CRP: A Diagnostic Aid For Frailty Virtual Wards
Managing patients living with frailty is a priority for NHS England, and detailed in the guidance laid out in 2021[1]:
Central to this approach is services working towards providing a model that is patient centred, and in which home is an option for care. This is part of the shared decision-making process, in line with personalised care principles.
A Hospital at Home for frailty should be available as an option for clinicians to refer adults (aged 65 or over) who have an acute exacerbation of a frailty-related condition. The concept of a Hospital at Home or virtual ward for frailty is well established.
NHS – Guidance Note Frailty Virtual Ward (Hospital at Home for Those Living with Frailty)
It is the responsibility of the local Integrated Care System to implement this policy as soon as practicably possible.
| Hospital at Home | |
|---|---|
| What? | Technology-enabled remote monitoring and in-person care/treatment |
| Who? | – People aged 65 or over with frailty-related illness. – Higher acuity patients who would otherwise be in hospital because they require in-person monitoring/treatment |
| When? | Admission alternative and early discharge |
| Where? | In the patient’s own home or usual place of residence, such as a care home |
| Why? | – Improved patient experience and outcomes – Shared decision-making – Improved patient hospital flow – Reduced nosocomial transmission of infections – Home First as a principle |
| How? | – In-person and/or technology-enabled care from a multidisciplinary team – Early deterioration recognition and appropriate clinical input – Proactive monitoring/escalation |
Taken from: NHS England Guidance on Virtual Frailty Wards
What is Frailty?
Frailty is described by the Royal College of Physicians as:
“…a consequence of decline in several physiological systems, which collectively results in a vulnerability to sudden health state changes triggered by relatively minor stressor events.”[2]
There are five key elements to frailty as determined by the British Geriatric Society[2]:
- Falls
- Immobility
- Delirium
- Incontinence
- Susceptibility to side effects of medication
Why is the health service targeting frailty as an area of concern?
Frailty is increasingly associated with significant healthcare costs and burden on secondary care provision. Patients identified as frail were much more likely to visit their GP, make visits to emergency medicine and have extended stays in the hospital.[3]
Using reference costs from 2013/14 suggested that additional economic burden to the healthcare system from frail patients was estimated at £5.8 billion annually.[3]
How could a virtual ward/hospital at home help?
Appropriate assessments and clinical intervention in a patient’s usual place of residence could identify those who with additional support and monitoring could remain at home (escalation in place). It would also ensure that escalation to secondary care was appropriate and objective.[1]
How can diagnostics help?
NHS England recommend various assessments, including point of care diagnostics. As diagnostics are indicated in 70% of all clinical decisions[4], they can be instrumental in identifying appropriate management and treatment.
Traditionally, diagnostics are provided in secondary care settings which is often why, in an urgent scenario, frail patients are sent to hospital in order to gather more information for signposting and management decisions.
Enabling clinicians to access diagnostic results in the patient’s home supports much earlier decision-making and management.
CRP: a case study for virtual wards
Respiratory infection is a major cause of exacerbation in frail older patients, especially those with chronic lung conditions such as COPD. For example, community-acquired pneumonia (CAP) is a major cause of hospital admission in this patient cohort, with admission rising by 35% since 2013. In some of these cases admission may not have been necessary.[5]
C-reactive protein (CRP) is an acute phase reactant, a protein made by the liver that is released into the blood within a few hours after tissue injury, the start of an infection or other inflammation.[6]
CRP has been recommended by NICE[7] in order to appropriately initiate antibiotics in patients with a suspected diagnosis of CAP, which benefits patients from both a management and AMR perspective by making an objective decision.
Emerging urgent response/hospital-at-home teams also use CRP to support decision-making in frail patients, for four key reasons:
- To confidently manage the patient at home
- To know when to refer to community hospital
- To know when to urgently admit the patient to acute care
- To understand the efficacy of antibiotics[8]
References and Further Reading
[1] NHS England Guidance on Virtual Frailty Wards: https://www.england.nhs.uk/wp-content/uploads/2021/12/B1207-ii-guidance-note-frailty-virtual-ward.pdf
[2] BMA – Identification and management of patients with frailty – https://www.bma.org.uk/advice-and-support/gp-practices/gp-service-provision/identification-and-management-of-patients-with-frailty
[3] The impact of frailty on healthcare resource use: a longitudinal analysis using the Clinical Practice Research Datalink in England – LuHan, Andrew Clegg, Tim Doran, Lorna Fraser: https://pubmed.ncbi.nlm.nih.gov/31297511/
[4] BIVDA, The Value of IVDs – https://www.bivda.org.uk/The-IVD-Industry/The-Value-of-IVDs
[5] NICE, Respiratory conditions: reducing pressure on emergency hospital services – https://indepth.nice.org.uk/respiratory-reducing-emergency-pressure/index.html
[6] Lab Tests Online, C-reactive protein (CRP) – https://labtestsonline.org.uk/tests/c-reactive-protein-crp
[7] NICE, Pneumonia in adults: diagnosis and management – https://www.nice.org.uk/guidance/cg191/chapter/1-Recommendations
[8] Una Health, QuikRead go® easy CRP – a perfect fit for the Hospital-at-Home model – https://er59hzwvdnk.exactdn.com/wp-content/uploads/QuikRead-go-CRP-Article-Rev-5.pdf