What are we missing here? (Are at risk older people spotted early enough in hospital?) – Dr Kinda Ibrahim, Research Fellow at Academic Geriatric Medicine

Nearly two thirds (65%) of people admitted to hospital in the UK are aged over 65 years old. Many of them are frail and at high risk of poor healthcare outcomes – like staying longer in hospital, reduced physical abilities, becoming dependant, going to a care home, and even death.

National recommendations suggest that these high-risk older individuals should be routinely identified when they are admitted to hospital to allow healthcare teams to provide appropriate individual care that meets patient’s needs (1).  It is unclear whether and how those people are identified in hospital. Therefore our study looked at the current practice in one hospital with regard to identification of patients at high-risk of poor healthcare outcomes. To do that, we reviewed a random sample of patient’s clinical notes and interviewed staff members who worked at five acute medicine for older people wards (2).

We found that patients at risk of poor healthcare outcomes were not explicitly identified on admission to acute medical wards.  A number of tools were used by nursing staff on admission to the wards to assess risk of malnutrition, falls and pressure ulcers.  However, the purpose of these assessments was to identify the risk of a single adverse outcome (for example, malnutrition) and they were not used together to highlight patients at risk of poor healthcare outcomes. No specific tool was used for the assessment of frailty or risk of adverse events.

Staff relied on their “clinical judgment” and “therapy assessment” to recognise high-risk patients. The multi-disciplinary setting (medical, therapy, and nursing staff) appeared to aid clinical judgement of patients’ needs. However, staff discussed a number of challenges in making this clinical judgment leading to possible delays. These included: presence of delirium, delayed clinical judgment due to incomplete information, lack of communication between staff and the difficulty of predicting risk of falls.

This is what one consultant had to say: “What is harder to understand, is how much patients will decline functionally during their admission, and we can certainly take a best guess, but sometimes we are surprised that our best guess is not right“.

Staff recognised the potential benefits of using a measure that could identify high-risk patients to assist clinical judgment.

One junior doctor stated: “I guess in the people where it’s marginal and you then have a delay in making that assessment, if there was something immediately done on admission that identified that person, it would speed up the process and reduce their admission“ 

Therefore, we believe that identification of these patients early on admission to acute medical wards using a valid measure, alongside staff clinical judgment and existing risk assessment tools, could be highly relevant. Our current research assesses the feasibility of using a simple grip strength measurement by staff as a tool to identify older patients at risk of poor healthcare outcomes and examine whether it aids staff clinical judgment (3).

We should be able to share the results soon.

1. Turner G, Clegg A. Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age and ageing. 2014;43(6):744-7.
2. Ibrahim K, Owen C, Patel HP, May C, Baxter M, Sayer AA, Roberts HC. Can routine clinical data identify older patients at risk of poor healthcare outcomes on admission to hospital? BMC research notes. 2017 Aug 10; 10(1):384.
3. Ibrahim K, May C, Patel HP, Baxter M, Sayer AA, Roberts H. A feasibility study of implementing grip strength measurement into routine hospital practice (GRImP): study protocol. Pilot and Feasibility Studies. 2016;2(1):1-10.