From Pilot to Practice: Implementing Routine Digital Frailty Screening for Elective Surgical Patients Across Swansea Bay

Introduction

Frailty is a major predictor of adverse postoperative outcomes, yet routine identification within elective surgical pathways remains inconsistent. National perioperative guidance recommends early frailty identification to facilitate optimisation and shared decision-making, but sustainable implementation at scale has proved challenging. Swansea Bay University Health Board developed and evaluated a digital patient self-assessment pathway using a modified patient-reported Clinical Frailty Scale (CFS). Following a successful pilot in elective general surgery, the pathway was adopted into the Health Board's official digital health screening questionnaire for patients awaiting surgery. This quality improvement project describes the implementation and spread of routine digital frailty screening across surgical services.

Methods

Using quality improvement methodology, evidence from a successful pilot was translated into routine clinical practice through stakeholder engagement, iterative digital pathway redesign and integration within existing waiting-list processes. Patients aged ≥65 years receive a digital health screening questionnaire via SMS incorporating a patient-completed modified Clinical Frailty Scale. Patients identified as living with frailty complete additional perioperative risk assessment questions to support referral to the Perioperative Care of Older People Undergoing Surgery (POPS) service where appropriate. Following governance approval, the frailty assessment was embedded within the official Swansea Bay University Health Board digital health screening questionnaire.

Results

The initial pilot demonstrated that digital frailty self-assessment was feasible and acceptable, with 343 of 738 patients responding (46.5%), including significant additional responses following automated reminders. Of respondents, 24.8% self-identified as living with frailty (CFS ≥5), enabling targeted perioperative assessment and optimisation. Successful implementation has resulted in permanent adoption of digital frailty screening within the Health Board's standard surgical waiting-list questionnaire. The pathway has now been successfully rolled out across General Surgery, Orthopaedics and Ear, Nose and Throat (ENT) services, with implementation planned across all remaining surgical specialties by the end of the current financial year. This has standardised frailty identification, embedded early risk stratification into routine waiting-list management and established a sustainable mechanism for equitable access to perioperative optimisation.

Conclusions

This project demonstrates successful translation of a digitally enabled frailty screening pathway from pilot evaluation to Health Board-wide implementation. Embedding patient-completed frailty assessment within an existing digital infrastructure has enabled sustainable service transformation without increasing clinical workload. Progressive rollout across multiple surgical specialties illustrates how implementation science and quality improvement methodologies can support adoption of frailty screening at scale, providing a transferable model for perioperative services across the NHS.