Context

Annual data from ED showed 150–200 weekly ED attendances from patients aged >75 years, with weekly and seasonal fluctuation within expected limits of normal variation. During winter 2017/2018, an occupational therapist (OT) was available to identify older patients with therapy needs at point of attendance. Data from this project showed a frailty prevalence of 53% (Rockwood scores 5 or above) in patients over 75 years attending ED, similar to previous work.15 16 Due to funding constraints this was not ongoing, but had proved the concept and feasibility of identifying frailty at the front door.

Our ED has 15 assessment spaces in majors, with an adjacent eight-bedded clinical decision unit (CDU). Once a decision has been made to admit a patient, the majority are moved to a 34-bedded medical admissions unit or directly admitted to an inpatient specialist ward. We noticed that 32% of all admissions were for less than 24 hours, and hypothesised that there is a cohort of older patients who take longer than the national 4-hour ED target to fully assess, but who could potentially go home from hospital without admission. Furthermore, a proportion of this group of patients were likely to be frail and would benefit from CGA to address unmet need, integrate with community services and reduce readmissions.

Our key enablers were an MDT workforce including a specialist nurse in older people, skilled therapies input, clinical and leadership colleagues from ED, geriatrics and acute medicine, as well as pharmacy, informatics and project support. A general practitioner (GP) frailty fellow with experience in QI techniques was available to support the project. The Whittington Hospital has an established ambulatory care department,17 staffed from 08:00 to 20:00, with clinical leadership supportive of transferring stable frail adults from ED to this department for CGA initiation. Safer discharge is facilitated with the help of our virtual ward, including local GPs, and CGA can be completed in the patient’s own home by our community geriatrics service.

Our baseline data also showed that for patients over 75 years attending ED and discharged directly, 17% would reattend ED within 7 days (although without manually reviewing notes, it is not possible to comment on whether the same or unrelated problem). We also knew that for patients over 75 years discharged from the hospital within 24 hours after an unplanned admission, 11% will be readmitted within 30 days. For patients discharged from the inpatient geriatrics wards, the 30-day readmission rate is 24% (with an average length of stay of 15 days).

Specific aims and rationale

Our aim was to use recognised QI tools to implement a frailty pathway into the ED and ambulatory care setting, increasing CFS scoring at the front door and providing an MDT CGA intervention, while paying attention to balancing factors including reattendance and readmission rates. Our driver diagram (figure 1) explains our rationale, along with the change ideas that we developed and planned to implement. This was developed in an iterative manner using the skills and knowledge of all members of our MDT clinical team.

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Figure 1

Driver diagram. CFS, Clinical Frailty Scale; CGA, comprehensive geriatric assessment; ED, emergency department.

Intervention and study

Our frailty pathway launched in April 2018 (online supplementary appendix 1). As described by the National Health Service (NHS) Model for Improvement,18 we used established QI methods combining measurement and analysis with small tests of change (plan-do-study-act (PDSA) cycles). A core project team met weekly to discuss the data from the previous week and to problem-solve. This meeting was specifically not for discussion of clinical content, but to support the implementation of this change project. Contemporaneous data from the informatics team were displayed using Life QI and Excel statistical process control (SPC) charts. We reviewed what real-life changes had occurred during the week (including staffing, operational, planned and unplanned changes) to assess whether our intervention had resulted in an improvement.

Our first intervention was the creation of a CFS template for our electronic record system (Medway). This can be completed by any staff member at any stage of the patient attendance. As part of this PDSA cycle, we trialled different ways of promoting this to staff. We used posters, which have been amended and redisplayed both physically as laminates above computers in ED and virtually as screen-savers across the trust. Promotion work continued with attendance at daily shop floor clinical gatherings in ED (known locally as ‘10@10’, 10 min at 10:00), use of ‘Message of the Month’ forums to promote the frailty service and encourage CFS scoring, and training on how to use the assessment tool provided through monthly ED nursing clinical team meetings as well as ad-hoc shop floor training and electronic guides via email. In July, we developed a ‘Frailty Highlights’ report showing a run chart of how many scores had been completed, which was sent fortnightly by email to clinical, operational and leadership teams. In July, a paper ED checklist was developed to complement the existing hard copy nursing paperwork, which included completion of the electronic CFS as a prompt. This was incorporated into the patient safety checklist, completed for all patients in the ED, by October. In November, the ED admin team began prompting clinicians to complete CFS for any patient over 75 years who had been in the department for more than 1.5 hours without it already completed.

Our second intervention was the creation of the ambulatory care frailty pathway. Initially patients were informally transferred to the department as part of the existing case load. We made changes to this pathway, including the creation of an electronic case load folder ‘Medical Frailty’ to distinguish these patients from the routine work of ambulatory care, and confirming of consultant-to-consultant handover between ED and ambulatory care. Operational issues with this pathway were dealt with at the weekly meetings and escalated to managerial support as required.

Our third intervention was about developing support for the service. In August, one of the ED matrons took on a leadership role within the department to promote the service, encouraging and reminding staff members to use the pathway. Through organisation-sponsored ‘Superweeks’ allowing focus on a specific clinical area, in July and December, we were able to free up clinician time to support adaptations to the service. In the first ‘Superweek’, a consultant geriatrician led a daily 14:00 huddle in ED, along with a specialist nurse in older people, therapy and ED nurse colleagues. This became an ongoing part of the service in September. The second ‘Superweek’ in December allowed the team to introduce a twice-daily huddle (09:00 and 14:00), patient handover was done directly from ED consultant to the geriatrician supporting the service, and frail patients identified out of hours stayed overnight in CDU beds before transfer to ambulatory care in the morning. There was difficulty staffing the service over the December holiday periods due to staff; however, a full-time OT was available from November to support the pathway in ED triage.

Measures and analyses

We included a range of process and outcome measures in response to the views of our different stakeholders.

Our main outcome measure was the recording on the electronic patient record system of a clinical frailty score for patients over 75 years, expressed as a percentage of total ED attendances. This was our measure for tracking whether we could create a reliable system for identifying frailty within ED. This was remotely extracted on a weekly basis by the informatics team. Related process measures were the total number of ED attendances and types of attendance. Additional analyses were done of day and time of attendance to offer insights to guide improvement work.

Our second main outcome measure was on conversion rate from ED attendance to hospital admission for the over 75 years group. These data are routinely collected and offered an easily understood metric to communicate with hospital managers.

Our third principal set of measures was around the activity of the frailty pathway. We tracked the number of patients seen, completion of an electronic CGA template (when became available in November 2018) and the admission rate to hospital of patients assessed on the pathway.

We used time series to display and measure change, analysed using the theory of SPC.19 This enabled modifications of the improvement activities, based on real-time changes. By using Life QI software, we could distinguish between background or ‘common cause’ variation in our data and ‘special cause’ variation. We recognised that unintended adverse effects are particularly likely in frail older people, such as impact on patient experience or an increased occurrence of unplanned hospital readmissions. A retrospective analysis was done on patients seen within the pathway to establish whether they re-presented to hospital after the described intervention. This gave us our main balancing measures of ED reattendance and hospital readmission. Patient and staff feedback was gathered using the Meridian patient survey system20 and coordinated by the hospital patient experience team during the ‘Superweeks’.