Frailty is a biological syndrome of decreased physiological reserve shown to cause disability, independent of clinical conditions.1 Systematic review of the literature has shown frailty in older adults is associated with adverse outcomes and decreased survival.2 Identification of frail patients in order to optimise management has been shown to improve outcomes.3 The gold standard for assessing older people with frailty is the “Comprehensive Geriatric Assessment” (CGA),4 an evidence-based intervention associated with better outcomes in mortality, readmissions and institutionalisation5 supported by Cochrane systematic review.6

The Royal Surrey County Hospital (RSCH) NHS Foundation Trust is a 500-bed single-site district general hospital (DGH) serving a population of 330,000 people across Surrey, admitting 90,000 patients for treatment annually.7 Of 24,117 medical admissions in 2016/17, 3,109 were admitted to geriatric medical wards,8 though many patients living with frailty were admitted to non-geriatrician led medical or surgical wards.

The inpatient Older People’s Advice and Liaison (iOPAL) service at RSCH was established in 2015 to improve the care of older patients on medical or surgical wards, as well as to streamline a pathway for access to community rehabilitation beds. Since its inception, this liaison service has been essential in ensuring access to CGA and specialist geriatric advice despite patients belonging to a non-geriatric specialty.

Information sharing between secondary and primary care is notoriously poor and as with most hospitals, is reliant on the information transposed in the discharge summary written by the ward junior doctor. The British Geriatric Society advocates for the GP to complete holistic CGAs on any patients identified as frail in the community, suggesting a minimum 45-minute assessment.9 Given ever-increasing pressures on primary care services, sharing the information gathered by iOPAL during acute inpatient admission could be invaluable if effectively transferred to the GP, to ensure best care for the patient is continued beyond their discharge.


  • To evaluate the impact of iOPAL involvement on patient outcomes (30-day readmission rates and inpatient mortality).
  • To increase awareness of the iOPAL service on non-geriatric wards by developing methods to prompt referral for CGA (most notably implementation of a Frailty Sticker within patient notes).
  • In recognition of best practice in the community, to establish what information from the CGA would be beneficial to the patients’ community team and how best to share this.


Study design and setting

An observational analysis was performed on patients admitted to non-geriatric medical wards at RSCH identified as meeting frailty criteria. Numbers of referrals were monitored pre and post introduction of a “Sticking up for frailty” sticker placed in identified inpatients’ notes. Surveys were prospectively gathered from community teams at a regional frailty forum hosted by the local clinical commissioning group (CCG) and analysed using thematic analysis.


Admitted patients with frailty markers on non-geriatric wards were identified for the database. Patients were followed up for 30 days following discharge and inpatient mortality and readmission data documented as well as whether or not the patient had been referred and assessed by iOPAL. Key stakeholders for community care such as GPs, community matrons and district nurses were asked for feedback on the CGA and ideas for data sharing.

Data collection

From January to April 2018, the Emergency Assessment Unit (EAU) acute medical and surgical admissions lists were screened daily to identify patients admitted to non-geriatric inpatient wards who met the modified Bournemouth criteria10 for frailty. Identified patients’ medical notes were screened on the ward using the Clinical Frailty Scale11 (CFS). Patients scoring greater than or equal to 4 on the CFS were added to the database.

Patients were followed up for 30 days following discharge, with inpatient mortality and 30-day readmission rates calculated retrospectively. The first 92 patients identified, referred to and assessed by iOPAL were compared to the first 92 patients identified but not referred or seen. Statistical significance was calculated using the unpaired T-test.

Prior to this period, the percentage of patients referred to the iOPAL service who had been identified with frailty was calculated. An intervention was introduced to try to increase awareness of iOPAL (Table 1) and referral rates monitored thereafter.

Community involvement

Following positive feedback from a local GP who had read a CGA by iOPAL following the discharge of his patient, a key stakeholder meeting was held with all local GP practices invited to discuss further (Table 2). This led to commencing electronic completion of CGA based on feedback regarding increased information sharing with the community and transfer to practice DocMan computer system.

Data analysis

A mixed methods analysis was performed using observational and thematic analyses to explore the data.

Ethical considerations

As per the Health Research Authority, ethical approval was not required for this service evaluation and audit.12


Impact on patient outcomes: inpatient mortality and 30-day readmission rates

92 patients with frailty markers (CFS ≥4) were assessed by iOPAL with completion of CGA (Table 3, Cohort 1) throughout the four-month period of January to April 2018. All of these patients had been actively referred to the service. The average CFS for Cohort 1 was 6.

Cohort 2 comprised of 92 patients with frailty markers (CFS ≥4) who were identified, but not referred or assessed by iOPAL. The average CFS for cohort 2 was 6.

The number of patients and average CFS were the same for both cohorts with slightly more males represented in the non-referred cohort (59% compared with 48%) as per Table 3.

Both inpatient mortality and 30-day readmission rates were lower in Cohort 1 where the patients had been assessed by iOPAL and received a CGA. 13% inpatient mortality was seen compared to 16% not assessed (p=0.06) and 19% readmission within 30 days of discharge compared with 24% in the non-assessed cohort (p=0.05), as per Figure 1.

Increasing awareness of the service: iOPAL referrals pre- and post- Intervention

Referral rates were monitored throughout the database pre-intervention. Of 107 patients identified with frailty markers, 22% (n=23) were referred to iOPAL for assessment. In the month following introduction of the Frailty Sticker, 110 patients were identified with frailty markers and 41% (n=45) were referred for assessment (Figure 2).

Community information sharing: primary care stakeholder feedback

19 primary care team members provided written feedback: 12 (63.2%) GPs, 6 (31.6%) community matrons and 1 (5.2%) other professional.

All respondents felt either confident managing frailty (42.1%, n=8) or very confident (57.9%, n=11) yet most (84.3%, n=16) had never heard of either Rockwood or Bournemouth frailty criteria. 31.6% (n=6) had never heard of CGA and no respondents had completed a CGA, but 13 respondents (68.4%) had received a CGA in the community. Almost all (89.5%, n=17) felt having access to a CGA would be very useful and 10.5% (n=2) thought it would be useful, with no respondents reporting it would not be useful.

On exploring what domains from the CGA should be included, the average number of domains was 11.4 out of 14 possible domains.

Feedback was divided into three themes:

  • Positive thoughts that CGAs would be very useful as a baseline and to form the basis for care plans particularly for nursing home residents in addition to community matron assessments.
  • Suggestions for improvement included merging assessments with the community matron documentation due to duplicated work, and including additional information such as who is involved and important to the patient, any follow up arrangements made, separate action plan for the GP, ceiling of care, clear resus status and discussion with family.
  • Areas of concern included duplication of data collection from various different teams and the risk of information becoming outdated.


Main findings

  • This study showed that 30-day readmission and inpatient mortality rates were lower for patients with frailty referred and assessed by iOPAL compared to a matched cohort not referred or assessed.
  • Referral rates to iOPAL increased following the introduction of the “Sticking up for Frailty” sticker.
  • Community feedback regarding sharing CGA material was positive and this has led to greater information sharing between iOPAL in a secondary care setting, through to the community.

Impact of iOPAL on patient outcomes

The raw data collected implied that the cohort of patients who received CGA by iOPAL had better outcomes in terms of lower readmission and mortality rates, in line with previous evidence.5 We attempted to ensure that similar cohorts were compared by calculating the CFS, the average of which was the same for both groups. However, we did not have large enough samples to compare, and following statistical testing these outcomes were not statistically significant (p=0.06 for inpatient mortality and p=0.05 for readmission within 30 days). We have planned to adapt our database with the help of our Trust Data Analyst and adopt a more measurement-minded ethos and continue to collate data to re-analyse.

It is difficult as a liaison service to reduce length of stay (LOS) as often we find problems that need to be addressed following our CGA, or require family meetings or care diaries in order for us to coordinate a robust and appropriate discharge. However, by doing this we hope that we may reduce readmission rates. By the very nature of our specialty, the cohort referred to the service are patients with multi-morbidity, frailty, complex health and social needs, so will naturally require longer admissions and be at high risk of readmission.

We hope that by delivering holistic care, and identifying outstanding medical and surgical issues, we may reduce inpatient mortality. Furthermore, iOPAL aims for early identification of patients coming towards the end of their lives; we can then reduce inpatient mortality and help to facilitate palliation in the community in line with patient preference. This was an important part of the CGA particularly for GPs and community matrons.

Increasing awareness of iOPAL and referral rate

Surgical specialties were included in this key aim of our service given the poor referral rate to iOPAL. The evolution of orthogeriatrics has demonstrated that joint specialty care of patients with frailty is associated with better outcomes. Geriatric liaison services such as iOPAL are a stepping stone towards this in other surgical specialties.

The implementation of a Frailty Sticker doubled referrals to iOPAL, meaning that more inpatients with frailty had access to CGA. However, over half of patients with frailty were still not referred to the service, suggesting education is needed to increase awareness and identification of frailty across non-geriatric wards. A small staff survey was conducted to gain feedback and ideas for development of iOPAL: suggestions included small group teaching about frailty such as frailty board rounds and frailty magnets. Indeed, following this, iOPAL has recently undertaken a new project conducting daily board rounds on a cardiology ward with use of silver frailty magnets to identify patients in need of CGA. This will greatly increase awareness of the service, as well as referrals, and measurement of this will influence future endeavours to support other specialties.

Community liaison and sharing of the CGA information

Following the stakeholder meeting ‘Frailty Forum’ and feedback from local GPs, it was decided that the entire CGA document should be shared as it is a useful reference document for the community.

iOPAL converted to typing CGAs through Microsoft Word, and have established a system of online uploading of the whole document to the local GP system ‘DocMan’ via Electronic Data Transfer. We will aim to re-evaluate the response to this and seek feedback from community stakeholders at future meetings.

We have also improved liaison with the community through Proactive Care Service meetings, where our frailty nurses receive referrals from district nurses and community matrons direct to iOPAL. It is also an opportunity to discuss complex discharges in the hope of avoiding unnecessary readmissions by true continuity of care.

Acknowledgements: Thank you to the staff and residents at the Royal Surrey County Hospital and the local primary care teams for their participation. We would like to thank Dr James Adams and Dr Helen Wilson for their support in the development of the iOPAL service. Finally to our fantastic frailty specialist nurses past and present for their passion and drive to improve care for patients with frailty (Hayley Harvey, Claire Parten, Sophie Rees, David Hart).

Conflict of interest: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


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Dr Hannah Field

GP Registrar, Department of Ageing and Health, Royal Surrey County Hospital

Dr India Merrony

Specialty Doctor, Department of Ageing and Health, Royal Surrey County Hospital

Dr Hiro Khoshnaw

Consultant Physician and Geriatrician, Department of Ageing and Health, Royal Surrey County Hospital