Severe Frailty
CFS SCORE: 7 and more
KEY INTERVENTIONS: Crisis Response and Recovery, Hospital-based Frailty Care
| Involve
Enhance the voice of older people, carers and families to tackle the frailty challenge together at a community and individual level.
Visit the Frailty icare website for more on ‘Involve’
| Consider
Always think frailty! An awareness of the modifiable risk factors for frailty and complications related to frailty can help with early appropriate lifestyle interventions.
Prolonged Hospital Stay
Frail patients with acute care needs are especially vulnerable to harm from delays in diagnosis and to ‘deconditioning’ while in hospital. For example, 35% of 70-year-olds experience functional decline. For 90-year-olds this is 65% reduction.
People seen in hospital with a high frailty risk had a 1.7 times more likely to die at 30 days compared a low frailty risk people. They also had a 6 times higher chance of emergency re-admission within 30 days compared to low-risk people.
One-fifth of beds are occupied by people who have been in hospital for over three weeks. Most of these people have frailty (e.g. reduced functional ability and/or cognitive impairment).
Post-Hospital Discharge
Around a third of adult patients in an NHS acute bed are in the last year of their lives, although many won’t know it, and nor can doctors necessarily predict it. About 40% of over 65s will die within 12 months of leaving hospital. Those with severe frailty are four times more likely to die within 12 months.
Older people who saw deterioration in their balance and mobility in the first 48 hours of hospital admission had a 17-fold increase in risk of death within fourteen days.
Half of frail older people discharged home within 72 h from such settings are readmitted and one-third die within a year, with the majority of these events occurring in the first 90 days.
Older people have nearly a 40% readmission rate at 6 months after discharge from A&E.
Visit the Frailty icare website for more on ‘Consider’
| Assess
If there are any signs of pre-frailty or frailty, patients should be assessed using the Clinical Frailty Scale for verification and classification of their level of frailty.
Visit the Frailty icare website for more on ‘Assess’
| Respond
Access to community crisis and recovery services (with active recuperation, rehabilitation and re-ablement) including frailty-focused transport and timely transfers of care from hospital involving families and carers. Also, where needed, access to experts offering frailty-based care in hospital with frailty assessment, diagnostics and pathways.
What Works?
Implement a front door MDT to assess frailty, commence CGA with links to community teams and VSCE for robust discharge – 24/7
Implement strategies to avoid unexpected deaths - warning scores, critical care outreach, regular senior review and adequate access to high dependency beds.
Create safer care - prevention and treatment of falls, pressure sores, hospital-acquired infection, medication errors, deep vein thrombosis and malnutrition, delirium and immobility as a result of bed rest.
Minimise in-patient moves (especially in patients with delirium)
Offer frailty liaison and in-reach services
Offer crisis response with access to multi-disciplinary teams within 2 hours.
Single point of access with specialist opinion and diagnostics
Design adequate and flexible step-up and step-down home-based and bed-based rehabilitation and re-ablement services
Implement assertive discharge planning, early senior review, ‘discharge to assess’, a clear focus on flow and sharing information – ‘date of discharge’ within 2 hours and care package available within 24 hours of referral
Adopt a trusted assessor approach with access to step-up and step-down home-based and bed-based services - 2 days target
Adequate and timely information must be shared between services whenever there is a transfer of care between individuals or services
Visit the Frailty icare website for more on ‘Respond’
| Evaluate
To see if you are making a difference, whether at an individual level or within your local area or system, consider the following…
The benefit for individuals
Measuring what you’re doing
The impact on populations, communities and services
Benefits
Reduce the likelihood of living in residential care at six months’ follow-up when avoiding acute hospital admission
Decrease treatment costs compared with admission to acute hospital when excluding caregiver costs
Increase patient satisfaction
Reduce length of stay for people who can be safely discharged early from acute hospital
Increase the number of patients discharged home, rather than to an institution, after three months (although this was not sustained at six months)
Reduce ongoing care needs
Improve functional status when compared with usual home care
Reduction in falls, medication errors, VTEs, and delirium
Reduced functional decline
Improved experience of care
Reductions in bed occupancy, readmissios and length of stay
Reduction in mortality without affecting re-admission rates or requiring additional resources.
Improved survival at home after discharge
Impact
Across NENC, bed usage following non-elective admission. The frail population (moderate and severe combined) makes up 2.44% of the population across the North East and North Cumbria, but account for 19.1% of general and acute bed usage.
Frail patients make up 11.8% of the 65+ population and account for 27.3% of bed usage for that age group.
Length of stay following non-elective admission is 7.9 days for the frail population compared to 4.4 days for the non-frail population (all ages) and 7.3 days for the non-frail population aged 65+.
Thirty-day emergency readmission rates for the frail population is 20.7% compared to 16.9% for the non-frail population and 19.3% for the non-frail population aged 65+.
Ninety-day emergency readmission rates for the frail population is 33.4% compared to 25.4% for the non-frail population and 29.4% for the non-frail population aged 65+.
Place of death
Acquired hospital problems
Bed occupancy rates
Visit the Frailty icare website for more on ‘Evaluate’
+ Resources
Reducing long stays: Where best next campaign (NHS England)
National Audit of Intermediate Care (NHS Benchmarking Network)
Discharging Older Patients from Hospital Report (National Audit Office)
Transition between inpatient hospital settings and community or care home settings for adults with social care needs - Guidance (NICE)
The Silver Book - guidelines for the emergency care of older people (British Geriatrics Society)
Acute Care Toolkit 3: Acute medical care for frail older people (Royal College of Physicians)
NHS Elect Website - has information on acute frailty care
Managing Acute Frailty Toolkit - Acute Frailty Network
Same-day Acute Frailty Services (NHS Improvement, NHS England)
For more useful resources, visit the ‘Community Crisis Response and Recovery’ and ‘Frailty-based Hospital Care’ sections of the Frailty iCARE website.
