Acute Medical Admissions Research Articles

The key role of an ‘acute neurology triage nurse’ in transforming emergency neurology services

We describe a seemingly novel UK approach to managing acute neurological problems presenting to a district general hospital by using an acute neurology triage nurse as the coordinator of the acute neurology service. We describe in detail how the post works, and present 4-year data comparing 2014–15, the year prior to the nurse starting, with 2015–17, the first 3 years of the service. The nurse, based in the acute medical admission ward, assessed all patients within 2 hours of referral. Key improvements were a dramatic rise both in number of patients seen, and the percentage of patients seen on the day of referral. Early discharge was facilitated, where possible, by urgent ‘hot’ clinic appointments by the nurse, both in person or by telephone, at present 5–6 times per week. The success of this model in Croydon leads us to believe it is worthy of wider consideration.

42THE IMPACT OF DEMENTIA ON MORTALITY IN ACUTE MEDICAL ADMISSIONS

42THE IMPACT OF DEMENTIA ON MORTALITY IN ACUTE MEDICAL ADMISSIONS

Examining trainee awareness of dermatoses and dermatological assessments during acute admissions (A quality improvement project)

Studies demonstrate 67% of elderly patients can have dermatoses, which could result in functional and psychological consequences. Elderly presentations are further complicated by comorbidities and polypharmacy. This combined with limited dermatology training at undergraduate and postgraduate levels creates diagnostic challenges. This project investigated dermatology assessments by trainees using the Trust’s acute medical admissions proforma. 100 proforma were reviewed for skin assessments alongside nursing skin care bundles. Subsequently, a skin survey was conducted amongst trainees evaluating knowledge and confidence when diagnosing and managing common dermatoses. Successively, a dermatology teaching series was delivered. Post-intervention the above were reassessed, demonstrating improvements in most areas. The dermatology teaching series will continue alongside a Trust hospital guideline to sustain improvements in dermatological care on admission.

For older people admitted to hospital for acute care or rehabilitation after an acute medical admission, how does comprehensive geriatric assessment compare with standard care in improving outcomes?

For older people admitted to hospital for acute care or rehabilitation after an acute medical admission, how does comprehensive geriatric assessment compare with standard care in improving outcomes?

Improving the use of treatment escalation plans: a quality-improvement study

ObjectivesTreatment escalation plans (TEPs) are vital in communicating a ceiling of care. However, many patients still deteriorate and die without a pre-established ceiling of care for attending clinicians to rely...

Do medical admission pro formas ­improve the completeness of documentation? A multisite observational study

There is little evidence as to whether clerking pro formas are more or less effective than continuation sheets for the acute medical admission clerking process. This two site audit aimed to assess the effect of introducing clerking pro formas on the completeness of documentation in 32 areas. Data were collected at two sites both pre- and post-introduction of two different clerking pro formas, and a two-tailed z-test used to assess the significance in changes in documentation at each individual site and combined across both sites. Site one showed improvements in 23/32 areas, with 7/32 (21.9%) being significant; three areas saw a decline and 1/32 showed a statistically significant decline. Site two showed improvement across 25/32 sites with 19 (59.4%) being significant; there were no areas showing less complete documentation. Cross-site analysis showed improvements in 30/32 categories, with 15 (46.9%) being significant; one area showed a non-significant decline. The greatest percentage improvement was seen in documentation of cardiopulmonary resuscitation / escalation decisions - an important consideration in this clinically unstable population. The introduction of clerking pro formas across two sites improved the completeness of documentation in a number of areas. This data supports the widespread introduction of clerking pro formas as a tool to improve the completeness of admission documentation.

Mortality and other outcomes after paediatric hospital admission on the weekend compared to weekday.

Mortality is higher for adults admitted to hospital and for babies born on weekends compared to weekdays. This study compares in-hospital mortality and in children admitted to hospital on weekends and weekdays. Details for all acute medical admissions to hospitals in Scotland for children aged ≤16 years between 1st January 2000 and 31st December 2013 were obtained. Death was linked to day of admission. There were 570,403 acute medical admissions and 334 children died, including 83 who died after an admission on Saturday or Sunday and 251 who died following admission between Monday and Friday. The adjusted odds ratio (aOR) for a child dying after admission on a weekend compared to weekday was 1.03 [95% CI 0.80 to 1.32]. The OR for a child admitted over the weekend requiring intensive care unit (ICU) or high dependency unit (HDU) care was 1.24 [1.16 to 1.32], but the absolute number of admissions to HDU and ICU per day were similar on weekends and weekdays. We see no evidence of increased in-hospital paediatric mortality after admission on a weekend. The increased risk for admission to ITU or HDU with more serious illness over weekends is explained by fewer less serious admissions.

Is Frailty a Predictor of Outcomes in Elderly Inpatients with Acute Kidney Injury? A Prospective Cohort Study

BackgroundFrailty and acute kidney injury are independently associated with an increased risk of morbidity and mortality. The degree of frailty can be assessed by the Clinical Frailty Score (CFS). This study assessed whether an individual's CFS was associated with acute kidney injury in acute elderly medical admissions and recorded the short-term outcomes. MethodsThis was a single-center prospective observational cohort study. All patients aged ≥65 years admitted under an acute medical take over 12 nonconsecutive days were included. Patient demographics, comorbidities, baseline CFS, and renal status on admission were recorded. Outcomes of death, length of stay, and hospital re-attendance were assessed 2 weeks following admission. ResultsOf 164 patients (77 males), 19% had acute kidney injury on admission and 22% were considered severely frail. Severe frailty was associated with acute kidney injury (P = .01) and death within 2 weeks (P = .01). Two-week mortality was highest among patients with both (36%). ConclusionThe incidence of acute kidney injury in “severely frail” acutely unwell elderly patients is significantly higher and associated with an increased short-term mortality. The CFS may be useful in acute illness to guide clinical decisions in elderly patients.

Editorial Volume 17 Issue 2

As those working in Acute Medicine gather at SAMsterDAM2, the spring conference of the Society for Acute Medicine, the growth, reputation and global representation of the specialty continues to grow. Alongside, the traditional strongholds of the UK, Ireland, Netherlands, Denmark and Australia growth in Asia continues with an AMU now established in Pakistan among other countries. The global growth and interest in Acute Medicine is reflected in this issue of the journal, in which we are delighted to have a truly international cohort of authors. The papers in this issue add to the understanding of some of the fundamental tenets of the specialty key to delivering high quality acute medical care, including international adaptation of the AMU model of care, the Acute Medicine/Primary Care interface, the referral of older patients to Critical Care, readmissions and a reminder of the opportunities an acute medical admission presents to perform important health screening interventions. Rombach et al. describe the impact of implementing an AMU model of care in Amsterdam. The results of the first four years of the model mirror those seen following their introduction in the UK with improved patient flow and reduced length of stay with no effect on readmission rates. The crucial topic of trying to ensure and describe optimal transfer of clinical information between the Acute Medicine and Primary Care interface is addressed through a quality improvement project by Lockman et al. with an accompanying editorial by Professor Dan Lasserson. Their success highlights the opportunities to drive quality through multi-specialty working and innovative thinking. Nannan-Panday et al. examine the vital sign changes in readmitted patients. They describe that deterioration in key physiological signs is common in patients with unplanned readmissions and suggest early intervention through wearable technologies may be a strategy for reducing this adverse event. Bosch et al. retrospectively analyse the outcomes of elderly patients admitted to Intensive Care directly from the Emergency Department compared to those admitted from general wards finding the former group have better outcomes. This reinforces the importance of early decision making, particularly in elderly patients, so fundamental to the practice of Acute Medicine. Rice et al. report the results of a quality improvement project focusing on HIV testing in their Emergency Department at the world’s largest cancer hospital. They reflect that acute care specialties are uniquely positioned to influence clinical practice because of the large cross section of patients for whom it supports. As we as Acute Medicine practitioners reflect on what we are achieving and what there is to accomplish, we need to remind ourselves that the global footstep of our specialty is increasing and we have the opportunity to imprint its principles further in the acute care of medical patients.

Fifteen-year outcomes of an acute medical admission unit.

The Acute Medical Admission Unit (AMAU) model of care has been associated with improved short- and medium-term outcomes; whether these improvements are sustained remains unclear. We report on the 15-year outcomes of an AMAU in our institution. All emergency medical admissions between 2002 and 2016 were examined and 30-day in-hospital mortality, admission rates, readmission rates and length of stay (LOS) assessed. We used logistic and Poisson regression and margin statistics to evaluate outcomes. There were 96,305 admissions in 50,612 patients. By admission, the 30-day in-hospital mortality averaged 5.6% (95% CI 5.4 to 5.7%); there was a relative risk reduction (RRR) of 33.9% between 2002 and 2016, from 7.0 to 4.6% (p = 0.001), number need to treat (NNT) 41.9. By unique patient the 30-day in-hospital mortality averaged 10.5% (95% CI 10.3 to10.8%); there was a RRR of 61.7% between 2002 and 2016, from 15.1 to 5.8% (p = 0.001), NNT 10.7. The median LOS was 5.0days (IQR 2.1, 9.8) and was unaltered over time. Deprivation status strongly influenced the admission rate/1000 population increasing from Q1 7.7 (95% CI 7.6 to 7.8) to Q5 37.8 (95% CI 37.6 to 38.0); this showed a slight trend to increase over time. Total readmissions increased as a function of time; early readmissions (< 4weeks) remained constant 10.5% (95% CI 9.6 to 11.3). The 30-day in-hospital mortality showed a linear trend to reduce over the 15years following the institution of an AMAU; other key parameters were unaltered.

Prudent healthcare in emergency departments: a case study in Wales.

To deliver a patient-centred service, emergency departments (EDs) must be efficient, effective and meet the needs of the local population. This article describes a service redesign of unscheduled care in a hospital in Wales, which followed the principles of prudent healthcare to improve patient experiences. Extending the roles of nurse specialist practitioners was a major component of the redesign. Six working groups were established to guide the process, one of which was responsible for working cooperatively with the local community, which was concerned about perceived 'downgrading' of the ED. The service redesign was completed in 2016 and evaluation shows the target for patients being seen in under four hours improved from 88% to 96%, significantly more acute medical admission patients were discharged in less than 24 hours, and patient satisfaction increased overall.

Key components of the delirium syndrome and mortality: greater impact of acute change and disorganised thinking in a prospective cohort study

BackgroundDelirium increases the risk of mortality during an acute hospital admission. Full syndromal delirium (FSD) is associated with greatest risk and subsyndromal delirium (SSD) is associated with intermediate risk, compared to patients with no delirium – suggesting a dose-response relationship. It is not clear how individual diagnostic symptoms of delirium influence the association with mortality. Our objectives were to measure the prevalence of FSD and SSD, and assess the effect that FSD, SSD and individual symptoms of delirium (from the Confusion Assessment Method-short version (s-CAM)) have on mortality rates.MethodsExploratory analysis of a prospective cohort (aged ≥70 years) with acute (unplanned) medical admission (4/6/2007–4/11/2007). The outcome was mortality (data censored 6/10/2011). The principal exposures were FSD and SSD compared to no delirium (as measured by the CAM), along with individual delirium symptoms on the CAM. Cox regression was used to estimate the impact FSD and SSD and individual CAM items had on mortality.ResultsThe cohort (n = 610) mean age was 83 (SD 7); 59% were female. On admission, 11% had FSD and 33% had SSD. Of the key diagnostic symptoms for delirium, 17% acute onset, 19% inattention, 17% disorganised thinking and 17% altered level of consciousness. Unadjusted analysis found FSD had an increased hazard ratio (HR) of 2.31 (95% CI 1.71, 3.12), for SSD the HR was 1.26 (1.00, 1.59). Adjusted analysis remained significant for FSD (1.55 95% CI 1.10, 2.18) but nonsignificant for SSD (HR = 0.92 95% CI 0.70, 1.19). Two CAM items were significantly associated with mortality following adjustment: acute onset and disorganised thinking.ConclusionWe observed a dose-response relationship between mortality and delirium, FSD had the greatest risk and SSD having intermediate risk. The CAM items “acute-onset” and “disorganised thinking” drove the associations observed. Clinically, this highlights the necessity of identifying individual symptoms of delirium.

The Increasing Burden of Atrial Fibrillation in Acute Medical Admissions, An Opportunity to Optimise Stroke Prevention

Background Atrial fibrillation is a major risk factor for ischaemic stroke. We investigated whether active screening for atrial fibrillation in secondary care, followed by careful evaluation of risk factors and communication to general practitioners from stroke specialists, could increase appropriate anticoagulation prescription. Methods Between 1/9/14 and 28/2/15 all acute medical admissions were screened for atrial fibrillation at Cambridge University Hospital. Individualised letters were sent to the general practitioners of patients who it was felt would benefit from anticoagulation. Results In total, 847 patients with atrial fibrillation (15% prevalence, 52% female, median age 81.9 years, median CHA2DS2-VASc 4.4) were identified; 671 (79.2%) had known atrial fibrillation, and 176 (20.8%) were diagnosed on admission. After screening and identifying 'at risk' patients, 112 individualised letters were sent to GPs. A 91% response rate was achieved, resulting in an additional 43 individuals being appropriately anticoagulated. Conclusions Atrial fibrillation prevalence is significantly increasing among acute hospital admissions; these patients have high risk of cardioembolic stroke. Careful screening and identification in secondary care can lead to improved rates of anticoagulation.

Reduced level of arousal and increased mortality in adult acute medical admissions: a systematic review and meta-analysis

BackgroundReduced level of arousal is commonly observed in medical admissions and may predict in-hospital mortality. Delirium and reduced level of arousal are closely related. We systematically reviewed and conducted a meta-analysis of studies in adult acute medical patients of the relationship between reduced level of arousal on admission and in-hospital mortality.MethodsWe conducted a systematic review (PROSPERO: CRD42016022048), searching MEDLINE and EMBASE. We included studies of adult patients admitted with acute medical illness with level of arousal assessed on admission and mortality rates reported. We performed meta-analysis using a random effects model.ResultsFrom 23,941 studies we included 21 with 14 included in the meta-analysis. Mean age range was 33.4 - 83.8 years. Studies considered unselected general medical admissions (8 studies, n=13,039) or specific medical conditions (13 studies, n=38,882). Methods of evaluating level of arousal varied. The prevalence of reduced level of arousal was 3.1%-76.9% (median 13.5%). Mortality rates were 1.7%-58% (median 15.9%). Reduced level of arousal was associated with higher in-hospital mortality (pooled OR 5.71; 95% CI 4.21-7.74; low quality evidence: high risk of bias, clinical heterogeneity and possible publication bias).ConclusionsReduced level of arousal on hospital admission may be a strong predictor of in-hospital mortality. Most evidence was of low quality. Reduced level of arousal is highly specific to delirium, better formal detection of hypoactive delirium and implementation of care pathways may improve outcomes. Future studies to assess the impact of interventions on in-hospital mortality should use validated assessments of both level of arousal and delirium.

Intermediate-term and long-term mortality among acute medical patients hospitalized with community-acquired sepsis: a population-based study

Admission with severe sepsis is associated with an increased short-term mortality, but it is unestablished whether sepsis severity has an impact on intermediate-term and long-term mortality following admission to an acute medical admission unit. This was a population-based study of all adults admitted to an acute medical admission unit, Odense University Hospital, Denmark, from September 2010 to August 2011, identified by symptoms and clinical findings. We categorized the mortality periods into intermediate-term (31-180 days) and long-term (181-365, 366-730, and 731-1096 days). Mortality hazard ratios (HRs), comparing patients admitted with sepsis with those of a well-defined background population, were estimated using multivariable Cox regression. HRs were presented with 95% confidence intervals. In total, 621 (36.3%) presented with sepsis, 1071 (62.5%) presented with severe sepsis, and 21 (1.2%) presented with septic shock. Thirty-day all-cause mortality for patients with sepsis, severe sepsis, and septic shock was 6.1, 18.8, and 38.1%, respectively. The adjusted HR among patients with sepsis of any severity within the time periods 31-180, 181-365, 366-720, and 721-1096 days was 7.1 (6.0-8.5), 2.8 (2.3-3.5), 2.1 (1.8-2.6), and 2.2 (1.7-2.9), respectively. Long-term mortality was unrelated to sepsis severity [721-1096 days: sepsis HR: 2.2 (1.5-3.2), severe sepsis HR: 2.1 (1.5-3.0)]. Patients admitted with community-acquired sepsis showed high intermediate-term mortality, increasing with sepsis severity. Long-term mortality was increased two-fold compared with sepsis-free individuals, but might be explained by unmeasured confounding. Further, long-term mortality was unrelated to sepsis severity.

Musical Hallucinations Treated with Atypical Antipsychotics in a Geriatric Population – A Case Series

Musical hallucinations have been likened to the auditory equivalent of Charles Bonnet Syndrome, which involves complex visual hallucinations, most often in the context of visual impairment. Musical hallucination frequently take the form of hymns, carols, and show-tunes and are strongly associated with hearing loss, with some studies suggesting a prevalence of 2.5–3.6% in the hearing impaired. Musical hallucinations are typically treated with anticonvulsant and anticholinesterase medications, with some studies having evaluated the efficacy of sedative hypnotics, antipsychotics and antidepressants in various psychiatric and medical subpopulations suggesting a heterogeneous spectrum of causes for this disorder. We present two cases of musical hallucinations in both a 70-year-old African American female with past psychiatric history of major depressive disorder who developed hymnal auditory hallucinations during an acute medical and psychiatric admission and an 86-year-old Caucasian female, who complained of hearing gospel music with eventual onset of visual hallucinations after a fall at age 80. Our patients were successfully treated in both the inpatient and outpatient settings with atypical antipsychotics. The presented cases add to the paucity of literature regarding utilization of atypical antipsychotics for treatment of musical hallucinations and demonstrate efficacy to this effect. This study lends further validity to the use of psychopharmacologic agents for novel purposes that have yet to be fully explored.

Delirium, Frailty, and Mortality: Interactions in a Prospective Study of Hospitalized Older People.

BackgroundIt is unknown whether the association between delirium and mortality is consistent for individuals across the whole range of health states. A bimodal relationship has been proposed, where delirium is particularly adverse for those with underlying frailty, but may have a smaller effect (perhaps even protective) if it is an early indicator of acute illness in fitter people. We investigated the impact of delirium on mortality in a cohort simultaneously evaluated for frailty.MethodsWe undertook an exploratory analysis of a cohort of consecutive acute medical admissions aged ≥70. Delirium on admission was ascertained by psychiatrists. A frailty index (FI) was derived according to a standard approach. Deaths were notified from linked national mortality statistics. Cox regression was used to estimate associations between delirium, frailty, and their interactions on mortality.ResultsThe sample consisted of 710 individuals. Both delirium and frailty were independently associated with increased mortality rates (delirium: HR 2.4, 95% CI 1.8–3.3, p < .01; frailty (per SD): HR 3.5, 95% CI 1.2–9.9, p = .02). Estimating the effect of delirium in tertiles of FI, mortality was greatest in the lowest tertile: tertile 1 HR 3.4 (95% CI 2.1–5.6); tertile 2 HR 2.7 (95% CI 1.5–4.6); tertile 3 HR 1.9 (95% CI 1.2–3.0).ConclusionAlthough delirium and frailty contribute to mortality, the overall impact of delirium on admission appears to be greater at lower levels of frailty. In contrast to the hypothesis that there is a bimodal distribution for mortality, delirium appears to be particularly adverse when precipitated in fitter individuals.

National Quality Assurance &amp; Improvement System (NQAIS) – Medicine

Introduction: Length of stay varies by hospital, admission type, diagnosis and clinical team, while waiting lists, emergency department throughput and delayed discharges generate frustration for patients and health professionals. The National Acute Medical Programme (NAMP) was established in 2010 by the Royal College of Physicians of Ireland and the Health Service Executive (HSE) to enable: - Swifter access to senior decision makers - Swifter access to investigations and interventions - Reduced overnight admissions - Shorter average length of stay (AvLOS) - Optimal use of Acute Medical Assessment Unit (AMAU) NQAIS Medicine: NQAIS Medicine supports NAMP and hospitals to re-engineer care delivery based on interdisciplinary co-operation using timely and relevant data. The system was developed by Health Intelligence, Health & Wellbeing, Health Service Executive, in collaboration with NAMP and OpenApp. It is deployed under the governance framework of the Joint NQAIS (Surgery & Medicine) Steering Group. NQAIS Medicine is a web-enabled, role-based quality assurance and improvement system providing an evidence base to inform decisions. Innovative “diamond” plots (simplified box and whisker) and trend plots in easily understood “ribbons” are displayed by hospital (or group), admission category, diagnosis and clinical team. Patient profiles (age, co-morbidity, admission day/time etc.) can be flexibly explored. Selected records can be identified for chart review. The predictive impact of meeting targets are summarised by the novel computation of the potential “number of beds freed per day” which could be made available for other patients. The Clinical Classification System (CCS) - Agency for Healthcare Research & Quality (AHRQ) - converts the principal (admission) diagnosis into clinically meaningful groups. The Charlson Index is used to convert secondary diagnoses into a “complexity” score. AvLOS and readmission rates are dynamically analysed in the context of data-driven targets: AvLOS per CCS diagnosis as achieved by top quartile (Irish) teams; 50%+ all acute medical admissions should be routed via the AMAU of whom 25% should be discharged home. AvLOS is computed for each CCS nationally in the context of its trim point - national 75%ile + 3 X (25% – 75%ile). If the target AvLOS is achieved and AMAU usage optimised, the potential impact is translated into simple summary metrics - beds used within, close to and off target. These metrics identify and prioritise processes in hospital most likely to reveal potential learning and reengineering opportunities for using beds for other patients. Implementation: A train-the-trainers approach within hospital groups, guided by a national training team, supports the national deployment of the system. NQAIS Medicine combines science and art to provide detailed but very understandable feedback to unequivocally identify areas for review. Modest meeting of targets would transform a system struggling to cope with increasing demands. The successful implementation of NAMP, using NQAIS Medicine as a continuous improvement enabler, requires sustained focus and commitment from clinicians and management alike. The system is currently being deployed to all acute hospital in Ireland, and is being extended to encompass surgery and other domains within a single system referred to as NQAIS Clinical.

Development Integrated Model of Care for Neurology Services in Ireland

Introduction: To develop a Model of Care for Neurology which would provide a framework for neurology services using international best practice and describes care provision using an integrated service approach. The Framework was developed by a team of multidisciplinary professionals and patient representation to cover the full spectrum of care provided in hospitals (in-patient & out-patient) and make specific recommendations to the type of care considered best practice in the management of patients in the community. Context & Population: Over 700,000 people in Ireland have a neurological illness which accounts for one in five acute medical admissions with one in eight patient attendances to a general practitioner. Many of these brain, spinal, nerve and muscle disorders are increasingly treatable but access to diagnosis and treatment in Ireland presents a significant challenge. Against a backdrop of ever increasing prevalence and service under development, a strategic approach to the development of neurology services nationally was required. Highlights: A review of the current status of neurology services was essential. This was needed from the perspective of service providers, service users, their families/carers and the organisations which represent them. Consultants, nurses and health & social care professionals working in all service delivery environments were engaged. The model of care which arose from this extensive consultative process is one that is relevant and patient centred. The recommendations are also reflective of issues raised by patient and their families and as such are not driven by service delivery priorities but also patient priorities. Comments of Transferability: Any future service developments within the area of neurology services can be aligned with the key recommendations and themes outlined in the model of care thus ensuring an improved patient experience from access to diagnostic services, treatment and interventions, rehabilitation services through to palliation irrespective of individual diagnosis. The process for developing this model of care, the multi-stakeholder engagement and the links between service users and service providers is one that could be applicable to any acute and/or chronic illness management. Conclusions: The Model of Care was launched by the Director General of the HSE, in September 2016, with a commitment to implement the recommendations over a phased basis. The model of care describes; -Clear recommendations on; - Integrated services - Comprehensive MDT & requirements of same - Person centred approach - Staffing & resourcing within neurology in line with best practice - Service configuration and managed clinical networks - Care pathways for MS, Parkinson’s Disease, Motor Neurone Disease, Headache - support for GPs in managing chronic neurological conditions - Education & Training - Research The model of care also has developed proposed programme metrics with respect to quality, access and value. With the development of agreed care pathways, for the first time, parameters are available against which patient pathway/journey can be measured. Proposed metrics include; - Progression through identified care pathways - Improved patient experience - Ensure access to the right service at the right time - Earlier diagnosis - Reduction in unscheduled admissions to acute hospital Measurement of these indicators would not have been feasible without agreed care pathways against which care could be measured.

A National Frailty Education Programme

Rationale for Training: Population ageing is occurring rapidly and between 2015 and 2050, the number of people aged 60 years and older is expected to increase from 12% of the global population to 22% (WHO, 2012). In Ireland, currently 13% of the population is 65 years or older and this number is expected to double by 2040 (Central Statistics Office, 2008). As older people have different healthcare requirements, the Irish healthcare system needs to adapt to meet the demands associated with this demographic change. Healthcare spending in Ireland is expected to rise from 5.8 to 6.7% of GDP by 2035 (European Commission, 2009). Almost 22% of all hospital emergency department attendees are aged 65 and over and this age group account for 40% of all acute emergency medical admissions and 47.3% of total hospital bed days (HSE, ED Task Force Report, 2015, NCPOP, 2012). One of the greatest challenges posed by an ageing population is the ability of healthcare professionals to understand, recognise and manage frailty.Frailty: Frailty is theoretically defined as a clinically recognisable state of increased vulnerability resulting from age-associated decline in reserve and function across multiple physiologic systems (Qian-Li Xue, 2011). Frailty affects approximately 8-10% of people over the age of 65 and 25-50% of those aged 85 and over (Mytton et al., 2012; Collard et al., 2012; Savva et al., 2013). Although frailty is an increasingly common condition in older people, it is not an inevitable part of ageing and in some cases it can be treated or prevented depending on its underlying cause. A lack of consensus regarding the operational definition of frailty makes it difficult to identify and manage in clinical practice (Rodríguez-Mañas, et al., 2013). However, conceptualizing frailty as a continuum from not frail, to pre-frail, to frail is considered a valid way to identify subgroups of older adults at risk of adverse outcomes such as falls, worsening disability, prolonged hospitalization and death (Clegg &amp; Young, 2015). The potential for serious adverse outcomes is a central problem associated with frailty. For people with frailty even a relatively minor event such as an infection can result in a dramatic change in health state: from independent to dependent; mobile to immobile; postural stability to falling; lucid to delirious (Clegg, 2013).Further to this, frailty has been shown to be a strong and independent predictor of emergency department visits and hospitalizations (McNallan et al., 2013), hospital re- admissions (Pugh et al., 2014) and in-hospital mortality (Bagshaw et al., 2013). Unplanned admissions to hospital in an emergency situation can be both distressing and disruptive for frail older people, their families and carers. These admissions create rising demands on acute hospital beds and result in enormous costs to Ireland’s health service. Therefore, this topic has relevance for policy makers, clinicians and nursing staff who need to understand the risk factors for frailty to enable them to implement programmes for early detection, prevention and management. By increasing awareness and understanding of frailty, we can improve outcomes for these older adults and reduce demands on the health service.Methodology: It is proposed that the methodology applied to the implementation of the National Early Warning Score would be applied to the roll out of a frailty education programme. This includes:- Providing a training programme for a cohort of national trainers (N= to be agreed) who will:- Provide local education programmes- Maintain a database of locally trained staff- Lead local governance groupEstablishment of National Steering Group (incl. cohort of national trainers, and nominated stakeholders) to:- Develop an educational programme for delivery locally- Develop a framework for interdisciplinary education- Develop an e-learning programmeThe Longtitudinal Study on Aging (TILDA): Using cutting edge research and the unique resources at the TILDA Health Assessment Centre in Trinity College, TILDA will deliver a one-day training course to nurses interested in learning more about frailty. The course will incorporate key research findings from TILDA, provide an overview of the theoretical models underpinning frailty and include training in key frailty assessment tools. Nurses are an integral part of the collaborative approaches to services for patients with frailty. This training will encourage nurses to be proactive members in the early identification and assessment of frailty, ensuring effective management to improve outcomes for these vulnerable adults.