The Whittington Frailty Pathway: improving access to comprehensive geriatric assessment: an interdisciplinary quality improvement project

Strategies to improve care for older adults who present to the emergency department: a systematic review

BACKGROUND

The aim of this systematic review was to examine the relationship between strategies to improve care delivery for older adults in ED and evaluation measures of patient outcomes, patient experience, staff experience, and system performance.

METHODS

A systematic review of English language studies published since inception to December 2022, available from CINAHL, Embase, Medline, and Scopus was conducted. Studies were reviewed by pairs of independent reviewers and included if they met the following criteria: participant mean age of ≥ 65 years; ED setting or directly influenced provision of care in the ED; reported on improvement interventions and strategies; reported patient outcomes, patient experience, staff experience, or system performance. The methodological quality of the studies was assessed by pairs of independent reviewers using The Joanna Briggs Institute critical appraisal tools. Data were synthesised using a hermeneutic approach.

RESULTS

Seventy-six studies were included in the review, incorporating strategies for comprehensive assessment and multi-faceted care (n = 32), targeted care such as management of falls risk, functional decline, or pain management (n = 27), medication safety (n = 5), and trauma care (n = 12). We found a misalignment between comprehensive care delivered in ED for older adults and ED performance measures oriented to rapid assessment and referral. Eight (10.4%) studies reported patient experience and five (6.5%) reported staff experience.

CONCLUSION

It is crucial that future strategies to improve care delivery in ED align the needs of older adults with the purpose of the ED system to ensure sustainable improvement effort and critical functioning of the ED as an interdependent component of the health system. Staff and patient input at the design stage may advance prioritisation of higher-impact interventions aligned with the pace of change and illuminate experience measures. More consistent reporting of interventions would inform important contextual factors and allow for replication.

Care pathways in older patients seen in a multidisciplinary same day emergency care (SDEC) unit

BACKGROUND

Same day emergency care (SDEC) services are being advocated in the UK for frail, older patients in whom hospitalisation may be associated with harm but there are few data on the 'ambulatory pathway'. We therefore determined the patient pathways pre- and post-first assessment in a SDEC unit focussed on older people.

METHODS

In consecutive patients, we prospectively recorded follow-up SDEC service reviews (face-to-face, telephone, Hospital-at-Home domiciliary visits), outpatient referrals (e.g. to specialist clinics, imaging, and community/voluntary/social services), and hospital admissions <30 days. In the first 67 patients, we also recorded healthcare interactions (except GP attendances) in the 180 days pre- and post-first assessment.

RESULTS

Among 533 patients (mean/SD age = 75.0/17.5 years, 246, 46% deemed frail) assessed in an SDEC unit, 210 were admitted within 30 days (152 immediately). In the 381(71%) remaining initially ambulatory, there were 587 SDEC follow-up reviews and 747 other outpatient referrals (mean = 3.5 per patient) with only 34 (9%) patients being discharged with no further follow-up. In the subset (n = 67), the number of 'healthcare days' was greater in the 180 days post- versus pre-SDEC assessment (mean/SD = 26/27 versus 13/22 days, P = 0.003) even after excluding hospital admission days, with greater healthcare days in frail versus non-frail patients.

DISCUSSION AND CONCLUSION

SDEC assessment in older, frail patients was associated with a 2-fold increase in frequency of healthcare interactions with complex care pathways involving multiple services. Our findings have implications for the development of admission-avoidance models including cost-effectiveness and optimal delivery of the multi-dimensional aspects of acute geriatric care in the ambulatory setting.

Is the clinical frailty scale feasible to use in an emergency department setting? A mixed methods study

BACKGROUND

The Clinical Frailty Scale (CFS) is a frailty assessment tool used to identify frailty in older patients visiting the emergency department (ED). However, the current understanding of how it is used and accepted in ED clinical practice is limited. This study aimed to assess the feasibility of CFS in an ED setting.

METHODS

This was a prospective, mixed methods study conducted in three Swedish EDs where CFS had recently been introduced. We examined the completion rate of CFS assessments in relation to patient- and organisational factors. A survey on staff experience of using CFS was also conducted. All quantitative data were analysed descriptively, while free text comments underwent a qualitative content analysis.

RESULTS

A total of 4235 visits were analysed, and CFS assessments were performed in 47%. The completion rate exceeded 50% for patients over the age of 80. Patients with low triage priority were assessed to a low degree (24%). There was a diurnal variation with the highest completion rates seen for arrivals between 6 and 12 a.m. (58%). The survey response rate was 48%. The respondents rated the perceived relevance and the ease of use of the CFS with a median of 5 (IQR 2) on a scale with 7 being the highest. High workload, forgetfulness and critical illness were ranked as the top three barriers to assessment. The qualitative analysis showed that CFS assessments benefit from a clear routine and a sense of apparent relevance to emergency care.

CONCLUSION

Most emergency staff perceived CFS as relevant and easy to use, yet far from all older ED patients were assessed. The most common barrier to assessment was high workload. Measures to facilitate use may include clarifying the purpose of the assessment with explicit follow-up actions, as well as formulating a clear routine for the assessment.

REGISTRATION

The study was registered on ClinicalTrials.gov 2021-06-18 (identifier: NCT04931472).

Frailty assessment in emergency medicine using the Clinical Frailty Scale: a scoping review

BACKGROUND

Frailty is a common condition present in older Emergency Department (ED) patients that is associated with poor health outcomes. The Clinical Frailty Scale (CFS) is a tool that measures frailty on a scale from 1 (very fit) to 9 (terminally ill). The goal of this scoping review was to describe current use of the CFS in emergency medicine and to identify gaps in research.

METHODS

We performed a systemic literature search to identify original research that used the CFS in emergency medicine. Several databases were searched from January 2005 to July 2021. Two independent reviewers completed screening, full text review and data abstraction, with a focus on study characteristics, CFS assessment (evaluators, timing and purpose), study outcomes and statistical methods.

RESULTS

A total of 4818 unique citations were identified; 34 studies were included in the final analysis. Among them, 76% were published after 2018, mainly in Europe or North America (79%). Only two assessed CFS in the pre-hospital setting. The nine-point scale was used in 74% of the studies, and patient consent was required in 69% of them. The main reason to use CFS was as a main exposure (44%), a potential predictor (15%) or an outcome (15%). The most frequently studied outcomes were mortality and hospital admission.

CONCLUSION

The use of CFS in emergency medicine research is drastically increasing. However, the reporting is not optimal and should be more standardized. Studies evaluating the impact of frailty assessment in the ED are needed.

REGISTRATION

https://doi.org/10.17605/OSF.IO/W2F8N.

The value of qualitative data in Quality Improvement Projects in the care of older adults: the case of frailty scores in the emergency department

This commentary discusses the role and value of qualitative data when undertaking quality improvement (QI) focussing on the care of older adults. To illustrate this, we reflect on our own experiences of planning a QI project to improve the documentation of Clinical Frailty Scale (CFS) scores in the emergency department (ED) during the coronavirus disease of 2019 (COVID-19) pandemic. National clinical guidance for COVID-19 states that all adults over the age of 65 should be given a CFS at the first point of contact during hospital admission. Therefore, there is a need to improve CFS documentation, specifically in acute care settings.

We describe how qualitative methods facilitated an understanding of the barriers to CFS documentation in ED. Staff see the CFS as a useful tool for inter-professional communication, though there are tensions between clinical guidance and their beliefs. Staff had moral concerns about how an ED-allocated CFS might limit available treatment options for older adults. Our findings demonstrate how qualitative methods can illuminate the important social and moral dimensions of why improvement does or does not occur.

Clinical Frailty Scale, K-FRAIL questionnaire, and clinical outcomes in an acute hospitalist unit in Korea

BACKGROUND/AIMS

Frailty increases the risks of in-hospital adverse events such as delirium, falls, and functional decline in older adults. We assessed the feasibility and clinical relevance of frailty status in Korean older inpatients using the Clinical Frailty Scale (CFS) and Korean version of the Fatigue, Resistance, Ambulation, Illnesses, & Loss of Weight scale (K-FRAIL) questionnaires.

METHODS

Frailty status was measured using the Korean-translated version of the CFS and K-FRAIL questionnaire within 3 days from admission in 144 consecutive patients aged 60 years or older. The correlation between CFS and K-FRAIL score was assessed. The criterion validity of CFS was assessed using receiver operating characteristic analysis. As outcomes, delirium, bedsore, length of stay (LOS), in-hospital mortality, and unplanned 30-day readmission were measured by reviewing medical records.

RESULTS

The mean age of the study population was 70.1 years (range, 60 to 91), and 75 (52.1%) were men. By linear regression analysis, CFS and K-FRAIL were positively correlated (B = 0.72, p < 0.001). A CFS cutoff of ≥ 5 maximized sensitivity + specificity to classify frailty using K-FRAIL as a reference (C-index = 0.893). Higher frailty burden by both CFS and K-FRAIL was associated with higher LOS and bedsores. Unplanned readmission and in-hospital mortality were associated with higher CFS score but not with K-FRAIL score, after adjusting for age, gender, polypharmacy, and multimorbidity.

CONCLUSION

Frailty status by CFS was associated with LOS, bedsores, unplanned readmission, and in-hospital mortality. CFS can be used to screen high-risk patients who may benefit from geriatric interventions and discharge planning in acutely hospitalized older adults.

Frailty in patients with interstitial lung disease

PURPOSE OF REVIEW

The incidence of age-related diseases such as interstitial lung disease (ILD) is rising, and the importance of multimorbidity and accumulation of health deficits in patients with chronic lung diseases is increasingly recognized. There are multiple relationships between aging and ILD on a demographic and a biological level. Frailty conceptualizes the decline of a patient's physiological reserves and complements the chronological and biological aspects of aging.

RECENT FINDINGS

Frailty affects more than 50% of patients with ILD, with respiratory impairment, accelerated biological aging, comorbidities, medication adverse effects, and social factors collectively playing important roles. Frailty is an independent risk factor for adverse health outcomes such as hospitalizations and early mortality, including before and after lung transplant. Given the multicomponent determinants of frailty, programs such as pulmonary rehabilitation are promising strategies for managing this complex issue.

SUMMARY

Frailty is a common risk factor for adverse outcomes in patients with ILD. The multiple pathways leading to frailty are not completely understood, and further studies are needed to determine the optimal tools for assessment and to develop strategies to prevent and counteract frailty in the aging ILD population.

Factors associated with admission to bed-based care: observational prospective cohort study in a multidisciplinary same day emergency care unit (SDEC)

BACKGROUND

The development of ambulatory emergency care services, now called 'Same Day Emergency Care' (SDEC) has been advocated to provide sustainable high quality healthcare in an ageing population. However, there are few data on SDEC and the factors associated with successful ambulatory care in frail older people. We therefore undertook a prospective observational study to determine i) the clinical characteristics and frailty burden of a cohort in an SDEC designed around the needs of older patients and ii) the factors associated with hospital admission within 30-days after initial assessment.

METHODS

The study setting was the multidisciplinary Abingdon Emergency Medical Unit (EMU) located in a community hospital and led by a senior interface physician (geriatrician or general practitioner). Consecutive patients from August-December 2015 were assessed using a structured paper proforma including cognitive/delirium screen, comorbidities, functional, social, and nutritional status. Physiologic parameters were recorded. Illness severity was quantified using the Systemic Inflammatory Response Syndrome (SIRS> 1). Factors associated with hospitalization within 30-days were determined using multivariable logistic regression.

RESULTS

Among 533 patients (median (IQR) age = 81 (68-87), 315 (59%) female), 453 (86%) were living at home but 283 (54%) required some form of care and 299 (56%) had Barthel< 20. Falls, urinary incontinence and dementia affected 81/189 (43%), 50 (26%) and 40 (21%) of those aged > 85 years." Severe illness was present in 148 (28%) with broadly similar rates across age groups. Overall, 210 (39%) patients had a hospital admission within 30-days with higher rates in older patients: 96 (87%) of < 65 years remained on an ambulatory pathway versus only 91 (48%) of ≥ 85 years (p < 0.0001). Factors independently associated with hospital admission were severe illness (SIRS/point, OR = 1.46,95% CI = 1.15-1.87, p = 0.002) and markers of frailty: delirium (OR = 11.28,3.07-41.44, p < 0.0001), increased care needs (OR = 3.08,1.55-6.12, p = 0.001), transport requirement (OR = 1.92,1.13-3.27), and poor nutrition (OR = 1.13-3.79, p = 0.02).

CONCLUSIONS

Even in an SDEC with a multidisciplinary approach, rates of hospital admission in those with severe illness and frailty were high. Further studies are required to understand the key components of hospital bed-based care that need to be replicated by models delivering acute frailty care closer to home, and the feasibility, cost-effectiveness and patient/carer acceptability of such models.