CQ - Improved Access to Service

Introduction

Fragility fractures are a significant cause of morbidity and mortality in the UK. An estimated 549000 fragility fractures occur each year, with a significant financial and social cost. By identifying and treating those at risk we can reduce the incidence of fragility fractures. We wished to assess how we could optimise management of bone health in those presenting to our acute frailty unit(AFU). 

Method

We conducted a retrospective review of patients admitted to AFU with falls on a background of frailty. 2 PDSA (plan, do, study and act) cycles were undertaken in 2023 and 2024 respectively. We audited if patients had a full assessment of bone health (calcium, Vitamin D levels and FRAX score) and if they had been started on appropriate treatment. Interventions included multiple educational sessions for members of the elderly medicine team, updated guidelines for primary and secondary prevention and concise poster guidelines visible on all elderly care wards. 

Results 

Over two cycles, we noted an improvement in bone health assessments amongst those admitted. By the end of our cycles, 48% had appropriate bone health bloods compared to 13% prior and 33% had a FRAX score calculated compared to 7% before. 32% of the patients had a clearly defined treatment plan for bone health compared to 0% at the start of the cycle. 

Conclusions 

1. Education proved a moderately successful tool for increasing the awareness of bone health in frail patients admitted to AFU and also in increasing appropriate assessment and management of these patients. 2. Despite this, the majority of patient’s did not receive an assessment. Possible factors limiting this included; time, clinical acuity and uncertainty about best management option. 3. This QIP has demonstrated the need for the development of a fracture liaison service to provide robust assessment and management in the frail population.

Introduction: Frailty is a clinically recognized condition characterized by increased vulnerability due to age-related decline across various physiological systems, leading to reduced ability to cope with daily and acute stressors . Managing frailty requires a person-centred approach, involving patients, families, and caregivers, and utilizing evidence-based practices such as Comprehensive Geriatric Assessment (CGA), delivered by specialist multidisciplinary (MDT) teams. Research indicates that older individuals receiving CGA are more likely to be alive and living independently at home six months after an acute illness. To support the development of Older People’s Services, a review of the service model was conducted to deliver a rapid access service for patients referred by general practitioners (GPs). This service aims to avoid emergency department (ED) visits while providing necessary CGA assessments. Method: The initiative involved creating a direct referral option within the GP’s electronic referral system (Clinical Commissioning Group), developing a standard operating procedure for the triage process, establishing an education process for staff to clarify roles and responsibilities including data collection, and scheduling MDT members for triage support. Results: Following the implementation of the agreed procedures, there was a notable improvement in scheduling urgent GP referrals within three days. A daily referral system with live triaging was established, along with daily post-clinic MDT meetings. The backlog of urgent GP referrals was cleared. This successful system was replicated using Plan-Do-Study-Act (PDSA) cycles to integrate ED referrals. Conclusion: Collaborating with a team whose values aligned with Health and Social Care (HSC) principles—working together, striving for excellence, openness, honesty, and compassion—was a rewarding experience. The project provided valuable learning opportunities in team-building and service development. The success of the GP referral system was also leveraged to expand the service to other areas, such as ED referrals, demonstrating effective duplication of successful strategies.

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 week’s 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
 

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 

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

The Frailty Virtual Ward Pathway aims to optimise the care for frail patients (with a frailty score between 4 and 7) aged 65 and above. by addressing the main frailty domains falls, polypharmacy, functional decline, and new incontinence. Timely referrals can enhance patient outcomes and reduce hospital length of stay. However, awareness and utilisation of the pathway among medical teams remain unclear. This project aimed to assess the awareness and usage of the pathway on three medical wards at West Suffolk Hospital, F7, G3, and G10, and to implement a quality improvement intervention to increase appropriate referrals. A baseline review of patients’ records identified eligible patients who were not referred, while surveys assessed multidisciplinary teams' (MDTs) awareness and referral practices. Interventions included providing educational materials, conducting ward visits, and organising awareness events. Pre-intervention data showed twenty-three total referrals to the Virtual Ward Pathway, with low ward-specific uptake to Frailty Pathway (F7: 1, G3: 0, G10: 0). During the intervention, referrals increased to 35, though ward-specific referrals remained limited (F7: 4, G3: 0, G10: 1). Post-intervention, referrals increased to thirty-two, highlighting the need for sustained efforts. The project improved overall referral rates to all Virtual Ward pathways, but frailty pathway referrals showed modest gains. Ongoing education, embedding referral criteria in routine workflows, and continuous MDT engagement are essential for sustained improvement.

Background 

Delirium and acute functional decline are common in hospitalized older people (HOP), yet data remain scarce. A shortage of geriatricians and geriatric-trained doctors in our healthcare system contributes to poor clinical outcomes, including increased readmissions, morbidity, and mortality. This pilot study aims to assess the clinical burden of HOP—including rates of readmission, delirium, and acute functional decline—before implementing frailty care bundles in general medical wards. 

Methodology 

This prospective cross-sectional study recruited HOP (≥65 years) admitted to general medical wards from 1–31 March 2024. Data collected included demographics, prior-year readmissions, ADL and mobility status (1 month pre-admission vs. discharge), presence of delirium (via symptoms or Confusion Assessment Method), and length of stay. Acute functional decline was defined as deterioration in at least one ADL or mobility domain. Patients transferred to other specialties or district hospitals were excluded. 

Results 

Of 107 HOP (33.7% of total admissions), 103 were analyzed. Median age was 73; 80.6% were 65–80 years, and 59.2% were male. At baseline, 76.7% were CFS ≤5, while 23.3% were moderately/severely frail (CFS 6–7). Prior to admission, 48.5% walked unaided, while 51.5% required assistance. Readmission history was noted in 46.6%. Mean length of stay was 6.5 days. Acute mobility decline occurred in 37.9%, functional decline in 35%, and delirium in 17.5%. 

Conclusion 

This study highlights a substantial clinical burden among hospitalized HOP. A standardized frailty care bundle has been developed to aid non-geriatric-trained healthcare personnel in early detection and management of frailty-related issues, aiming to improve patient outcomes.

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

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: Fracture liaison services (FLS) aim to prevent secondary fractures by ensuring high-quality care to all patients with fragility fractures above 50 years. The standard recommendation by FLS Database (FLS-DB) is to identify 80% of the expected fragility fractures, commencing treatment for 50% and monitoring 80% at 16 weeks and 52 weeks.

Methods: FLS team noted that only 18.4% (n=92) patients were followed at one-year of the total 875 patients identified in the year 2021 (National benchmark=22.3%). Whilst FLS team identified 42.6% (n=1649) patients in the year 2022, an 88% increase as compared to the year 2021. But there was reduction in the one-year follow-up from 18.4% to 13.8% (n=149) in 2022. Quality improvement methodology based on the model of improvement; Plan-Do-Study-Act cycles, was used. Process mapping for the existing FLS showed that follow-up was only ad-hoc and not formalised. Our objective was to improve follow-up at one-year.

Results: Process mapping supported the development of a separate clinic code for annual review of patients, led by a geriatrics specialty trainee and supported by the FLS Clinical Lead. The patient lists were drawn from the FLS-DB and new patients booked for one-year follow-up clinic. FLS identified more fragility fracture patients (n=2181, 61.4%) in 2023, a further increase of 32.2% as compared to previous year. Clinical leadership and dedicated one-year follow-up clinic supported improved performance (21.4%, n=310) in the year 2023, which is comparable to the national benchmark (22.2%).

Conclusion: Several challenges were identified including lack of accurate telephone numbers for many patients; patients are transferred to primary care at one-year but there but the is osteoporosis knowledge gap in the community and need for dedicated time for follow-up clinic. This quality initiative has streamlined our follow-up clinics but need dedicated time to meet the service demand and increased capacity.