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The National Clinical Programme for Older People in Ireland recommends the implementation of methods to identify frailty in the Emergency Department (ED) and to integrate the care of frail older adults between primary, secondary and social care.  Although several models of frailty assessment teams have been piloted nationally, research into their effects on healthcare outcomes is limited. Description of practice change implemented: An integrated care pathway, consisting of dedicated medical, nursing and health and social care professional (HSCP) staff, was developed through the department of geriatric medicine, to assess frail older adults at the earliest possible point following admission through the ED. All patients >75 years admitted over the preceeding 24 hours are screened for frailty using the PRISMA-7. Those screening positive are discussed by the Frailty Service Multi-Disciplinary Team (MDT) and those deemed frail are assessed by Comprehensive Geriatric Assessment (CGA) in the ED and managed as inpatients, if appropriate. The same MDT meet daily to review progress to provide consistent and integrated care linking in with community services and an intergrated care manager. Aim and theory of change: To evaluate the experience of developing and integrating a Frailty Medicine strand within an University Hospital with existing medical, nursing and HSCP models of caring for frail older adults and to investigate whether this new model has a positive impact on healthcare outcomes including hospital length of stay (LOS) and 30-day readmission rates. Targeted population: Consecutive older adults (aged ≥75 years) that were medically stable (not requiring immediate resuscitation, intensive care or specialist medical care) and admitted through a University Hospital ED, on service operational days, were targeted. Frailty was screened using the PRISMA-7 (cut-off ≥3) and confirmed by a Consultant Geriatrician using CGA. Those admitted overnight and remaining on ED trolleys were prioritized. Timeline: We examined differences in outcomes for frail older adults after the introduction of the new service during 14 days in October 2016. Highlights: In total, 102 older patients were screened for frailty; their median age was 81 years (interquartile +/-8) and their median PRISMA-7 score was 5 (+/-4). Of these, 22 frail inpatients admitted overnight and remaining on ED trolleys were assessed and managed on the new integrated frailty pathway. Of the remainder, 54/80 (67.5%) patients were confirmed as frail but were not managed due to limited service capacity or exclusionary criteria. There was no statistically significant difference in median age (82.5+/-6 versus 83+/-8, respectively, z=-0.46, p=0.65) or PRISMA-7 scores (5+/-2 versus 5+/-2, respectively, z=-0.49, p=0.63) between those managed on the frailty pathway and frail patients receiving usual care. The median LOS of those taken over and managed throughout their admission on the frailty pathway (n=21) was 7 days (9-5=+/-4) compared to 8.5 days (12-6=+/-6), for those receiving usual care, z=-1.2, p=0.23. Likewise, no significant differences in 30-day readmission rates were found. Comments on Sustainability: Sustainability of this Frailty Service is dependent on targeted goal setting, enhanced resources and the incorporation of patient important outcomes particularly the quality of care (access, effectiveness and patient-centeredness). Wider integration with community services is planned. Comments on Transferability: Different models of frailty assessment have been created as a response to the increasing numbers of older adults attending and admitted through Irish ED’s. This new model incorporating dedicated medical with nursing and HSCP resources shows potential but requires comparison and validation against existing models nationally and internationally. Conclusions: While no statistically significant differences in outcomes were shown, a trend towards reduced LOS and readmission rates over those receiving usual care was found. Discussions: These results suggest that targeting frail older adults (≥75), screening positive for frailty with CGA and management, directly after admission into an ED, may improve healthcare outcomes. Further research with larger samples (as the sample is likely underpowered), measured over longer periods, is now required to overcome potential sources of bias. Lessons learned: This project shows the potential to identify and manage frail older adults with interdisciplinary integrated care from ED admission throughout their inpatient stay until discharge. While the Frailty Service is yet limited, there is scope to further integrate with existing hospital and community-based services for older adults to improve patient flow and transitions of care.

Integrating Care and Improving Flow for Frail Older Adults through the Development of an Acute Inpatient Frailty Service