Embedding the Clinical Frailty Scale into Acute Elderly Care: Improving Documentation to Support Safer Decision-Making

Introduction

Frailty is a recognised clinical syndrome associated with increased vulnerability to adverse outcomes, including higher morbidity, prolonged hospital stays, and increased mortality. 1,2 Assessment of frailty, utilising Clinical Frailty Scale (CFS), rather than using chronological age and social history, supports individualised clinical decision-making by guiding treatment goals. 3,4 CFS provides a standardised, reproducible, and evidence-based measure of physiological reserve. 4 Despite its importance, frailty assessment is not consistently documented during hospital admissions. This Quality Improvement Project (QIP) aimed to assess and improve documentation of the CFS for patients admitted to the Pinderfields Acute Care of Elderly ward (PACE).

Methods

A two-cycle QIP was undertaken. The first cycle included 43 patients admitted via PACE. Data was collected on whether a CFS score was documented during the initial clerking and at other stages of admission, including the post-take ward round (PTWR) and therapy assessments. The presence of sufficient social history to allow retrospective calculation of a CFS score was also evaluated.

Following the first cycle, results were presented at elderly medicine departmental meetings, and CFS prompt cards were distributed to clinicians. These interventions facilitated engagement with a large proportion of clerking doctors, while the prompt cards helped mitigate barriers such as time pressures on acute wards, high staff turnover, and rota patterns. After implementation of these measures, a second audit cycle reviewed 48 patients, focusing on documentation of the CFS during clerking, PTWR, and therapy assessments.

Results

In the first cycle, a CFS score was documented during clerking for 26% of patients, with 32 of 43 patients having no recorded CFS at admission. Documentation was even less frequent in subsequent admission records, including PTWR notes and therapy assessments. Despite this, 75% of patients had a sufficiently detailed social history to allow retrospective calculation of a CFS score. Assessment demonstrated most patients admitted to PACE were frail, with the majority having a CFS score of 6 or above.

In the second audit cycle, documentation of the CFS during clerking increased by 34% compared to the first cycle. Additionally, 93% of patients had an adequate social history recorded to allow retrospective CFS calculation.

Conclusions

CFS was frequently not documented during clerking, despite inclusion within the clerking proforma, and was recorded even less consistently in subsequent admission documentation. However, most patients had sufficient social history recorded to allow calculation of a CFS score, highlighting missed opportunities for formal frailty assessment and earlier recognition of frailty. The high prevalence of frailty among patients admitted via PACE emphasises the importance of early frailty identification to facilitate comprehensive geriatric assessment.

The improvements observed in the second audit cycle demonstrate that targeted interventions can significantly enhance CFS documentation, supporting safer clinical decision-making and more appropriate care planning for frail older adults. Future plans include modifying the clerking proforma to mandate completion of a CFS score for all patients and incorporating the CFS into the handover checklist. Further education sessions are also planned for physiotherapists and occupational therapists, who play a key role in obtaining detailed social histories.

References 

1. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752-762.
2. Hatheway OL, Mitnitski A, Rockwood K. Frailty affects the initial treatment response and time to recovery of mobility in acutely ill older adults admitted to hospital. Age Ageing. 2017;46(6):920-925.
3. Morley JE, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6):392-397. 
4. Rockwood K, Theou O. Using the Clinical Frailty Scale in allocating scarce health care resources. Can Geriatr J. 2020;23(3):210-215.