Quality Improvement Process for General Surgery Clinic: Incorporating Frailty Screening
TimeThursday, April 154:00pm - 4:30pm EDT
LocationPatient Safety Research and Initiatives
DescriptionBackground: Introducing new processes into a busy medical clinic can be challenging. Despite the challenge, innovation and progress is essential to offer the best care to our patients. Our general surgery clinic has made improvements by introducing a frailty screening for new patients being evaluated for surgery. Though frailty is not a new concept, the utilization of frailty screening is not standardized nor is there a consensus among the medical community as to which frailty screening tool to use.
Frailty is a state of increased vulnerability to physiologic stress (such as surgery or illness) due to diminished physiologic reserve. Decline in physiological reserve can be caused by a combination of factors such as increasing age, malnutrition, immunosuppression, ambulatory status, or chronic medical conditions. By 2030, 20% of the population is expected to be over 65 years of age. Within this population, 25% have been found to be frail. Up to 50% of patients greater than 65 years of age are undergoing major surgery. Frailty has been associated with longer hospital stays, worse 30 and 90 mortality rates, and increased ICU admissions. It must also be noted that while age is a risk factor for frailty, it is not the sole determinate. Thus, frailty status should be considered for all patients. While many elements of frailty assessment are part of the pre-op evaluation, and surgeons intuitively assess patient’s robustness, a formal frailty screen during the initial clinic encounter, is not universal. Multiple studies have shown that frailty is associated with worse outcomes in patients undergoing a range of procedures from smaller elective surgeries to large cancer related procedures. Multiple frailty assessments have been developed, but the components of the assessments are not the same, some are pre-op – others post-op, and the use of these screening tools has not been standardized. Cognitive decline is one feature that is not include in every frailty assessment even though it has been found to be an important contributor to frailty. For these reasons we implemented a system to both measure and document frailty for every surgical patient.
Methods: Several frailty screening tools were studied including: Edmonton Frailty Assessment, Fried Frailty Phenotype, the 5-point Frail Questionnaire, and Risk Analysis Index. Surgical quality improvement programs (Veteran Affairs Surgical Quality Improvement Project, National Surgical Quality Improvement Project) utilize certain patient characteristics and type of surgical procedure to predict post-operative risks for the patient undergoing the respective procedure. These risk tools were reviewed along with the American College of surgeons best practice guidelines for geriatric surgery to develop a robust, meaningful frailty assessment. Aspects of efficiency, usability, and completeness were used to guide tool development. Several Plan-Do-Study-Act cycles resulted in the final frailty assessment that captures cognitive decline, nutrition, ambulatory status, social status, and important chronic medical problems. The frail scale was then trialed in the general surgery clinic on patients presenting for pre-operative consultation. The screening tool is also being made into a Frailty Note, available in the Electronic Medical Record, to allow any physician to easily document patient frailty. The components of our frailty scale include: Get Up and Go test, weight loss, functional status, mood, social status, previous hospitalizations, history of stroke, heart attack, heart failure and shortness of breath, and a mini cognitive assessment utilizing the three word recall and clock draw test.
An additional aspect of our quality improvement program included teaching medical students the components of a quality improvement initiative. First year medical students were given the opportunity to learn how to implement a quality improvement initiative from start to finish and participating in Plan-Do-Study-Act cycles. They have been trained in how to utilize the screening tool and data collection and are now available to assist in frailty screenings.
Conclusion: Frailty screening as an integral part of surgical evaluation, can potentially influence outcomes for patients of any age undergoing a wide variety of surgical procedures. There are several advantages of incorporating this screening tool into surgery clinics: it provides a method to identify which patients are frail, it enables providers to determine why the patient is frail, it provides an opportunity to improve any potentially modifiable patient factors, and finally, it could guide surgical planning and lead to better patient outcomes. This project was also used as an opportunity to teach budding physicians how to conduct quality improvement initiatives. This quality improvement process demonstrates that change and innovation can be introduced in a way that is practical, meaningful, and useful.