1. Frazer Underwood Consultant Nurse for Older Peoples Services Associate Director of Nursing Royal Cornwall Hospitals NHS Trust Assessment Units for Older People

2.  What older people are we looking for? Care home admission deflections Selected long-term conditions Complex co-morbidity ‘Step-up’…but not step over the front door Day hospital assessment candidates ‘Sub-acute’ cases The Very Frail

3. “The debate has centred on whether frailty should be defined purely in terms of biomedical factors or whether psychosocial factors should be included” Lally, F and Crome, P (2007) Understanding Frailty. Post Graduate Medical Journal. 83 pp16-20 What‘s frailty?

4. THREE OR MORE:TWO OR MORE  Unintentional weight loss  Self-reporting exhaustion  Weakness (reduced grip strength)  Slow walking speed  Low physical activity  Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA; Cardiovascular Health Study Collaborative Research Group. J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-56.  Inability to perform one or more ADL in three days before admission  Stroke in prev. three months  Depression  Dementia  History of falls  One or more unplanned admission in prev. three months  Difficulty walking  Malnutrition  Prolonged bed rest  Incontinence  BGS 2010 (Best Practice Guide 3.5)

5.  Kings' A&E over 75 risk assessment Waterlow (+ neurological deficit, mobility pre A&E, trauma and pre existing medical conditions inc. Clinical dehydration)  Davies-Gray M (2003) Nurse led fast track for vulnerable older people. Emergency Nurse 11(5). pp34-38 Finding the frail

6.  Comprehensive Geriatric Assessment  BGS (2005) Comprehensive Assessment of the Frail Older Person in Hospital.BGS Website Compendium 3.5  BGS (2010) Comprehensive Assessment of the Frail Older Person. BGS website  Ellis, G and Langhorn, P. (2005) Comprehensive Geriatric Assessment for Older Hospital Patients. British Medical Bulletin. 71. pp 45-59 Assessing the frail

7. Multi-factorial Inter- professional Assessment Frail Older Person TriageTrajectory Transfer Diagnostics Treatment initiation Liaison Negotiation Plan Co-ordination Communication ACUTECAREACUTECARE COMMUNITYCARECOMMUNITYCARE Wrapping the system around…

8.  Unit set-up and evaluation  Criteria Over 70 years old plus one of the following:  Presence of delirium or dementia (AMTS)  Fracture as presenting problem but medically unstable (not NOF)  Care home resident  ED frailty score ≥ 25 (Waterlow+) University Hospitals of Leicester Frailty Unit

9.  Unit set-up Single front door = shrinking MAU bed base (OPAL Unit on MAU ward template) Establishing bed base from ED and MAU frailty data – Frailty Tool (Waterlow+) (19 beds and ALOS = 72 hours) One geriatrician on unit 7/7 (plus 0.5 for OPAL Team 5/7) Specialist nursing and AHP team on unit Royal Cornwall Hospitals OPAL Unit Frail Older Person’s Rescue Service

10. Triage Transfer Trajectory Frailty Unit OPAL Unit Frail Older Person’s Rescue Service