CGA

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.

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:

The geriatric population has a high incidence of dementia, delirium and frailty meaning often these patients cannot give comprehensive histories themselves. We are left with missing pieces of the puzzle; we might not know their ‘normal’ and frequently ask: ‘Are they always like this?’.

A collateral history becomes a valuable tool, contributing to a Comprehensive Geriatric Assessment and assisting the whole MDT to make informed decisions for patient-centred care.

The primary aim of this project was to improve the quality of collateral histories taken for patients admitted to the geriatric wards, with content measured against 8 domains. A secondary aim was to encourage timely collateral histories within 48 hours of admission to the ward.

Method:

Using PDSA methodology, collateral histories were analysed before and after implementation of a poster and teaching session.

Results:

At baseline each domain was covered a mean of 40.5% of the time (range 9% - 81%). Following intervention this increased by 22% to 62.5% (range 18% - 89%), demonstrating a significant improvement (paired t-test, P<0.05).

It was already common practice to take collateral histories within 48 hours of admission to the ward (91%) which was sustained post-intervention (88%).

Conclusion:

Use of a poster as a prompt, and delivering teaching, led to more thorough collateral histories. This suggests two barriers are knowing what to ask and perceived importance; elements which could be integrated into early postgraduate education. The impact on patient care has the potential to be significant and multidimensional but further work would be needed to understand this.

Introduction NELA (National Emergency Laparotomy Audit) and British Geriatric Society guidance states patients aged ≥ 80 years, or ≥ 65 years and frail, should have a comprehensive geriatric assessment (CGA) from a perioperative frailty team within 72 hours of admission or critical care step-down. Patients aged ≥ 65 years represented 55.3% of those undergoing emergency laparotomy; and frailty doubled the mortality rate in this group, but post-operative geriatrician review was associated with reduced mortality (NELA project team, RCoA, 2023).

Method The Perioperative Care of Older People Undergoing Surgery (POPS) service was established in our trust in October 2020 in response to NELA recommendations. Over three years our service has grown from one whole-time equivalent geriatrician and one 0.6WTE nurse practitioner, to a team of six, adding a clinical nurse specialist, physician associate, junior clinical fellow and memory link worker. With staff training, all surgical admissions aged ≥ 65 are screened for frailty to enable identification of patients who will benefit most from CGA and subsequent support during the admission. An internal database was established to prospectively capture patient demographics and outcomes.

Results Added team capacity has allowed us to see more patients year-on-year, including more patients not requiring laparotomy. Median frailty score and age have increased from 5 to 6, and 77 to 80 years, respectively, without a significant change in median length of stay. Mean trust compliance with NELA guidance around geriatrician review has improved significantly from 3% to 88% post POPS establishment.

Conclusions Introduction and expansion of a POPS service at our trust has resulted in an increased number of patients receiving geriatrician-led CGA, though meeting 100% of NELA standard likely requires a second consultant or cross-cover arrangement. However, we are reviewing more patients, who are on average older and frailer, without an increase in length of stay.

Introduction 

The British Geriatrics Society advocates for the development of local protocols to address frailty (1). A Cochrane Review on the use of Comprehensive Geriatric Assessment (CGA) resulted in higher survival rates at 3 months and fewer admissions to nursing homes at one year following hospital admission (2). Key components of CGA, including Treatment Escalation Plans (TEPs), Universal Care Plans (UCPs), Clinical Frailty Scores (CFS), and Abbreviated Mental Test (AMT) play pivotal roles in identifying frailty, establishing timely end-of-life care plans, preventing future inappropriate admissions, supporting early discharge and detecting cognitive impairment.  

Methods 

A retrospective analysis of documentation of 4 GCA parameters (TEP, UCPs, CFS, AMT) on admission to an Elderly Care ward over 2-weeks was conducted.  An intervention was introduced which included the development of departmental posters; training medical staff and a frailty proforma, following which a second audit cycle was performed.  

Results 

Cycle one (N=34): Demonstrated poor documentation of CGA parameters. TEP completion 100 % (34/34), Day 2 TEP Completion 64% (19/34), UCP present 21% (7/34), CFS 12% (4/34), AMT completed 15% (5/34).  

Cycle two (N=24). Documentation improved across all parameters. TEP completion 100 % (24/24), Day 2 TEP Completion 100% (24/24), UCP present 29% (7/24), CFS 58% (14/24), AMT completed 58 % (14/24). The proforma was used in 54% (13/24). 

Conclusions 

The use of a frailty proforma, visual aids and teaching is useful in improving documentation of frailty assessments. All parameters showed significant improvement in documentation when the proforma was used.  This tool could be extended to include more data points in a CGA and would be useful to implement across the department to create uniformity, ease of access to information and improve management of elderly patients. 

References: 

1. British Geriatrics Society (2014). Fit for Frailty.  

2. Ellisa et al. Cochrane Database Syst Rev. 2017 Sep 12;9(9):CD006211. 

Introduction Swansea Bay Health Board is covered by eight community clusters (240 virtual beds), each with their own Virtual Ward (VW) MDT which provides community based Comprehensive Geriatric Assessment and reablement. The VW governance structure includes the routine collection of person centred metrics. There is no recognised PROM or PREM specifically designed for needs of frail older people and PROMs and PREMs are rarely used to inform quality and continuity in services at transitions of care (e.g. at discharge from hospital) Methods VW data from June 2023 to February 2024 was analysed. Patient-reported outcomes and experiences (PROMS and PREMS) were collected by the VW team at set timepoints in the patient journey. Data was collected using the PRO-MAPP digital interface ensuring inter-user consistency. Results 1858 VW patients, 1094 (58.9%) female, median age 86 years. The majority, 1044 (56.2%) were referred from secondary care, primarily from acute frailty services, with the remainder identified by primary care. In total, 418 PROMS and 344 PREMS were collected. PROMS - Reported improvements in mobility, self-care, usual activities, pain and anxiety & depression (p001 after vw input. prems – the majority of patients found had been explained well prior to referral (84.0%), were contacted promptly (95.6%), staff professional and friendly (100%), provided patient-centred care (94.2%), contactable (92.4%), glad they avoided or reduced length hospital admission (95.3%). when speaking with 72 care-givers, happy patients' needs met (100%) positively impacted their lives as carers (90.1%). discussion there was high patient care-giver satisfaction service. prom data suggested a significant positive impact on outcomes. not all referred have sampled which is missed opportunity variability between collection clusters. 

Introduction

It is increasingly recognised within oncogeriatrics that standard fast-track pathways for suspected malignancy can be inappropriate for frail and elderly patients (Thomas et. al.; Age and Ageing; 2021; 50; ii8-ii13). Specifically for colorectal referrals, following standard pathways can mean undergoing invasive and expensive endoscopic investigations which may be unwanted and not alter overall management. Streaming frail patients to elderly medicine may increase opportunities for comprehensive geriatric assessment whilst reducing unwanted invasive tests and time spent on fast-track pathways.

Methods

A 3-month retrospective audit of frail patients seen in colorectal fast-track clinic was conducted to evaluate existing practice at Bradford Teaching Hospitals. This informed the design of a new pathway streaming frail patients directly to elderly clinic within 2 weeks. This was implemented in a 3-month pilot with data prospectively collected to compare outcomes. Cohorts:
- 26 patients (median age 79, WHO performance status 3) seen by colorectal team March-June 2022.
- 20 patients (median age 85, WHO performance status 2) streamed to elderly medicine clinic October 2022- March 2023.

Results

- Median time to fast-track pathway removal was 62 days for patients managed via colorectal clinic compared to 31 days via elderly medicine.
- Invasive tests and imaging (CT/endoscopy) fell from 1.4 tests per patient in colorectal clinic to 0.4 patients in the pilot. - 2 diagnoses of cancer made via colorectal clinic, but no further treatment for either patient. 1 diagnosis of lung cancer in pilot group, patient undergoing radiotherapy.
- Patients seen in elderly clinic had greater rates of positive diagnosis for symptoms (eg: infective/iatrogenic).

Conclusions

Streaming frail elderly patients referred via colorectal fast-track to elderly medicine reduced the number of invasive investigations undertaken and time spent on fast-track pathways. Expanding this successful pilot could improve long-term clinical quality in the service and more widely if disseminated.

Introduction

Little is known about how Health Care Professionals (HCPs) conducting Comprehensive Geriatric Assessment (CGA) assess spiritual needs.  

The aim of this study was to better understand how UK HCPs understand and incorporate assessment of spirituality into CGA for community dwelling frail older people.

Methods

Semi-structured interviews were undertaken with HCPs who regularly undertake CGA in the community as well as Anna Chaplains (ACs) whose remit is to provide chaplaincy to community dwelling older people. An inductive approach was taken using a topic guide to structure the interviews.  Thematic analysis was undertaken using NVIVO. Ethics approval was granted through St Augustine’s College of Theology.

Results

Three HCPs and two ACs were interviewed. Three themes emerged.

Firstly, that spiritual assessment needs time, trust and skill and cannot be established using checklists. Assessment hinges on building a rapport between the patient and HCP. HCPs and ACs suggested potential questions that could support assessment of spiritual needs.  Secondly, supporting spirituality is focused on sustaining identity, fostering hope and encouraging spiritual growth.  Finally, health care professionals lacked confidence and understanding in how to recognise and meet spiritual needs. Several suggestions were made as to how to address this. 

Key conclusion

All participants agreed that incorporating assessment of spirituality into CGA was important but that doing so effectively requires understanding and skill. The questions suggested by participants mapped well onto existing models of spirituality in ageing and frailty. Study findings could be used to develop training for HCPs undertaking CGA.

Introduction:

Nationally, there have been increased attendances to hospital for older frailer adults. Recommendations from GIRFT and NHS England acknowledge the importance of identifying frailty, and the role that dedicated specialist services play. Best practice indicates when frailer adults receive a Comprehensive Geriatric Assessment (CGA), this reduces patient harm and improves outcomes.

Locally in October 2022, Bolton NHS Trust converted an Acute Medical Assessment Unit (AMU) to a 22 bedded frailty unit, the Older Person’s Assessment Unit (OPAU) to provide older frailer adults with early specialist input and review from a dedicated multi-disciplinary team (MDT). The unit is run by three Consultant Geriatricians and a dedicated wider MDT, with links to community partners and when needed preferential admission to Geriatric base wards.

Methods:

Data was collated and analysed with set metrics by the Trust’s Business Intelligence Department. Data was compared for the 3 months pre and post inception of the frailty unit. Regular service reviews occur and utilise PDSA cycles to assess interventional change.

Results:

The average age of patients pre-intervention was 69, and post intervention was 79.6.

Pre-intervention, the average length of stay for patients admitted from AMU to Geriatric base wards was 25.93 days. This reduced to 18.79 days post-intervention.

The average length of stay for patients admitted to non-Geriatric base wards was 10.77 days, this reduced to 8.62 days post intervention.

Conclusion:

Specialist Consultant Geriatrician and MDT input on a dedicated frailty unit has reduced the average length of stay of patients to all base medical wards assessed, especially base Geriatric wards. This has clear implications on patient flow, and benefits patients and the Trust. We expect this will have a compound and positive effect on patients by reducing the risk of deconditioning and potential development of inpatient harms.