Frailty

Introduction: Hospital-Associated Deconditioning Syndrome (HADS) can lead to prolonged length of stay (LOS). Evidence indicates that early intervention may reduce HADS and LOS. (British Geriatrics Society, Deconditioning, Healthy Ageing, 11 May 2017, Dr Amit Arora, NHS England, 24 January 2017, Time to Move). The Acute Frailty Team (AFT) at Eastbourne District General Hospital piloted a Frailty Early Discharge Scheme (FEDS) in the Frailty Unit for 8 weeks between May-June 2023 with the aim of providing early mobilisation and discharge planning to reduce LOS.

Methods: Patients were admitted to either FEDS or Non-FEDS (NFEDS) beds depending on the bed availability. FEDS patients were provided with additional early assessments and interventions including discharge plans from day 1 after admission, offering early, continuous and active mobilisation by a trained FEDS team of a registered Nurse and Health Care Assistant. The FEDS team worked in conjunction with the medical team to actively promote discharge planning while patients were still receiving acute medical treatment, before patients becoming medically fit for discharge (MFFD). NFEDS followed the standard care plan, usually initiated after patients were declared MFFD. Data was collected for all patients, comparing FEDS 12 beds with NFEDS 12 beds.

Results: 83 patients were enrolled 45 FEDS, 38 NFEDS Discharged within 48hrs FEDS 11.11%, NFEDS 2.63% Discharged within 7 days FEDS 44.44%, NFEDS 28.94% LOS 8.07 days FEDS, 11.36 days NFEDS (30 day trim point).

Conclusions: 1. Increased rate of discharge within 48 hrs and 7 days. 2. Reduced LOS within 30 days. 3. The benefit is mostly noticed within the first 7 days indicating the need to apply the intervention early 4. The adoption of a FEDS-project in all frailty wards could be beneficial for elderly patients.

Background

Frailty in over 65s is common, but is not often assessed on medical admission at Barnsley Hospital. Identifying frail patients is clinically important, as it can highlight those who may benefit from a Comprehensive Geriatric Assessment –an intervention which has been shown to reduce mortality and improve independence.

Introduction

At Barnsley Hospital, only 13.49% of patients aged over 65 admitted to the Acute Medical Unit (AMU) were found to have a documented Rockwood Clinical Frailty Score (CFS). This project aimed to increase this to a target of 30%.

Methods

A survey conducted amongst clerking doctors (27 respondents) identified multiple barriers to documenting frailty, which influenced a quality improvement project with 4 PDSA cycles.

Changes made included: modifications to the electronic clerking template, education around frailty, posters, and a daily frailty WhatsApp reminder.

The effectiveness of each PDSA cycle was assessed by a retrospective audit of the percentage of over 65s admitted to AMU per day receiving a CFS assessment.

Results

A total of 2816 patient admissions were reviewed over a 3 month period. Rates of CFS documentation improved from a baseline of 13.49% to 21.42% after cycle 1, 28.43% after cycle 2, 28.13% after cycle 3, and 28.19% after cycle 4.

Conclusion

Although the intended target of 30% was not met, this project achieved a significant increase in the rate of CFS documentation for patients admitted to a busy AMU. Overall the programme was well received, although further work is needed to continue to improve frailty recognition.

Introduction

The Frailty Network, initiated in November 2023, aims to enhance care for frail patients through multidisciplinary collaboration across acute and community settings. By fostering partnerships with Health and Social Care teams, GPs, district nurses, and third sector organisations, the Network strives to provide realistic and patient-centric improvements in Lanarkshire. The initiative focuses on proactive, personalised, and coordinated support to help frail older adults maintain independence and well-being.

Methods

The Frailty Network is supporting multiple teams to implement new pathways to streamline care and improve outcomes. The aim is to understand our systems and have a focus on the data impacting our older adults. Stakeholder Engagement Table was utilised to show project success so far. Quantitative methodology such as LOS, number of referrals will be used to show impact. With a progress / Driver Diagram to show Quality Improvement Journey thus far. As the Network is a large piece of work, many aims are long term.

Results

The implementation of the Frailty Network has resulted in notable improvements in communication, engagement, collaboration and innovation. There has been reduced LOS in the frailty wards, improved transfers to community hospitals and more pathways to keep people at home. There are structures now imbedded to encourage multi system working from all settings.

Conclusion

The Frailty Network's innovative design has begun to successfully improve care for frail older adults in Lanarkshire. The collaboration between acute and community teams, combined with proactive interventions and the use of digital technology, has started the journey to a more sustainable future. Continued focus on integrated leadership and shared goals will further refine and sustain these improvements, setting a gold standard for frailty care in the region. Further research is required to assess long-term impacts.

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.

Following COVID and an aging population waiting lists in Swansea Bay for elective procedures along with the rest of the UK had reached an all time high. Many patients have become frailer over time and may no longer be suitable or keen for surgery. There was not an efficient mechanism in place for screening these patients and many were being cancelled on the day or having pre-op assessments close to the time of surgery and found to be unsuitable. As part screening our elective surgical waiting lists for frailty we used a number of mechanisms including a electronically screening questionnaire. This was sent to 78 patients highlighted through power BI as meeting frailty criteria and on surgical waiting lists. The questionnaire consisted of a ‘self CFS’ reworded alongside K Rockwood and questions from the CRANE questionnaire. The patients were sent a link with a brief outline of the purpose of the questionnaire and the potential need to be called to clinic if they had any frailty needs. There was a contact number for a admin assistant if there were queries. If they couldn’t access the technology they could also contact them complete via telephone. Over 50% of patients completed the questionnaire online. Interestingly the majority of patients completing the questionnaire had a clinical frailty score over 4 (calculated via clinicians). A clinician also calculated a frailty score for the patients completing the questionnaire which showed good concordance between patients ‘self score’ and a clinicians score. This work showed that our frailer population are able to use technology to good effect and pending more research there may be a role for patients to ‘self score’ themselves in a clinical frailty score. This is invaluable in cutting down resources needed for screening for frailty in many areas

Introduction

It is predicted that over 4,000,000 patients will be on an elective waiting list in England by 2030 (1) with increased demand, age and frailty following COVID (2). The importance of early assessment of frailty and geriatrician input to allow optimisation and shared decision making is key. A Geriatrician led perioperative clinic was established in Swansea Bay for patients on elective general surgical waiting lists in September 2023.

Method

Using an electronic Power Business Intelligence frailty flag, we highlighted patients and screened either electronically or via telephone using a combination of CFS and CRANE questionnaire. Covering a number of areas including continence, falls and cognition. The outcomes are reviewed by a geriatrician and directed to appropriate avenues such as face-to-face perioperative clinic, continence services or virtual wards. All patients who decide to continue on their journey to surgery are given advice r.e. operative risk, diet and fitness along with optimisation of medications and tests such as echo to minimize delays going forward.

Results

Over 250 patients >65 have been screened to date-either Digitally/Paper/Telephone. Digital responders have an average CFS of 4.48. Over 20 patients have been seen per month since initiating the service with a variety of outcomes. Over 50 (~20%) have decided against surgery following shared decision making demonstrating cost savings of approx. £200,000. There are a number of new diagnoses including dementia and incontinence. Over 20 patients have accepted referral to continence services.

Conclusion

Formalising a perioperative clinic has allowed improvements in patient care and cost savings. We have now completed an initial screen on all general surgical patients who have been on the waiting list over 1 year and have initiated ongoing screening to detect changes in frailty going forward. The next step is initiation of frailty screening at point of referral on WCCG referral.

Introduction

Physical and cognitive decline at an older age is preceded by changes that accumulate over time until they become clinically evident difficulties. These changes, frequently overlooked by patients and health professionals, may respond better than fully established conditions to strategies designed to prevent disabilities and dependence in later life. The objective of this study was twofold: to provide further support for the need to screen for early functional changes in older adults and to look for an early association between decline in mobility and cognition.

Methods

A cross-sectional cohort study was conducted on 95 active functionally independent community-dwelling older adults in Havana, Cuba. We measured their gait speed at the usual pace and their cognitive status using the MMSE. A value of 0.8 m/s was used as the cut-off point to decide whether they presented a decline in gait speed. A quantitative analysis of their EEG at rest was also performed to look for an associated subclinical decline in brain function.

Results

Results show that 70% of the sample had a gait speed deterioration (i.e., lower than 0.8 m/s), of which 80% also had an abnormal EEG frequency composition for their age. While there was no statistically significant difference in the MMSE score between participants with a gait speed above and below the selected cut-off, individuals with MMSE scores below 25 also had a gait speed < 0.8 m/s and an abnormal EEG frequency composition.

Conclusions

Our results provide further evidence of early decline in older adults – even if still independent and active - and point to the need for clinical pathways that incorporate screening and early intervention targeted at early deterioration to prolong the years of functional life in older age.

Introduction:

Population is growing old worldwide and UK is no exception. Health service models designed to cater the needs of service users are under immense pressure due to the aging phenomenon. With unprecedented demand, their often low acuity, hence low priority and delayed conveyance to hospital and unavailability of services to address their needs due to delayed arrival; frail older patients often have to wait longer in emergency department (ED) to receive care in ED. Innovation and news models of care are therefore need of the hour to address this challenging situation.

Methods:

Quality improvement initiative to establish acute frailty service.

Development of Older Person assessment unit (OPAU) in Oct 2022 with already established and functional acute frailty team.

Plan for direct referral to OPAU from South East coast ambulance service (SECAmb) colleagues.

Weekly meetings with SECAmb.

Geriatrician of the Day supporting alternative pathways instead of ED.

Development of frailty poster with criteria to referral and uploaded on SECAmb work iPads, displayed in ambulances delivery area and ambulance queuing area inside the hospital.

Single point of access phone number launched April 2023 to access frailty team & other alternative services from outside the hospital.

SECAmb webinar for education and awareness of alternative pathways (UCR, SDEC, frailty, virtual ward), attended by 40 front line SECAMB staff.

Results:

October 2022 – 0 patients.

November 2022 – 2 patients.

December 2022 – 8 patients.

January 2023 – 18 patients.

February 2023 – 32 patients.

March 2023 – 33 patients.

April 2023 – 39 patients.

Conclusion:

With sustained efforts and effective collaboration, number of patients being referred to alternate pathway (frailty team) are increasing with anticipated significant reduction to SECAmb conveyance to ED in the long run, addressing overcrowding issues.

• Frailty is an important consideration in the health and wellbeing of older adults, particularly as it is associated with a risk of falls, and mental health difficulties such as depression.

• After Option appraisal of various frailty assessment tools we chose Edmonton frail scale which consists of 9 domains ( Ref: ROLFSON DB, ET AL, VALIDITY AND RELIABILITY OF THE EDMONTON FRAIL SCALE, AGE AND AGEING 2006; 35 (5): 526–529 DOI: 10.1093/AGEING/AFL041​).

Abstract

• This was a feasibility study exploring the use of the Edmonton frail scale (EFS) among patients with highly complex mental health needs within a Psychiatric Inpatient Setting with a view to develop a service integration process leading to further research.

• Completion rate of the assessment was 55% as the domains requiring patient participation for cognitive and physical performance assessment were difficult to complete for this cohort of patients.

• It is feasible to use EFS in this setting but older adults with psychiatric disorders may benefit from having an adapted assessment of the cognitive and functional domains to promote complete administration of EFS Results

• 118 assessments were administered to 45 patients, over a 12-month period (months 1, 6 and 12).

• There was a 55% assessment completion rate.

• This was largely attributed to the challenges of administering two components of the EFS; the cognitive domain (Clock Drawing test) whose completion rate was 32%, and the Functional Performance Domain (Timed Get Up and Go Test).

• It was quite difficult for patients with highly complex mental health needs to understand and comply with the assessment instructions in the above domains

. • Average age was 73.5 years​ and 29 out of 45 patients were found to have moderate or severe frailty.

• 24 out of 29 patients with moderate or severe frailty had documentation of DNACPR discussions in their clinical records.

• Falls incidences did not change significantly during the year of implementation.

Conclusions

• It is feasible to use EFS in an inpatient psychiatric facility, particularly one where the patients have highly complex mental health needs​.

• The findings also indicate that this population has a high prevalence of moderate to severe frailty​.

• The continued use of the EFS as a holistic assessment tool would enable the MDT to focus on the areas/domains in which a patient is identified to be deteriorating​.

• To improve the tool’s completion rate alternative assessments for cognition and functional ability (Clock drawing test and timed get up and go test) need to be explored.

Acknowledgements This project could not have been done without engagement of staff and patients, and support of Dr Muthusamy Natarajan, CD of Neuropsychiatry division and Agnieszka

INTRODUCTION: Frailty is common in hospitalised older patients and hospitalisation can lead to negative outcomes. Our study aimed to provide insights into current decision-making processes on treatment, care and discharge by clinical teams. 

METHODS: We conducted a prospective cohort study in frail older patients ≥ 65 years old admitted to acute medical and surgical wards. Clinical Frailty Scale ≥ 5 was used to identify frail patients and process mapping was undertaken to identify common themes, trajectories and potentially modifiable factors. We followed patient journeys from admission to discharge and examined factors contributing to longer hospitalisation. We documented existing processes, environmental, system and clinical factors influencing patient care. Comprehensive geriatric assessments identified underlying geriatric syndromes and where gaps in management were identified, we recommended frailty interventions. 

RESULTS: Fifteen patients provided informed consent, of whom 73% were female and average age 80 years, ranging 69-95 years. 67% were frail (CFS 5-6) and 33% were severely frail (CFS 7-9). Most patients were sarcopenic with a SARC-F score of ≥4 and had functional and gait impairment. 60% were underweight (BMI <22). Process mapping revealed gaps in frailty-focused care and included delayed transfer to acute wards, delayed investigations, and multiple unidentified geriatric syndromes which were prevalent in this cohort.Patients fell into three broad groups, short (1-6 days), intermediate (7-14 days), or long (>14 days) length of stay and delays in discharge-planning were common, mean of 4.17 days, as were delays in identification of a caregiver. Recommendations for community support services were provided to >50% patients. 

CONCLUSION: Our study shows that mapping the frail patient's journey can identify gaps in existing processes and opportunities for improvement and collaboration. Integrating geriatric care into general wards could improve patient outcomes. We aim to use this work to guide frailty-attuned care for hospitalised older patients.