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      Development and assessment of an educational intervention to improve the recognition of frailty on an acute care respiratory ward

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          Abstract

          Background

          Frailty is a robust predictor of poor outcomes among patients with chronic obstructive pulmonary disease yet is not measured in routine practice. We determined barriers and facilitators to measuring frailty in a hospital setting, designed and implemented a frailty-focused education intervention, and measured accuracy of frailty screening before and after education.

          Methods

          We conducted a pilot cross-sectional mixed-methods study on an inpatient respiratory ward over 6 months. We recruited registered nurses (RNs) with experience using the Clinical Frailty Scale (CFS). RNs evaluated 10 clinical vignettes and assigned a frailty score using the CFS. A structured frailty-focused education intervention was delivered to small groups. RNs reassigned frailty scores to vignettes 1 week after education. Outcomes included barriers and facilitators to assessing frailty in hospital, and percent agreement of CFS scores between RNs and a gold standard (determined by geriatricians) before and after education.

          Results

          Among 26 RNs, the median (IQR) duration of experience using the CFS was 1.5 (1–4) months. Barriers to assessing frailty included the lack of clinical directives to measure frailty and large acute workloads. Having collateral history from family members was the strongest perceived facilitator for frailty assessment. The median (IQR) percent agreement with the gold-standard frailty score across all cases was 55.8% (47.2%–60.6%) prior to the educational intervention, and 57.2% (44.1%–70.2%) afterwards. The largest increase in agreement occurred in the ‘mildly frail’ category, 65.4%–81% agreement.

          Conclusions

          Barriers to assessing frailty in the hospital setting are external to the measurement tool itself. Accuracy of frailty assessment among acute care RNs was low, and frailty-focused rater training may improve accuracy. Subsequent work should focus on health system approaches to empower health providers to assess frailty, and on testing the effectiveness of frailty-focused education in large real-world settings.

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          Most cited references30

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          Frailty in elderly people

          Andrew B. Clegg, John Young, Steve Iliffe … (2013)
          Frailty is the most problematic expression of population ageing. It is a state of vulnerability to poor resolution of homoeostasis after a stressor event and is a consequence of cumulative decline in many physiological systems during a lifetime. This cumulative decline depletes homoeostatic reserves until minor stressor events trigger disproportionate changes in health status. In landmark studies, investigators have developed valid models of frailty and these models have allowed epidemiological investigations that show the association between frailty and adverse health outcomes. We need to develop more efficient methods to detect frailty and measure its severity in routine clinical practice, especially methods that are useful for primary care. Such progress would greatly inform the appropriate selection of elderly people for invasive procedures or drug treatments and would be the basis for a shift in the care of frail elderly people towards more appropriate goal-directed care. Copyright © 2013 Elsevier Ltd. All rights reserved.
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            A global clinical measure of fitness and frailty in elderly people.

            Kenneth Rockwood, Xiaowei Song, Chris MacKnight … (2005)
            There is no single generally accepted clinical definition of frailty. Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians. We aimed to develop a tool that would be both predictive and easy to use. We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging (CSHA). We followed this cohort prospectively; after 5 years, we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools. The CSHA Clinical Frailty Scale was highly correlated (r = 0.80) with the Frailty Index. Each 1-category increment of our scale significantly increased the medium-term risks of death (21.2% within about 70 mo, 95% confidence interval [CI] 12.5%-30.6%) and entry into an institution (23.9%, 95% CI 8.8%-41.2%) in multivariable models that adjusted for age, sex and education. Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition, function or comorbidity in assessing risk for death (area under the curve 0.77 for 18-month and 0.70 for 70-month mortality). Frailty is a valid and clinically important construct that is recognizable by physicians. Clinical judgments about frailty can yield useful predictive information.
            Article 0 comments Cited 1654 times – based on 0 reviews     Review now
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              Physical frailty and pulmonary rehabilitation in COPD: a prospective cohort study

              Matthew Maddocks, Samantha S C Kon, Jane L Canavan … (2016)
              Background Frailty is an important clinical syndrome that is consistently associated with adverse outcomes in older people. The relevance of frailty to chronic respiratory disease and its management is unknown. Objectives To determine the prevalence of frailty among patients with stable COPD and examine whether frailty affects completion and outcomes of pulmonary rehabilitation. Methods 816 outpatients with COPD (mean (SD) age 70 (10) years, FEV1% predicted 48.9 (21.0)) were recruited between November 2011 and January 2015. Frailty was assessed using the Fried criteria (weight loss, exhaustion, low physical activity, slowness and weakness) before and after pulmonary rehabilitation. Predictors of programme non-completion were identified using multivariate logistic regression, and outcomes were compared using analysis of covariance, adjusting for age and sex. Results 209/816 patients (25.6%, 95% CI 22.7 to 28.7) were frail. Prevalence of frailty increased with age, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, Medical Research Council (MRC) score and age-adjusted comorbidity burden (all p≤0.01). Patients who were frail had double the odds of programme non-completion (adjusted OR 2.20, 95% CI 1.39 to 3.46, p=0.001), often due to exacerbation and/or hospital admission. However, rehabilitation outcomes favoured frail completers, with consistently better responses in MRC score, exercise performance, physical activity level and health status (all p<0.001). After rehabilitation, 71/115 (61.3%) previously frail patients no longer met case criteria for frailty. Conclusions Frailty affects one in four patients with COPD referred for pulmonary rehabilitation and is an independent predictor of programme non-completion. However, patients who are frail respond favourably to rehabilitation and their frailty can be reversed in the short term.
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Open Qual
                Journal ID (iso-abbrev): BMJ Open Qual
                Journal ID (hwp): bmjqir
                Journal ID (publisher-id): bmjoq
                Title: BMJ Open Quality
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2399-6641
                Publication date Collection: 2022
                Publication date (Electronic): 5 August 2022
                Volume: 11
                Issue: 3
                Electronic Location Identifier: e001935
                Affiliations
                [1 ]departmentDepartment of Medicine , Dalhousie University , Halifax, Nova Scotia, Canada
                [2 ]departmentDepartment of Medicine , McMaster University , Hamilton, Ontario, Canada
                [3 ]departmentSchool of Nursing , University of Ottawa , Ottawa, Ontario, Canada
                [4 ]departmentDivision of Geriatric Medicine , Department of Medicine, University of Ottawa , Ottawa, Ontario, Canada
                [5 ]The Ottawa Hospital , Ottawa, Ontario, Canada
                [6 ]departmentDivision of Respirology , Department of Medicine, University of Ottawa , Ottawa, Ontario, Canada
                [7 ]departmentClinical Epidemiology Program , Ottawa Hospital Research Institute , Ottawa, Ontario, Canada
                [8 ]departmentDivision of General Internal Medicine , Department of Medicine, University of Ottawa , Ottawa, Ontario, Canada
                [9 ]departmentDepartment of Anesthesia and Pain Medicine , University of Ottawa , Ottawa, Ontario, Canada
                Author notes
                [Correspondence to ] Dr Sunita Mulpuru; smulpuru@ 123456toh.ca
                Article
                Publisher ID: bmjoq-2022-001935
                DOI: 10.1136/bmjoq-2022-001935
                PMC ID: 9362820
                PubMed ID: 36454710
                SO-VID: 125f2513-bd10-45a5-9d28-a9106ba67283
                Copyright © © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
                License:

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                Date received : 11 April 2022
                Date accepted : 21 July 2022
                Categories
                Subject: Original Research
                Subject: 1506
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                Keywords: health professions education,hospital medicine,chronic disease management
                Data availability:
                Keywords: health professions education, hospital medicine, chronic disease management

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