Frailty indexes

Abstract 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 – NHS England have included the identification and response to frailty in emergency departments (ED) as an area of clinical priority, producing the CQUIN05. At the Oxford University Hospitals Trust (OUH) we have designed a front door frailty service and are participating in the CQUIN05 scheme. The Clinical Frailty Scale (CFS) score is recorded by nurses in ED. Following the CQUIN05 criteria, patients aged above 65 years old and scoring 6 or above on the CFS (moderately frail) are identified by the front door frailty service and a comprehensive geriatric assessment (CGA) initiated. From initial audits, we identified that CFS scores were only identifying frailer patients (correctly scoring above or below a score of 6) in 45-51% of patients seen by the frailty team. We created a simple lanyard card with the key descriptors of characteristics above and below a CFS of 6. This was in addition to regular, brief education sessions and pre-existing CFS educational posters displayed in ED. Method. We retrospectively audited patients seen by the frailty team over 4, 7 day periods and compared CFS scores with that of the ED nurse’s. We calculated the difference and whether ED’s score was correctly above or below a CFS of 6. Results. Prior to the intervention, frailer patients were correctly identified in 45-50% in those patients seen by the frailty team. Subsequent to this intervention, this increased to 65-70%. The accuracy (difference of 0) before and after remained between 16-30%. Conclusion(s). In the context of emergency care, correctly identifying groups of frailer patients rather than strictly accurate scores, is key for front door frailty services. A simple lanyard card in conjunction with brief teaching was effective at increasing the rate in which frailty was correctly identified in patients and thus referred to appropriate frailty teams.

Introduction: Any Frailty Index (FI) measures overall health. The FI-Lab employs common laboratory data and clinical measures to do so.  

Objective: To examine how an FI-lab constructed from vital signs, laboratory tests, and electrocardiographic data is associated with in-patient admission and time to death. FI-Lab performance was compared with an FI from a Comprehensive Geriatric Assessment (FI-CGA), the Clinical Frailty Scale (CFS), and the Canadian Triage Acuity Scale (CTAS).

Methods: Participants were Emergency Department (ED) patients aged 65+ years referred to Internal Medicine, staffed by a geriatrician (KR). Fifty-seven FI-Lab variables were binarized (0 = no deficit; 1 = deficit) using standard normal ranges. Each FI was calculated as the fraction of items present as deficits. Age- and sex-adjusted Cox proportional hazard and logistic regression models were used to assess relationships with all-cause mortality, and in-patient admission, respectively.  

Results: Of 928 patients, an FI-Lab was calculable in 780. Median age was 81 years (IQR:13); 53.9% were female. FI-Lab values ranged from 0.02–0.78 (mean: 0.42; standard deviation (SD) ±0.10). No significant sex differences were found [females (mean: 0.41±0.11) vs males (0.42±0.09; p=0.067)]. At 30 days, each 0.01 FI-Lab unit increase showed higher mortality hazard rate (HR) (95% confidence interval (CI):1.05 (1.03–1.07) and inpatient admission risk: Odds ratio (OR) 1.02 (1.00–1.04), as did the FI-CGA (1.02; 1.00-1.04) and CTAS (1.20; 0.83-1.75). Similar results held for inpatient admission, same for CTAS (1.18; 0.82-1.72). At one year, only the FI-lab and CFS significantly predicted mortality risk.

Conclusions: FI-Lab scores were associated with higher mortality rates and in-patient admission risk in older ED patients referred to Medicine. In acute care, the FI-Lab appears to integrate baseline frailty with illness severity. As such data often are routinely available, the FI-Lab might be an additional measure of frailty-related risk, potentially available in real time.

Introduction: According to the latest NELA report(1), frailty doubles the risk of mortality in patients >65 and above, but review by a geriatrician can significantly reduce this risk. To identify patients at risk, the report recommended that a formal frailty assessment for all patients>65 should be performed. The aim of this audit was to check compliance with this recommendation.

Methods: Data were collected retrospectively from a prospectively maintained electronic hospital records. Patients > 65 years admitted acutely under general surgery were identified from handover lists spanning a period of two weeks. The admission documents were reviewed to check for a formal assessment of clinical frailty score (CFS) had been completed. Following initial results, posters were put up in the SAU doctors office and all clerking doctors made aware via e-mails, WhatsApp groups and teaching to complete a CFS for patients >65 years. Results: In the first cycle, 50 patients were identified and compliance rate was 18%. Following intervention, 51 patients were identified in the subsequent cycle with a compliance rate of 47%. After a second intervention, 99 patients were identified with a compliance rate of 61%.

Discussion: The NELA report highlighted only 23% of patients had a CFS documented and this was similar to the results of the initial audit. The main reason was lack of awareness, which was addressed by creating an awareness among the colleagues via poster, group chats and emails. This brought compliance up to 47% Another reason was doctors being unable to locate the CFS on the electronic clerking document. A second round of intervention by poster, group chat, email communication and teaching achieved a 61% completion rate. The recommendation is to continue to improve the documentation of CFS further and utilize this to get input from geriatricians.

Background: Older individuals living with frailty face a heightened risk of experiencing significant deterioration in their mental and physical well-being following seemingly minor health challenges. Our aim was to assess and enhance the practice of the Clinical Frailty Scale (CFS) during inpatient assessments within a large teaching hospital.
Methods: We conducted 2 cycles of retrospective data collection within a single centre setting, screening a total of 600 patients focussing on; age ≥65, level of frailty, location of CFS assessment - Emergency Department (ED), Medical Assessment Unit (MAU); and the health-care professionals involved in CFS practice. We compared practices amongst young-old (65-74), middle-old (75-84), and old-old (≥ 85) age groups.  
Results: The CFS documentation rate for eligible patients was 76.7% in the first cycle, involving 240 patients, and 83% in the second cycle which included 247 patients, whereas the rate for the above-mentioned age sub-groups was 13.8%, 67.7%, 98.3% respectively. The prevalence of frailty amongst the age sub-groups was 74.1%, 84.7%, and 93.9% respectively, while male-to-female prevalence was 88.9% and 89.2%. Overall, 72.7% of the CFS assessments were completed in ED. The Frailty Interface Team (FIT) significantly contributed to the CFS assessment by completing 58.1% of overall assessments.
Conclusion: The results underscore the significance of integrating frailty education into core teachings to enhance CFS practice among junior doctors. Identifying inpatient frailty in the 65-74 age group is crucial, as they are frailer than initially perceived and will further decline with aging. Interdisciplinary collaboration is essential, particularly a specialized FIT, proving pivotal in CFS practice within our hospital. Larger studies into inpatient frailty in the young-old age groups are recommended. 

Introduction: The Acute Frailty Team (AFT) review all acute admissions referred to Medicine for the Elderly within our organisation. Our team is comprised of a consultant, AHPs and a specialist clinical pharmacist. The Clinical Frailty Scale Score (CFS) was used to quantify frailty within our patient population. Recognising that older patients are at increased risk of medicine related harm, medication reviews are undertaken as part of the comprehensive geriatric assessment. The aim of this project was to determine the number of documented Level 3 medication reviews on discharge including number of medication interventions and determine any correlation with CFS. 

Methods: For a 5 month period, all patients reviewed by AFT (Monday to Friday) had a documented CFS score on admission. A retrospective review was then undertaken with data collected on CFS score, patient demographics and number of Level 3 medication reviews documented on discharge. Data was then collated to indicate medication interventions and the most common medication changes.

Results:  212 patients were reviewed during the study period. Range of CFS score was 2 to 8 and 81.2% were classified as CFS ≥5. 101 patients had a documented Level 3 medication review accounting for 380 medication interventions; 210 medications were stopped and 82 medications were started. 36.6% of the patient group were deceased within 1 year of review.

Conclusion(s):

In order to optimise effective prescribing and minimise harm in older, frail people, this data will be used locally to promote the importance of medication reviews during an acute admission and ensure this is reliably communicated on discharge. Deprescribing accounted for 55.3% of changes. Since 1/3 of patients are deceased within one year, a targeted medication review is essential and should influence our prescribing practice going forward.

Introduction:

The benefits of early frailty scoring for patients over 65 presenting to emergency settings are well established. A scoping exercise in the Emergency Department (ED) at the University Hospital of Wales (UHW) identified lack of familiarity with the Clinical Frailty Scale (CFS) and time pressures as barriers to achieving frailty screening at triage. In response, the Frailty Intervention Team (FIT) at UHW developed the Self-Assessment of Frailty in the Emergency Settings Tool (SAFE-T).

Methods:

A PDSA cycle was performed to assess SAFE-T validity and the feasibility of implementation in ED and in a community intermediate care clinic. A 5-day pilot was conducted in April 2023 where all patients >65 years were asked to complete and return a SAFE-T. In parallel, blinded to the result of the SAFE-T, the FIT team completed a CFS score and the results were compared. Process feedback was collected from the FIT team, ED staff and hospital volunteers to identify implementation barriers.

Results:

Data were analysed from 58 questionnaires (50 from ED, 8 from Community Clinic). 42 participants completed SAFE-T alone, 16 completed it with support (e.g. family advocate/hospital volunteer). 7 were excluded from final analysis due to insufficient data to enable comparison. Initial results indicate that the SAFE-T is a sensitive screening tool for frailty and that sensitivity maybe improved where the patient is supported by a collateral informant. Process feedback identified problems with SAFE-T layout, resource implications and the perceived labour intensiveness of the tool.

Conclusions:

SAFE-T is a sensitive tool for the identification of frailty in different clinical settings. Process feedback suggests that further development of the tool will improve ease of use for patients and healthcare professionals. A further PDSA cycle is now underway to assess how the tool may assist in improving compliance with frailty scoring in ED

Introduction: Frailty is under-recognised in hospital leading to unwarranted variation in care. National guidance recommends that all healthcare professionals can identify frailty and offer interventions to reduce risk factors for frailty. Previously, physiotherapists working in Older People’s Medicine (OPM) did not record frailty status in their clinical assessment. This quality improvement project seeks to translate and implement best practice, supporting physiotherapists to record the Clinical Frailty Scale (CFS) score within routine patient assessment, so interventions can be initiated to optimise outcomes.

Project aim: Within 3 months, to achieve a 50% increase in the number of patients with a Clinical Frailty Scale (CFS) score recorded within their physiotherapy assessment.

Methods: Plan-Do-Study-Act cycles with interventions of bespoke teaching and assessment proforma re-design were employed targeting the OPM physiotherapy team on ward 31, RVI.

Measures: The weekly number of patients with a CFS score recorded within physiotherapy assessment was collected over 13 weeks and evaluated on a run chart. Staff knowledge and skills self-assessment scores and cohort data were also recorded and described using descriptive statistics.

Results: At baseline – 0/114 (0%) physiotherapy patients had a CFS score recorded, this improved to 95/192 (49%), suggestive of effective change post interventions. Staff confidence scores also improved.

Conclusions: This project has led to improved frailty awareness and identification amongst OPM physiotherapy staff. This work supports a collaborative approach to improving frailty care; better identification of frailty can reduce harm by informing healthcare needs, supporting patient flow, and resulting in better, safer, and more equitable care.

Introduction: Living with frailty is a risk factor for increased short and long term mortality. We aim to describe the uptake of escalation of care and resuscitation status discussions in frail older patients admitted to general, colorectal, and upper gastrointestinal wards.

Methods: Prospective observational study of all patients aged 65 years and over admitted under general surgery 11th February to 11th March 2022 and a second cohort of patients hospitalised between 1st and 31st of October 2022. We scored frailty using the clinical frailty scale (CFS) and identified escalation of care discussions through review of electronic patient records.

Results: We included 196 patients, average age 75.9 (65-97), 90 (46%) females and 106 (54%) males, 107 (54.6%) emergency (EM) and 89 (45.4%) electives (EL). 64 (32.7%) patients were frail (F = CFS ≥5) and 132 (67.3%) non frails (NF = CFS≤ 4). Length of stay was 14 days, 14.9 in F and 11.4 in NF, 14 EM and EL 18.3. Surgery was carried out in 14 (25.9%) F and 33 (40.7%) NF. In total 6 patients died in hospital: 4 F (7.3%) and 3 (3.7%) NF individuals, one without resuscitation decision. Resuscitation discussions had in 20 (36.4%) F vs 4 (4.9%) NF, 19 (16.8%) EM and 6 (6.7%) EL. Percentage of discussions increased in frail patients from 24% to 42.4% overall, and 92% non-frail patients were not offered discussion.

Conclusion: 1 in 3 patients in our cohort of older adults hospitalised under surgery were frail. Higher frailty scores were associated with increased in-hospital mortality. 30% frail and 8% non-frail older patients underwent resuscitation discussions. We advocate early proactive discussions of resuscitation status and advance care planning in high risk surgical patients.