Frailty

Frailty is defined as a state of increased vulnerability to poor resolution of homoeostasis after a stressor event, increasing the risk of adverse outcomes (1). The Clinical Frailty Scale (CFS) is a validated infographic tool used to assess frailty in clinical settings (2). It aims to provide a standardised framework for frailty assessment, however determining the CFS is primarily subjective in nature, relying on clinical judgement and observation. NHS Elect have launched a CFS application, helping to improve the objectiveness of the CFS outcome. A quality improvement project performed at Royal Surrey Foundation Trust explored the difference in the CFS calculated by junior doctors from Non-Geriatric specialties and referred to the Inpatient Older Person Advice and Liaison (iOPAL) team, compared with the CFS calculated by the iOPAL team using the CFS application. The audit showed 27% of referrals had no CFS provided, despite it being a referral criterion, 20% had the same CFS score, 30% had an over scored CFS and 23% had an underscored CFS. The iOPAL team updated the referral form to include advice on how to calculate the CFS and included webpage and QR-code links to access the CFS application. In addition, direct verbal feedback and education was provided. Since the interventions, an improvement of CFS calculations has been seen with a repeat audit showing a reduction of referrals not providing a CFS to 17%, an increase having the same CFS score to 34% and reduction of underscoring CFS to 9%. Over scoring of CFS remained an issue at 40%. In conclusion, education around CFS and use of the CFS application has led to improved CFS scoring by junior doctors from Non-Geriatric specialties. Further micro-learning sessions are being developed to target clinicians of all grades from Non-Geriatric specialties, in particular surgical specialties.

Introduction: 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. There has been no validation of frailty assessment tools among older adults with Psychiatric disorders. 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.

Methods: 45 participants were recruited from 8 older adult wards across Neuropsychiatry and Medium Secure divisions. EFS assessments were completed every six months by trained members of Multidisciplinary Teams over a 12 month period.

Results: About 118 assessments were administered to approximately 45 patients, regardless of a patient’s length of stay at the hospital during the 12-month period. There was a 55% assessment completion rate. This was largely the result of difficulties in administering the cognitive domain of the EFS (Clock Drawing test) to patients with highly complex mental health needs, as the completion rate was 32%. It was also quite challenging for patients to understand and comply with the assessment instructions in the Functional Performance Domain (Timed Get Up and Go Test). As a result, many assessments in this domain were conducted through covert observation of patients’ movement during the course of the day. 29 of 45 patients had at least moderate level of frailty.

Conclusion: Older adults with psychiatric disorders may benefit from having an adapted assessment of the cognitive and functional domains to promote complete administration of assessments. Prevalence of frailty is high in this setting. Continuous support towards staff engagement and education would be beneficial in promoting EFS use in determining frailty and integrating it into care planning.

Background

The East Kent Frailty Home Treatment Service (Frailty HTS) provides person-centred, hospital-level care for people living with frailty. The Frailty HTS can diagnose and treat acute medical illness at home or in care homes. The team philosophy is “we identify what you want and strive to make it happen”. This project was underpinned by advance care planning for people living in care homes, which the frailty team supports through proactive work with the primary care network care homes teams.

Frailty is associated with increased healthcare costs and poor outcomes associated with hospitalisation. The acute hospitals were under extreme pressure. The Frailty HTS serves 360 care homes.

Methods

Carers and the ambulance service discuss all acutely unwell care home residents with the Frailty HTS prior to conveyance except in the case of a long bone fracture or acute cardiac/cardiovascular event (unless care plan is not for escalation).

There were communications initiatives to care homes and Ambulance Trust explaining referral process and eligibility. A dedicated frailty HTS clinician was available to respond to calls.

Results

The pilot has seen an increase in referrals of people living in care homes from SECAMB to Frailty HTS (monthly average up from 49 up to 64) an increase in direct referral from care homes (monthly average up from 15 to 21.5). We also saw a reduction in attendance of care home residents at ED (monthly average down from 276 to 209) and reduced admissions to hospital from care homes (monthly average down from 203 to 191).

Conclusion

This project raised awareness of an alternative to acute hospital care for people living in care homes. Referrals to the Frailty HTS were increased and attendance at ED and admissions to hospital reduced.  Due to system pressures it continued to run and became business as usual.

Background: Non-communicable disease, multimorbidity and frailty are posing considerable challenges as global populations age. Healthcare systems in Low- and Middle-Income Countries are having to rapidly adapt services to meet the needs of older people.

Objective: This study, the first of its kind in sub-Saharan Africa, aimed to establish whether screening older people for frailty on admission to hospital could be used to identify those at greatest risk of adverse outcomes.

Methods: At baseline assessment, 308 participants aged ≥60 years, admitted to medical wards at four hospitals in the Kilimanjaro Region of Tanzania, were screened for frailty using the Clinical Frailty Scale (CFS). After 10-12 months, participants, and their informants, were contacted by telephone to establish clinical outcomes. The primary outcome was all-cause mortality. Cox regression was used to estimate hazard ratios (+ / - 95% confidence interval) for mortality, with dichotomised CFS frailty status (frail if ≥5) as the independent variable.

Results: Primary outcome data were obtained for 194 (63.0%) of the original participants after a mean follow-up period of 10.8 (+/- 0.9) months. Mean age was 75.1 years and 99 (51%) of the respondents were female. A total of 100 (51.5%) respondents were deceased and hazard ratios for all-cause mortality demonstrate that those with frailty were at significantly greater risk of mortality (HR 2.27 [CI 1.39 – 3.69], p<0.01), an effect that persisted even after adjustment for age, baseline Barthel Index, education and number of chronic conditions.

Conclusion: For older people living in Tanzania, unplanned admission to hospital is associated with high mortality and frailty is a strong independent predicator. In accurately identifying which older people are at the greatest risk, frailty screening using the CFS could provide a starting point for the development of targeted care pathways and interventions. 

Background: This study aims to investigate the relationship between frailty and in-hospital cardiopulmonary resuscitation (CPR) outcomes in the COVID-19 pandemic.

Methods: The study was carried out in a tertiary hospital in Scotland and included all patients over the age of 18 who had an in-hospital CPR attempt between April 2020 and March 2022. Patients were identified via the pre-existing National Cardiac Arrest Audit Database which was collected prospectively. Data collected from this included age, sex, initial arrest rhythm, return of spontaneous circulation (ROSC) and in-hospital mortality. The electronic and paper patient notes were retrospectively reviewed to calculate a Rockwood clinical frailty scale (CFS) and Charlson comorbidity index (CCI). The data was stratified in to frail (CFS ≥5) and non-frail (CFS <5) cohorts.

Results: 65 patients were included in the study. In univariate analysis, there was a significant difference between the frail and non-frail groups in age (p=0.006), ROSC (p=0.02) and survival to discharge (p=0.004). Only 10 out of 34 (29.4%) frail patients had ROSC and of those only 3 (8.8%) survived to discharge compared to 35.3% of non-frail patients. In a binary logistic regression, there was a significant association between frailty and both ROSC (adjusted OR 3.31 [95% CI: 1.12-9.78}) and survival to discharge (adjusted OR 6.33 [95% CI: 1.48-27.13]) and no significant association with age, CCI or sex.

Conclusion: The findings support the relationship between frailty and poor CPR outcomes independent of age and co-morbidity.

Background:

An estimated 10% >65-year-olds and 25-50% >85-year-olds live with frailty in the UK, ¹ making up a greater proportion of surgical caseloads. Perioperatively, frailty is an independent risk factor for adverse outcomes.^2,1  Timely recognition and assessment is vital in prevention, however, awareness of frailty and the Clinical Frailty Scale³ (CFS) is limited amongst clinicians.⁴

Methods:

A survey was completed by doctors of all grades across surgical specialties in Sandwell General Hospital. Questions explored recognition of frailty, use of CFS, and their influence in perioperative decision making.

Results:

A total of 33 Doctors completed the survey (33.3% Junior Doctors). Whilst 97% believed they look after frail patients, 69.7% were aware of the CSF but only 30.3% had used the scale.

All doctors thought frailty plays a role in their decision making post-operatively, however >87% rated their confidence in recognising frailty ≤3/5.

Key Messages:

Across all grades, there is an awareness of the importance of frailty, however a lack of confidence in its recognition. Need for further education is evident, particularly regarding the CFS. In this respect, focused education sessions are being implemented for all grades of doctors to consolidate knowledge and facilitate a multidisciplinary approach to decision making in surgery

Poster Title: CT head requests – Are they clinically indicated?  A QIP conducted in Acute Frailty Unit (AFAU) at Princess Royal University Hospital.

Aim:
1. To find out how many inpatient CT heads are being completed for patients reviewed at AFAU.
2. To assess the main indications for requesting a CT head.
3. To assess how many CT heads were not clinically indicated, and to explore if there are any particular reasons why non-indicated scans are being done.
4. To identify areas of improvement in relation to CT head requests.
5. To improve the CT head request practice to 90% in a period 3 months.   

Methodology:
Patient selection: all patients reviewed in AFAU in June 2022 (n= 132) and January 2023 (n=143).
 
June constituted our baseline data and January 2023 was the 1st PDSA cycle
 
The EPR CT head request forms were reviewed, and the data copied in an excel spreadsheet. The medication history at the time of admission was reviewed in order to confirm if the patients were on anticoagulation.

Baseline results:
1. 4 CT head request forms referred to head Injury whilst on anticoagulation, however on review the patients were not on anticoagulants.
2. None of the CT head requests querying stroke provided information on focal neurological deficit, stroke requests included only ‘slurred speech’ or ‘dizziness’ or ‘new onset weakness’ (site/side unspecified).

Conclusions:
1. This QIP has shown a large improvement in the CT head request practice.
2. Our PDSA interventions were easy to implement and several areas were identified for further improvement.
3. Although the CT head request standards consistently improved, we did not achieve the overall 90%. This suggests that additional interventions are required.

QIP methods
1. Baseline results were communicated at the Geriatrics weekly teaching meeting and NICE guidelines were revisited.
2. Educational announcement at ED and Visual prompt of NICE CT head guidelines placed in ED

Recommendations
   1. Further teaching sessions on the latest NICE guidelines for the indications of CT head.
   2. Additional Posters, particularly in A&E where most scans are ordered.
   3. EPR CT head request form can be updated to include NICE guidelines sections

Abstract (max 250 words)

Introduction: Virtual frailty wards, where patients are treated at home who otherwise would be in an acute hospital, are a model of care being promoted within the NHS in the UK, with the aim to ‘provide an alternative to admission and/or early discharge’. The evidence base for this model of care is limited and the ideal set up has not been defined. The aim is to describe the implementation and delivery of a virtual frailty ward serving a rural community.

Methods: Creating a 7 day a week frailty virtual ward integrated across primary and secondary care. A multidisciplinary team (MDT) focus was adopted utilising existing staffing from partner organisations. Data was collected over a 12 month period. A comprehensive geriatric assessment (CGA) approach was adopted. Daily patient reviews were completed and treatments adjusted with findings. On discharge from the ward patient, carer and staff satisfaction feedback was gathered.

Results: 466 patients managed on the ward, with an average length of stay of 3.7 days. 1724 inpatient bed days saved. Minimum save to the acute trust £862, 000. Average 37% direct hospital avoidance community step-up patients. Average 63% early discharge from hospital step-down patients. 98% positive feedback.

Discussion: Close collaboration across healthcare services and development of trust are key to success of a virtual frailty ward. Impact was clear over a 12 month period with 1724 acute bed days saved. Patient and carer satisfaction was high. MDT attendance remained consistent, with positive feedback from across sectors of the hidden value of the shared learning and education. Actual savings in relation to wider effects are outside of this scope of this study e.g. deconditioning, mortality, but positive outcomes from CGA have been widely published. Further work is required to become more proactive in hospital avoidance and increasing numbers of step up patients.

Introduction

Causeway Hospital’s frailty service consists of an Acute Elder Medicine/Stroke unit of 30 inpatient beds and a Frailty Direct Assessment Unit (DAU) for GP referrals and EmergenIntroductioncy Department (ED) patients suitable for same-day turnaround with comprehensive geriatric assessment (CGA) from our multidisciplinary team. 

We have devised a new Frailty Model to enhance our service, maximise integration between primary and secondary care services and facilitate more effective short-stay care and early supported discharge. 

Method

To initiate this model, we plan to: 

1. Strengthen our DAU admission pathways – by identifying ED patients more quickly, promoting anticipatory care pathways, and ensuring all GP’s in the Causeway locality are made aware of the direct referral pathway. 

2. Explore new ways of working within DAU – by collaborating with the NI Ambulance Service to develop a direct access pathway to DAU for patients meeting specific criteria (e.g. non-injurious falls), and setting up pathways for residential homes (offering CGA in DAU for new permanent admissions into residential homes). 

3. Open an Acute Frailty Unit – by developing a 6-bedded Acute Elderly Area, and testing a model in the coming months to assess the long-term viability of this project. 

Results

We expect early results for the impact of this model in the coming months, and hope our enhanced service will provide comprehensive short-stay care and support timely discharge back to the community with a safe wrap-around service. 

Conclusion

To meet the increasing needs of today’s ageing population, we need pathways that decrease reliance on acute secondary care services, promote independent living for frail, older people where possible and strengthen our relationship with primary care colleagues. 

Our Frailty Model aims to streamline services and create new ways of ensuring our older population are given the best chance to have a healthy, fulfilling and well-supported later life.

Introduction: The Frailty Intervention Team (FIT) is a multidisciplinary team that provides a service to community based frail adults. This particular service is novel in the sense that it is a hospital based out-patient service as opposed to frailty at the front door or a community based service and has access to rapid diagnostic and intervention services.

Aims: The aim of this research is to share and describe the model of this relatively new and novel service for the benefit of other service providers.

Method: A prospective database review was performed to provide descriptive data on the service between 2021 & 2022. Variables examined included referral source, MDT members involved on initial assessment and follow up, patient’s objective outcome measures and a history of falls.

Result: Between the years 2021 and 2022, 350 new patients and 912 review patients were seen by the team with an additional 139 Medical Assessment Unit consultations carried out also. Of these service users 37.38% were male and 62.61% female. The average Clinical Frailty Score was 4.98 (4.91 men, 5.05 women). This indicates the mean service users is ‘Living with Mild Frailty’ - a cohort that may be otherwise missed by other services.

Conclusion: This research highlights the demand for access to out-patient frailty interventions in line with the National Clinical Programme for Older Persons which promotes access to ‘the right person, in the right place, at the right time’.