures and poor team continuity. Information from the Comprehensive Geriatric Assessment (CGA) by the Perioperative care of Older People undergoing Surgery (POPS) team is often omitted, leading to queries from primary care colleagues and duplication of work on readmission to hospital.

Methods

Eight core CGA components were determined for inclusion in the EDS. Twenty EDS were reviewed to for each PDSA cycle to assess compliance. Various strategies were trialled to increase compliance including junior doctor education (attendance at induction plus separate teaching), a checklist poster, the POPS team directly entering information into the EDS and a separate CGA summary.

Results

Baseline data demonstrated poor compliance with core CGA components (mean 25%, range 0-62.5%). PDSA 1 demonstrated improvement after junior doctor education and introduction of a checklist poster (mean 35%, range 12.5-87.5%). Mean compliance increased to 53% during PDSA 2 with the POPS team directly entering information into the EDS, but with continued wide variation (range 12.5 – 100%). The introduction of a POPS CGA summary to complement the EDS in PDSA 3 increased compliance with reduced variation in practice (mean 99%, range 87.5-100%).

Conclusions

Sharing information gleaned from a CGA was marginally improved with education, but is challenging due to the rotational nature of staff completing the EDS. The improvement seen with the POPS team entering EDS information was limited by the lack of 7-day working and the ‘locking’ of the completed EDS by the parent team. A separate CGA summary markedly improves information-sharing, with reduced variation in practice. This has benefitted primary and secondary care colleagues, as well as the POPS team when patients are readmitted or attend clinic.

Introduction: In the cancer setting, Comprehensive Geriatric Assessment (CGA) reduces chemotherapy toxicity, improves QOL and increases advance directive completion (ASCO 2020: The Geriatric Assessment Comes of Age; Soto-Perez-de-Celis et al; The Oncologist). We wanted to look at whether CGA improved symptomatology, as patients attending our oncogeriatric clinic complained of a range of symptoms, related to their cancer, as well as other co-morbidities and frailty.

Methods: We retrospectively analysed follow up clinic letters of patients who had attended the oncogeriatric clinic, between June 2022 and June 2023. We used a Lirkert scale, to see whether symptoms they had complained of had 1 – got worse, 2 – stayed the same, 3 – improved or 4 – resolved.

Results: 32 patients with a wide range of malignancies were included. 59 patients were excluded because they: died before the 2nd appointment, did not require a second appointment, had their second appointment outside the analysis window, DNA or in 1 case the follow up letter could not be found. On average each patient complained of 3 symptoms. 30 different symptoms were noted (2 excluded as there was no mention of them in the 2nd visit.) The top presentations were pain, constipation, low mood, breathlessness, reduced mobility, falls and dizziness. 68% of the symptoms complained of showed improvement – including all the top presentations. The average score on the Lirkert scale was 2.76 78% of patients had shown improvement or resolution in at least some of their symptoms.

Conclusions: Our retrospective review shows that older, cancer patients, have a high burden of varied symptomatology, because of their cancer, co-morbidities and frailty. Attendance at an oncogeriatric clinic results in improvement in the symptom burden for the majority of older adults, and an improvement in some symptoms, whether they are related to cancer, or other frailty syndromes.