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

2. “Our glory and our burden” K Rockwood
“Think Frailty”
“Our glory and our burden”
K Rockwood

3. 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

4. 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

5. “anybody over 65”
Why we changed
How we changed
What we achieved

6. 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 +++)

7. 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 +++)

8. Do they work?

9. 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

10. Already validated tools
ISAR
EISAR
HARP
REFS

11. Simple Clinical Criteria

12. ACE ward
Referral Document

13. ‘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

14. ‘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

15. ‘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

16. 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?

17. Challenges (2)
Applicability for use in areas other than acute medical receiving
Transfer tool versus referral tool
Resources

19. 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

20. 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

21. 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.