Improving Recognition of Frailty, and Documentation of ReSPECT discussions in Surgical Patients

Introduction:

Early recognition of frailty and risk of deterioration is important to support patient-centred decision making. This project aims to identify and improve rates of Recommended Summary Plan for Emergency Care and Treatment (RESPECT) discussions in Airedale general hospital’s surgical department alongside increasing the rate of documentation of clinical frailty score (CFS).

Methods:

A retrospective audit reviewed patients aged ≥65 years with ≥3 co-morbidities admitted under general surgery in Airedale hospital over one month. Documentation of CFS, RESPECT and DNACPR was assessed. Following the first cycle of data collection, the surgical clerking document was amended to include a section for RESPECT status, and CFS was incorporated into the trust-wide handover document. Teaching was provided to colleagues on identifying patients requiring advanced care planning. A second audit cycle followed.

Results:

In cycle one, 82 patients aged ≥65 years with ≥3 comorbidities were reviewed. 80% did not have a documented RESPECT plan. 50% of patients ≥65 had a CFS recorded (41/82). Among patients with CFS≥4, 78% (49/64) lacked RESPECT forms, and 54% (13/24) with a CFS≥5 had no documented RESPECT plan.

In the second cycle, 63 patients aged ≥65 years with ≥3 co-morbidities were reviewed. Documentation of CFS improved to 67% (33/49) showing a 17.3% improvement (p=0.069). Among patients with CFS ≥4, RESPECT and DNACPR discussions had improved from 37.1% (13/35) to 44.4% (12/27). In patients with CFS ≥5, 47.6% (10/21) had both RESPECT and DNAR documentation.

Following teaching, mean self-reported confidence in identifying patients requiring RESPECT forms increased from 3.46/5 to 4.54/5, and confidence initiating discussions from 3.46/5 to 4.62/5 (n=13).

Conclusions:

Documentation of CFS and treatment RESPECT forms improved following changes to clerking sheets, handovers and teaching sessions. Larger samples and longer follow-up are required to determine whether these improvements are sustained and statistically significant. Future work will explore geriatric input for patients with CFS ≥5 undergoing laparotomy.