Getting to the core of Front Door Frailty Screening

Dr Elizabeth Moloney is a consultant geriatrician working in the Mercy University Hospital, Cork City, Ireland. She has completed doctoral research on frailty screening among older adults in the emergency department. Her current post involves overseeing a Frailty Intervention Team in the emergency department, as well as inpatient and community work. Her research paper Core requirements of frailty screening in the emergency department: An international Delphi consensus study is published in Age and Ageing. Twitter @DrLizMoloney

The sprightly 79-year-old lady seated in front of me in the emergency department (ED) grimaced in pain. Her left knee was swollen, and it ached. “I keep falling,” she sighed. She had injured her knee several times, falling heavily on her side. She apologised for coming to ED in winter, feeling she was a burden, “taking up your time better spent on more serious cases”. She was stoical but lamented that her confidence was waning with each fall. She described orthostatic symptoms prior to each event.

Her recurrent fall history, noted at triage, triggered a rapid Multidisciplinary Frailty Intervention Team review. Instead of waiting hours on a trolley, she was swiftly seen on a dedicated ED Older Adult Pathway. Within 4 hours, imaging revealed no acute fracture. A medication review was undertaken, and bloods and dynamic BP readings checked. The Frailty Intervention Team assessed her gait and balance in ED and provided her with a knee brace and mobility aid. She was discharged with a plan for rapid MRI knee imaging the following week (which showed a traumatic bursitis), analgesia and referral to a community-based balance programme. To the uninitiated, her story may sound like banal ED fare, but within weeks, her balance and confidence improved, and her falls stopped. As she left ED after our initial assessment, she mused that she “must face up to getting older” but was heartened that a whole team was working to help maintain her independence.

The volume and diverse demographics of older adults arriving at ED are a challenge to the traditional triage pathway^{1, 2 , 3}.Frailty screening is not a standardised component of established ED triage systems, so many hours can pass before the “right time, right care, right place” ethos can be implemented. Presenting complaints are often viewed in isolation, rather than as a result of progressive frailty and complex multimorbidity⁴. These older adults often require more time and resources than ED environments are designed to provide.

However, if an older adult attends a frailty-attuned ED, frailty screening can be rapidly undertaken by specialist multidisciplinary teams, working collaboratively to provide comprehensive care. This comprehensive care model can reduce ED reattendance or hospital admission 30 days post index attendance⁵. Therefore, instead of being viewed as a problem created by an ageing population, this triage challenge should focus our attention on how to screen for frailty more practically and more efficiently in ED.

Our recent international Delphi consensus research aimed to achieve agreement on core requirements of frailty screening in ED⁶. It addressed practical questions such as when to screen and where screening should take place. Our key findings add clarity to a subject area that is awash with multiple frailty screening instruments, yet still awaits a tool that is universally accepted by healthcare staff. Our Delphi panel agreed that an ideal frailty screen should be short (≤5 minutes) and multidimensional, reflecting baseline 2-4 weeks before presentation. Screening should be routine, prompt (< 4hours after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use, and social factors were identified as the most important variables to use.

These consensus findings should prompt us to operationalise rapid screening in clinical practice. Embedding frailty screening in ED should be part of a broader ED protocol to reflect the unique needs of older adults, ideally incorporated into the ED IT system. As our case example demonstrated at the start of this blog, the benefits of front-door frailty screening can last well beyond the initial assessment and intervention, with holistic and tailored treatment plans delivered quickly and efficiently. Educational initiatives for the clinical workforce should be implemented to create an age-attuned hospital environment and serve to cement a frailty-aware ethos in ED. Rather than relying on clinical judgement alone, training in frailty screening can assist staff to identify frailty-associated deficits and intervene early in vulnerable adult cases. These progressive changes would mean meandering admission pathways become short steps, initiated at the ED entrance, by those with specialist geriatric medicine knowledge. As older adult populations increase, global ED-based frailty research is growing in tandem, with the aim of responding to a need for more complex care provision in ED^7,8,9. Let us be committed to implementing clinical research findings in ED to effect positive change - there is no time to lose.

Read the full research paper Core requirements of frailty screening in the emergency department: An international Delphi consensus study in Age and Ageing.