More Than Just a Score: Improving Clinical Frailty Scale Assessment and ReSPECT Documentation
Abstract
Introduction
Despite the importance of advance care planning and ReSPECT documentation, many older people living with frailty progress through healthcare systems without meaningful discussions regarding future care preferences or treatment escalation. Early identification of frailty using the Clinical Frailty Scale (CFS) can act as a catalyst for these conversations and support care that aligns with an individual's values and preferences.
This quality improvement project aimed to improve CFS assessment, ReSPECT decision-making, and documentation on a geriatric medicine ward.
Methods
A prospective quality improvement project was undertaken on a geriatric medicine ward at Lincoln County Hospital. Baseline data were collected through a snapshot audit of eligible admissions in November 2025, with re-audit performed in January 2026. Patients aged under 65 years were excluded as the CFS is not validated in this population. Data were extracted from electronic patient records and anonymised prior to analysis. Eighteen patients were included in each cycle.
Practice was evaluated against predefined standards: CFS documentation (100%), ReSPECT decision-making within 48 hours of admission for patients with a CFS >4 (95%), complete ReSPECT documentation (100%), and documentation of ReSPECT discussions in the clinical record (100%).
A threshold of CFS >4 was selected as it identifies people living with at least mild frailty who may benefit from early escalation planning and advance care discussions.
Interventions included routine discussion of frailty during daily board rounds, targeted staff education, and incorporation of CFS scores into electronic documentation.
Results
Following intervention, documented CFS assessment increased from 22% to 100%. Documentation of ReSPECT discussions improved from 40% to 100%. Completion of all sections of the ReSPECT form increased from 28% to 33%. The proportion of patients with a CFS >4 who had a ReSPECT decision documented within 48 hours decreased from 83% to 67%.
Conclusions
Frailty assessment should be more than just a score; it should prompt timely conversations about future care. This project demonstrated that simple, sustainable interventions substantially improved both CFS assessment and documentation of ReSPECT discussions. Embedding frailty assessment into routine ward processes may facilitate earlier advance care planning, improve multidisciplinary communication, and help ensure that treatment decisions reflect an individual's wishes and preferences. Further work is required to improve the timeliness of ReSPECT decision-making for people with a CFS >4
Comments
Really interesting project,…
Really interesting project, particularly the improvement in CFS documentation from 22% to 100%. I like the focus on using frailty assessment to prompt meaningful conversations about future care, rather than treating it as just a score. The findings around ReSPECT completion and timely decision-making also highlight how improving documentation does not always translate into earlier decision-making. It would be interesting to see whether further changes to the ward workflow could help address this.
Frailty as the trigger, and what the score is worth downstream
Thank you, and the honest reporting of the 48 hour measure going backwards while documentation went up is the most useful part of the poster; it is the pattern we see too, that the form gets completed but the decision is not made any earlier. Two things from our side that may be of interest. First, your CFS over 4 trigger: when we needed to identify dying patients in bed management data for a corridor care analysis, a frailty score of 8 or more was one of the markers that held up, whereas a ReSPECT form on its own was present in about one in five of all admissions and discriminated nothing, so your instinct to treat the score as the prompt and the form as the output seems right. Second, we found that opening a dedicated end of life ward changed the conversation on the acute wards by giving the decision somewhere to go; "is this person for the end of life ward" turned out to be an easier opener than "shall we complete the ReSPECT". The analysis is at https://www.bgs.org.uk/ending-corridor-care-for-the-dying-reverse-boarding-of-end-of-life-patients-before-and-after-a if useful.