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

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.