Dr Thomas Gilbert is a consultant geriatrician (Hospices Civils de Lyon, FRANCE), with interests in Health Services Research. He worked with Dr Jenny Neuburger and colleagues from the Nuffield Trust in London on the development of the Hospital Frailty Risk Score whilst he was a clinical research fellow under the mentorship of Prof. Simon Conroy in Leicester (Department of Health Sciences). He will be speaking at the Urgent care for frail older people event on 25 May at Horizon in Leeds.
Advances in health care have helped people in developed countries live longer than ever before. This is good news for all of us, but it also presents a challenge to our health systems and a need to rethink the way that we provide healthcare. Out of nearly 20 million people admitted to an NHS hospital in the UK in 2015, a quarter were aged 75 years or older, and this proportion is set to increase.
For some older people, hospitalisation is associated with increased harms over and above their presenting clinical condition. Recognising that age alone is insufficient to identify and respond to such vulnerability, the term ‘frailty’ is increasingly being employed to highlight patients exposed to an increased risk of poor outcomes and likely to require higher resource use. In contrast to the single disease-focused model of medicine, the notion of frailty prompts a need to embrace and get to grips with a more holistic and integrated approach to care; one that takes into account the full range of interacting health and social conditions.
Irrespective of major efforts within the NHS to reduce admissions to hospitals, it is increasingly evident that a growing number of older people are likely to develop disorders requiring acute hospital care. The development of appropriately designed acute care services will be fundamental for the optimal management of such disorders, as well as the implementation of robust preventive strategies going forward. It follows that effective approaches for identifying patients who are frail will be of paramount importance in evolving standardised schemes, especially in acute care settings.
The Acute Frailty Network (AFN), which is supported by the NHS, has emphasised the importance of early systematic identification of people with frailty, so as to enable an effective multi-disciplinary team response. Although this is done well by some hospitals, there remains wide variation between settings. Further, frailty is not routinely identified or documented in hospital disease coding systems and methods for identifying people vary widely.
In primary care, the development of the Electronic Frailty Index (in Leeds, where the BGS conference will take place) has met with very promising success. Other researchers have aimed to develop in-hospital risk stratifying tools, based mainly on Rockwood’s cumulative deficit model of frailty, which can be translated into an index; or on the identification of ‘geriatric syndromes’ such as falls from lists of ICD-10 disease codes.
We have developed a Hospital Frailty Risk Score (HFRS), which will be presented at the joint SAM/RCEM/BGS conference in Leeds, by way of dynamic response to all these considerations. The overarching aim was to develop a pragmatic approach to identifying older patients ‘at risk of frailty’ by using information from their previous hospital records. For example, an older person with a previous admission for a fall, fracture or pneumonia and with prior diagnoses of dementia or delirium would be picked up as having a high risk of frailty by such an approach.
The HFRS has the potential to be implemented in any hospital system relying on the international ICD-10 disease coding system. In terms of risk-stratifying patients by risk of mortality, it compares favourably with most existing tools although the main aim is not to predict mortality, which is inherently uncertain in acute settings and not only related to frailty (and which none of the tools do very well). Rather than replacing personalised clinical evaluation, the HFRS complements such procedures by prompting which patients are likely to be most ‘at risk of frailty’ and might benefit from a more holistic assessment, and suitably tailored clinical care.
Overall, the HFRS could help to improve the triage of patients admitted to Emergency Departments. At the system level, the tool could help service mapping and commissioning by concentrating resources in areas where there are most needed. For example, a HFRS showing an intermediate to high risk could become an objective criteria for placing a patient on dedicated pathways such as an ‘Acute Frailty Unit’ or ‘Emergency Frailty Unit’. However, an improved screening for frailty would not always lead to increased resource needs, as in some situations of severe frailty, a more supportive or palliative approach of care might be decided.