CQ - Improved Access to Service

Introduction:

Despite clear national guidelines and government support for Fracture Liaison Services, the osteoporosis treatment gap remains significant.  The Fracture Liaison Service Database (FLS-DB), a national audit run by the Royal College of Physicians (RCP), has recently expanded its reporting to highlight this issue.

Method:

Previously the FLS-DB benchmarked data from those trusts submitting data to the audit.  From January 2025, an extra column has been added to show ‘Missed Opportunities’ that includes data from sites not participating in the FLS-DB.  Using local hip fracture data for 2022 from the National Hip Fracture Database (NHFD) figures, the predicted local FLS caseload was determined by multiplying the number of hip fractures by 5.  Expecting 80% of the predicted caseload to be identified, at least 50% of those to be recommended treatment (accounting for mortality, severe comorbidities etc.) and 80% of those initiating and staying on treatment up to 12 months gives the expected on treatment population. This was compared with the data from the FLS-DB and NHFD KPI set to generate the number with a missed opportunity.

Results:

77 FLS are participating with the FLS-DB with 82 NHFD sites not covered by an FLS. While 80,767 records were submitted in 2022, the missed opportunity count was estimated to be 56,550 patients (48,214 in England and 6,180 in Wales) per annum. When the missed opportunity estimate was analysed in 36 ICSs, there was an over 10 fold difference in the estimate.

Conclusions:

Despite clear guidelines and prioritisation of FLSs, over 50,000 patients are not on osteoporosis treatment when they should be. By making this data visible at the local hospital and ICS / Health board level, care providers can better judge the level of resources required for FLS locally, and the data provides support for ICSs in FLS implementation. 

Introduction: An acute hospital-regional nursing home service (EAGLEcare ACT) were established with an aim to reduce preventable emergency department visit and inpatient hospitalisations of nursing home residents. We aim to explore the experiences of nursing home nurses using the service. Method: Ten focus group discussions were conducted in six partnering nursing homes. A total of 57 nursing home nurses with an average of 4.9 years of working experience participated in the discussions. Transcripts were analysed using qualitative interview analysis. Results: Three main themes emerged: empowerment, feasibility of use, and needs unmet. The EAGLEcare ACT service provided by an acute hospital were welcomed to supplement the inavailability of resident general practitioner. It promotes capability building among partnering nursing home nurses and provides assurance to the next-of-kin of ill residents. The processes and teleconsultations were found to be convenient, and the service was responsive. Medication ordering to administration time, and laboratory investigation ordering to collection and dispatch time were identified as areas for service improvement. Conclusion: Teleconsultation service partnership between an acute hospital with nursing homes were generally well received and perceived as helpful and scalable collaboration.

Introduction: There are approximately 549,000 new fragility fractures each year in the UK and the prevalence of both osteoporosis and risk of falling increases with age. Care home residents are three times more likely to fall and have a 3- to 4-fold higher incidence of fractures than people of the same age living in the community. These older, frailer and multimorbid patients often have the highest fracture risk and therefore the most to gain from anti-osteoporosis treatments to reduce this risk. 

Method: Retrospective audit of residents who were reviewed by the newly started Enhanced Health in Care Homes (EHCH) team within the 5 residential homes for an initial comprehensive geriatric assessment (CGA) between March 2022-June 2024. These initial CGAs were reviewed to determine if a FRAX assessment had been completed and subsequent sub-analysis of those with high/very high FRAX scores to determine whether they were on appropriate bone protection. 

Results: 100% of residents (183) had a bone health assessment including a FRAX score (age-adjusted if appropriate). Prior to CGA, 37% patients with a high/very high FRAX score were on appropriate bone protection, having excluded patients who were not suitable for any treatment for reasons including poor renal function or not clinically appropriate. Following EHCH initial CGA and management plan, this average improved to 85% across the residential homes. The most significant improvement in one residential home was from 0% to 83% post bone health assessment. 

Conclusion: There has been a considerable improvement from 37% to 85% in the number of residents at high and very high risk of fractures who are on appropriate bone health protection following an initial bone health assessment and subsequent management plan initiated by the Enhanced Health in Care Home team. 

Introduction: 

Following the publication of ‘Call to action: A Five nations consensus on the use of intravenous zoledronate after hip fracture,’ Craigavon Area Hospital began offering IV Zoledronic acid (IV Zol) to patients with a fragility neck of femur (NOF) fracture. However, the administration of IV Zol is based on the bone health assessment, vitamin D level, and requires ongoing post-discharge care. An oral bisphosphonate should be started one year after IV Zol administration. This study aimed to analyse whether discharges from Craigavon Area hospital following a NOF fracture had clear instructions for post-discharge care.

Methodology: 

Discharge letters of patients with a NOF fracture from the Trauma Ward between 4/11/24 and 22/12/24 were divided into three groups:

A (Bone health, IV Zoledronic acid and post discharge instructions), B (Bone health and IV Zoledronic acid mentioned but no post discharge instructions given)

C (Bone health, IV Zoledronic acid and post discharge instructions not mentioned). 

These groups were then analysed for potential interventions to improve future discharge letters. The second stage assessed the 4 week period between 14/1/25 and 18/2/25 with the same methodology.

Discussion: 

Only 38% (16) of the 42 discharge letters were included in group A and 37.5% of these contained ambiguous instructions. There were 13 discharge letters in group B and C of which 15% and 38% were discharged during outside of normal working hours respectively. Standardised wording and poster reminders were implemented and the impact reassessed. In the second stage 96% of discharge letters contained a full bone health assessment with follow up instructions.

Conclusion:

This study has highlighted the importance of adequate post discharge care for patients who have received IV Zoledronic acid. Unfortunately, many discharges did not mention the necessary information for GPs so proposals were made to improve ongoing care. The impact has been significant with 96% of letters containing the required information and so these changes will be introduced permanently.

The acute care system is operating at maximal capacity, A&E is in an ‘awful state’, and there is continual rising of demand [1]. The ageing population is a triumph and challenge, with more living with frailty and complex needs [2]. Demand continues to escalate, and our services need to respond to this new reality [3]. 

Barnet Hospital is situated within the largest population of older people and with the greatest number of care homes in London. Our local ageing population provides opportunities to develop SDEC services for frail patients traditionally underserved and excluded [4]. For patients ≥65 and ≥80years with CFS≥5, conversion from attendance to admission is 72% and 76% respectively, with mean LOS on our geriatric wards 13.6days [5]. Despite embedded frailty initiatives, the traditional models of inpatient focussed care for those with frailty are unsustainable [3]. 

Barnet Hospital was an early adopter of Geriatrician and MDT presence within the ED, however a previous iteration of a front-door frailty service was unrecognisable and non-functional in 2024. This was driven by focus on expansion of Geriatric medicine inpatient areas, increasing capacity of rapid-access HotClinic and workforce shortages. 

With emerging evidence showing the oldest old waiting longest to be assessed in the ED, frail people waiting longest to be seen on the medical take, and increased mortality of those who remain in ED for longer, a new front-door Frailty Service was never more urgent [6,7,8]. 

Using quality and service improvement methodology, facilitated by a multidisciplinary working group, a new Frailty Service was planned, piloted and delivered despite staffing and infrastructure challenges. The service expanded, providing CGA to 20patients in June 2024 to over 80patients in January 2025, with 63% same-day discharge rate and excellent patient/carer feedback. With ongoing workforce challenges and changes to dedicated assessment areas, the team have learnt to adapt and work dynamically to provide an ever-improving service.

References: 

1. Darzi A, 2024. Independent Investigation of the NHS in England.​

2. Department of Health and Social Care, 2023. Chief Medical Officer’s Annual Report 2023.​

3. NHSE, 2024. FRAIL Strategy.​

4. GIRFT, 2024. Principles for Acute Patient Care. 

5. Royal Free London NHS Foundation Trust Frailty CPG (Clinical Practice Group), 2024. Barnet Frailty Dashboard.  

6. Maynou L, et al. 2023. Factors associated with older patients’ ED wait times. Emerg Med J.​

7. Knight T, et al. 2023. The impact of frailty and geriatric syndromes on metrics of acute care performance: results of a national day of care survey. E Clin Med.

8. Iozzo P, et al. 2024. Mortality risk linked to prolonged ED boarding of frail individuals. J Clin Med.​

Introduction 

The Commissioning for Quality and Innovation (CQUIN) framework sets a 10% minimum and an ideal goal of 30%  of acutely presenting patients over the age of 65 to receive frailty assessment scores. Early recognition of frailty helps mitigate risks such as deconditioning. This project aims to assess and improve the adoption of this standard in medical emergency admissions of a Birmingham district general hospital by working with medical admissions teams and frailty services and observing for associated outcome measures.

Methodology

PDSA methodology was used. Data was retrospectively collected for patients aged 65 and above from the electronic patient records (EPR) over a weeks interval from the acute medical take. Collected data included prevalence of CFS scoring and social history, escalation discussions and mortality. Interventions were delivered via an educational presentation to resident doctors and displayed posters in key areas. The data was examined for improvements in CFS prevalence and its relationship with onwards referral, escalation discussions or mortality.

Results

Pre-intervention only 3.31% (8/242 patients) had a recorded CFS score .  .

Post-intervention, 19.10% (34/178) patients had a CFS score documented.

Post-intervention, 82.35% of those with CFS scores were referred to the frailty therapy service, as opposed to 17.36% of those without CFS scoring. Escalation discussions were had with 41.17% of those with CFS scoring and 29.17% of patients without. Mortality was 5.88% in the CFS scored patients and 9.72% in the patients with no CFS score.

Conclusion

After focused interventions, the CFS prevalence was above the 10% minimum requirement and closer to the 30% goal set by the CQUIN 05. Patients with a CFS score saw higher rates of onwards referrals to older person services, and higher rates of escalation discussions  . In forwards application, CFS could be discussed in induction, incorporated into IT clerking systems

The Frailty Virtual Ward Pathway aims to optimise the care for frail patients (with a frailty score between 4 and 7) aged 65 and above. by addressing the main frailty domains falls, polypharmacy, functional decline, and new incontinence. Timely referrals can enhance patient outcomes and reduce hospital length of stay. However, awareness and utilisation of the pathway among medical teams remain unclear. This project aimed to assess the awareness and usage of the pathway on three medical wards at West Suffolk Hospital, F7, G3, and G10, and to implement a quality improvement intervention to increase appropriate referrals. A baseline review of patients’ records identified eligible patients who were not referred, while surveys assessed multidisciplinary teams' (MDTs) awareness and referral practices. Interventions included providing educational materials, conducting ward visits, and organising awareness events. Pre-intervention data showed twenty-three total referrals to the Virtual Ward Pathway, with low ward-specific uptake to Frailty Pathway (F7: 1, G3: 0, G10: 0). During the intervention, referrals increased to 35, though ward-specific referrals remained limited (F7: 4, G3: 0, G10: 1). Post-intervention, referrals increased to thirty-two, highlighting the need for sustained efforts. The project improved overall referral rates to all Virtual Ward pathways, but frailty pathway referrals showed modest gains. Ongoing education, embedding referral criteria in routine workflows, and continuous MDT engagement are essential for sustained improvement.

Background 

Delirium and acute functional decline are common in hospitalized older people (HOP), yet data remain scarce. A shortage of geriatricians and geriatric-trained doctors in our healthcare system contributes to poor clinical outcomes, including increased readmissions, morbidity, and mortality. This pilot study aims to assess the clinical burden of HOP—including rates of readmission, delirium, and acute functional decline—before implementing frailty care bundles in general medical wards. 

Methodology 

This prospective cross-sectional study recruited HOP (≥65 years) admitted to general medical wards from 1–31 March 2024. Data collected included demographics, prior-year readmissions, ADL and mobility status (1 month pre-admission vs. discharge), presence of delirium (via symptoms or Confusion Assessment Method), and length of stay. Acute functional decline was defined as deterioration in at least one ADL or mobility domain. Patients transferred to other specialties or district hospitals were excluded. 

Results 

Of 107 HOP (33.7% of total admissions), 103 were analyzed. Median age was 73; 80.6% were 65–80 years, and 59.2% were male. At baseline, 76.7% were CFS ≤5, while 23.3% were moderately/severely frail (CFS 6–7). Prior to admission, 48.5% walked unaided, while 51.5% required assistance. Readmission history was noted in 46.6%. Mean length of stay was 6.5 days. Acute mobility decline occurred in 37.9%, functional decline in 35%, and delirium in 17.5%. 

Conclusion 

This study highlights a substantial clinical burden among hospitalized HOP. A standardized frailty care bundle has been developed to aid non-geriatric-trained healthcare personnel in early detection and management of frailty-related issues, aiming to improve patient outcomes.

Introduction: Frailty is a growing concern, particularly for older adults attending Emergency Departments (EDs). Frailty accounts for 5-10% of all ED visits and up to 30% of acute admissions1. The NHS mandates that hospitals with Type 1 EDs provide a minimum of 70 hours of Acute Frailty Services per week to address this challenge1. At Salford Royal Foundation Trust (SRFT), a Frailty Same Day Emergency Care (SDEC) service was introduced to deliver rapid assessment and care for frail older adults, aiming to reduce hospital admissions and improve patient outcomes2. This service operates five days per week and is staffed by a multidisciplinary team2. Methods: A mixed-methods approach was used to evaluate the Frailty SDEC service3. Data was collected through paper surveys distributed to patients aged 65 years or older with a Clinical Frailty Score (CFS) >5 and their relatives or carers during their admission to the SDEC service24. The survey included both closed-ended and open-ended questions4. Quantitative data was analyzed using descriptive statistics and qualitative data was analyzed using thematic analysis5. Results: A total of 32 responses were collected over a two-month period in 20244. The results showed high levels of patient and family satisfaction (97%) with the Frailty SDEC service35. Participants particularly valued the compassionate and personalized care, clear and professional communication, and the efficient and timely service delivery67. Areas for improvement included upgrading the physical environment and providing clearer communication about waiting times and procedures89. Conclusion: The Frailty SDEC service at SRFT demonstrates high levels of patient satisfaction and effectiveness in delivering care for frail older adults10. This evaluation provides valuable insights for enhancing patient-centered care and highlights the importance of further research to explore long-term outcomes and compare different models of SDEC services for older adults11

Introduction Early access to specialist care is recognised to be beneficial for older adults living with frailty. Decision-making around assessing function and mobility to facilitate safe discharge can be challenging for staff in an Emergency Department environment. This can result in patients being admitted to await specialist review. The aim of this test of change was to explore the role and contribution of a Specialist Frailty Allied Health Professional (AHP) within the ED and to evaluate the impact on the care of patients living with frailty.

Methods For a 12-month period, the ED has had a dedicated frailty AHP to support staff in assessment. The role was adapted based on the needs of the clinical service. The impact of this intervention was evaluated using system-level performance data including frailty ascertainment; length of stay and discharge from ED. Staff feedback and patient journeys were collected to supplement quantitative insights. 

Results There has been a 257% increase in patients being assessed by an AHP in ED (implementing early Comprehensive Geriatric Assessment (CGA)) and a 247% increase in number of patients discharged directly from the ED. In the first five months, there was a significant increase in referrals to appropriate community services, to support patients after discharge home, equivalent to 84-196 bed days. For those who are admitted, their CGA has already commenced and goals established. Staff feedback has shown an increase in confidence of supporting these patients, and greater awareness of both frailty and the services available to support patients after discharge from ED, rather than defaulting to admission. 

Conclusions Having timely access to a dedicated frailty AHP is critical in effective decision making and improving patient outcomes. The Frailty AHP is a well-integrated member of the ED team and wider backdoor services. This has benefitted patients who are admitted and discharged