Hospital Wide CGA and the Hospital Frailty Risk Score
In many respects, our ageing population is something to be celebrated, reflecting years of sustained improvements in how our society cares for older people through health and social care.
But while nowadays many older people live full, vibrant lives extending into their 80s and beyond, others do not enjoy such ‘successful’ ageing. Though it is undoubtedly important to focus on resilience and the positive aspects of ageing, it is equally important to support those older people who are less resilient, or frail.
Where do we stand?
We already know quite a lot about how to improve outcomes for older people, primarily though using holistic care models. This is about assessing and managing the whole person, rather than just one aspect, such as a heart condition or 'urinary difficulties'. It typically involves a team of doctors, nurses and therapists working together to improve outcomes, and in the literature is referred to as a comprehensive geriatric assessment.
There is still work to be done, however, in promoting the concept of comprehensive geriatric assessment (CGA) in hospital. CGA is not unique to geriatricians and geriatric teams (or shouldn’t be). Much of the skill set is generic and the remainder is teachable.
As geriatricians we are all aware of the evidence that CGA can reduce untimely deaths as well as prevent admission to long-term care. However, given that older people are such a mixed group – some relatively fit and well, others more vulnerable – a major difficulty for this type of work is how best to identify those most likely to benefit.
Promoting understanding in hospitals
In our Hospital Wide CGA campaign, we have collaborated with the Nuffield Trust in an NIHR-funded initiative to promote CGA hospital-wide. The overall aim of the project is to inform NHS managers, clinicians, patients and the public about how best to organise hospital services for older people.
The project introduces a hospital wide CGA self assessment tool encouraging hospital management to audit their services and the infrastructure they have in place to assess a patient in terms of frailty and the four domains of CGA. The assessment suggests ways to fill gaps in their services (e.g. tools such as Rockwood, PRISMA 7 etc).
Hospitals are then encouraged to use an interactive tool with a set of indicators. These have been populated with data for each local authority and NHS Acute Trust in England to describe populations, hospital costs and hospital activity.
An important part of the campaign promotes patient and public involvement, including ensuring patient and carer representation on the hospital board, the identification of older people’s champions etc.
Finally, the campaign provides practical guidance on disseminating and propagating good CGA practice throughout the hospital.
The concept of frailty - The Hospital Frailty Risk Score (HFRS)
Using the concept of frailty, which captures vulnerability to poor outcomes or harm, researchers from the Nuffield Trust, London School of Economics and the universities of Leicester, Newcastle and Southampton have created a Hospital Frailty Risk Score (HFRS).
The score focuses on older people who are likely to be frail and who are more likely to experience poor outcomes during or after an acute hospital admission.
We focused on the hospital because, at present, there are no routine systems in place to allow hospitals or commissioners to identify frail older people. This contrasts with health care settings such as primary care (where the Electronic Frailty Index is in use) and other conditions such as stroke or heart failure, which are well captured on routine hospital information systems.
Identifying people at risk
The HFRS was developed using Hospital Episode Statistics (a database containing details of all admissions, A&E attendances and outpatient appointments at NHS hospitals in England), and validated on over one million older people using hospitals in 2014/15.
We found that the score was able to identify a relatively small proportion of people over 75 years old in hospitals who were at the greatest risk of harms. The group of people with the highest HFRS were 1.7 times more likely to die in hospital, had a six-fold increase in staying more than 10 days in hospital, and were 1.5 times more likely to be readmitted following discharge.
Importantly the HFRS can be calculated automatically, which removes the burden and potential errors associated with manual scoring systems. It performed at least as well, if not better, than many existing risk-scoring systems.
What are the advantages?
Routinely identifying older people at risk of adverse clinical and/or service outcomes in hospitals means being able to provide interventions specifically for frailty throughout their hospital episode. This could include broadening the assessment to take account of the whole patient and not just the medical issues – such as assessing cognition, for example. Doing so is critical in the acute setting, as it might prompt clinicians to differentiate delirium (an acute medical emergency) from dementia (a long-term condition) – the management for which is very different.
Alongside better service mapping, commissioning and evaluation that is focused on frail older people, a widely accepted method of identifying those people in acute hospital settings could also help to highlight the magnitude of the issue, enable more tailored services, and improve patient and service outcomes.
That could really change how we think about and organise acute hospital care, and make a real difference for both patients and services.