NIHR Signal A frailty checklist was completed in only a quarter of older people at hospital admission

Published on 20 February 2018

Frailsafe is a simple safety checklist offering the opportunity to improve safety and quality of care for frail older people while in hospital. It aims to increase key clinical assessments or practices on things like risk of falls, mobility and delirium, and to facilitate communication between staff. However, the relatively low completion rate highlights the need to understand how this approach can be better embedded in the complex care that is typical of services provided for older people.

Comprehensive assessment of the frail older person in the emergency department is rarely feasible. Frailsafe was introduced in 12 NHS hospitals to help health professionals complete key frailty assessments and ultimately improve patient outcomes. Views on the checklist and completion rates were assessed through staff interviews and ward observations.

The tool was mostly used by senior doctors, with a minimal challenge from junior staff and other healthcare disciplines. Most successes came when geriatricians were available in the acute setting to undertake the assessments.

There appears need to consider organisational changes of geriatric services within hospitals before wider implementation of the checklist.

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Why was this study needed?

There are 1.8 million people over 60 living with frailty in England and 800,000 over 80 years. As the population continues to age, so will the number of people with frailty and multiple care needs. These people are at higher risk of emergency admission, longer inpatient stays and discharge planning can be complex.

The Frailsafe checklist was designed to improve quality of care and health outcomes for frail older people needing emergency admission. It was intended as a ‘check and challenge’ list that would increase communication between junior and senior staff members in acute medical assessment units. The checklist was piloted in 12 NHS hospitals over a one year period (September 2014 to 2015) supported by three learning events.

This mixed methods study aimed to evaluate how local teams had implemented Frailsafe across 12 participating NHS trusts and what they thought about it and its influence on patient safety and quality of care.

What did this study do?

A total of 139 health professionals took part in 110 interviews, 10 joint interviews and three group discussions. Participants included geriatric specialists, junior doctors, nurses, ward staff, physiotherapists and occupational therapists. 

Researchers shadowed ward rounds and team meetings to give 100 hours of real-time observations of formal and informal discussions. All assessments and admissions documents from the first 24-48 hour period in the acute medical assessment units were collected for review. Preliminary findings were shared with project leads to comment before results were summarised.

They looked at whether specific elements of Frailsafe had been completed, such as assessment of falls, mobility, pressure ulcers, dementia, delirium, resuscitation status and medicines review.

The mixed methods study included both quantitative data and qualitative data. As participants were aware of the purpose of the study, it is possible that compliance with the checklist was more than what might have been seen in real life or if they were unaware of an audit. Additionally, the extent of data capture varied between the 12 sites making the comparison of findings difficult.

What did it find?

  • Overall compliance with the items on the checklist for the whole period across the 12 sites was 24% (1,687 completed 7,201 checklists). This means only about 1 in 4 patients had evidence if receiving all the appropriate checks. Most hospitals completed the medication reviews and pressure ulcer risk assessments (around 60 to 100%). There was wide variation in the completion of delirium and dementia assessments (between 3 and 96%).

Qualitative findings:

  • The effect on multidisciplinary team-working varied between sites. In hospitals with previously poor multidisciplinary interaction, the introduction of Frailsafe helped teams re-think their approach to acute elderly care. In hospitals with good hierarchical structures to start with, the checklist did not change communication patterns but tended to accentuate differences between specialities.
  • Failsafe was rarely used as a verbal ‘check and challenge’ process as initially intended. Use of the checklist was largely driven by senior doctors, with minimal challenge from junior staff. Sometimes actions would be added to patient notes but were not directly communicated to responsible staff.
  • Participants found the checklist useful for identifying frail patients in acute admissions and as a prompt to identify tasks perhaps being missed. Drawbacks included views the checklist overlapped with existing practices, didn’t prompt action but relied on individual decisions, and the potential for the ‘tick box’ format to prevent proper reflection on the person’s condition.
  • Frailsafe worked well in hospitals where geriatricians started working in acute care settings. Bringing frailty care to the point of hospital admission highlighted the relevance and impact of the checklist.

What does current guidance say on this issue?

There is no specific guidance on frailty checklists in acute care, though Frailsafe is endorsed by the British Geriatrics Society.

NICE guidelines on assessment of multi-morbidity, and transitioning between hospital and community care, recommend that Comprehensive Geriatric Assessment is started at the point of hospital admission, ideally in specialist units for older people.

Comprehensive Geriatric Assessment is considered the gold standard for assessing frailty. The British Geriatrics Society provides a toolkit for completing these assessments in primary care, which is endorsed by NHS England. NIHR has funded some studies in this area, including a review showing the benefits of assessment in promoting independence and wellbeing (Ellis 2017).

As part of their 2017/18 contract, GPs are also required to identify patients aged over 65 who may be living with moderate to severe frailty. The annual review of medication and any falls in the past 12 months contains similar components to the hospital-based assessments.

What are the implications?

A 2017 NIHR themed review on comprehensive care for older people with frailty in hospitals highlighted that Comprehensive Geriatric Assessment is time intensive and may be unsuited to the urgent acute setting. It suggested that single assessment tools may be helpful for specific symptoms, such as delirium.

Frailsafe could, in theory, support Comprehensive Geriatric Assessment by providing a plan of action at the point of admission. However, it seems that the tool should be considered as part of a complex intervention. A key feature of Comprehensive Geriatric Assessment is having input from a multidisciplinary team on important questions of mobility, hydration, risk of delirium and so on.

Structural changes within hospitals seem necessary for successful implementation. This includes wider attention of geriatric services, with greater resource allocation, staff training and specialist availability.

Citation and Funding

Papoutsi C, Poots A, Clements J, et al. Improving patient safety for older people in acute admissions: implementation of the Frailsafe checklist in 12 hospitals across the UK. Age and Ageing. 2018. [Epub ahead of print].

This project was funded by the National Institute for Health Research (NIHR) under the Collaborative for Leadership in Applied Health Research and Care (CLAHRC) North West London and a Health Foundation ‘Closing the Gap in Patient Safety’ award.

Bibliography

British Geriatrics Society. Comprehensive Geriatric Assessment (CGA). London: British Geriatrics Society; 2014.

Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017;9:CD006211.

Frailsafe. The Safety Tool. London: Frailsafe; 2018.

NHS England. Older people living with frailty. London: Department of Health; 2018.

NHS England. Toolkit for general practice in supporting older people living with frailty. No. 2. Leeds: NHS England; updated 2017.

NHS England. Updated guidance on supporting Routine Frailty Identification and Frailty Care through the GP Contract 2017/2018. No. 2. Leeds: NHS England; updated 2017.

NICE. Guidance on multimorbidity: clinical assessment and management. NG56. London: National Institute for Health and Care Excellence; 2016.

NICE. Guidance on transition between inpatient hospital settings and community or care home settings for adults with social care needs. NG27. London: National Institute for Health and Care Excellence; 2015.

NIHR DC. Comprehensive care. Older people living with frailty in hospitals. Southampton: National Institute for Health Research Dissemination Centre; 2017.

Why was this study needed?

There are 1.8 million people over 60 living with frailty in England and 800,000 over 80 years. As the population continues to age, so will the number of people with frailty and multiple care needs. These people are at higher risk of emergency admission, longer inpatient stays and discharge planning can be complex.

The Frailsafe checklist was designed to improve quality of care and health outcomes for frail older people needing emergency admission. It was intended as a ‘check and challenge’ list that would increase communication between junior and senior staff members in acute medical assessment units. The checklist was piloted in 12 NHS hospitals over a one year period (September 2014 to 2015) supported by three learning events.

This mixed methods study aimed to evaluate how local teams had implemented Frailsafe across 12 participating NHS trusts and what they thought about it and its influence on patient safety and quality of care.

What did this study do?

A total of 139 health professionals took part in 110 interviews, 10 joint interviews and three group discussions. Participants included geriatric specialists, junior doctors, nurses, ward staff, physiotherapists and occupational therapists. 

Researchers shadowed ward rounds and team meetings to give 100 hours of real-time observations of formal and informal discussions. All assessments and admissions documents from the first 24-48 hour period in the acute medical assessment units were collected for review. Preliminary findings were shared with project leads to comment before results were summarised.

They looked at whether specific elements of Frailsafe had been completed, such as assessment of falls, mobility, pressure ulcers, dementia, delirium, resuscitation status and medicines review.

The mixed methods study included both quantitative data and qualitative data. As participants were aware of the purpose of the study, it is possible that compliance with the checklist was more than what might have been seen in real life or if they were unaware of an audit. Additionally, the extent of data capture varied between the 12 sites making the comparison of findings difficult.

What did it find?

  • Overall compliance with the items on the checklist for the whole period across the 12 sites was 24% (1,687 completed 7,201 checklists). This means only about 1 in 4 patients had evidence if receiving all the appropriate checks. Most hospitals completed the medication reviews and pressure ulcer risk assessments (around 60 to 100%). There was wide variation in the completion of delirium and dementia assessments (between 3 and 96%).

Qualitative findings:

  • The effect on multidisciplinary team-working varied between sites. In hospitals with previously poor multidisciplinary interaction, the introduction of Frailsafe helped teams re-think their approach to acute elderly care. In hospitals with good hierarchical structures to start with, the checklist did not change communication patterns but tended to accentuate differences between specialities.
  • Failsafe was rarely used as a verbal ‘check and challenge’ process as initially intended. Use of the checklist was largely driven by senior doctors, with minimal challenge from junior staff. Sometimes actions would be added to patient notes but were not directly communicated to responsible staff.
  • Participants found the checklist useful for identifying frail patients in acute admissions and as a prompt to identify tasks perhaps being missed. Drawbacks included views the checklist overlapped with existing practices, didn’t prompt action but relied on individual decisions, and the potential for the ‘tick box’ format to prevent proper reflection on the person’s condition.
  • Frailsafe worked well in hospitals where geriatricians started working in acute care settings. Bringing frailty care to the point of hospital admission highlighted the relevance and impact of the checklist.

What does current guidance say on this issue?

There is no specific guidance on frailty checklists in acute care, though Frailsafe is endorsed by the British Geriatrics Society.

NICE guidelines on assessment of multi-morbidity, and transitioning between hospital and community care, recommend that Comprehensive Geriatric Assessment is started at the point of hospital admission, ideally in specialist units for older people.

Comprehensive Geriatric Assessment is considered the gold standard for assessing frailty. The British Geriatrics Society provides a toolkit for completing these assessments in primary care, which is endorsed by NHS England. NIHR has funded some studies in this area, including a review showing the benefits of assessment in promoting independence and wellbeing (Ellis 2017).

As part of their 2017/18 contract, GPs are also required to identify patients aged over 65 who may be living with moderate to severe frailty. The annual review of medication and any falls in the past 12 months contains similar components to the hospital-based assessments.

What are the implications?

A 2017 NIHR themed review on comprehensive care for older people with frailty in hospitals highlighted that Comprehensive Geriatric Assessment is time intensive and may be unsuited to the urgent acute setting. It suggested that single assessment tools may be helpful for specific symptoms, such as delirium.

Frailsafe could, in theory, support Comprehensive Geriatric Assessment by providing a plan of action at the point of admission. However, it seems that the tool should be considered as part of a complex intervention. A key feature of Comprehensive Geriatric Assessment is having input from a multidisciplinary team on important questions of mobility, hydration, risk of delirium and so on.

Structural changes within hospitals seem necessary for successful implementation. This includes wider attention of geriatric services, with greater resource allocation, staff training and specialist availability.

Citation and Funding

Papoutsi C, Poots A, Clements J, et al. Improving patient safety for older people in acute admissions: implementation of the Frailsafe checklist in 12 hospitals across the UK. Age and Ageing. 2018. [Epub ahead of print].

This project was funded by the National Institute for Health Research (NIHR) under the Collaborative for Leadership in Applied Health Research and Care (CLAHRC) North West London and a Health Foundation ‘Closing the Gap in Patient Safety’ award.

Bibliography

British Geriatrics Society. Comprehensive Geriatric Assessment (CGA). London: British Geriatrics Society; 2014.

Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017;9:CD006211.

Frailsafe. The Safety Tool. London: Frailsafe; 2018.

NHS England. Older people living with frailty. London: Department of Health; 2018.

NHS England. Toolkit for general practice in supporting older people living with frailty. No. 2. Leeds: NHS England; updated 2017.

NHS England. Updated guidance on supporting Routine Frailty Identification and Frailty Care through the GP Contract 2017/2018. No. 2. Leeds: NHS England; updated 2017.

NICE. Guidance on multimorbidity: clinical assessment and management. NG56. London: National Institute for Health and Care Excellence; 2016.

NICE. Guidance on transition between inpatient hospital settings and community or care home settings for adults with social care needs. NG27. London: National Institute for Health and Care Excellence; 2015.

NIHR DC. Comprehensive care. Older people living with frailty in hospitals. Southampton: National Institute for Health Research Dissemination Centre; 2017.

Improving patient safety for older people in acuteadmissions: implementation of the Frailsafe checklist in 12hospitals across the UK

Published on 5 January 2018

C Papoutsi, A Poots, J Cllements, Z Wyrko, N Offord, J Reed

Age and Ageing , 2018

Background: Checklists are increasingly proposed as a means to enhance safety and quality of care. However, their use has been met with variable levels of success. The Frailsafe project focused on introducing a checklist with the aim to increase completion of key clinical assessments and to facilitate communication for the care of older patients in acute admissions. Objectives: To examine use of the Frailsafe checklist, including potential to contribute to improved safety, quality and reliability of care. Methods: 110 qualitative interviews and group discussions with healthcare professionals and other specialties, 172hrs of ethnographic observation in 12 UK hospitals and reporting of high-level process data (completion of checklist and relevant frailty assessments). Qualitative analysis followed a thematic and theory-driven approach. Results: Through use of the checklist, hospital teams identified limitations in their existing assessments (e.g. absence of delirium protocols) and practices (e.g. unnecessary catheter use). This contributed to hospitals reporting just 24.02% of sampled patients as having received all clinical assessments across key domains for this population for the duration of the project (1687/7021 checklists as fully completed). Staff perceptions and experiences of using the checklist varied significantly, primarily driven by the extent to which the aims of this quality improvement project aligned with local service priorities and pre-existing team communications styles. Conclusions: The Frailsafe checklist highlighted limitations with frailty assessment in acute care and motivated teams to review routine practices. Further work is needed to understand whether and how checklists can be embedded in complex, multidisciplinary care. Keywords:

Comprehensive Geriatric Assessment (CGA) is a multidisciplinary assessment of an older individual for physical symptoms, mental health, level of function and social circumstances. CGA allows the formulation a management strategy that includes individual care and rehabilitation plan tailored to each patient’s needs, wants and priorities.

Expert commentary

This rigorous multi-method study highlights that checklists alone are not enough when introduced in complex care settings. The Frailsafe tool was used more as a tick-box exercise, rather than as a reflective way to review frailty assessments.

Given that findings are consistent with previous research, this study reminds us (again) of the importance of relationships and developing communities of practice to deliver evidence-informed innovation.

These are important messages not only for quality improvement collaboratives but also, research funders. We need to ask more questions about what is known to work, or not, earlier in the research process.

Julienne Meyer CBE, Professor of Nursing: Care for Older People; City, University of London