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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, 1 st Feb 2013 - PowerPoint PPT Presentation
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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.