Introduction of Frailty Tools and Change Package Brian McGurn NHS Lanarkshire Michelle Miller Healthcare Improvement Scotland

“Our glory and our burden” K Rockwood “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

Identification of Frail Patients Infrastructure and Resources Focus on Frailty Triage Identification of Frail Patients Bournemouth Criteria North Staffs Simple Clinical Criteria NHSL 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 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?

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 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 CGA Would 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

Identification of Frailty Education, Leadership and Culture Improving Care for Older People in Acute Care: Think Frailty Driver Diagram Secondary Drivers Primary Drivers Aim 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 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. 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 Care pathway Education, Leadership and Culture 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.