Introduction of Frailty Tools and Change Package

Brian McGurnNHS Lanarkshire

Michelle MillerHealthcare Improvement Scotland

“Think Frailty”

“Our glory and our burden”K Rockwood

Brief – from the Dragon’s Den!

• Focus on Frailty- Consensus Building Workshop, 1st Feb 2013

• Share good practice and learning from NHS Lanarkshire in screening for frailty

• The benefits of this work• Introduce the Frailty Triage Tool

Triage

Identification of Frail Patients

Focus on Frailty

Bournemouth CriteriaNorth Staffs

Simple Clinical CriteriaNHSL

Acute Care of Elderly Ward

ACE nurses in MAU

Nurse specialist in MAU

Checklists for CGA

Infrastructure and Resources

Delivering CGA

to frail patients

“anybody over 65”

• Why we changed• How we changed• What we achieved

Simple Clinical Criteria Predict Frailty

General Medicine• Clear need for specialty

input (eg ischaemic chest pain)

• Mono-pathology (eg large pleural effusion)

• Minor impairment of daily function (eg UTI, safely mobilised by rapid response team)

• Uncomplicated discharge planning

CoTE• Falls/immobility/confusion• Multiple co-morbidity

(eg heart failure, anaemia and confusion)

• Major impairment of ADL (eg hoisting to transfer)

• Complicated discharge (eg delirium plus dementia, carer stress +++)

Simple Clinical Criteria Predict FrailtyGeneral Medicine

• Clear need for specialty input (eg ischaemic chest pain)

• Mono-pathology (eg large pleural effusion)

• Minor impairment of daily function (eg UTI, safely mobilised by rapid response team)

• Uncomplicated discharge planning

CoTE• Falls/immobility/confusion• Multiple co-morbidity

(eg heart failure, anaemia and confusion)

• Major impairment of ADL (eg hoisting to transfer)

• Complicated discharge (eg delirium plus dementia, carer stress +++)

Do they work?age

70

72

74

76

78

80

82

84

Cote Med Suitable Cote Suitable Med

survival by catagory

50556065707580859095

100

0 3 6 9

months

% a

live COTE

MED

suitable COTE

suitable MED

05

1015

2025

3035

4045

50

0-0.1 0.1-0.2 0.2-0.3 0.3-0.4 0.4-0.5 0.5-0.6

frailty index

% o

f pat

ient

s de

cese

d

3/12

6/12

9/12

0102030405060708090

0-.1 .1-.2 .2-.3 .3-.4 .4-.5

frailty index

% p

atie

nts

suita

ble

for C

OTE

Developing a frailty tool

• Deceptively difficult– Frailty syndromes vs Frailty– Exclusions to reduce disadvantage ie equitable

access to other specialties• Domains to cover

– Age– Functional status including cognition– Disease burden

• Collaboration

Already validated tools

• ISAR• EISAR• HARP• REFS

Simple Clinical Criteria

ACE wardReferral

Document

‘Think Frailty’ Triage Tool Step 1 Would this person benefit from Comprehensive Geriatric Assessment (CGA)?

Over 65 and ….Yes No

Complex multiple conditions

Falls in the last 3 months

Resident in a care home

Acute or chronic confusion

Impaired mobility or self care

Likely to need complex support for discharge

Are any of the above criteria met?

If YES to any of the above move to Step 2

‘Think Frailty’ Triage Tool Step 2 – for those potentially being referred for CGAWould this person be better managed by another specialty team at present?

Indicator for care by another acute specialty Yes No

Need for HDU / ITU (including non-invasive ventilation

Suspected new stroke or TIA

Trauma with suspected fracture

Head injury with loss of consciousness

Acute abdominal pain with collapse

Chest pain with suspected MI

Clear need for other specialty input

Are any of the above criteria met

‘Think Frailty’ Triage Tool If YES to anything in Step 2:

please ask for specialist multidisciplinary review while in their current unit but do not transfer directly to the geriatric assessment service

If NO to the list in Step 2:

prioritise for transfer of care to specialist geriatric assessment service please note this person should not be boarded unless unavoidable

Challenges (1)

• Precise application of tool– Entry criteria for CGA ward

• N Staffs/Bournemouth criteria– Or Define specialty entry criteria

• Patients for whom criteria not clear• Age – is 65 not just too young?

Challenges (2)

• Applicability for use in areas other than acute medical receiving– Transfer tool versus referral tool

• Resources

To improve the early identification of frailty and ensure that older people who are identified as frail have access to comprehensive geriatric assessment or are admitted to a specialist unit within a day of admission to hospital, by March 2014.

Care pathway

Identification of Frailty

Education, Leadership and

Culture

Aim

Primary Drivers Secondary Drivers

Screening of admission to identify frailty•Apply the ‘Think Frailty Triage Tool’ or equivalent screening tool on all older inpatients in acute care to identify those who are frail. •Promote the use of patient, family, carer feedback to improve care•Ensure patient requirements are accurately reflected in the care plan

Care Pathways•Ensure inpatients identified as frail receive early specialist comprehensive geriatric assessment•Optimise efficiencies in flow, handovers and discharge•Create a culture that involves patients and family in care

Improving Care for Older People in Acute Care: Think Frailty Driver Diagram

•Develop an infrastructure to support local testing of the ‘frailty triage tool’ using improvement approaches•Align work with other relevant work streams including wider older people’s improvement work, person centred health and care, patient flow•Optimise opportunities for spread and sustainability•Optimise opportunities to learn from and share good practice•Clinical Leadership•Develop measurement framework to guide improvement•Ensure reliable communication across clinical teams of at risk patients

Measures and Data Collection - Frailty

Reporting

enter data on excel spreadsheet (run charts automatically generated and populate monthly report – add in challenges and highlights)Send monthly report – last Friday of every month

Aim: people who are identified as frail have access to comprehensive geriatric assessment or are admitted to a specialist unit within a day of admission to hospital

Core Measures

Compliance with screening for frailtyTime from admission/identified as frail to having comprehensive geriatric assessment or admission to a specialist unit (aim: within a day of admission)

What did we get right for you?

How could we have made your experience during this time even better?

Learning About Experience Card - Frailty

Learning from the experience of patients, families and carers

This card should be completed by:A patient in hospitalA family member or carer of a patient who in hospital

Thank you for taking the time to complete this card – this will help us to understand your requirements and how we can improve your experience.