Older patients face a unique set of health challenges – including chronic fatigue, low muscle mass, cognitive impairment, bone fractures and reduced mobility – that can raise their risk of illness or injury during hospitalization.
Launched in 2016, the BWH Frailty Identification and Care Pathway is a multidisciplinary program addressing these challenges by providing clinicians with standardized guidelines for identifying and accommodating frailty – a complex, often age-related syndrome characterized by physical decline and increased vulnerability to stressors.
“Frailty and cognitive impairment are often key contributing factors in falls and accidents that lead to fractures and other injuries among older patients presenting in our Emergency Department,” said Zara Cooper, MD, MSc, FACS, of the Division of Trauma, Burn and Surgical Critical Care. “We believe that focusing on these underlying conditions is essential to optimizing the care and outcomes of these patients.”
Physician assistant Lynne O’Mara, PA-C, of the Department of Surgery, was one of many BWHers who played a key role in implementing the pathway in the Emergency Department (ED) and the Surgical, Burn and Trauma Intermediate Care Unit on Tower 8ABCD. Part of a multidisciplinary team that sought to identify and remove barriers to care for older patients, O’Mara worked closely with Cooper and Samir Tulebaev, MD, of the Division of Aging and Center for Older Adult Health, to create order sets for the pathway.
The Frail Scale
At the heart of the initiative is an assessment tool known as the “frail scale,” which is used to screen for frailty in patients over the age of 65 when they arrive at the ED. In the frail scale, “frail” also functions as an acronym, with each letter representing the constellation of symptoms and conditions that may indicate frailty. Patients are considered frail if they meet three or more of these criteria:
- Fatigue (“Are you fatigued?”)
- Resistance (“Can you climb one flight of stairs?”)
- Ambulation (“Can you walk one block?”)
- Illnesses (“Do you have more than five illnesses?”)
- Loss of weight (“Is your weight loss greater than five percent?”)
It’s important to recognize these risk factors early because frail patients are more likely to experience negative health outcomes, including increased rates of morbidity, obesity and trauma, O’Mara explained.
In addition to the normal effects of aging, a patient’s circumstances at home may contribute to or worsen their frailty, O’Mara said. For example, a patient might have poor muscle mass because they’re not eating, and they might not be eating because they’re on a fixed income and don’t have the financial means to purchase food. While such challenges are not unique to frail patients, understanding this context is key to helping these patients recover smoothly, avoid injury, discharge safely and reduce readmissions, O’Mara said.
During hospitalization, frail patients are also at greater risk of experiencing delirium, an acute state of confusion that is separate from dementia. Patients who experience delirium may try to pull out their IV lines or attempt to get out of bed when they cannot safely do so, leading to a secondary injury, O’Mara said.
The frailty pathway includes standardized ways to prevent, assess for and treat delirium. Since implementing these measures, the rate of delirium has decreased by a remarkable 50 percent among patients over 65 on Tower 8ABCD. The mortality rate for the same population has dropped by 30 percent, and complications have decreased by 47 percent.
“Our main goals when we first started the pathway were to prevent delirium and preserve function for these patients, which we have since been able to achieve,” O’Mara said.
Once a patient is screened and meets the criteria for frailty in the ED, providers enter a set of admission orders to standardize the care for each patient on the pathway. Within 72 hours, the patient receives a comprehensive geriatric assessment, which includes an evaluation of medical conditions, cognition, function, nutrition, emotional status and risk for delirium, with a geriatrician, and a nutritional assessment with a nutrition consultant. This information is detailed in the patient’s electronic medical record to ensure a safe transition of care.
On Tower 8ABCD, care teams work closely with patients on the pathway to ensure they eat, get out of bed, have bowel movements and perform other self-care tasks on a routine basis.
O’Mara said collaborating with her colleagues to develop and implement the pathway – and ultimately achieve better outcomes for patients and their families – has been extraordinarily fulfilling.
“I really enjoy the personal interaction with the patients,” she said. “I like having that one-on-one time to talk with them on the floor, meet their families, discuss their diagnoses and create a personal care plan. You really become part of the patient’s family for a couple of days.”
Reiterating the importance of the frailty pathway’s multidisciplinary model, O’Mara has engaged both staff and trainees in the program. To date, she has trained 70 residents on the pathway, and she continues to offer ongoing training for new residents and providers.
“The pathway has brought the entire trauma floor together and has gotten me really excited about geriatrics,” O’Mara said.