Introduction of Frailty Tools and
Change Package
Brian McGurn
NHS Lanarkshire
Michelle Miller
Healthcare 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
Focus on Frailty
Triage
Bournemouth Criteria
North Staffs
Identification of Frail Patients
Simple Clinical Criteria
NHSL
Infrastructure and Resources
Acute Care of Elderly Ward
ACE nurses in MAU
Delivering CGA
Nurse specialist in MAU
to frail patients
Checklists for CGA
“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 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 +++)
Do they work?
age by catagory
survival
50
78
76
74
72
% of patients decesed
80
% alive
82
% patients suitable for COTE
45
100
84
90
80
40
95
35
90
30
85
80
25
70
60
50
COTE
40
75
20
30
70
15 20
65
10 10
60
5 0
55
Cote
9/12
suitable COTE
suitable MED
0-.1
0-0.1
0
70
6/12
MED
0
50
3/12
.1-.2
0.1-0.2
3
.2-.3
0.2-0.3
6
Med
0.3-0.4
0.4-0.5
frailty index
0.5-0.6
9
frailty index
Suitable Cote
months
.3-.4
Suitable Med
.4-.5
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 ward
Referral
Document
‘Think Frailty’ Triage Tool
Step 1
Would this person benefit from Comprehensive Geriatric Assessment (CGA)?
Over 65 and ….
Yes
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
No
‘Think Frailty’ Triage Tool
Step 2 – for those potentially being referred for CGA
Would this person be better managed by another specialty team at present?
Indicator for care by another acute specialty
Yes
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
No
‘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
Improving Care for Older People in Acute Care: Think Frailty Driver Diagram
Primary Drivers
Aim
Screening of admission to identify frailty
Identification of
Frailty
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.
Secondary Drivers
Care pathway
Education,
Leadership and
Culture
•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
•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
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 frailty
Time from admission/identified as frail to having comprehensive geriatric
assessment or admission to a specialist unit (aim: within a day of admission)
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
Learning About Experience Card - Frailty
Learning from the experience of patients, families and carers
What did we get right
for you?
How could we have
made your experience
during this time even
better?
This card should be completed by:
A patient in hospital
A 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.