Frailty-based care in hospital

Access to experts offering frailty-based care in hospital with frailty assessment, diagnostics and pathways.

What works

  • Implement a front door MDT to assess frailty, commence CGA with links to community teams and VSCE for robust discharge – 24/7
  • Implement strategies to avoid unexpected deaths – warning scores, critical care outreach, regular senior review and adequate access to high dependency beds.
  • Create safer care – prevention and treatment of falls, pressure sores, hospital-acquired infection, medication errors, deep vein thrombosis and malnutrition, delirium and immobility as a result of bed rest.
  • Minimise in-patient moves (especially in patients with delirium)
  • Offer frailty liaison and in-reach services
 Benefits

  • Reduction in falls, medication errors, VTEs, and delirium
  • Reduced functional decline
  • Improved experience of care
  • Reductions in bed occupancy, readmissions and length of stay
  • Reduction in mortality without affecting re-admission rates or requiring additional resources.
  • Improved survival at home after discharge

Useful resources

BGS silver book https://britishgeriatricssociety.wordpress.com/2012/06/21/the-silver-book-guidelines-for-the-emergency-care-of-older-people/

RCP – acute care toolkit https://www.rcplondon.ac.uk/guidelines-policy/acute-care-toolkit-3-acute-medical-care-frail-older-people

NHS elect. Website with access to acute frailty care https://www.nhselect.nhs.uk/

AFN Toolkit http://www.acutemedicine.org.uk/wp-content/uploads/2016/05/4.1-Managing-Acute-Frailty.pdf

SDEC NHS England/Improvement https://improvement.nhs.uk/documents/6111/SDEC_guide_frailty_May_2019_update.pdf

Evidence summaries

Redesigning the system of care for older emergency patients led to reductions in bed occupancy and mortality without affecting re-admission rates or requiring additional resources – https://academic.oup.com/ageing/article/43/4/472/15318

Acute Geriatric Units have been shown to reduce the risk of functional decline and increase the probability of returning home; such units have not been compared directly to an Acute Medical Unit (AMU) in the UK – https://www.dc.nihr.ac.uk/themed-reviews/frailty-in-hospital-research.htm

Older Persons’ Assessment and Liaison (OPAL) teams have shown to improve outcomes in hospital for older people’s care.

Silver book – https://britishgeriatricssociety.wordpress.com/2012/06/21/the-silver-book-guidelines-for-the-emergency-care-of-older-people/

Embedding comprehensive geriatric assessment in the emergency assessment unit: the impact of the Comprehensive Older Person’s Evaluation (COPE) zone – More patients with

markers of frailty were discharged directly from EAU without increasing readmissions. Mean length of stay was reduce- https://www.rcpjournals.org/content/clinmedicine/16/1/19.full.pdf

NIHR Themed Review – Comprehensive care for older people living with frailty in hospitals – https://www.bgs.org.uk/resources/nihr-themed-review-comprehensive-care-for-older-people-living-with-frailty-in-hospitals

Impact and Measures

We know that  frailty has a significant impact on people, populations and health and care systems. Frail older people are highly susceptible to adverse health outcomes, such as falls, disabilities, institutionalisation, hospitalisation and death. However, trying to understand this impact on populations and health and care system is challenging due to poor recording of frailty status and the lack of information sharing and interoperability that exists. The following examples of impact are guestimates based on current intelligence.

 

  • Potential Impact
    • The frail population (moderate and severe combined) makes up 2.44% of the population across the North East and North Cumbria, but account for 19.1% of general and acute bed usage.
    • In the North East and North Cumbria region the average length of stay in hospital was 7.9 days for a person with frailty compared to 4.4 days for a non-frail person and the 30-day emergency readmission rate for the frail population was 20.7% compared to 16.9% for the non-frail population.
  • Potential measures
    • People aged 65 years and over with severe frailty who have received an annual medication review
    • A&E attendance rates for patients aged 65 years and over
    • Emergency hospital admission rates for patients aged 65 and over
    • Proportion of stranded patients in hospital: Length of stay 7+ and 21+ days
    • Emergency readmissions within 30 days of discharge from hospital (patients aged 65 years and over)
    • Hospital activity in the last year of life (patients aged 65+ years)
    • Hospital Trust indicator set (Falls with harm, Pressure ulcers, Patient experience of hospital care, A&E waiting time 4 hour standard)

 

For more information to aid local delivery see what works, resource links, benefits, evidence, local stories and case studies as well as impact/measures in ‘word version of draft frailty toolkit’ page 85