Clinical Quality

The acute care system is operating at maximal capacity, A&E is in an ‘awful state’, and there is continual rising of demand [1]. The ageing population is a triumph and challenge, with more living with frailty and complex needs [2]. Demand continues to escalate, and our services need to respond to this new reality [3]. 

Barnet Hospital is situated within the largest population of older people and with the greatest number of care homes in London. Our local ageing population provides opportunities to develop SDEC services for frail patients traditionally underserved and excluded [4]. For patients ≥65 and ≥80years with CFS≥5, conversion from attendance to admission is 72% and 76% respectively, with mean LOS on our geriatric wards 13.6days [5]. Despite embedded frailty initiatives, the traditional models of inpatient focussed care for those with frailty are unsustainable [3]. 

Barnet Hospital was an early adopter of Geriatrician and MDT presence within the ED, however a previous iteration of a front-door frailty service was unrecognisable and non-functional in 2024. This was driven by focus on expansion of Geriatric medicine inpatient areas, increasing capacity of rapid-access HotClinic and workforce shortages. 

With emerging evidence showing the oldest old waiting longest to be assessed in the ED, frail people waiting longest to be seen on the medical take, and increased mortality of those who remain in ED for longer, a new front-door Frailty Service was never more urgent [6,7,8]. 

Using quality and service improvement methodology, facilitated by a multidisciplinary working group, a new Frailty Service was planned, piloted and delivered despite staffing and infrastructure challenges. The service expanded, providing CGA to 20patients in June 2024 to over 80patients in January 2025, with 63% same-day discharge rate and excellent patient/carer feedback. With ongoing workforce challenges and changes to dedicated assessment areas, the team have learnt to adapt and work dynamically to provide an ever-improving service.

References: 

1. Darzi A, 2024. Independent Investigation of the NHS in England.​

2. Department of Health and Social Care, 2023. Chief Medical Officer’s Annual Report 2023.​

3. NHSE, 2024. FRAIL Strategy.​

4. GIRFT, 2024. Principles for Acute Patient Care. 

5. Royal Free London NHS Foundation Trust Frailty CPG (Clinical Practice Group), 2024. Barnet Frailty Dashboard.  

6. Maynou L, et al. 2023. Factors associated with older patients’ ED wait times. Emerg Med J.​

7. Knight T, et al. 2023. The impact of frailty and geriatric syndromes on metrics of acute care performance: results of a national day of care survey. E Clin Med.

8. Iozzo P, et al. 2024. Mortality risk linked to prolonged ED boarding of frail individuals. J Clin Med.​

Introduction

Frailty in older adults increases risk of hospital admission, prolonged stay, and poorer outcomes. The NHS Long-Term Plan emphasises early identification, admission avoidance, and shifting care into the community to reduce system pressures and improve patient outcomes. Bromley has one of the largest and fastest-growing older populations in South East London. The One Bromley Hospital at Home (H@H) service is a multidisciplinary, person-centred service, integrating step-up and step-down pathways. Dedicated frailty and palliative care arms ensure high-risk patients receive coordinated, specialist-led care, embedding multidisciplinary meetings with geriatricians and palliative care teams. 

Methods 

A one-year retrospective evaluation (April 2023–2024) assessed service utilisation, clinical outcomes, technology integration and patient satisfaction for frailty/palliative arms of this service. 

Results

• Service growth: H@H referrals tripled from 32 to 107 (April 2023 vs 2024). Over the year, 800 patients received care with 17,400 patient contacts, 53% face-to-face. • Frailty and palliative care expansion: frailty referrals increased by 200% contributing 45% of H@H referrals, palliative referrals accounted for 15%, supporting complex end-of-life care at home. • Patient Profile: average age 84.1 years; 55.1% male • Pathway Impact: step-down referrals (62%) facilitated early hospital discharge, whilst step-up admissions (38%), prevented acute hospitalisation. Frailty vs Palliative LoS were 8 vs 4.5 days respectively. • Digital Integration: 25-30% of patients benefited from remote monitoring, reducing hospital escalation and improving clinical oversight. • Readmission rates averaged 12.5%, reflecting the complexity of the caseload. • Patient satisfaction remained consistently >90%, highlighting positive patient experience and acceptability of home-based frailty care. 

Conclusion 

This H@H model aligns with national UEC transformation priorities by: reducing hospital dependency through proactive frailty management, integrating frailty/palliative pathways within the virtual ward, enhancing health equity and access to out-of-hospital care. Future research to evaluate long-term sustainability and cost-effectiveness is key before wider adoption across Integrated Care Systems.

Introduction 

There is a drive for same day emergency care (SDEC) assessments of older frail patients attending hospitals. Multiple documents suggest how frailty SDEC services could work. 

Methods 

A trial of a mobile frailty SDEC, the Frailty Intervention Team (FIT) took place for 4 weeks in October 2020.. Data were collected manually but most of the presented data was indirect, such as length of stay of all older frail patients, rather than directly related to who FIT had seen. As FIT developed it was clear that data collection required automation. This was achieved through use of specific “Clinical Data Capture” (CDC) forms on the Trust’s Electronic Patient Record (EPR). Utilising a combination of emergency care and admitted patient datasets, a bespoke dashboard has been produced which visualises the data using Statistical Process Control methodology. A CDC form was developed that enabled identification of patients assessed by FIT. 

Results 

Initially the success depended on where the patient was when the CDC form was completed with 135 patients identified a month from ED dropping to 73 after the establishment of a SDEC unit (non significanton SPC) and 51 identified a month among inpatients, with 160 after the SDEC unit opened (p<.05 on spc) . through collaborative working, adjustments were made to how the data was extracted and transformed for reporting. there no significan diferenceinthenumbersofin november 2024, 284 patients seen with 260 cdc forms. of these 250 recognized by developed dataset (96%). 

Conclusion 

Collaborative working between analyst & fit clinical lead has led bespoke dashboard allow demonstrate value system trust board. work is ongoing generate reports demonstrating levels compliance girft standards aligned model hospital sets benchmarking.

Introduction 

The Commissioning for Quality and Innovation (CQUIN) framework sets a 10% minimum and an ideal goal of 30%  of acutely presenting patients over the age of 65 to receive frailty assessment scores. Early recognition of frailty helps mitigate risks such as deconditioning. This project aims to assess and improve the adoption of this standard in medical emergency admissions of a Birmingham district general hospital by working with medical admissions teams and frailty services and observing for associated outcome measures.

Methodology

PDSA methodology was used. Data was retrospectively collected for patients aged 65 and above from the electronic patient records (EPR) over a weeks interval from the acute medical take. Collected data included prevalence of CFS scoring and social history, escalation discussions and mortality. Interventions were delivered via an educational presentation to resident doctors and displayed posters in key areas. The data was examined for improvements in CFS prevalence and its relationship with onwards referral, escalation discussions or mortality.

Results

Pre-intervention only 3.31% (8/242 patients) had a recorded CFS score .  .

Post-intervention, 19.10% (34/178) patients had a CFS score documented.

Post-intervention, 82.35% of those with CFS scores were referred to the frailty therapy service, as opposed to 17.36% of those without CFS scoring. Escalation discussions were had with 41.17% of those with CFS scoring and 29.17% of patients without. Mortality was 5.88% in the CFS scored patients and 9.72% in the patients with no CFS score.

Conclusion

After focused interventions, the CFS prevalence was above the 10% minimum requirement and closer to the 30% goal set by the CQUIN 05. Patients with a CFS score saw higher rates of onwards referrals to older person services, and higher rates of escalation discussions  . In forwards application, CFS could be discussed in induction, incorporated into IT clerking systems

Introduction: In operative patients, frailty results in increased rates of postoperative morbidity and mortality. The BGS guidelines for perioperative care stipulate that all patients over the age of 65 should have a clinical frailty score (CFS) documented within 72 hours of admission. One benefit of recognising frailty and increased risk of death is timely establishment of a ceiling of care (CoC) for patients undergoing emergency surgery, in line with the NICE guidelines for advanced care planning. In our orthogeriatric department preliminary data suggested that the CFS was almost never routinely calculated, and that clinicians were not always establishing ceilings of care for patients. Methods: Y/N data was recorded for CFS completion and CoC documentation, which included a pre-existing DNACPR and for full active treatment, pre- and post- intervention. Inclusion criteria were patients aged >65yrs on admission, presenting with a neck of femur fracture undergoing operative management. 2 plan-do-study-act (PDSA) cycles were completed, with the aim of improving completion rate of a CFS and establishment of CoC within 72 hours of admission. Intervention: Alteration of the clerking pro-forma to make CFS and consideration of CoC mandatory pre-op assessments, alongside communication to current and incoming resident doctors on the orthogeriatric ward. Results were shared at a clinical governance meeting, initiating discussion between anaesthetic, surgical, and geriatric departments regarding advanced care planning best practice. Results: Following intervention, completion of CFS for patients within 72hrs increased from 4.5% to 41% and documentation of a CoC within 72hrs increased from 68% to 82%. Conclusions: This QIP improved both completion of CFS and consideration of CoC for elderly patients with hip fractures. In discussion at the clinical governance meeting it was agreed that careful consideration and documentation of CoC is always warranted and is an important component of care for this patient cohort.

Aim: We aimed to improve the assessment, documentation, and management of inpatient falls by introducing a memorable CARE poster and promoting the use of a digital falls proforma for both nurses and doctors. This initiative aims to standardize practices and enhance patient safety. Method: Cycle 1: Initial data revealed poor documentation of falls, with missing elements such as Clinical Frailty Scale (CFS) scoring, medication review, pain management, and lying/standing blood pressure (LSBP) measurement. These critical aspects were incorporated into the CARE poster. Cycle 2: The CARE poster and digital falls proforma were launched, accompanied by brief training sessions on the geriatric ward. These sessions encouraged resident doctors to prescribe analgesia and supported comprehensive documentation. We audited falls documentation before and after the intervention to evaluate improvements in recording relevant data. For the next cycle, we aim to engage a broader audience, including all medical and surgical teams, by conducting face-to-face campaigns and distributing email reminders. The focus will be on ensuring doctors and nurses complete every section of the proforma. Conclusion: The CARE poster and digital falls proforma have significantly improved falls documentation, ensuring the inclusion of critical elements like LSBP, blood sugar checks, and thorough physical examinations. It also highlights key management steps, such as requesting investigations, prescribing analgesia, and reducing polypharmacy. Our project demonstrated a 40% improvement in LSBP documentation and medication review. However, analgesia care improved by only 2%, despite 85% of post-fall patients sustaining injuries. Further education for doctors and nurses is needed to address this gap. Currently in its third cycle, this QIP continues to evolve, with ongoing implementation and a planned audit. We are optimistic that it will enhance clinical practice and uphold our trust's core value: putting the patient first.

Introduction: 

Urgent Community Response (UCR) teams need innovative solutions to deliver timely and effective care to frail older adults. This project explores the combined impact of remote assessment, continuous monitoring, and AI scribes to enhance UCR service delivery, aiming to improve patient care, staff efficiency, and resource utilisation.

Methods: 

This service initiative integrates three key remote technological interventions within a UCR frailty service:

• Assessment: Digital examination devices (TytoCare) were used by Clinical Support Workers for remote clinician assessment. Data from 74 remote examinations conducted between April and September 2022 were analysed.
• Monitoring: Biobeat chest and wrist monitors were piloted with 20 patients within a Frailty Virtual Ward for four months. Data was collected to assess the impact on clinical decision-making, patient care, and system efficiency.
• AI Scribes: An AI scribe (Heidi) was introduced to the frailty team, to evaluate its impact on note-taking efficiency and documentation quality. Usage data from 419 sessions were collected and analysed.

Results:

• Assessment: Remote examinations using digital devices allowed clinicians to avoid hospital admissions in 70.3% of cases. The use of Clinical Support Workers saved between £13 and £78 per hour, equating to a potential yearly saving of up to £13,853.
• Monitoring: Continuous monitoring improved clinical decision-making and facilitated safe discharge to the patient's usual residence (91% with monitoring vs. 69% without).
• AI Scribes: Within the UCR workstream, the use of the AI scribe reduced time spent on documentation, with some areas experiencing time savings of 15-20 minutes per patient. Note quality improved and the AI scribe also decreased administrative burden.

Conclusion: 

This service initiative demonstrates the potential of combining remote assessment, continuous monitoring, and AI scribes to transform urgent community response for frailty enabling more efficient use of resources, improved patient outcomes, and enhancing note quality in the UCR workstream. This warrants further development.

Introduction: The Frailty Same Day Emergency Care (SDEC) unit at Fairfield General Hospital provides same day Comprehensive Geriatric Assessments (CGA). Bone health is an integral part of CGA, however recognition and management of osteoporosis is often not prioritised in acute hospital settings. We noticed that bone health was an area that was often overlooked within our CGAs. Our goal was to increase the number of bone health assessments performed and improve access to appropriate treatment for patients in the Frailty SDEC. The aim of this project was to increase the number of appropriately managed FRAX scores by 40% within 12 weeks in high-risk patients. 

Method: Baseline data was collected on all patients attending Frailty SDEC 2 days per week over an 8 week period. We measured how many patients were having FRAX scores calculated. Analysis of the baseline data indicated that patients presenting with falls were not having FRAX scores completed. Our change idea was implementing a bone health pathway which was displayed on the Frailty SDEC unit. This helped guide and remind clinicians when to calculate a FRAX score. 

Results: Bone health assessment in patients presenting with falls to Frailty SDEC was improved from 40% pre-intervention, to 80% post-intervention. Of those who were identified as needing treatment for osteoporosis, all patients had an appropriately assessed treatment plan and none were untreated who had been deemed appropriate for treatment. 

Conclusion: The implementation of a bone protection pathway has led to an improvement in the amount of FRAX scores calculated for patients attending with a fall. Our pathway was implemented across the Northern Care Alliance as part of a Quick Reference Guide for Frail Fallers Attending Frailty SDEC.

Introduction and Aims
The Older People’s Same Day Emergency Care (OSDEC) unit at Portsmouth Hospitals University NHS Trust accepts admissions for older patients referred by South Central Ambulance Services (SCAS), aiming to deliver early patient reviews and reduce emergency department (ED) waits. Timely blood test results are critical for decision-making and early discharge. NHS England SDEC protocols recommend pathology access comparable to ED processes, though no national standards exist for pathology turnaround times.
This quality improvement project aimed to implement targeted interventions to improve patient admission processes in OSDEC and to assess the sustainability and long-term impact of these improvements.

Methods
Data were collected for 88 SCAS direct attendances to OSDEC from February to September 2024. Patient arrival times, time of pathology request, laboratory receipt and blood results availability were recorded. Analysis focused on the average times from arrival on OSDEC to blood sample collection and laboratory receipt.

Results
Baseline data showed an average sample receipt time of 91 minutes and time to first results of 147 minutes. Improvement interventions were introduced to include printing of blood forms on receipt of referral and identification of staff to obtain blood sample on patient arrival. In May, sample receipt times were reduced by 7 minutes (8%), and time to results improved by 26 minutes (18%). By July, sample receipt times decreased further by 35 minutes (38%), and time to results improved by 35 minutes (24%) from baseline.

Although times increased in July and September (to 124–165 minutes), consistency improved, with fewer delays. Additional interventions included daily checklists to ensure stock levels for phlebotomy supplies and enabling senior nurses to request appropriate pathology investigations based on common frailty presentations.

Conclusion
Implementation of several interventions using a Plan-Do-Study-Act method improved availability of blood tests results that is important to enable prompt decision-making.

Introduction:

It is important to identify delirium on admission as delirium increases patient mortality and also is linked to an increased length of hospital admission (1). Delirium is identified through a scoring system such as 4AT (2) and should be done on all patients over 65, with new confusion, or reduced mobility (3) as per NICE guidelines. The aim of the QIP is therefore to bring the department in line with NICE guidelines and increase the number of patients in the over 65 cohort having a cognitive assessment, and in particular looking at those with confusion and falls as these can be presenting symptoms of delirium(3).

NICE guidelines state that all over 65s should have a cognition screen on admission to identify delirium and particularly those with symptoms of delirium (3).

This completed two cycle QIP aimed to improve the proportion of patients over 65 who presented with a fall, new confusion, or both fall and new confusion, who had a documented completed cognition screen on admission to CDU from Eastbourne ED.

Method:

From a random 2 week interval of CDU admissions, we identified those aged over 65. Using their clerking documentation we identified those presenting with fall, new confusion, or both. We assessed if they had an accepted completed cognition screen (MMSE, MOCA, 4AT, AMTS, SQuID) documented in their clerking. This required reading through the entirety of the clerking as there was no dedicated place for a cognition screen to be documented. This was repeated post intervention.

For cycle 1, a 4AT box with the four questions which generated a score was added to the electronic clerking proforma. For cycle 2 we organised and delivered in person teaching sessions for the junior doctors within the department. Juniors were recruited to act as 'delirium champions' and encourage a culture of delirium awareness through discussion at board rounds and within the department on a daily basis. The high turnover of A&E staff and the highly varied rota's posed a challenge to the efficacy of in person teaching sessions. To ensure the educational element was delivered to all, we created posters to educate on the presenting symptoms of delirium, the importance of early identification, and screening tools to use such as the 4AT box.

Results:

For CDU admissions for all over 65s, the percentage with a completed cognition screen increased from 0.02% to 5.10% after cycle 1, and increased further to 11.25% after cycle 2. For those admitted to CDU aged >65 with new confusion only (no falls), the percentage with completed cognition screen increased from 9.09% to 25.00% in cycle 1 and to 66.67% in cycle 2. For those aged >65 presenting with fall only (no confusion), the percentage increased from 0.00% to 4.35% in cycle 1 and to 26.32% in cycle 2. For those aged >65 with both fall and new confusion, the percentage increased from 0.00% to 11.76% in cycle 1 and to 33.33% in cycle 2.

Conclusion:

Including a 4AT prompt on the clerking proforma improved cognition screening for those with symptoms of delirium. However, clerking proforma changes alone are insufficient and much greater improvement was achieved through the combination of proforma changes (4AT box) and departmental educational initiatives. It is additionally important to consider a variety of educational initiatives in a department such as A&E with high staff turnover and varied rota's which can limit engagement with traditional in person teaching sessions.

References:

1. Anand, A. et al. (2022). Positive scores on the 4AT delirium assessment tool at hospital admission are linked to mortality, length of stay and Home Time: Two-centre study of 82,770 emergency admissions. Age and Ageing, 51(3). Available at: https://doi.org/10.1093/ageing/afac051.
2. Jeong, E., Park, J. and Lee, J. (2020). Diagnostic test accuracy of the 4AT for delirium detection: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 17(20), p. 7515. doi:10.3390/ijerph17207515.
3. NICE (2010). Recommendations: Delirium: Prevention, diagnosis and management in hospital and long-term care: Guidance (2010) NICE. Available at: https://www.nice.org.uk/guidance/cg103/chapter/Recommendations#assessment-and-diagnosis (Accessed: 07 January 2024). Last updated: 18 January 2023