The Whittington Frailty Pathway: improving access to comprehensive geriatric assessment: an interdisciplinary quality improvement project

Abstract

National guidelines mandate identification and tailored management of patients living with frailty who attend the acute hospital setting. We describe using quality improvement (QI) techniques to embed a system that allowed identification of frailty in older patients attending the emergency department (ED), creation of a clinical pathway to facilitate comprehensive geriatric assessment and appropriate same-day discharge of suitable patients. Integration of Clinical Frailty Scale (CFS) scoring within an electronic record system, a continuing programme of education and awareness, and dedicated project staff allows patients to be identified for an ambulatory frailty pathway. Our results show a sustained improvement over 9 months of the project, with 73% of patients over the age of 75 years presenting to ED by ambulance now receiving a CFS score. Over 300 patients have been identified, transferred to ambulatory care and treated via a new frailty pathway, with an admission rate for this cohort of 14%, compared with an overall admission rate of 50% for patients over 75 years. We report a decrease in overall ED admission of 1%. Analysis of patients discharged through this same-day pathway showed a 7-day ED reattendance rate of 15.1% and a 30-day readmission rate of 18.9%, which are comparable with current pathways. Consultant review estimated 87% of patients to have avoided a longer admission. Patient and staff satisfaction indicates this pathway to be feasible and acceptable to users. Our data suggest an ambulatory frailty pathway can deliver significant admission avoidance while maintaining low readmission rates. Similar schemes in other hospitals should consider using QI approaches to implementation of frailty pathways.