Frailty and delirium - the Scottish approach
Christine McAlpine is a consultant geriatrician at Glasgow Royal Infirmary. She served on the Working Group which developed the BGS’ Fit for Frailty guidance and was Chairman for some years, of the BGS Clinical Effectiveness and Quality Committee.
10% of patients admitted to hospital as an emergency stay more than two weeks, using 55% of all hospital bed days, and 80% of that group are aged over 65 years.
The average age of a hospital inpatient is over 80. Good care for older people in acute care is a key priority for health services.
In 2012 Healthcare Improvement Scotland (HIS) was asked by the Scottish Government to "improve acute care for older people by March 2014". A review of the published evidence plus the themes coming from the inspections of acute care services for older people suggested there were opportunities for improvement in the care of frail older people coming in to hospital, and that in particular delirium was often undetected with resulting poor outcomes for patients (including higher risks of death or institutionalisation).
The Older People in Acute Care (OPAC) improvement programme was therefore set up. HIS provided a small team who set off to look for enthusiasts for change. All Scottish Health Boards were asked to provide a test site for one or other of the 2 themes of the programme which were:
- Ensure frail older people who need to stay in hospital receive timely Comprehensive Geriatric Assessment (CGA) and input from a specialist team within a day of admission - Think Frailty
- Improve the identification and early management of delirium in acute care settings through the development and testing of a care bundle – Think Delirium
Alasdair MacLullich, Professor of Geriatric Medicine at Edinburgh University, took a lead role in the delirium work, which built on progress already made by the Scottish Delirium Association. Outputs from the delirium work-stream include a comprehensive delirium management pathway; work on the 4AT screening test; the Single Question to Identify Delirium (SQUID) – ‘Do you think [name of patient] has been more confused today?] ; and a delirium care bundle called TIME for use in acute wards :
- Think - exclude and treat possible triggers
- Investigate - and intervene to correct underlying causes
- Management - Plan
- Engage - and explore e.g. by communication with family members
For Frailty the main OPAC theme is ‘Think Frailty’. An assessment tool has been developed with the participating hospital teams with the aim of targeting Comprehensive Geriatric Assessment (CGA) at patients likely to benefit from it. The widespread use of simple screening assessments to direct older patients to the correct setting and trigger early interventions has significant potential to improve quality and effectiveness of care in acute settings. Work on care pathways and education and training of staff is an important part of the improvement work.
A number of Boards have already shown improvements: notably in Grampian where front door triage for CGA and fast track to a geriatric assessment unit has improved outcomes and contributed to an 18% reduction in rate of over-75 emergency bed days; in Lothian where the ECAT / COMPASS team use a frailty assessment tool to identify, assess and co-ordinate care pathways for older patients across the hospital it has contributed to a 10% reduction in over-75s bed day use; in Crosshouse Hospital in Ayrshire where screening for frailty in A and E and the emergency admissions units has greatly improved patient flows; and in Lanarkshire where work on frailty and redesign of the admission pathways has achieved a 20% reduction in admission of patients aged over 75 in the period 2009/10 to 2012/13. More information on these initiatives is available in the Think Frailty report published April 2014 – available on the OPAC website.
Regular Scotland-wide meetings of the staff working on these improvement projects have been invaluable in encouraging progress, facilitating the sharing of ideas, experience and expertise. There have also been WebEx calls and the improvement advisers make regular visits to the test sites to support the teams. One session of the BGS Scotland meeting Spring meeting 2014 was devoted to this work and the improvement adviser team were also well received at a recent King’s Fund event in London where at the invitation of our President-Elect, David Oliver, they shared their experiences of achieving change. They are setting up information days for various hospitals in Scotland to ensure all staff – not just those close to the projects – are aware what is being and can be done to improve the acute care of older people.
The programme is funded until April 2015 but we are currently working on ‘future steps’ to build on the progress made in team-working and collaboration to achieve continuing improvements in acute care for older people in Scotland.