Frailty

Over a 6 month period, all 92 residents were offered the opportunity to have a ReSPECT conversation and 86 accepted the opportunity. In addition to families/legal representatives, advocacy services were used to enable equitable participation. Digitally-facilitated communication tools were also offered.

The vast majority responded positively, and a mutually agreed ReSPECT form was completed. These were stored electronically on NHS systems and shared with the care home in paper format.

However, even when offered all available information some residents chose not to have a ReSPECT placing limitations on their care. Some family members objected strongly to what was being suggested. Case-by-case analysis is ongoing on the impact on unscheduled care use.

Conclusions

Our experiences highlight both the benefits of structured FCP, but also reflect the practical challenges and concerns among the population and those who support them. Empowering staff and family members to advocate in the event of a health deterioration was a powerful consequence. Equally, respecting individual preferences necessitates avoiding blanket approaches. ReSPECT discussions often enabled more timely hospital discharge when an admission occurred. Practical challenges, including the lack of care home access to NHS digital systems can be overcome, but reflect structural barriers to information sharing which integrated systems should avoid.

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: 

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.

Frailty is prevalent within the local community of the hospital, with long waiting times in ED, the trust has established an FDF service, with a dedicated team based in ED to assess frailty patients, who would have been pended for admission, to ensure they are diverted to appropriate services and discharged to their normal place of residence, as per GRIFT, BGS guidelines and NHS England long term plan.

Method

Data was audited over a 7-month period, all patients who presented to the ED and pended for admission, who were aged over 65, with a Clinical frailty score over 4

Results

The service has seen a total of 1082 patients (8 patients a day), with an average age of 86, with an 84% discharge rate, back to the patient?s normal place of residence.

The most common presentations seen by the team were Falls, (28%), UTI (8%), CAP (5%).  The team noted that there was a low re-presentation to the service, 27 patients (2.54%) within 7 days.  The patients prior to the implementation of the service would have been admitted to the trust with and average length of stay of 17 days.

The potential savings to the. Trust was considered as part of the audit which compared the national and local data for length of stay and costs per day for admission and attendance to ED, which was estimated between £5,600,000 (local) - £6,000,000 (National), and if the same numbers of presentations were looked at over a 12-month period this is estimated as £9,600,000 (local) - £11,310,000 (National)

Conclusion

The service has now enabled the trust to achieve the CQUIN targets, all patients that present to FDF have a CGA started, the patients identified are less likely to be admitted with an overall estimated saving to the trust.

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: 

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

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.

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.

Introduction

Older patients admitted to the emergency department (ED) do not have a pharmacist-led medication review within the comprehensive geriatric assessment (CGA), yet the presenting complaint can be attributed to overprescribing and problematic polypharmacy. Taking ten or more medications increases the risk of hospital admission by 300% due to adverse drug reactions (ADRs)1, therefore a medication review can reduce this outcome by optimising current therapy2. Responsibility of safely transferring this medication information between care settings is a healthcare professional's duty, as the rate of error is 30 - 70%3.

Method

Patients were identified by the ED Frailty Team according to local frailty criteria, including patients > 65 years presenting with delirium, a fall and/or multi-morbidities. Medicines reconciliation was carried out by the frailty pharmacist, and medications optimised to reduce future harm with investigations prompted where needed. Interventions were categorised. A summary plan was written to the General Practitioner (GP) and each patient was followed up after 4 weeks to assess if received and actioned appropriately.

Results

73 medication reviews were conducted for patients (mean age 84.4 years) from June to September 2022, majority presenting with fall (69%). High-risk medication review was most common intervention (90%), followed by counselling (50%). 92% patients required a pharmaceutical intervention (n=208). GP plans were actioned for 65% patients in Primary Care.

Conclusion

ED frailty pharmacist's input reduced inappropriate polypharmacy and optimised medication for this patient cohort, with majority of care plans carried out appropriately following discharge. A future study could examine re-admission rates of patients in comparison to those without a frailty pharmacist's input.

References

1. Payne RA et al. British Journal of Clinical Pharmacology 2014; 77: 1073 – 1082.

2. Department of Health and Social Care, 2021. Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf. Accessed 19/1/23.

3. Department of Health, 2011/2012. Available at: www.wp.dh.gov.uk/healthandcare/files/ 2011/01/outcomesglance.pdf. Accessed 19/1/23.