Building a frailty-friendly emergency department

Jay Banerjee Consultant in Emergency Medicine

Associate Medical Director for Clinical Quality & ImprovementUniversity Hospitals of Leicester NHS Trust

@POBanerjee

Improving care for older people in the ED

• 15-25% of attendances• 50-65% of trolley patients • 35-55% of admissions• 75-85% of non-elective bed days• Vast majority of harms (falls, pressure ulcers, HAI, wrong diagnosis,

adverse drug effects, delirium in hospital….)• Vast majority admitted through the ED• WE ARE ALL WORKING IN GERIATRIC EMERGENCY DEPARTMENTS....

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HBN Dementiahttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/416780/HBN_08-02.pdf

Segmentation - older people

• 90 year old, plays golf, stumbles on caddy, attends with fracture wrist• 78 year old, Alzheimer's, nursing home, needs help with

feeding/dressing/personal hygiene – fell – head injury + raised Trop I• 80 year old, lives alone at home, carer once/day, house dependent,

possible recent forgetfulness, fell in the kitchen – wrist fracture• 69 year old, bed-dependent, Lewis body dementia, pneumonia with

septic shock• PERSON CENTRED CARE – NOT CONDITION CENTRED CARE

Frailty - phenotypeFried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype.J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-56.

Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: • unintentional weight loss (10 lbs in past year)• self-reported exhaustion• weakness (grip strength)• slow walking speed and • low physical activity.

Frailty index – deficits accumulationRockwood K et al. The Canadian Study of Health & Aging Clinical Frailty Scale. Can Med Assoc J 2005;173(5):489-95.

• Frailty Index = Number of deficits in an individualTotal number of deficits measured

Changes with age in the frailty index.

Kenneth Rockwood, and Arnold Mitnitski J Gerontol A BiolSci Med Sci 2007;62:722-727

Copyright 2007 by The Gerontological Society of America

Frail phenotype and mortality prediction: a systematic review and meta-analysis of prospective cohort studiesChang & Lin. Int J Nurs Stud. 2015 Aug;52(8):1362-74. doi: 0.1016/j.ijnurstu.2015.04.005. Epub 2015 Apr 11.

RESULTS: • 35,538 older adults/7994 deaths/11 population-based studies. • Compared with robust older adults, older people with frailty have the

highest risks of mortality• Older men with frailty have a higher risk of mortality than do frail older

women. • No age threshold for mortality risk was observed.

CONCLUSION: • Frailty is a prevalent and critical geriatric syndrome associated with

decreased survival. Through geriatric assessment of frailty, essential information pertaining to mortality among older adults can be obtained

Differences in life expectancy in older people between general population and those with frailty

• Joosten E, Demuynck M, Detroyer E, Milisen K. Prevalence of frailty and its ability to predict in hospital delirium, falls, and 6-month mortality in hospitalized older patients. BMC geriatrics 2014;14:1.

• Fugate Woods N, LaCroix AZ, Gray SL, Aragaki A, Cochrane BB, Brunner RL, et al. Frailty: Emergence and Consequences in Women Aged 65 and Older in the Women's Health Initiative Observational Study. Journal of the American Geriatrics Society 2005;53:1321-30.

• Joseph B, Pandit V, Zangbar B, et al. Superiority of frailty over age in predicting outcomes among geriatric trauma patients: A prospective analysis. JAMA Surgery 2014;149:766-72.

• McNallan SM, Singh M, Chamberlain AM, Kane RL, Dunlay SM, Redfield MM, et al. Frailty and Healthcare Utilization Among Patients With Heart Failure in the Community. JACC: Heart Failure 2013;1:135-41.

• Abdelhafiz AH, Sinclair AJ. Diabetes in the elderly. Medicine 2015;43:48-50.• Johansen KL, Delgado C, Bao Y, Tamura MK. Frailty and Dialysis Initiation. Seminars in

Dialysis 2013;26:690-6.• Derck JE, Thelen AE, Cron DC, Friedman JF, Gerebics AD, Englesbe MJ, et al. Quality of Life

in Liver Transplant Candidates: Frailty Is a Better Indicator Than Severity of Liver Disease. Transplantation 2015.

• Le MP, Antoine R, Sigismond L, Karim A, Elsa C, Saint MM, et al. Prevalence and impact of frailty on mortality in elderly ICU patients: a prospective, multicenter, observational study. Intensive Care Med 2014;40:674-82.

Comprehensive Geriatric Assessment

• Treating 13 frail older people using CGA avoids one unnecessary death or admission to residential care at six months, compared with general medical care for an urgent care episode.

• To put this in perspective, we need to thrombolyse 17 people with acute ischaemic strokes to avoid 1 “unfavourable” outcome same time as causing 1 death for every 100 treated and 1 non-fatal bleed for every 20 treated

Delivering CGA

• A physician with expertise in the care of frail older people – usually, but not exclusively, a geriatrician

• Physiotherapists and/or occupational therapists• Nurse specialists that can offer a case management function• Peripatetic teams with skills and expertise in frailty• Administrative staff able to organise complex (and simple) discharge• An area more friendly to older people• Address outcomes

The Older Person Standard Set of outcomes

This is set is recommended for an older population, however there is no globally agreed definition on what age this is.

As a guideline, the Working Group recommend measuring outcomes for a population which, on average, is in the last 10 years of life based on average life expectancy at age 60 (Global AgeWatch Index 2014) :

For example:

UK: age 84 ≥74Japan: age 86 ≥76South Africa: age 76 ≥66Australia: age 85 ≥75Canada: age 85 ≥75

Scope

The Older Person Working Group was comprised of international volunteers across six continents www.ichom.org

Jay Banerjee Chair, NHSAsan Akpan, Research Fellow NHSJohn Young, NHS EnglandGill Turner, NHS, BGSDiane Bell, COBICArnold Fertig, Cambridge CCGBarbara Batty, Oxford CCGJenny Shand, UCLPartnersDavid Bramley, NHS EnglandHelen Lyndon, NHS EnglandTom Gentry, Age UKRuth Isden, Age UKJonathon Hope, NHS England

Ian Cameron, University of SydneyCathie Sherrington, University of Sydney

Claudia Bausewein,Munich University Hospital

Anne Ekdahl,Karolinksa Institute Liang-Kung Chen, Taipei Veterans

General HospitalGeorge Yi, Formal caregiver and Yuan Ze University

Joanne Lynn, AltarumInstituteJulie Bynum, TheDartmouth InstituteKaren Bandeen-Roche, Johns Hopkins

Nienke de Vries, Radboud University Nijmegen Medical CentreFrancesco Mattace Raso, ErasmusMarleen Harkes, Havenziekenhuis

Samir Sinha, University of TorontoDonna Haslehurst, Older person

Sheila Shaibu, University of Botswana

Mike Martin University of Zurich

Diana Rodirguez Hurtado, Universidad Peruana Cayeto Heredia

@POBanerjee jb234@le.ac.uk

Conditions to address

• Falls management – access to falls clinics/ MDT

• Delirium – when missed in ED, missed 90% of times in hospital, no tubes/lines unless it changes outcomes and no other means

• Medication review – STOPP START tool, pharmacy tech

• End of life care - GSF

TTO – Donebadian’s Triad

• Structure – building (HBN), staff - MDT, equipment – sensory, non-restrictive,

• Process – CGA – manually and digitally

• Outcomes – place of death, preventing injurious falls, quality of living, carer experience, loneliness and isolation - ?outcomes standard set