Implementing British Geriatric Society Guidance on Pragmatic Prescribing to reduce harm in people with moderate and severe frailty

Introduction

The BGS recently published ‘Pragmatic prescribing to reduce harm for older people with moderate to severe frailty’ endorsed by RCP, RCGP and RPS. This guidance provides a blood pressure target of 140 – 160 mmHg in patients with a CFS of ≥6. This is more lenient than standard guidelines, acknowledging the risk of overtreatment; a consideration which has not been previously incorporated in conventional blood pressure targets. To integrate this guideline into local prescribers’ practice, translating theory into benefit for our patients, we undertook a quality improvement project across our Ageing and Complex Medicine wards.

Methods

Pre and post intervention comparison in BP optimisation and medication management was completed in all patients presenting with a fall where CFS≥6. Interventions included departmental teaching, circulation of the BGS guideline electronically and distribution to posters on computers used during ward rounds.

Results

Pre-intervention data demonstrated that 30% of patients, admitted with a fall and living with moderate to severe frailty, were discharged on an anti-hypertensive despite their average blood pressure 24 hours prior to discharge being < 140 mmHg. 85% of patients were discharged on a Fall Risk Increasing Drugs (FRIDs). Following our intervention there was an improvement to 50% of patients being discharged with blood pressures targets which were in range, or with appropriate de-prescribing of anti-hypertensive agents if their blood pressure was below target. Data collection is ongoing with further rounds of intervention planned.

Conclusions

Our first round of data collection demonstrated a considerable potential for iatrogenic harm in the over prescribing of anti-hypertensives in a third of our patients presenting with fall and moderate to severe frailty. Initial results are promising regarding the improved compliance with the new BGS pragmatic prescribing standard following an educational intervention. Our data suggests that prescribers now feel more confident in making pragmatic prescribing decisions.