Clinical Quality

Introduction:

Frailty scoring is important for the identification of frailty. Frailty assessment can aid clinicians in targeting comprehensive geriatric assessment to improve patient experience and outcomes. We explored the feasibility of self-assessment for frailty, comparing patient-reported scores with specialist clinician assessments, evaluating its potential as a tool for improving frailty identification and intervention.

Methods:

Between August 2024 and January 2025, a modified Rockwood frailty score with eight descriptive categories was issued to patients in the Older Person’s Assessment Service, Emergency Department and Outpatient Clinic at Morriston Hospital. Patients completed the frailty score either on paper or electronically. The results of the patient’s and clinician’s frailty scores were compared and analysed.

Results:

A total of 173 paired questionnaires were completed. Twelve participants were excluded due to errors in completing the paper questionnaire. No electronically completed questionnaires were excluded. Among the remaining 161 paired questionnaires, there was a high level of agreement between patient and clinician, with most discrepancies being within a grade difference of one. The highest levels of agreement were observed in those with mild and moderate frailty, while the most significant discrepancies were found in the ‘’managing well’’ category. The mean self-assessed frailty score was 4.12 (with a standard deviation of 1.818), and the mean clinician-assessed frailty score was 4.29 (with a standard deviation of 1.637). The correlation coefficient between self-assessed and clinician-assessed frailty scores was 0.852, which was statistically significant (p<0.001).

Conclusion(s): 

The strong correlation between patient self-reported and clinician-assessed frailty scores highlights a general agreement between the two perspectives. However, clinicians tend to assign slightly higher frailty levels, particularly in less severe cases. These findings underscore the potential value of integrating electronic self-screening tools to assess patients for frailty in various settings, thereby enhancing the quality of care provided.

Introduction: 

Polypharmacy contributes to frailty, financially strains healthcare resources and causes unplanned hospital admissions. We audited how our Frailty Same Day Emergency Care (SDEC) addressed polypharmacy and the yearly financial impact of deprescribing on the NHS. 

Method: 

We analysed two months of patients seen and recorded medication changes in Excel. The BNF was used to provide the minimum NHS indicative price for a medication. Cost was calculated based on a year of prescribing for medications started, stopped or altered. For PRN medications, single pack usage was assumed. The average monthly saving was then multiplied by 12 to estimate the yearly value. 

Results: 

226 patients were reviewed, with 181 having recorded medication changes. From this sample, the estimated yearly saving through deprescribing is around £31,780. Furosemide, amlodipine and atorvastatin were the most frequently stopped. Anticipatory medication and laxatives were most frequently started. Stopping ticagrelor resulted in the greatest savings (£711.44), whilst the most expensive medication started was mesalazine granules (£897.16). 

Limitations: 

The estimated yearly saving is based on assumption and so can be subjected to anomalous results/prescribing. Alterations are assumed to be permanent and continue throughout the year. PRN usage was generalised and not reflective of true usage over a year. The estimated saving does not account for negative financial complications because of deprescribing (e.g. stopping stomach protection and then representing with an Upper GI Bleed). Whilst deprescribing can result in direct financial benefit to the NHS, true benefit has not been measured (reducing future admissions due to polypharmacy). 

Conclusion: 

The NHS can incur significant financial savings from a frailty day unit. The direct cost reduction of deprescribing is only one of the benefits of addressing polypharmacy. The true value is in improving quality of life, reducing the impact of frailty syndromes and avoiding hospital admissions in older people.

Introduction

The UK population is ageing quickly, with the number of individuals over 65 rising from 9.2 million to 11 million in the last decade. This increase has led to more comorbidities and complex treatment regimens, often referred to as polypharmacy, which can cause adverse effects, increase admissions, mortality and high healthcare costs. To address these issues, the NHS is adopting a patient-centred approach to optimise medication use and improve outcomes. This includes evaluating patients, setting shared goals, and identifying unnecessary or harmful medications. Data was gathered from community patients referred to the Early Intervention Team (EIT), which aims to ensure safe discharges and prevent hospital admissions related to falls, frailty, and cognitive or functional decline in Suffolk.

Method

Data were collected from March to May 2024 for fifty-one patients aged 65 and older who received home visits from EIT and were on five or more medications. Medical records were reviewed to identify medications associated with health deterioration and to assess the frequency of medication reviews, along with related costs. A survey was also conducted to evaluate the impact of their medication regimens on quality of life and gauge interest in reviewing and potentially reducing their medication burden.

Results

Out of fifty-one patients, 90.2% adhered to their medication regimen, but over half (54.9%) did not understand its purpose and reported side effects, including falls (82.4%), memory problems (64.7%), and constipation (54.9%). Additionally, 72.5% wanted their medications reviewed. Twenty-two patients GP were promptly contacted. Notably, one patient's annual medication cost was calculated as £5,256.96.

Conclusion

Polypharmacy leads to high financial and health costs, yet medication reviews are often inadequate or unavailable. The authors suggest conducting regular reviews in outpatient falls or frailty clinics to monitor adherence and tolerance. Further research is needed to ascertain the benefits of this practice.

Introduction Frailty is associated with delayed clinical assessment in ED, increased length of stay (LOS) and inpatient mortality. Frail older adults have complex medical and psychosocial problems, difficult to address in ED. In line with the NHS Long Term Plan, our fSDEC pilot aimed: to deliver early comprehensive geriatric assessments (CGA); manage acute presentations to avoid unnecessary admissions; reduce ED waits and reduce the LOS for those admitted. Methods The fSDEC pilot had an ACP, a trainee ACP and two resident doctors (SHO and registrar) with support from a consultant and access to a therapist, a pharmacist and urgent community response teams. Patients were triaged by fSDEC for suitability on weekdays 8am – 6pm. Ambulant patients were seen in pre-existing shared SDEC space; non-ambulant patients were managed in ED. All patients had a CGA within thirty minutes of arrival. Results In twelve months, 729 patients were seen and 81% discharged same-day. Table 1: Categories of presentation: Most common was fall 39%. Table 2: Number of patients seen each month and number of days fSDEC not run: average number of patients seen 3.5/day Without fSDEC it was estimated 80% of these patients would have been admitted. For example, patients who present with falls have an average LOS of 13 days. fSDEC saves 234 bed-days/month for falls, which amounts to £70,000/month. For total presentations this can be extrapolated to 620 bed days, saving £186,000/month. Conclusion With fSDEC there was higher likelihood of same-day discharge; improving flow, patient experience and offering financial savings. This was aided by engagement from stakeholders, access to community In-Reach CNS and flexibility of staff. In future, we aim to have a frailty friendly space and more consistent staffing. There was positive feedback from patients and the Trust (the team were finalists for 'All Star Team of the Year').

Introduction: Frailty is a growing concern, particularly for older adults attending Emergency Departments (EDs). Frailty accounts for 5-10% of all ED visits and up to 30% of acute admissions1. The NHS mandates that hospitals with Type 1 EDs provide a minimum of 70 hours of Acute Frailty Services per week to address this challenge1. At Salford Royal Foundation Trust (SRFT), a Frailty Same Day Emergency Care (SDEC) service was introduced to deliver rapid assessment and care for frail older adults, aiming to reduce hospital admissions and improve patient outcomes2. This service operates five days per week and is staffed by a multidisciplinary team2. Methods: A mixed-methods approach was used to evaluate the Frailty SDEC service3. Data was collected through paper surveys distributed to patients aged 65 years or older with a Clinical Frailty Score (CFS) >5 and their relatives or carers during their admission to the SDEC service24. The survey included both closed-ended and open-ended questions4. Quantitative data was analyzed using descriptive statistics and qualitative data was analyzed using thematic analysis5. Results: A total of 32 responses were collected over a two-month period in 20244. The results showed high levels of patient and family satisfaction (97%) with the Frailty SDEC service35. Participants particularly valued the compassionate and personalized care, clear and professional communication, and the efficient and timely service delivery67. Areas for improvement included upgrading the physical environment and providing clearer communication about waiting times and procedures89. Conclusion: The Frailty SDEC service at SRFT demonstrates high levels of patient satisfaction and effectiveness in delivering care for frail older adults10. This evaluation provides valuable insights for enhancing patient-centered care and highlights the importance of further research to explore long-term outcomes and compare different models of SDEC services for older adults11

Title: An overview of the Dementia UK Consultant Admiral Nurse service supporting families affected by frailty and dementia 

Authors: K Lyons1. Provenances: 1. Dementia UK 

Introduction: 

Emerging and increasing frailty often goes unidentified, and families living with dementia and frailty are missing vital opportunities to receive the right support at the right time. People living with frailty are less able to adapt to stress factors such as acute illness, injury, or changes in their environment, personal or social circumstances, leading to adverse health outcomes and an earlier loss of independence. 

Method: We developed a unique and innovative frailty Consultant Admiral Nurse role and service to address this concern. This service was created alongside a recognition of the need for equal access to better national awareness, knowledge, resources, and support around the management of frailty and dementia. The service provides professional leadership, consultancy, education, and expert clinical practice to families. Results: The service has been operational for 12 months, with excellent quantitative and qualitative outcomes. To date, 536 people have received specialist frailty and dementia training. Clinical interventions equated to 2862 activities directly delivered to support families. From carers surveyed, 100% stated that the service helped them manage symptoms of frailty alongside dementia, understand frailty, and cope with the challenges posed by frailty and dementia. 

Conclusion(s): The Dementia UK Frailty Consultant Admiral Nurse service has demonstrated significant positive impacts on families living with dementia and frailty. The service focuses on reducing barriers to care and support, ensuring equality in service provision. The involvement of Lived Experience partners in service planning and delivery has been crucial. The service aims to expand further, building on the successful outcomes of its first year.

Improving Advance Care Planning Within Residential Homes

Introduction:

As care home residents are living with advancing frailty and multi-morbidity, it is important to initiate advance care planning as part of the comprehensive geriatric assessment and create universal care plans (UCPs). There is evidence that it can reduce inappropriate escalations of care, reduce hospital admissions, increase the proportion of residents dying in their preferred place and improve both resident and relative satisfaction.

Method:

Retrospective audit in June 2024 of residents within the five residential homes covered by the newly formed enhanced health in care home (EHCH) team who had an initial comprehensive geriatric assessment (CGA) between March 2022-May 2024 to review if they had a universal care plan in place (UCP).

Further sub-analysis to review whether they had an existing UCP prior to EHCH review or this was created/edited by the EHCH team. Both the CGA and UCP would have either been completed by the EHCH matron or consultant geriatrician.

Results:

There was an average increase from 26% to 89% in the number of residents with a UCP following an EHCH CGA. We have created/edited a total of 117 UCPs across the care homes in addition to those already in place across the 177 CGAs completed over this time period.

Conclusions:

Advance care planning is a vital part of a comprehensive geriatric assessment and it is often not completed for many reasons including its time-consuming nature, lack of awareness and apprehension in having these discussions both amongst residents, relatives and staff and a lack of training and education.

As an EHCH team, we have managed to improve the number of residents with UCPs to 89%. We hope this will mean a greater proportion of residents receive appropriate personalised care according to their wishes in their chosen place as well as dying in their place of preference.

Introduction

The UCNH model is being implemented across Sussex to reduce ED pressures. Based at the Polegate Make Ready Centre, the UCNH launched in mid-November 2024 to provide alternative pathways for 999 callers. The UCNH operates as a multidisciplinary team of up to eight clinicians, including an Urgent Community Response Trainee Advanced Care Practitioner and a Consultant in Frailty, two Advanced Paramedic Practitioners, two Computer-Aided Dispatch drivers, and two remote consultation paramedics.

Method

The team triages calls, manages acute cases, and works collaboratively with ambulance crews and community services to avoid unnecessary ED attendance by offering interventions, referrals, or home-based management.

Results

Between 11 November and 31 December 2024, the hub operated on 33 weekdays, managing 554 contacts (16.8 per day). Their average age was 75 years. Of these, 184 were handled before dispatch, and 370 involved on-scene crews. The service avoided 121 ambulances (3.7 per day) and 339 ED conveyances (10.3 per day), significantly reducing unnecessary hospital visits.

Referral pathways included 254 patients directed to acute services, such as Same Day Emergency Care (SDEC) and specialist assessment units, and 139 patients referred to community services, with 4.2 supported at home daily.

Cost savings were substantial, totalling approximately £2395 per day (£1760 from avoided ambulances and £635 from ED avoidance), equating to £79,000 over this period.

Conclusions

The UCNH demonstrates significant benefit, reducing ambulance utilisation and ED conveyances while enhancing patient outcomes through community and home-based care. These results highlight its potential to improve ambulance response times and hospital handovers, although further data is needed to confirm this. Reinvestment of savings into SDEC and community services could enhance care pathways further. By preventing inappropriate ED attendances and facilitating access to suitable care services, the hub delivers both financial benefits and meaningful improvements to individual patient care.

Topic

We identified a deficiency in the identification and treatment of bone health in the Day Rehabilitation Unit. DRU is an Out-patient clinic where older people with falls or reduced mobility receive comprehensive geriatric assessment. We aimed to improve early screening for osteoporosis, prompting targeted investigation and intervention to improve patient outcomes.

Intervention

Our first intervention was consultant teaching specifically to the junior doctors working in clinic. This was followed up by the introduction of a Medical Assessment Proforma to include osteoporosis risk assessment. Finally we had departmental wide teaching on bone health assessment.

We hypothesised that a combination of clinical education and prompts in the proforma would improve our practice.

A total of 205 patients where audited across an 18 month period from Sept 20 to Feb 22. We reviewed the electronic care record of patients seen in clinic to determine if bone health had been considered. A spreadsheet was designed in accordance with the NICE⁽¹⁾ guidelines to record data. This included what supplements were prescribed, if a FRAX score had been recorded and the outcome of this.

Improvement

We noted an improvement in supplements prescribed (from 27% to 83%), FRAX score recorded (from 0% to 100%). Routine bloods including serum calcium remained unchanged (100%). Recording of Rockwood score also saw an improvement (from 0% to 49%).

Discussion

Increased use of a structured screening tool, supported by targeted education improves recognition and intervention of bone health. 54% of people who had a FRAX score done required a DEXA as per guidelines, of these 26% have osteoporosis. This early intervention helps to prevent osteoporotic fractures, therefore improving the quality of life of our elderly population.

References

1. Nice.org.uk. (2017). Osteoporosis: assessing the risk of fragility fracture | Guidelines| NICE. [Online] Available at: https://www.nice.org.uk/guidance/cg146

Introduction

Age is a risk factor for digital exclusion, but many older people have excellent access to digital services. Frailty may offer a clearer mechanism of exclusion. The aim of this study was to assess the association between living with frailty and digital exclusion from video consultation.

Methods

We undertook a multicentre cross-sectional study across primary care, interface, and secondary care services in South-West England. Patients were enrolled between 21st February and 12th April 2022. The primary outcome was complete digital exclusion from video consultation (defined as the no access for the individual and no option for help from their support network). A secondary analysis looked at digital exclusion of the individual only. Frailty was measured using the Clinical Frailty Scale. Outcomes were analysed with logistic regression.

Results

255 patients were included of which 39% were living with frailty. Only one person not living with frailty (CFS 1-3) experienced complete digital exclusion compared to 10.7% living with frailty (CFS ≥4). Frailty was not associated with complete digital exclusion, but was associated with individual digital exclusion: compared to CFS 1-3, CFS 4-5 aOR=36.5 (95%CI 4.40-304.9) and CFS 6-8 aOR=65.4 (95%CI 6.63-645.9). The imprecise estimates were caused by only one person not living with frailty digitally excluded.

Conclusion

Frailty was associated with individual digital exclusion. However, when considering a person living with frailty’s support network digital exclusion from video consultation was rare. To improve access to video consultation for people living with frailty their support network should be explored when booking appointments.