Admission

Title: Evaluation of Frailty Assessment, Management Practices, and Patient Outcomes in GIM Patients Under 85 Years: A Two-Cycle Audit in GIM Wards at Queen Alexandra Hospital, Portsmouth Hospital University NHS trust.

Introduction:

Frailty significantly affects outcomes like length of stay and readmissions in elderly patients. At Queen Alexandra Hospital, inpatients under 85 are under the care of General Internal Medicine (GIM) wards and they lack regular access to frailty services. This baseline audit evaluated frailty assessment, management practices and patient outcomes, implementing staff education, ward posters, and a frailty Multidisciplinary Team (MDT) between cycles. Methods: Data were retrospectively collected from three GIM wards over two cycles—January and August 2024.

Eligibility criteria:

Patients aged 65-85, admitted to GIM were included. The audit measured frailty assessment using the Clinical Frailty Scale (CFS), Comprehensive Geriatric Assessment (CGA) practices, frailty prevalence (CFS ≥ 5), advance care planning (ACP), and readmission rates.

Results:

Frailty assessment compliance rose from 76.6% to 94.4%. Frailty detection (CFS ≥ 5) increased from 36% to 75%. CFS documentation improved to 34.5%, with better CGA documentation. However, ACP rates remained low at 3.03%, and 56.6% of frail patients were readmitted within the year, indicating ongoing challenges.

Conclusion:

Improvements were seen in frailty assessments and detection, yet ACP remains underutilized, and readmission rates are high. Continued efforts are needed to enhance ACP documentation and frailty management strategies. Recommendations: 1. Implement robust policies for ACP and implement a straightforward pathway for ACP documentation by all doctors. 2. Educate all doctors to practice comprehensive geriatric assessment and participate in frailty MDT meetings. 3. Further audits to specifically investigate the proportion of patients admitted with frailty syndrome and assess their prognosis. 4. Prioritize triage based on CFS scores/frailty over age to enhance targeted care and resource allocation.

Introduction:

Care home residents are increasingly presenting to hospitals. In October 2022, a frailty team was formed in our district general hospital, consisting of two SHOs, one SpR and one consultant, with support from pre-existing care home ANP and community resource team (CRT). Focusing on patients presenting to the Emergency Department, their aims were early identification of care home residents in order to optimise their care by facilitating discharge, tackling polypharmacy and seizing opportunities for advanced care planning.

Method:

Care home residents were highlighted on the ED clinical system, using a unique icon, and reviewed by the frailty team. Anonymised patient statistics were logged into a bespoke e-database. This generated a dashboard of graphs showing trends in outcomes. The statistics from the first 8 months (3/10/22 to 5/6/23) were utilised to show patient demographics, number of reviews and rates of discharge.

Results:

297 care home residents were reviewed. 83.8% of these patients had a Rockwood Clinical Frailty Score of ≥ 7. Delirium was present in 91 (30.6%) patients. 121 (40.7%) had at least 1 medication stopped. 165 (55.6%) were discharged after frailty review. Do not resuscitate forms were completed for 208 (70.0%) patients. Advanced Care Planning was discussed with 138 (46.5%) patients and 6 (2.0%) patients were not for re-admission. End of life care was commenced for 17 (5.7%) patients.

Conclusion:

It is clear that patients attending the Emergency Department would benefit from an early comprehensive geriatric assessment. The benefits this has provided in one North Wales DGH are significant and have made strides in reducing unnecessary admissions, reducing polypharmacy and providing holistic, interdisciplinary and patient centred care including advanced care planning. Whilst the Emergency Department is not an ideal environment for this, the team have demonstrated the benefits to this model.

Older people with severe frailty are 5 times more likely to die in the next 12 months than older non-frail people however prognosis and disease trajectory in frailty remains difficult to predict. Advance care planning (ACP) is often not fully discussed or documented due to these prognostic uncertainties, plus time/workload constraints. This can result in multiple admissions for people with frailty in the last 12 months of life and can lead to care and death in a non-preferred place. Electronic Advance Care Plans (eACP) can be useful in reducing unwanted admissions and promoting care and death in preferred location. This project aimed to improve proportion of patients receiving care in their preferred location and reduce readmission rates. Identified patients who wished to avoid hospital readmission with clinical frailty score of 6 or more and at least 2 unplanned admissions in the preceding 12 months over a 4 month period at a district general hospital in south London. ACP was discussed with patients and families and an eACP was generated. Patients were then followed up at 3 and 6 months to assess readmission rate and rate of end of life care in preferred location. 24 patients consented - 17 women, 7 men. Mean age of 88.3 Mean pre-admission frailty score of 6.1. High level of pre-admission co-morbidity with 80% having 3 or more major comorbidities. Readmission rate was 8%. One third of patients alive at 3 months all without readmission. 23 patients had died at 6 months. 13% died in hospital versus a national average of 44%. 70% died in preferred place of death versus national average of 53%. Use of electronic Advance Care plans resulted in a low readmission rate and a higher proportion of people receiving end of life care in their preferred place of death.

Introduction: Around 10% of calls received by English ambulance services are for older adults who have fallen¹; with an ageing population there are significant care provision needs. Decision-making on the treatment for people who fall, can impact their future physical and mental health. Previous research in decision-making of ambulance staff found perception of role, confidence, service demands and training to be key drivers². The previous work highlighting drivers, but not the experiences that explain why they occur, leads this study aim to determine the experiences and confidence of frontline emergency clinicians in attending older adults who have fallen.

Method: Online cross-sectional survey of frontline emergency clinicians from one English ambulance service in May 2023. Open questions generated qualitative data for thematic analysis³. Ethical and regulatory approvals, and informed consent, were obtained.

Findings: 81 participants completed the survey. Analysis identified three themes.

• Care Provision: Provision of hospital avoidance pathways varies throughout the region. Concerns arose from not knowing what different areas had and reduced accessibility out of hours.
• Communication: Decision-making confidence was impacted by the participants’ experiences of interactions with hospital and community colleagues; positive experiences encouraged use of hospital avoidance pathways, whilst negative experiences impeded willingness to avoid hospital for fear of repercussion.
• Shared Decision-Making: Patients, family and clinicians were all valued as part of shared decision-making, with past feedback on decision-making informing future practice.

Conclusion: Confidence of frontline ambulance staff was impacted by the challenge of a regional and 24/7 ambulance service not having consistent pathways available. Communication with other services impacts ambulance clinician’s future decision-making and confidence. This variation led to concerns when responding to patients outside of the clinician’s usual area, and further challenges ambulance clinicians must balance in their practice.

References:

1. Snooks, Anthony, Chatters, et al. (2017) Health Technology Assessment, 21; 1-218.

2. Simpson, Thomas, Bendall, et al. (2017) BMC Health Services Research. 17; 299.

3. Braun and Clarke. (2022) Thematic Analysis: A practical guide.

Background: Elderly patients report less positive experience of hospital admission than younger patients¹. Targeted interventions have been shown to improve patient ability to perform activities of daily living and reduce frequency of discharges to long-term care facilities. Additionally, non-pharmacological interventions reduce incidence of delirium and prevent falls². We aimed to improve the inpatient experience on a care of the elderly ward through use of a recreation room for mealtimes and recreational activities.

Methods: We performed a quality improvement project using patient and staff surveys pre- and post-interventions, including the introduction of a poster and use of the recreation room for activities. We registered use of the recreation room to monitor attendance.

Results: Use of the recreation room increased by 175% from week 1 to week 4 (n=8 to n=22). Most visits were for mealtimes (71%) and the remainder for activities including listening to music, socialising, or playing puzzles. Patient satisfaction improved (82% to 87%) and awareness of the recreation room increased (27% to 75%). Staff satisfaction with patient experience increased (80% to 92%), and 100% of staff agreed that care was improved for patients attending the recreation room.

Conclusion: Use of a recreation room for mealtimes and activities on a care of the older person ward resulted in improved patient satisfaction and staff perception of patient satisfaction and care. Further inpatient-engagement will be sought through volunteer-run activities and a timetable of regular activity sessions.

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. 

Background

Time critical intervention delays contribute to increased waiting times, length of stay, worsening morbidity, and mortality for the already frail patient. Evidence suggests some clinicians decide to admit whenever test results are not yet available; mistakenly believing this decreases patient risk. Within one day, this project reduced waiting times for decision makers by upgrading the blood sample processing priority so results are available sooner.

Method

Our Quality Improvement (QI) team leader spent one shift observing practices in the Emergency Department, noting ED blood samples are processed as ‘urgent’. The QI team leader discussed with the laboratory manager if capacity existed to process the frailty unit’s bloods as ‘urgent’ rather than ‘routine’. This had zero impact on laboratory resources due to limited numbers attending the frailty service daily; they supplied different colour coded blood sample bags: purple. This immediately visually indicates to staff the sample is ‘urgent’. (Previous bags: red - haematology, yellow - biochemistry, green - microbiology). A start date was arranged for the following day. Red, yellow and green bags were removed from the frailty services’ unit and replaced with purple. Staff were informed the change would start that morning.

Results

Our main outcome measure was average waiting time for a decision to admit or alternative pathway. From day one, staff achieved 100% compliance with ‘urgent’ sampling and waiting times for a decision reduced by up to 80% (from up to eight hours to less than one hour).

Conclusion

QI identified a reason for delayed decision making contributing to increased waiting times for frail patients. This sustainable change reduced risk and improved quality of care.

Introduction:

The number one reason for older people to be taken to hospital emergency departments is a fall¹.

An “Ambulance Improvement Programme Pillar”² is trying to reduce conveyance to hospital for falls, however it is not understood how the attending clinician’s confidence impacts decision-making.

The objectives were to assess recruitment rate and feasibility of online survey delivery, and determine the experiences and confidence of frontline emergency clinicians in attending older adults who have fallen.

Method:

Online cross-sectional survey, undertaken in one English ambulance service in May 2023. 

Demographics were collected from participants and their role, with 5-point Likert scales of confidence.

Descriptive statistics and Chi-square analyses were used for quantitative data.

Results:

81 responses were received from across the regional ambulance service’s 16 localities.

76% of respondents were paramedics, and 53% were aged 25-34.

60% of respondents rated being ‘somewhat confident’ to ‘How confident do you feel in assessing older adults who have fallen?’, responses ranged between ‘Neither confident nor unconfident’ to ‘Completely confident’.

No significant difference was found between the locality and confidence levels for assessing this patient population. However, there appeared to be significant variation between confidence levels relating to utilisation of hospital pathways and localities (p-value=.0045).

Length of experience in both frontline ambulance and overall healthcare provision was not significantly associated with different levels of confidence.

Conclusion:

The overarching confidence of clinicians did not significantly vary around the region.

Locality of work had a relationship with confidence in utilising hospital avoidance pathways, however, did not relate to confidence in assessing this patient population.

Confidence was not found to increase for either total years providing healthcare, nor providing emergency frontline care.

References

1. Dewhirst. (2023). National Falls Prevention Coordination Group. https://committees.parliament.uk/writtenevidence/117837/pdf/

2. NHS England and NHS Improvement. (2019). Ambulance Improvement Programme. https://www.england.nhs.uk/wp-content/uploads/2019/09/planning-to-safetly-reduce-avoidable-conveyance-v4.0.pdf

Background

The Ageing Well programme within the NHS Long Term Plan promotes person-centred care aligning  with the goals of Integrated Care Systems (ICSs) in unifying health and social care aiming to increase the proportion of care to older people delivered in the community (NHS England, 2019). As most older people admitted to hospital are conveyed by ambulance services this presents a focus to reduce hospitalisation (Maynou L, Street A, Burton C, et al. Emergency Medicine Journal 2023).

North Central London ICS has invested in ‘Silver Triage’ a pre-hospital telephone support scheme which sees geriatricians and emergency physicians supporting the London Ambulance Service in their clinical decision making relating to older people at the point of assessment.

Methods

Data from the first fourteen months of the scheme was analysed.

Results

Between November 2021 and January 2023 there have been 452 Silver Triage cases with 80% resulting in a decision to not convey an older person to hospital. The mode clinical frailty scale (CFS) score was 6 with no difference in conveyance rates based on CFS. Prior to triage paramedics thought hospitalisation was not needed in 44% of cases (n=72/165). Most paramedics (93%, n=154/165) found it easy to contact the team with all 176 who responded to a post triage survey answering they would use it again. Many (66%, n=108/164) felt they learnt something from the discussion, with 16% (n=27/164) reporting it changed their decision-making process.

Conclusion

Silver Triage has the potential to improve the care of older people by preventing unnecessary hospitalisation and has been well received by paramedics.

Background

Up to 17.5% of admissions for older adults with frailty may be Preventable Emergency Admissions (PEAs). PEAs are costly and expose patients to complications including deconditioning, delirium, malnutrition and nosocomial infections. Royal Derby Hospital (RDH) has 1159 beds and cares for a population of around one million. The Frailty Emergency Assessment Team (FEAT) operates within the Emergency Department (ED) and Medical Assessment Unit. FEAT is multi-disciplinary, comprising nurses, physiotherapists and occupational therapists.

Aim

To reduce the number of PEAs for older adults presenting to RDH.

Design

We integrated a Geriatrician into FEAT with the aim of reducing PEAs through early medical reviews. Suitable patients were identified through referral from ED and routine screening of the patient information system. To support consistent medical reviews and automate data collection we created an e-form embedded within the Electronic Patient Record. This captured details and outcome of medical reviews including Clinical Frailty Score (CFS), problem list, medication review and ‘Medically Stable for Discharge’ (MSFD) status.

Results

Between 7th February 2022 and 20th February 2022 68 medical reviews were collected on the e-form. 72% were assessed first by an ED clinician. 81% had a CFS of 5-7 and 7% had a CFS of 8. The most common presenting complaint was ‘fall(s)’ (25%) followed by ‘clouded consciousness’ (13%). 66% of FEAT physician reviews resulted in planned discharge from ED, 13% of which avoided an admission planned by ED. Of 68 patients reviewed 42 (62%) were MSFD. Of these 29 (69%) were discharged home, 11 (26%) were admitted to a ward to await interim beds or new care package, one (2%) patient was discharged to a care home and one (2%) to another health care facility.

Conclusion

Our intervention reduced PEAs for older adults presenting to RDH. The e-form automated data collection successfully.