Clinical Quality

Introduction: Urgent Care Response (UCR) provides a rapid assessment, diagnostic and treatment service to prevent hospital admission. Occasionally, patients under the UCR team require acute hospital admission. Patients were experiencing long waits in the Emergency Department (ED), despite being referred directly from the UCR team due to the ED triage system. National Institute for Health and Care Excellence (NICE) recommends ensuring coordinated and patient-centred transfer of care from one healthcare team to another. We created an electronic alert icon to notify UCR referred patients to the ED triage team. 

Method: All patients reviewed by UCR from 1st January to 29th September 2024 requiring hospital admission were included. An electronic alert notifying the triage nurse that a patient has been assessed by UCR was created on 15th July. The time taken from patient arrival to Emergency Department (ED), ED team assessment, specialist team assessment and treatment initiation was recorded before and after the electronic alert was implemented. The readmission and mortality rates were recorded for this cohort of patients. 

Results: 47 patients assessed by UCR were seen in ED prior to the implementation of the electronic alert. 26 patients were seen in ED after the electronic alert. Average patient waiting times reduced by 47 minutes for ED review, reduced by 2 hours 2 minutes for specialty review and reduced by 1 hour for treatment initiation, after electronic alert implementation. 26/47 and 20/47 patients were readmitted and died respectively prior to electronic alert. 9/26 and 3/26 patients were readmitted and died respectively post electronic alert. 

Conclusion: The introduction of the electronic alert significantly improved time to ED team review, specialist team review and treatment initiation. Readmission and patient mortality within 12 months were recorded for the patient cohort. Post electronic alert, patient readmission reduced by 21% and patient mortality reduced by 31%.

Introduction 

The development of specialist acute frailty services is well recognised as crucial to meet the needs of our ageing population and is recommended by the NHS England Long Term plan. At the same time, same day emergency care (SDEC) services are rapidly expanding as an alternative to ED However, to date there is a limited evidence base for specialist frailty SDEC units. 

Methods 

We ran a 6-week pilot of a 7-day specialist frailty SDEC open from 8am-6pm. The unit was staffed by consultant geriatricians, frailty ACPs, specialist nurses, junior doctors, a therapy team and resident pharmacists. Patients were accepted both directly from the community (GPs, ambulance crews community frailty teams) and from ED. Criteria were loosely defined by Clinical Frailty Score (CFS 5 or above) and NEWS <3. 

Results 

A total of 256 patients were reviewed in the frailty SDEC over the 6 week pilot period. 166/256 (65%) of patients stayed <24 hours and a further 48 (19%) had a short stay of between 24-72 hours. 7-day ED re-attendance rates remained low at 6% (16/256) and 10% (26/256) of patients were re-admitted to hospital within 30 days of discharge (compared to 17.9% England national average for 2023-2024). 

Conclusions 

Frailty SDEC provides a safe, effective environment for rapid comprehensive geriatric assessment of patients living with frailty. Through close links with community teams we facilitate admission avoidance and person centred care in the right place, first time.

Ensuring Consultant Geriatrician reviews for patients on the Older Persons Assessment Unit.

Weston General Hospital (WGH) is working towards becoming a centre of excellence for frailty in keeping with its demographic. As part of this, there is a purpose-built Older Persons Assessment Unit (OPAU) compromising of 14 beds and Geriatric Emergency Medicine (GEM) unit compromising of 3 beds. Our OPAU medical team alongside the therapy team strive to ensure that each patient is reviewed by a Consultant Geriatrician during their admission, in addition to the routine medical and therapy teams to ensure expert oversight is sought to enhance patient care and subsequent outcomes as part of a gold standard Comprehensive Geriatric Assessment (CGA)(2,4).  The standard worked towards is that every patient admitted to the OPAU is reviewed by a Consultant Geriatrician to reduce length of stay and optimise their outcomes.

A retrospective audit was conducted of the patients admitted to OPAU in the months of August and December 2024. Notes were reviewed to ascertain if patients had a consultant Geriatrician review during their stay on OPAU. Data is captured on a spreadsheet to be reviewed and fed back to the wider teams to discuss current workings and any further work that is needed.

In December 90% of patients admitted to OPAU were reviewed by a Consultant Geriatrician during their admission. The 10% of patients that are not reviewed by a Consultant Geriatrician are reviewed by other specialties such as a Consultant Cardiologist or Oncologist; but still an expert in the patients complaining condition.

The majority of patients are reviewed by a consultant geriatrician, as part of the MDT for a CGA review on the OPAU which have further enabled more holistic care and successful discharges as well as a reduction in length of admissions and further readmissions. Those who were not reviewed by a geriatrician mostly presented at weekends; we aim to strive to 7 day consultant geriatrician cover in the future.

References: 
1 ) Hosoi, Tatsuya et al. Association between comprehensive geriatric assessment and short-term outcomes among older adult patients with stroke: A nationwide retrospective cohort study using propensity score and instrumental variable methods eClinicalMedicine, Volume 23, 100411 
2) Allen S, Bartlett T, Ventham J, McCubbin C, Williams A. Benefits of an older persons' assessment and liaison team in acute admissions areas of a general hospital. Pragmat Obs Res. 2010 Aug 21;1:1-6. doi: 10.2147/POR.S13355. PMID: 27774002; PMCID: PMC5044994. 
3) Ellis G, Whitehead M A, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials BMJ 2011; 343 :d6553 doi:10.1136/bmj.d6553 
4) Chen, Z., Ding, Z., Chen, C. et al. Effectiveness of comprehensive geriatric assessment intervention on quality of life, caregiver burden and length of hospital stay: a systematic review and meta-analysis of randomised controlled trials. BMC Geriatr 21, 377 (2021). https://doi.org/10.1186/s12877-021-02319-2

Implementation of Advanced Clinical Practitioners as part of developing a ‘front door’ frailty service at Weston General Hospital. 

Weston General Hospital (WGH) site, within University Hospitals Bristol and Weston is developing its front door frailty services with the aim of becoming a centre of excellence for frailty. With up to 55% of admissions resulting in deconditioning (1) and geriatric medicine being the largest specialty in general medicine, there is a clear need for an advanced practitioners. 21.4% of Weston-Super-Mare’s population is aged >65 (2); suboptimal management of this demographic of people costs the NHS approximately 5.8 billion a year (3). The development of a front door frailty service will encompass the Geriatric Emergency Medicine (GEMS) service, Same Day Emergency Care (SDEC) and the Older Persons Assessment Unit (OPAU) to provide ‘front door’ patient-centred reviews of older patients.

The recruitment of two ACPs will play an integral part of the front door frailty service as they will cover each ‘front door’ area to ensure equity between locations. ED and SDEC is expanding to include specific frailty sections aligned with the SAMEDAY (4) and FRAIL (5) strategies enabling gold standard patient care and encompassing Comprehensive Geriatric Assessments (6).

Although the project is in its infancy, two tACP’s have been recruited, are in post and have been focusing on OPAU initially where the key performance indicator is the patients length of stay has been reduced. Figure 1 highlights the length of stay for patients who were reviewed on OPAU as part of their admission. It is to be noted that most patients were admitted for between 1 and 5 days.

The initial benefit is visible. As an aspiring centre of excellence for older adult care, the expansion of ED and SDEC are a priority to widen the capacity of the frailty service alongside further upskilling of staff through in-house teaching which is in process. Although there is not enough evidence to prove causation, the reduction in length of admission is noted in correlation with the tACP recruitment.

References:
1) British Geriatrics Society (2020) Sit up, get dressed and keep moving. Available from: https://www.bgs.org.uk/policy-and-media/%E2%80%98sit-up-get-dressed-and-keep-moving%E2%80%99 
2) Office for National Statistics (2021) Weston-Super-Mare. Available from: https://www.ons.gov.uk/visualisations/customprofiles/build/#E14001038 
3) British Geriatrics Society (2022) 8 key issues for older peoples health care. Available from: https://www.bgs.org.uk/InvestInCare 
4) NHS England (2024) SAMEDAY strategy. Available from: https://www.england.nhs.uk/long-read/sameday-strategy/ 
5) NHS England (2024) FRAIL strategy. Available from: https://www.england.nhs.uk/long-read/frail-strategy/ 
6) Ellis G, Whitehead M A, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials BMJ 2011; 343 :d6553 doi:10.1136/bmj.

Introduction 

Malaysia is transitioning from an ageing to an aged nation. According to the Department of Statistics Malaysia (DOSM), 7.4% of Malaysia's population was aged 65 years or older in 2023, projected to exceed 15% by 2030. Frailty is increasingly prevalent, affecting 11% of adults aged 50–59 years and escalating to 51% among those aged 90 years or older, based on global data. A local pilot study in March 2024 in general medical wards highlighted common frailty-related issues, including deconditioning (36%), delirium (17%), and a 12-month readmission rate of 46%. 

Objectives 

To introduce a user-friendly, standardized frailty care bundle to support non-geriatric-trained healthcare personnel in detecting common issues related to frailty syndrome early and implementing appropriate interventions. 

Methods 

A multidisciplinary team comprising geriatricians, medical practitioners, pharmacists, nurses, therapists, dieticians, and medical social workers developed a care bundle focusing on three key components: (1) screening tools for identifying acute functional decline, sarcopenia, and delirium; (2) protocolized management pathways; and (3) a discharge planning checklist. The bundle is designed for ease of use in general medical wards by non-geriatric-trained personnel. 

Results 

The care bundle will be piloted in 2025 across general medical wards. Nurses and doctors will screen patients aged 65 and older for deconditioning and delirium upon admission, notifying geriatrician as needed. Early physiotherapist referrals will address deconditioning, and a structured delirium checklist will guide targeted management. The discharge checklist includes caregiver identification, discharge planning, medication reconciliation, equipment assessment, and welfare support. 

Conclusion 

Frailty amidst an ageing population poses significant clinical and economic burdens, including higher readmission rates and healthcare costs. A standardized frailty care bundle offers a systematic approach to optimizing elderly care, improving outcomes, and addressing ageing challenges. Future audits will assess its effectiveness in reducing readmissions, functional decline, and healthcare costs.

Introduction: 

With an aging population of major trauma patients admitted to the Southwest Major Trauma Centre, a dedicated team of medics, nurses, and therapists launched a pilot aimed at enhancing the care of frail major trauma patients in a Major Trauma Centre (MTC). This initiative - the Frailty and Trauma Liaison Team (FTLT), focuses on ensuring continuity and quality of care for this vulnerable population in major trauma. 

Methods: 

It targeted the completion of comprehensive geriatric assessments (CGA) within 72 hours for patients with a Clinical Frailty Scale (CFS) score greater than 4 and traumatic injuries. Key components included standardised frailty screening tools to identify at-risk patients upon admission, followed by individualized care planning that integrates geriatric principles with trauma care underpinned by the HECTOR daily assessment. Every morning, 3 to 4 patients from the major trauma ward round were selected based on their CFS, length of stay (LOS), and location. Priority was given to those not located in a Health Care of the Elderly (HCE) ward. 

Results: 

The average CFS of the patient reviewed was 5.18% with 70% overall having CFS 5 or above. The findings from this pilot indicate that the FTLT were successful in identifying early factors affecting patients including pain management, bowel and bladder care, hydration / nutrition and cognitive / delirium screening that all required interventions to mitigate negative patient outcomes on the ward. 

Conclusion: 

This multidisciplinary approach fosters collaboration among healthcare providers, patients, and families, ensuring tailored interventions that address specific needs of the frail older patient. Data collection will be crucial in assessing patient outcomes, allowing for continuous improvement of the FTLT model. By implementing this comprehensive framework, it aims to enhance the care and outcomes for frail patients in the major trauma population, contributing to improved standards and outcomes of geriatric trauma

Introduction: Older people living with frailty are core users of health and social care. Services attuned to their needs afford better outcomes, help avoid harm and improve the experience for people living with frailty and their carers. These services may also help with flow and capacity. The Glasgow Royal Infirmary (GRI) Team aimed to advance services in order to enhance the quality and provision of care for older people with frailty. 

Methods: As part of the Health Improvement Scotland Focus on Frailty Programme, the GRI Team developed processes for early identification of people living with frailty, using an electronic Frailty Assessment Tool. Processes were designed to streamline patients with frailty to specialist care in order to initiate early Comprehensive Geriatric Assessment (CGA). A Frailty Assessment Proforma was created to promptly identify the priorities, concerns and goals of patients and carers and to gather key collateral information swiftly. Daily CGA Huddles were commenced, which include participants from various acute and community health and social care services. Work is now being done to further develop the Acute Frailty Assessment Area. Rapid Access appointments at the Assessment and Rehabilitation Centres, to support early discharge, have been initiated. 

Results: There has been an improvement in frailty identification. 74% patients 75 years and over, admitted through the Acute Medical Receiving Unit, are being screened for frailty. The proportion of patients with frailty in our Acute Frailty Assessment Area has increased. Collaborative and integrated working has been enhanced, particularly through the CGA Huddles. Length of stay for people with frailty has reduced by 3 days and this has not been coupled with an increase in readmissions at 7 and 30 days. 

Conclusion: Frailty attuned acute services help patients receive person-centred, specialist care. Time in hospital can be reduced, which can contribute to improving flow and capacity.

Introduction Early access to specialist care is recognised to be beneficial for older adults living with frailty. Decision-making around assessing function and mobility to facilitate safe discharge can be challenging for staff in an Emergency Department environment. This can result in patients being admitted to await specialist review. The aim of this test of change was to explore the role and contribution of a Specialist Frailty Allied Health Professional (AHP) within the ED and to evaluate the impact on the care of patients living with frailty.

Methods For a 12-month period, the ED has had a dedicated frailty AHP to support staff in assessment. The role was adapted based on the needs of the clinical service. The impact of this intervention was evaluated using system-level performance data including frailty ascertainment; length of stay and discharge from ED. Staff feedback and patient journeys were collected to supplement quantitative insights. 

Results There has been a 257% increase in patients being assessed by an AHP in ED (implementing early Comprehensive Geriatric Assessment (CGA)) and a 247% increase in number of patients discharged directly from the ED. In the first five months, there was a significant increase in referrals to appropriate community services, to support patients after discharge home, equivalent to 84-196 bed days. For those who are admitted, their CGA has already commenced and goals established. Staff feedback has shown an increase in confidence of supporting these patients, and greater awareness of both frailty and the services available to support patients after discharge from ED, rather than defaulting to admission. 

Conclusions Having timely access to a dedicated frailty AHP is critical in effective decision making and improving patient outcomes. The Frailty AHP is a well-integrated member of the ED team and wider backdoor services. This has benefitted patients who are admitted and discharged

 Introduction: The pandemic has shown how vital patient-centred treatment escalation planning (TEP) is for older people. Locally we have seen inappropriate transfer of dying patients to acute hospitals from rehabilitation units. Mortality review found a lack of useful TEPs in these cases. Baseline data in our rehabilitation hospital showed 54% of patients had a TEP and 16% a decision made about repatriation during acute illness. We aimed to increase the proportion of patients in this setting with a TEP to 80% over six months.

Methods: A multidisciplinary team of doctors, ANPs and senior nurses worked together. We conducted stakeholder engagement to understand the factors that result in transfer of patients and found that completion of TEPs was felt to be an effective way to improve communication out of hours. Our first test of change involved an ANP raising the CPR status and TEP for all new patients at the weekly MDT. We measured the process of what decisions were made once a fortnight. Outcome data on the overall completion of TEPs and repatriation decisions was collected each month.

Results: New decisions were made at each MDT – for example, on one date two new DNACPRs and six new TEPs were completed. Overall TEP completion rate varies however since our first intervention we have seen a sustained increase in the number of TEPs which include consideration of repatriation – from 16% to 60%. Ongoing conversation with doctors in training reveals challenges with ward staff awareness of TEP content and their ability to guide unexpected events out of hours.

Conclusion: Involvement of motivated permanent staff across disciplines has allowed us to ensure escalation plans are being made each week and begin to see improvements. 

Introduction: Comprehensive Geriatric Assessment (CGA) improves outcomes for frail older adults in acute hospitals. Patients aged 75 and over admitted into the Emergency Department (ED) at the QEUH will automatically generate a “frailty icon” on their electronic record. The number of frail people accessing emergency care is increasing. This Healthcare Improvement Scotland (HIS) frailty tool prompts staff to assess for frailty and refer to the local Frailty Pathway if appropriate. We designed a multidisciplinary quality improvement project (QIP) to increase completion of the frailty icon and the number of referrals to the frailty service from the ED.

Methods: Both medical and nursing staff in the ED were targeted for intervention. Weekly data was collected on the percentage of patients aged 75 and above who were discharged from the ED with a “frailty icon” completed over a 3-month period. Our main intervention was to hold a frailty awareness month. This involved multiple sub-interventions such as; announcements at handovers, e-mails, word-of-mouth, and posters.

Results: The weekly percentage of completed “frailty icons” increased from 28% 2 weeks pre-intervention (n = 283) to 48% in 1 month (n = 258). A peak of 57% (n = 293) completed icons was achieved immediately after our intervention. These increases were then sustained for a further 6 weeks with a weekly average baseline of 45.2% completion (average n = 281). Increased “frailty icon” completion in the ED led to a 100% increase in referrals to the frailty pathway.

Conclusion: Increasing awareness of frailty amongst ED staff results in increased front door assessment for frailty, and subsequent referral to the frailty team. This allows for more patients to receive a CGA. Multidisciplinary QIPs utilise the skills of diverse staff groups to best achieve sustainable change.