Acute Frailty Research Articles

The Attitudes Towards the Use of Restraint and Restrictive Intervention Amongst Healthcare Staff on Acute Medical and Frailty Wards—A Brief Literature Review

Restraint in modern non-psychiatric-based healthcare is often regarded as a rare occurrence. It is deemed to be used as a last resort to prevent patients from directly harming themselves. However, techniques are used in modern day practice which are considered direct and indirect restraints with the justification of maintaining patient safety, but they are often not classified as “restraints”. Examples of these include the use of bed rails or tables to prevent patients from “wandering” and to reduce the risk of falls and injuries. More indirect techniques would involve passive interactions with patients or leaving mobility aids out of reach. Staff subconsciously restrain patients and reduce their liberties despite agreeing that patient autonomy should be upheld—a necessary evil to maintain a duty of care. Whilst the use of restraints is often justified to ensure patient care and prevent injury, it is not without consequence. There are physical and psychological health risks such as pressure sores from the inability to mobilise, or the brewing of anger and frustration when denied access to everyday actions. The reasons why restraints are used, whilst stemming from maintaining patient safety, are often due to low staffing levels and the inability to constantly watch at-risk patients due to a large workload. Inadequate training is another factor; by improving education in direct and indirect restraint and providing alternative methods, more ethical decisions and positive outcomes can be implemented. Healthcare professionals are reluctant to use restraint but often conduct it without realising it; assessing their understanding of restraint and providing education to raise awareness of the consequences of direct and indirect methods would result in positive steps toward reducing their use at the same time as looking to provide alternatives to uphold patient care whilst maintaining their dignity and liberty.

Analysis of the experienced-based design feedback data on a national scale.

The Health Foundation has noted a 46% increase in the number of hospital admissions for those aged over 65 between 2005 and 2016. Many will be admitted through accident and emergency (A&E) and remain on an acute medical unit during their stay. The Acute Frailty Network (AFN) has been working on improving the care of older and frail people in these acute …

The development of an acute frailty team

The development of an acute frailty team

Analysis of the experienced-based design feedback data on a national scale

The Health Foundation has noted a 46% increase in the number of hospital admissions for those aged over 65 between 2005 and 2016. Many will be admitted through accident and emergency (A&E) and remain on an acute medical unit during their stay. The Acute Frailty Network (AFN) has been working on improving the care of older and frail people in these acute …

The development of an acute frailty team

Older people living with frailty are more likely to be admitted to hospital when attending the emergency department (ED). Following admission, this population is also more likely to have prolonged inpatient stay, patient safety incidents and higher inpatient mortality.[1][1] NHS Improvement

Acute frailty services aim to cut avoidable emergency admissions

NHS Long Term Plan calls for acceleration towards same-day emergency care for older people

The Acute Frailty Network: experiences from a whole-systems quality improvement collaborative for acutely ill older patients in the English NHS

Key summary pointsAimTo describe the approach and methods of the Acute Frailty Network.FindingsLocal case studies are used to illustrate the early impact of the Network. Reflections on three years’ experience of planning and implementing a whole-systems quality improvement collaborative are shared.MessageInitiatives through which hospitals improved services and outcomes for older people with frailty and urgent care needs are illustrated.

Point-of-care blood tests in decision-making for people over 65 with acute frailty

Background: National ‘see, treat and discharge’ rates for paramedics have increased. However, despite the rise in demand on paramedic decision-making, there have been few improvements to prehospital diagnostics. Patients aged over 65 years presenting with acute frailty syndromes are a notably complex clinical patient group for whom informed risk stratification in clinical reasoning is paramount. Methods: This was a single-site quality improvement project using point-of-care blood testing (POCbT) to help inform decision-making for patients aged above 65 years with acute frailty syndromes. Results: This quality improvement project showed a self-reported improved confidence in clinician decision-making and patient disposition with the use of POCbT. This confidence was validated by improved discharge on scene and recontact rates. An unintended outcome of the project was the accumulation of practical knowledge on the use of POCbT in the prehospital arena. Conclusion: Continued use of POCbT in the prehospital environment has promise but this is not without limitations. Prehospital services wishing to implement POCbT should focus on demographic identification, staff training and interpretation of results.

3485 Frailty Associated with Increased Rates of Acute Cellular Rejection Within 3 Months After Liver Transplantation

OBJECTIVES/SPECIFIC AIMS: There is currently a gap in the literature regarding the relationship between acute cellular rejection and frailty in LT patients. We aimed to evaluate the association between frailty and acute cellular rejection in LT patients. METHODS/STUDY POPULATION: Included were LT recipients from 2014-16 at a single center who had a frailty assessment prior to LT using the Liver Frailty index consisting of grip strength, chair stands, and balance. Frailty was defined by a Liver Frailty Index > 4.5. Data on acute cellular rejection at 3 months (primary outcome) and immunosuppression regimens were collected from medical chart review. Univariable and multivariable logistic regression assessed the associations between frailty and acute cellular rejection. RESULTS/ANTICIPATED RESULTS: A total of 241 LT recipients were included. Of these, 37% were female, 55% had Hepatitis C, and the median (IQR) age was 60 (54-65); 46 (19%) were classified as frail. 98% of patients were on a combination of mycophenolate, corticosteroids and tacrolimus on discharge compared to 80% by 3 months. Within the first 3 months post-LT, 7 (15%) of frail patients versus 10 (5%) (p = 0.02) of non-frail patients experienced acute cellular rejection. In univariable logistic regression, frailty was associated with a 3.3 times higher odds of acute cellular rejection at 3 months (95%CI 1.19, 9.26, p = 0.02); age (OR 0.91), Black race (OR 3.2), autoimmune disease (OR 2.3), and diabetes (OR 0.3) were also associated with acute cellular rejection at 3 months with a p-value<0.20. In a multivariate analysis, after adjusting for age, frailty remained significantly associated with rejection (OR 3.06, 95%CI 1.04, 9.01, p = 0.043). There were no significant differences in immunosuppression regimens or rates of mycophenolate dose reduction in the first 3 months between frail and non-frail patients. DISCUSSION/SIGNIFICANCE OF IMPACT: Frailty is associated with an increased rate of acute cellular rejection within 3 months post-LT, despite similar immunosuppression regimens and doses. Future studies should evaluate whether frailty should be considered in the management of immunosuppression in the early post-transplant period.

The Acute Frailty Network – supporting people with frailty and urgent care needs to get home sooner and healthier

The Acute Frailty Network (AFN) supports the timely delivery of Comprehensive Geriatric Assessment (CGA) for frail older people in urgent care settings, in order to reduce reliance on acute hospitals, save lives and reduce functional deterioration. The AFN supports hospitals in reconfiguring and redesigning services in order to try and optimise the delivery of CGA within each setting. Each site participates for 12 months; the focus of the AFN is on the care of older people with frailty in the first 72 hours of an acute hospital attendance, with an emphasis on early discharge supported by the wider health and social care …

304Geriatric Giants on the Acute Floor Geriatric EMergency Services (GEMS) Team: An Acute Floor Frailty Model

304Geriatric Giants on the Acute Floor Geriatric EMergency Services (GEMS) Team: An Acute Floor Frailty Model

303What happens in the first 34 minutes? Geriatric EMergency Services (GEMS) Team: An Acute Floor Frailty Model

303What happens in the first 34 minutes? Geriatric EMergency Services (GEMS) Team: An Acute Floor Frailty Model

288Geriatric EMergency Services (GEMS): An Acute Floor Frailty Service Model

288Geriatric EMergency Services (GEMS): An Acute Floor Frailty Service Model

Selecting best-suited "patient-related outcomes" in older people admitted to an acute geriatric or emergency frailty unit and applying quality improvement research to improve patient care.

The population is aging worldwide, and hospitals are admitting a higher proportion of acutely unwell older people. Population-specific factors such as multimorbidity and frailty in older people compounded by deficient expertise contribute to longer lengths of stay, higher readmission rates, and increased rates of institutionalization. A wide range of acute geriatric care models are currently providing acute care to frail older people and these have been shown to provide a cost-effective high-quality service. In this review, population-specific factors, service models, and a wide range of patient-related outcomes of “at risk” older people admitted to an acute geriatric care unit are explored. In addition, we also discuss data measurements and a quality improvement methodology to improve the delivery of care based on the patient outcome data. We hope, in addition to ensuring effectiveness and sustainability of our current services, this may also enhance academic research. Regular monitoring and evaluation of patient-related clinical outcomes not only improve the patient care and reduce the caregiver burden but also help in implementing quality initiatives to develop existing services.

End of Life, Withdrawal, and Palliative Care Utilization among Patients Receiving Maintenance Hemodialysis Therapy.

Withdrawal from maintenance hemodialysis before death has become more common because of high disease and treatment burden. The study objective was to identify patient factors and examine the terminal course associated with hemodialysis withdrawal, and assess patterns of palliative care involvement before death among patients on maintenance hemodialysis. We designed an observational cohort study of adult patients on incident hemodialysis in a midwestern United States tertiary center, from January 2001 to November 2013, with death events through to November 2015. Logistic regression models evaluated associations between patient characteristics and withdrawal status and palliative care service utilization. Among 1226 patients, 536 died and 262 (49% of 536) withdrew. A random sample (10%; 52 out of 536) review of Death Notification Forms revealed 73% sensitivity for withdrawal. Risk factors for withdrawal before death included older age, white race, palliative care consultation within 6 months, hospitalization within 30 days, cerebrovascular disease, and no coronary artery disease. Most withdrawal decisions were made by patients (60%) or a family member (33%; surrogates). The majority withdrew either because of acute medical complications (51%) or failure to thrive/frailty (22%). After withdrawal, median time to death was 7 days (interquartile range, 4-11). In-hospital deaths were less common in the withdrawal group (34% versus 46% nonwithdrawal, P=0.003). A third (34%; 90 out of 262) of those that withdrew received palliative care services. Palliative care consultation in the withdrawal group was associated with longer hemodialysis duration (odds ratio, 1.19 per year; 95% confidence interval, 1.10 to 1.3; P<0.001), hospitalization within 30 days of death (odds ratio, 5.78; 95% confidence interval, 2.62 to 12.73; P<0.001), and death in hospital (odds ratio, 1.92; 95% confidence interval, 1.13 to 3.27; P=0.02). In this single-center study, the rate of hemodialysis withdrawals were twice the frequency previously described. Acute medical complications and frailty appeared to be driving factors. However, palliative care services were used in only a minority of patients.

Acute Kidney Injury and Subsequent Frailty Status in Survivors of Critical Illness: A Secondary Analysis.

Acute kidney injury frequently complicates critical illness and is associated with high morbidity and mortality. Frailty is common in critical illness survivors, but little is known about the impact of acute kidney injury. We examined the association of acute kidney injury and frailty within a year of hospital discharge in survivors of critical illness. Secondary analysis of a prospective cohort study. Medical/surgical ICU of a U.S. tertiary care medical center. Three hundred seventeen participants with respiratory failure and/or shock. None. Acute kidney injury was determined using Kidney Disease Improving Global Outcomes stages. Clinical frailty status was determined using the Clinical Frailty Scale at 3 and 12 months following discharge. Covariates included mean ICU Sequential Organ Failure Assessment score and Acute Physiology and Chronic Health Evaluation II score as well as baseline comorbidity (i.e., Charlson Comorbidity Index), kidney function, and Clinical Frailty Scale score. Of 317 patients, 243 (77%) had acute kidney injury and one in four patients with acute kidney injury was frail at baseline. In adjusted models, acute kidney injury stages 1, 2, and 3 were associated with higher frailty scores at 3 months (odds ratio, 1.92; 95% CI, 1.14-3.24; odds ratio, 2.40; 95% CI, 1.31-4.42; and odds ratio, 4.41; 95% CI, 2.20-8.82, respectively). At 12 months, a similar association of acute kidney injury stages 1, 2, and 3 and higher Clinical Frailty Scale score was noted (odds ratio, 1.87; 95% CI, 1.11-3.14; odds ratio, 1.81; 95% CI, 0.94-3.48; and odds ratio, 2.76; 95% CI, 1.34-5.66, respectively). In supplemental and sensitivity analyses, analogous patterns of association were observed. Acute kidney injury in survivors of critical illness predicted worse frailty status 3 and 12 months postdischarge. These findings have important implications on clinical decision making among acute kidney injury survivors and underscore the need to understand the drivers of frailty to improve patient-centered outcomes.

Reimagining unscheduled care – the Worthing Emergency Floor Project

This project combines acute medicine, acute frailty and surgical assessment units in a comprehensive redesign of service delivery, dissolving traditional care boundaries to deliver enhanced quality of care for patients and flow benefits to the organisation. The Emergency Floor concept was developed over a 2-year period including a presentation of concept with PESTLE analysis, multiprofessional input, business-case development and comprehensive design phase. Aims are being achieved by standardising the approach to referral, assessment and admission, and utilising in-house information systems to manage flow and collect data. There has been …

Frailty and acute coronary syndrome: A structured literature review.

The health burden of acute coronary syndrome (ACS) and frailty is high, but the impact of frailty on ACS treatment and outcomes is uncertain. In this structured literature review, we investigated the relationship between frailty, ACS treatment and outcomes. Between 2000 and 2016, we identified only a small number of primary research studies investigating frailty and ACS care ( n = 10). Frailty was independently associated with increased mortality following ACS (adjusted all-cause mortality hazard ratios for patients with frailty ranged from 1.54 to 5.39). Older people with frailty were significantly less likely to receive guideline-indicated ACS care, including percutaneous coronary intervention (PCI) (rates ranged from 6.7% to 43.7% vs. from 30.4% to 69.5%). Available data for PCI indicated a gap between treatment recommended by international guidelines and clinical practice. Further research is warranted in order to investigate methods for identifying frailty in the acute setting and opportunities for improving care among older people with frailty presenting with ACS.

Improving acute care for older people at scale – the Acute Frailty Network

Older people form a growing proportion and volume of those accessing urgent care. Non-specific presentations, multiple comorbidities and functional decline make assessment and management of this cohort challenging. Comprehensive Geriatric Assessment offers an evidence based framework to assess and mange older people, especially those with frailty. In this article we describe the CGA approach, underpinned by specific examples illustrating some of the key competencies required, and describe the role of the Acute Frailty Network (AFN). The AFN is a national improvement collaborative designed to support hospitals in delivering evidence based care for older people with frailty and urgent care needs. We describe the principles underlying the approach of the AFN, derived from working with over 20 hospitals, and some of the early successes.

Defining Functional Decline, Characteristics of Admitted Older Adults and Comparing Alternate Versions of the MoCA.

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