Developing reliable frailty care pathways: Glasgow Royal Infirmary

Glasgow Royal Infirmary were part of the Focus on Frailty programme which ran from May 2023 to December 2024.

Spotlight

Glasgow Royal Infirmary (GRI) in NHS Greater Glasgow and Clyde has reduced the average length of stay for people identified as frail by three days (reduction from 16 to 13 days) with no increase in readmissions. The team at GRI have demonstrated sustained improvement in frailty identification and implemented changes which enable early CGA and integrated discharge planning.

The team have tested and implemented changes including:

Frailty identification at the front door using the HIS THINK frailty tool.
Reliable use of a frailty icon on electronic systems to support getting the right person to the right speciality as early as possible.
Advanced frailty practitioner and elderly care assessment nurse roles at the front door.
Dedicated frailty assessment beds.
Daily integrated CGA huddles with members from acute and community teams.
Rapid access appointments to assessment and rehabilitation centres.

Having a comprehensive geriatric assessment huddle involving community rehab teams meant that patients could be flagged at an earlier point for discharge. They [community team] were …prepared and able to support a patient centred discharge home." Focus on Frailty programme member

Changes for impact

Glasgow Royal Infirmary has demonstrated that developing person centred frailty pathways can increase how quickly people living with frailty return to live at home or in a homely setting. Changes for impact include:

Reliable frailty identification

using a reliable frailty screening tool at the front door, and
an electronic icon to make it easier for people to benefit from a frailty pathway.

Early multidisciplinary CGA

establishing dedicated frailty assessment beds, and
developing frailty specialist roles across the multi-disciplinary team.

Integrated person centred care coordination

collaborating with community teams to deliver integrated CGA huddles, and
using existing outpatient services as alternative options to admission.

Transferable learning

Senior leader sponsorship of frailty improvement work accelerates the pace of change.
Using local data over time to demonstrate the impact of changes supports momentum and buy in.
Including the voice of the person, their family and carers is a powerful lever for keeping focused on what matters most.
Interdisciplinary integrated teams create the conditions for innovation.

Further information

More information and updates on the Focus on Frailty programme are available on our webpages.

To find out more about Glasgow Royal Infirmary's approach, or to join the frailty learning system, please email: his.frailty@nhs.scot

Frailty learning system