Optimizing the Acute Frailty Pathway: A QIP to Standardize and Enhance Collateral History Documentation

Introduction:
Collateral history is a cornerstone of comprehensive geriatric assessment, particularly in patients with frailty, delirium, or cognitive impairment where self-reported information may be unreliable. Failure to capture baseline cognitive, functional, and social status can compromise diagnostic accuracy, delay discharge planning, and hinder multidisciplinary decision-making. Despite its clinical importance, collateral history documentation is often inconsistent. This quality improvement project aimed to improve the completeness, accessibility, and standardisation of collateral history documentation within an acute frailty pathway through the introduction of a structured 10-point documentation standard.

Methods:
A baseline audit (Cycle 1, n=25) assessed compliance with a newly developed 10-point collateral history framework encompassing patient identification/confidentiality, informant details, comorbidities, baseline cognition, mobility and recent decline, package of care, community support, advance care planning (ACP), safeguarding concerns, and documentation location. A multifaceted intervention was implemented over eight weeks, combining targeted junior doctor education, multidisciplinary team engagement, and physical and electronic documentation prompts. A repeat audit (Cycle 2, n=23) evaluated post-intervention performance against the same standards.

Results:
Baseline compliance across all domains averaged 47%, demonstrating substantial variation in documentation quality. Following intervention, marked improvements were observed in several clinically important domains. Documentation of baseline cognition increased from 56% to 87%, package of care from 44% to 83%, comorbidities from 44% to 78%, family updates from 40% to 74%, and recording within the designated Family Discussion section from 44% to 74%. Baseline mobility documentation improved from 72% to 78%, while patient identification/confidentiality increased from 32% to 52%. ACP documentation remained unchanged at 40% across both audit cycles.

Conclusions:
Implementation of a structured collateral history framework was associated with substantial improvements in the documentation of cognitive, functional, and social baseline information within an acute frailty service. Simple, low-cost interventions successfully enhanced the quality and accessibility of information critical to clinical decision-making. Persistent deficiencies in ACP documentation suggest that barriers extend beyond documentation processes alone and warrant dedicated future interventions. These findings demonstrate how standardised collateral history collection can strengthen the delivery of person-centred frailty care.