Identifying frailty in surgical patients: introducing a patient-generated frailty score in a UK district general hospital

Abstract

Royal Devon and Exeter NHS Trust

Frailty is a syndrome of functional decline across physiological systems, predisposing patients to adverse events. As an independent predictor of surgical outcomes, frailty should be assessed pre-operatively to inform shared decision-making and reduce complications, loss of independence and mortality. Frailty is difficult to quantify and an effective way of identifying it is needed to adapt a patient’s peri-operative pathway. We describe the first phase in the introduction of an adapted Risk Analysis Index C (RAI) frailty score [1], which we aim to use for elective surgical patients.

Methods

The RAI tool is a validated tool for generating frailty scores by the patient. Patients were asked to complete the RAI at home before attending the high-risk anaesthetic clinic. RAI records social settings, medical conditions, nutrition, cognition and activities of daily life. Following feedback-guided improvement cycles, the RAI was adapted for use in surgical patients. The RAI forms were analysed for completion and accuracy and used to calculate a frailty score stratifying patients by risk, based on the original research paper. The RAI score was correlated with a clinician determined Rockwood frailty score.

Results

Fifty-five patients trialled our adapted RAI. Ninety-six per cent of forms (52/55) were complete and 91% of these were factually accurate when compared against clinical records. Thirty patients were scored very low risk, 10 were low risk, eight were medium risk and two were high risk. There was little correlation (r = 0.3182, p = 0.024) between the RAI and Rockwood scores.

Discussion

Our refinement of the original RAI has created a usable self-assessment frailty tool for patients in a pre-assessment pathway. We have demonstrated that patients can use the RAI reliably and accurately, allowing early risk categorisation. Our efforts to enact change have been hampered by COVID-19 and the next step in our quality-improvement project is to use the RAI to guide pre-operative planning with at-risk patients referred for physiological optimisation, review of polypharmacy, improved physical conditioning and discharge planning. It will help with shared decision-making. The lack of correlation between the RAI and Rockwood scores needs further study. This may be explained by the fact that the Rockwood score is not generally reliable unless used alongside a clinical assessment of frailty.

Acknowledgements

The authors thank Dr Suzy Hope, COTE Department, Royal Devon and Exeter NHS Trust.