Implementing BGS Pragmatic Prescribing Guidance in an Acute Frailty Unit

Introduction / Background:

Problematic polypharmacy is common in older people and is associated with adverse drug reactions, hospitalisation, and mortality. Hospital admission provides an opportunity to review potentially inappropriate medications; however, deprescribing in acute care is often reactive rather than proactive(1). The British Geriatrics Society (BGS) Pragmatic Prescribing guidance provides condition-specific recommendations to support deprescribing in people living with moderate to severe frailty(2). We aimed to explore how this guidance could be implemented proactively within an Acute Frailty Unit (AFU) using rapid quality improvement methodology.

Method:

A series of Plan-Do-Study-Act (PDSA) cycles was undertaken on the AFU at Chesterfield Royal Hospital, an acute assessment area receiving patients from the Emergency Department and the community. Cycles were designed to test the feasibility of identifying deprescribing opportunities and implementing medication changes in real time.

Results:

PDSA 1 assessed the feasibility of retrospective data collection across all domains of the BGS guidance. Documentation alone did not reliably determine whether deprescribing was indicated or had occurred.

PDSA 2 narrowed the focus to patients with a Clinical Frailty Scale (CFS) score ≥7 prescribed statins and/or antihypertensives. Approximately two-thirds of patients met these criteria, demonstrating a substantial burden of potentially inappropriate prescribing. However, retrospective identification limited the ability to act on findings in a high-turnover assessment unit environment.

PDSA 3 tested prospective application of the full BGS guidance during post-take ward rounds. Although assessment of prescribing appropriateness was easier prospectively, time constraints prevented comprehensive review of all guidance domains.

PDSA 4 combined a prospective approach with the focused review of statins and antihypertensives. Real-time "check and challenge" of prescribing during ward rounds enabled shared decision-making and timely implementation of deprescribing decisions and was considered both feasible and impactful.

Conclusion:

Targeted real-time review of statin and antihypertensive prescribing appears feasible within an AFU and may provide a practical starting point for embedding a deprescribing culture. Standardised documentation of medication review and deprescribing decisions is needed to support evaluation and sustainability of future improvement work. We plan to develop this deprescribing project into a resident-led continuous QI programme on our AFU.

References:

Deprescribing admission medication at a UK teaching hospital; report on quantity and nature of activity

1. Scott S, Clark A, Farrow C, May H, Patel M, Twigg MJ, Wright DJ, Bhattacharya D. Deprescribing admission medication at a UK teaching hospital; a report on quantity and nature of activity. Int J Clin Pharm. 2018 Oct;40(5):991-996

2. British Geriatric Society. Pragmatic prescribing to reduce harm for older people with moderate to severe frailty. 2025 (Accessed 7th September 2026) https://www.bgs.org.uk/PragmaticPrescribing