Implementing Geriatric Frailty Screening in Acute Care Implementing Geriatric Frailty Screening in Acute Care

Practice Problem: Frailty is a syndrome of age-related physiologic decline characterized by an increased burden of symptoms and higher susceptibility to adverse health, including higher functional decline rates, pressure ulcers, falls, and delirium. In the general medicine unit of this project, geriatric patients were not screened for frailty. PICOT: The PICOT question that guided this project was: In hospitalized patients 65-years-of-age and older (P), how does implementing a geriatric frailty screening tool (I), compared to standard assessments (C), influence frailty identification and personalized plans of care (O) over eight weeks (T)? Evidence: Literature supports screening for frailty in the hospitalized geriatric population. Intervention: For eight weeks, a group of four RN clinicians piloted the CFS and collected data on patient appropriateness for screening, completion of screening, CFS scores, and influence of CFS scoring on personalized patient care plans. Outcome: Statistical analysis results suggest that completing the CFS and adjusting the individualized plan of care were related to one another. Conclusion: Applying best practices to identify frailty during hospitalization demonstrated a measurable influence on health promotion in acutely ill geriatric patients.


Implementing Geriatric Frailty Screening in Acute Care
Normal aging is usually characterized by predictable, progressive physiologic changes associated with higher susceptibility to multiple diseases and disabilities (Taffet, 2019). Frailty is a phenomenon within the geriatric population that is distinctly separate from disease or disability (Fried et al., 2004). Frailty is a syndrome of age-related physiologic decline characterized by an increased burden of symptoms and higher susceptibility to adverse health. An international physician consensus group formally defined frailty as "a medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual's vulnerability for developing increased dependency and/or death" (Morley et al., 2013, p. 4). Several characteristics are associated with higher prevalence of geriatric frailty, including smoking, female gender, Hispanic or African American ethnicity, depression, lower education level, and intellectual disability (Bandeen-Roche et al., 2015;de Labra et al., 2018;Evenhuis et al., 2012;Lakey et al., 2012;Woods et al., 2005).
In the acute care setting, geriatric frailty is associated with higher functional decline rates, pressure ulcers, falls, and delirium (Hubbard et al., 2017). Given the higher vulnerability to adverse health outcomes and reduced tolerance to adapt to acute illness, trauma, or medicalsurgical interventions, frailty screening should be implemented in patients 65 years and older (Morley et al., 2013). Screening for geriatric frailty may indicate an opportunity to implement interprofessional consultation and facilitate favorable or supportive discharge status. This evidence-based practice (EBP) project implemented frailty screening on patients aged 65 years old or older admitted to a general medicine unit during an eight-week period.

Significance of the Practice Problem
Frailty is an increased vulnerability to adverse health outcomes across clinical settings due to a decline in physiologic reserve related to age-related changes (Xue, 2011). The state of frailty leads to a prolonged and incomplete recovery after any new injury, stress, or acute disease (Perna et al., 2017). In the United States, 14.9% of the total population is geriatric, characterized as 65 years and older (U.S. Census Bureau, 2020). The US geriatric population has experienced rapid growth since 2011 as individuals born between 1946-1964, the Baby Boomer generation, began reaching 65 years old (U. S. Census Bureau, 2020). Frailty in the US geriatric population ranges from 4-16% in community-dwelling elders over 65 years old, with prevalence increasing to 24% in individuals 90-94 years old and 39.5% in individuals >95 years old (Cawthon et al., 2007). Nearly 40% of hospitalized adults are >65 years old, and frailty rates are estimated as high as 27.4%, and pre-frailty rates range from 34. 6-50.9% in this population (Archibald et al., 2019).

Significance of Frailty on Patient/Family
Geriatric frailty significantly impacts patients and families in several aspects of function, quality of life, and harm. In hospitalized patients identified with geriatric frailty, 45% experience functional decline characterized as requiring subacute care or additional services after discharge or performing below baseline function in daily living activities (Greorevic et al., 2016). This functional decline can lead to loss of independence and often requires increased support/dependency on family for Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Using a quality of life (QOL) questionnaire, QOL domains of health and mobility are lower in geriatric individuals identified with frailty than non-frail or pre-frail counterparts (Henchoz et al., 2016). Additionally, up to 38.6% of individuals identified with geriatric frailty experience a fall event, with over 50% of frailty geriatric falls resulting in injury and 78% resulting in fear of falling again (Fhon et al., 2013). Higher rates of pressure ulcer incidence and use of restraints during hospitalization are also associated with geriatric frailty (Barry & Nugent, 2015;Gunawardena & Smithard, 2019). Additionally, frailty is associated with higher 2-year mortality following hospitalization (Keeble et al., 2019).

Significance of Frailty on the Health System
Geriatric frailty significantly impacts the healthcare system across the continuum. Frail hospitalized geriatric patients can incur a longer length of stay and higher readmission rates than non-frail or pre-frail elders depending on admission diagnoses (Ritt et al., 2016). In patients admitted with atrial fibrillation, length of stay was 3-5 days longer in frail geriatric patients compared to non-frail geriatric patients, and readmissions occurred in nearly 74% of frail geriatric general medicine patients compared to 62% of non-frail cohorts (Hao et al., 2019;Nguyen et al., 2015). Geriatric frailty also leads to higher use of skilled nursing facility resources, nursing home placement, and aged care services (De Silva et al., 2017).

Significance of Frailty on Society
Geriatric frailty is associated with particular social determinants and results in higher dependency on family and increased healthcare services needs with increased healthcare costs.
Evaluating acute medical costs of U.S. Medicare patients in 2013, the mean cost of care over nine months for frail patients was $25,320, compared to $16,305 for pre-frail geriatric patients and $8,099 for non-frail geriatric patients (Simpson et al., 2018). These costs represent a staggering opportunity to identify geriatric frailty and modify care strategies to maximize patient access to health promotion services, implement interventions to avoid adverse healthcare outcomes, and streamline service costs (Cunha et al., 2019;Lee et al., 2020;Xue, 2011).

PICOT Question
Compared to non-frail geriatric patients, frail geriatric patients are unique with higher risks for poor healthcare outcomes. These poor outcomes include increased incidence of adverse events during hospitalization, incurring longer lengths of stay, experiencing higher hospital readmission rates, and having an increased need for institutionalization after hospital discharge (Engelhardt et al., 2018;Walston et al., 2018). Given these adverse outcomes personal and organizational impact on hospitalized elders, this practice project sought to implement a geriatric frailty screening process. In hospitalized patients 65-years-of-age and older (P), how does implementing a geriatric frailty screening tool (I), compared to standard assessments (C), influence frailty identification and personalized plans of care (O) over eight weeks (T)? This project focused on hospitalized patients 65 years and older in a general medicine unit in an academic medical center in the southern United States. On the general medicine unit, registered nurses and advanced practice providers assess all adult patients using standard head-to-toe assessments with additional separate screenings focused on falls, delirium, and hospital-acquired pressure injury risk. On this unit, geriatric patients are currently not explicitly screened for geriatric frailty. Patients 65 and older were screened using a geriatric frailty screening tool during the eight-week project implementation period. Data were collected on patient appropriateness for frailty screening, compliance of frailty screening, frailty scores, and the influence of frailty scoring on personalized patient care plans.

Evidence-Based Practice Framework & Change Theory
The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model was used to guide the implementation of this geriatric frailty screening project and evaluate the impact of frailty screening on individualized plans of care. The JHNEBP utilizes three steps: practice question, evidence, and translation (Dang & Dearholt, 2017). Using the JHNEBP framework, the first step of this project focused on recruiting a group of clinicians to implement frailty screening on the general medicine unit, defining the problem, refining the evidence-based practice question for geriatric frailty screening, and identifying unit-based and organizational stakeholders. The second step entailed searching for evidence related to geriatric frailty screening and interventions, appraising, summarizing, synthesizing the level and quality of evidence, and developing a formal recommendation for practice change based on compelling evidence. The final step included determining the appropriateness of implementing geriatric frailty screening, creating and implementing an action plan, evaluating outcomes, reporting results, and disseminating findings based on results.
Lewin's change theory is the foundation for this project. Lewin's theory recognizes change as a dynamic balance of driving and restraining forces working in opposite directions within a group/system (Lewin, 1951;White et al., 2021;Zaccagnini & White, 2014). Lewin's theory highlights three stages of change: unfreezing, moving, and refreezing. Unfreezing is characterized by identifying a need for change and preparing participants for the upcoming change; in this project, unfreezing identified the impact of geriatric frailty and collaborated with clinicians to conceptualize geriatric frailty screening in general medicine patients. The moving stage includes implementing the change while balancing motivating forces and minimizing barriers; for this project, moving included piloting a geriatric frailty screening tool and measuring appropriateness of patients, compliance of screening, frailty scores, and impact of frailty scoring. Finally, refreezing formalizes the change and disseminates results; in this project, refreezing formalized geriatric frailty screening on the general medicine unit.

Evidence Search Results
The initial search results included 1757 total articles from CINAHL (141), ProQuest (1308), PubMed (281), and Cochrane (2). Titles and abstracts were reviewed, with inclusion and exclusion criteria applied. The initial review excluded 1711 articles for not meeting inclusion criteria or including exclusion criteria. Articles were excluded due to not including a study or studying the impact of the Comprehensive Geriatric Assessment, which is not a screening tool.
Forty-six articles were extracted for full-text review, and 26 were excluded after full-text screening due to limited evidence supporting reliability, validity, or application with measurable outcomes, as shown in Figure 1. Twenty articles are included in the Evidence Summary Table   (see Appendix A). Of the twenty articles, six individual frailty screening tools were studied, and two tools had several studies validating use: eleven studies focused on the Clinical Frailty Scale (CFS), and three focused on the FRAIL Questionnaire. The 14 focused on the CFS and FRAIL questionnaire and reflected Level III evidence with 8 Quality Grade A, 5 Quality Grade B, and 1 Quality Grade C. The four other screening tools included studies with Level III (4 studies), Level IV (1 study), and Level V (1 study). Currently, there are no randomized controlled trials testing a geriatric frailty screening against a control.

Themes with Practice Recommendations
Frailty describes the increased vulnerability of select individuals to adverse outcomes compared to people within the same chronologic age. Since the foundational conceptual model of geriatric frailty in 2001, research on geriatric frailty has produced an expanding body of literature that focuses on the impact of frailty on patient outcomes (Maxwell et al., 2019). As the global life expectancy lengthens, the number of older patients presenting with frailty continues to rise (Zhao et al., 2020). Because not all older adults are frail, recent literature highlights the importance of identifying geriatric frailty to avoid or anticipate and prepare for adverse outcomes (Theou et al., 2018).

Population
In a review of geriatric frailty screening literature, 20 articles focused on screening for frailty in hospitalized geriatric patients during hospitalization. Nearly 40% of hospitalized adults are >65 years old, and frailty rates are estimated as high as 4.9%-27.4%, and pre-frailty rates range from 34.6-50.9% in the geriatric population (Archibald et al., 2019). Fifteen studies focused on geriatric patients presenting with various conditions and diagnoses and admitted to acute or intensive care units. A unique theme in five studies focused on frailty screening in geriatric patients presenting with trauma or requiring emergency surgical interventions. These studies on frailty screening reflected research across several continents: North America with six studies from the United States and Canada; Europe with six studies from the United Kingdom and Spain; South America with three studies from Brazil; Asia with three studies from Singapore and Bejing; and two studies from New Zealand and Australia (Aliberti et al., , 2019Aprahamian et al., 2018;Brummel et al., 2017;Cheung et al., 2017;Chong et al., 2017Chong et al., , 2019Curtis et al., 2018;Ellis et al., 2020;Engelhardt et al., 2018;Flaatten et al., 2017;Hilmer et al., 2009;Hii et al., 2015;Ibrahim et al., 2019;Joseph et al., 2014;Liu et al., 2020;Maxwell et al., 2018;Moreno-Arino et al., 2020;Pugh et al., 2019;Torsney & Romero-Ortuno, 2018).

Ease of Use
The most effective and accurate method to identify geriatric frailty is conducting a Comprehensive Geriatric Assessment (CGA). However, the time and resource requirement for a CGA is often not possible in the acute care setting, and a more rapid screening tool is desirable.
The 20 studies in this review included six different frailty screening tools: 11 used the Clinical Frailty Scale (CFS); three used the FRAIL Questionnaire; and the Reported Edmonton Frail Scale (REFS), Emergency General Surgery Specific Frailty Index, Trauma Specific Frailty Index, and Targeted Geriatric Assessment (TaGA) each had two studies. As shown in Table 1, the six different frailty tools used in 20 studies evaluated different functional, cognitive, and health status components. All six frailty tools evaluated gait or ambulation. Five focused on Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), and nutrition. Four tools included evaluating mood, and three tools evaluated symptoms/health perception, cognitive status, comorbidities, and the ability to climb stairs (resistance). Fatigue, polypharmacy, sexual activity, and falls were included in two tools. Furthermore, hospitalizations/ED visits in the previous 12 months and urinary incontinence were each evaluated in one tool (Aliberti et al., , 2019Aprahamian et al., 2018;Brummel et al., 2017;Cheung et al., 2017;Chong et al., 2017Chong et al., , 2019Curtis et al., 2018;Ellis et al., 2020;Engelhardt et al., 2018;Flaatten et al., 2017;Hilmer et al., 2009;Hii et al., 2015;Ibrahim et al., 2019;Joseph et al., 2014;Liu et al., 2020;Maxwell et al., 2018;Moreno-Arino et al., 2020;Pugh et al., 2019;Torsney & Romero-Ortuno, 2018).

Prediction of Outcomes
Nearly all tools in these 20 studies included 1-2 studies on user validity and reliability.
Literature supports screening for frailty in the hospitalized geriatric population. Based on the level of evidence, quality grades of evidence, the number of supportive articles, and tool content inclusion, the CFS had the most support for implementation (see Appendix B) (Brummel et al., 2017;Cheung et al., 2017;Chong et al., 2017Chong et al., , 2019Curtis et al., 2018;Ellis et al., 2020;Flaatten et al., 2017;Liu et al., 2020;Moreno-Arino et al., 2020;Pugh et al., 2019;Torsney & Romero-Ortuno, 2018). The practice recommendation for this EBP project was to implement the CFS in hospitalized general medicine patients 65 years of age and older to determine how the CFS influenced geriatric frailty identification and personalized plans of care during eight weeks.
Data collection, evaluation, and analysis focused on patient appropriateness for frailty screening, compliance of frailty screening, CFS frailty scores, and influence of CFS scoring on personalized patient care plans.

Setting, Stakeholders, and Systems Change
This project occurred at a not-for-profit level 1 trauma academic medical center in the southern United States. The organization's mission is focused on providing superlative quality, innovation, and excellence in patient care, health professional training, and creating health knowledge promoting diversity, equity, and inclusiveness (University of Virginia Health, 2020). This organization's main hospital has 612 beds with three designated acute care general medicine units. One of the general medicine units served as the geriatric frailty screening implementation setting. This unit has 27 beds, and over 50% of patients are older than 65, with nearly 25% older than 80. The most common admitting diagnosis on this unit is sepsis. The unit's nurse-sensitive indicators reflect consistent outperformance of the National Database for Nursing Quality Indicators benchmarks in central line-associated bloodstream infections rate, catheter-associated urinary tract infection rate, and hospital-acquired pressure injuries. However, this unit demonstrates higher inpatient falls with injury than national peers and has a higher use of restraints than many other acute care units in the organization. Additionally, readmission data reveals this unit has the third-highest readmission rate across the organization.
Hospitalized frail elders have a higher risk of adverse events during hospitalization and increased dependence at discharge in frail elders. In this organization, general medicine physician leadership attempted to pilot an unvalidated frailty screening question 18-24 months before this EBP project. However, this previous screening was not considered valuable because it was inconsistently completed by inexperienced clinicians and did not activate any interprofessional interventions.
The directing physician for general medicine, geriatrics, and palliative care supported piloting a validated geriatric frailty screening tool. This organization's commitment to safety outcomes, revenue, and national recognition aligned with literature promoting geriatric frailty screening and improved care provision. Geriatric frailty screening implementation impacted micro-level change with individual patient screening and intervention implementation on an individual unit. Frailty screening and an interprofessional geriatric frailty program impact the meso-level of system change beyond a single unit. Based on current literature, factors contributing most consistently to geriatric frailty include dependence with ADLs and IADLs, impaired gait, and poor nutrition (Brummel et al., 2017;Cheung et al., 2017;Chong et al., 2017Chong et al., , 2019Curtis et al., 2018;Ellis et al., 2020;Flaatten et al., 2017;Liu et al., 2020;Moreno-Arino et al., 2020;Pugh et al., 2019;Torsney & Romero-Ortuno, 2018). Interprofessional collaboration is essential to maximizing the care of frail geriatric patients. This project's interprofessional stakeholders included a group of clinicians recruited to screen for geriatric frailty and unit nursing clinicians, physicians, physical therapy (PT), occupational therapy (OT), social work, palliative care, and registered dieticians. Sustainability planning included the spread of geriatric frailty screening to other units and departments with completion by other clinicians. The longterm objectives included leveraging the electronic medical record (EMR) to trigger a geriatric frailty order set with interprofessional best practices based on CFS scores. An analysis of this project's strengths, weaknesses, opportunities, and threats (SWOT) revealed project advantages included a current interest in frailty identification, extremely competent staff, a geriatric expert APRN project manager, and alignment with organizational priorities for improved patient outcomes. However, project vulnerability was also due to limited interprofessional staffing availability, competing priorities, and limited familiarity with the Clinical Frailty Scale (see Appendix C).

Implementation
The objectives of this EBP project were • Implement the CFS to all patients >65 years old admitted during the eight-week pilot • Evaluate patient appropriateness and compliance of frailty screening completion • Evaluate CFS frailty scores and influence of CFS scoring on personalized patient care plans.
Lewin's change theory and the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model guided the development of this geriatric frailty screening project. As shown in Table 2  Step associated with dissemination. In this EBP project, the project manager reported geriatric frailty screening results to interprofessional stakeholders for practice implications and dissemination to organization leadership.
The Doctor of Nursing Practice (DNP) student served as the project manager in this EBP project, facilitating organization, collaboration, and prioritization. Using standard project management tools, the DNP student is equipped to complete a needs assessment, develop topic expertise, identify stakeholders, scope an EBP project, and determine the project flow (Zaccagnini & White, 2014). Proficiency in project flow and estimating completion times allowed the EBP project manager to determine the sequence of project tasks, parallel work and ultimately plan the implementation and dissemination completion times. In this EBP project, the project manager was a geriatric nurse practitioner and adult geriatric clinical nurse specialist with over ten years of project management experience and an established interprofessional collegial network.
Two weeks before project implementation, the APRN project manager completed CFS education to a group of clinicians. Training on CFS completion utilized resources developed from the CFS creators from the Department of Medicine at Dalhousie University, associated with the Geriatric Medicine Research (GMR) department of Nova Scotia Health (see Appendix B & E). Permission was obtained for the use of the CFS (see Appendix F). The implementation portion of this EBP project included eight weeks of a group of clinicians using the CFS to score hospitalized geriatric patients' frailty levels (see Appendix G). Clinicians recorded patient appropriateness for frailty screening, compliance of frailty screening, CFS frailty scores, and the influence of CFS scoring on personalized patient care plans on a paper tool (see Appendix H).
After eight weeks of CFS piloting, the project manager evaluated and analyzed findings for four weeks and discussed results with the interprofessional stakeholder team and organizational leadership. This EBP project budget included 10 hours for clinicians screening for geriatric frailty and materials to inform the project team and unit staff, as shown in Table 3. Throughout this DNP project, interprofessional leadership was kept apprised of project status.

Data Collection
For eight weeks, a group of four RN clinicians collected data on patient appropriateness for frailty screening, completion of frailty screening, CFS frailty scores, and influence of CFS scoring on personalized patient care plans. The group of clinicians completed data collection with 40 participants through verbal interactions with the participants and/or family/care provider using a paper collection tool (see Appendix H). The APRN project manager collected the paper forms and transcribed data into an electronic spreadsheet to store and analyze data. The risk of privacy of participants was impacted by semi-private patient rooming. Participant exclusions were those admitted >24 hours before data collection for the day and those who could not describe functional level before admission and information was not available from other sources.
However, the CFS did not include disclosure of sensitive information and focused on ADL/IADL independence and functional and physical status before admission (Hicks, 2019a(Hicks, , 2019b. (See Appendix B).

Data Evaluation
Data evaluation utilized primary data in this EBP project from the patient or family/caregivers. Descriptive data analysis evaluated patient appropriateness for frailty screening, compliance of frailty screening, CFS frailty scores, and influence of CFS scoring on personalized patient care plans after the pilot for summative evaluation. There are no benchmarks for geriatric frailty screening or benchmarks for other data elements in this EBP project. Project measures, level of data, and statistical analysis are shown in Table 4.
Missing data was limited to the CFS scores of four participants who were not screened using the CFS; the CFS completion data and individualized plan of care data were included in evaluation and analysis to determine comparison/associations. Completed data collection sheets were kept in a locked office, and data collection software storage was stored on a passwordprotected computer. Confidentiality was maintained because data collection did not include participant identifying information. The data in this EBP project was not protected health information and did not violate the Health Insurance Portability and Accountability Act Privacy

Data Analysis
This pilot included 40 participants with an average age of 75.33 years (SD = 7.31) as shown in Table 5. All participants were appropriate for CFS screening, 90% were screened (n=36), and 90% experienced an adjustment to the individualized plan of care (n=35). Of the 36 screened with the CFS, the average CFS score was 5.56 (SD = 1.78).
Most data elements in this pilot project were nominal and statistical analysis focused on determining associations through the chi-square test and Fisher exact test as shown in Table 6 & 7 (Kim & Mallory, 2017). A chi-square test of independence was conducted to examine whether CFS completion (completed, not completed) and plan of care (adjusted, not adjusted) were independent. The results of the chi-square test were significant based on an alpha value of 0.05, χ2(1) = 20.86, p < .001, suggesting that completed and plan of care are related to one another.
Due to the small sample size of this project, a Fisher exact test was used to supplement the chisquare results. The results of the Fisher exact test were significant based on an alpha value of 0.05, p = .002, suggesting that completion of the CFS and adjustment to the individualized plan of care are related to one another (OR = 68.12).
Clinically meaningful change in this project focused on completing the frailty screening and the influence of CFS scoring on personalized patient care plans. The CFS screening identified various levels of frailty between 3 (managing well) and 9 (terminally ill). No participants were scored 1 (very fit) or 2 (well). In the hospital setting, the CFS guided clinicians and patients to identify pre-morbid frailty status. This view of pre-morbid illness and functional independence facilitated patient and provider goal setting, planning, and interprofessional consultation. In this project, clinicians performing screening reported the CFS improved awareness of pre-hospital ADL/IADL independence and frequently focused interventions for pro-active mobilization, toileting, cognitive stimulation, and PT or OT consultation. In this eightweek project of hospitalized general medicine patients 65-years-of-age and older, a valid geriatric frailty screening tool influenced frailty identification and personalized plans of care.

Project Approval
Permission was obtained for the use of the CFS. (See Appendix F). The University of St.
Augustine for Health Sciences Evidence-based Project Review Committee approved this EBP project. The IRB of the organization where CFS piloting occurred designated this project as QI and not research.

Impact
Hospitalized frail older patients frequently have a reduced tolerance to medical interventions and a higher risk for adverse events. This pilot project sought to determine the impact of geriatric frailty screening and revealed that frailty identification influenced patients' personalized care plans. Applying best practices to identify frailty during hospitalization demonstrated a measurable influence on risk reduction and health promotion in acutely ill geriatric patients. The CFS effect was shown in a patient who scored Mildly Frail (5) and was being discharged after a lengthy ED stay and overnight admission. After screening, the CFS revealed that this patient needed more assistance at home than realized by the primary team.
Without adequate resources, the patient would likely require readmission very quickly. The CFS led to consultation with PT, OT, and orders for home health services, including home safety evaluation, OT, PT, and Social Work. The CFS objectively identified this patient's frailty, and the frailty score prompted the primary team to adjust the patient's plan of care. This is an example of the effect seen throughout the population of interest within this EBP project. The use of the CSF consistently improved the identification of frailty concerns that may have been overlooked before implementation and increased interprofessional collaborative interventions based on patient needs.
Limitations of this project included small sample size and the use of a paper screening tool. Using a paper screening tool was challenging for clinicians because all patient condition documentation is electronic, and the paper CFS tool was not part of routine workflows.
Additionally, one clinician was confused by scoring as a single number (versus adding scores) because the paper format did not clarify only a single score was needed. This format also required the collection of paper forms and manual entry into software to evaluate data and trends.
The CFS does not include nutrition status within the screening content despite poor nutrition being a primary contributing factor in geriatric frailty. There is a gap in the current literature on what interventions should be automatically implemented based on frailty screening scores. Therefore, frailty screening is a clinical prompt to assess additional patient details related to nutrition, ADLs, and IADLs.
Future implications for the Clinical Frailty Scale include recommendations to add it to the organization's electronic medical record admission database. An electronic screening tool aligns with the current RN admission practices workflow. Interprofessional access to the CFS through the EMR will facilitate sharing frailty information and potentially prompt interventions based on unique patient needs.

Dissemination
This evidence-based practice project and outcomes were shared within the facility in October 2021 and will be shared across the professional community in 2022. The project manager shared results with the group of screening clinicians and the unit manager, unit medical director; associate chief medical officer; general medicine nursing director; therapies director; registered dieticians director; palliative care director; nursing practice director; clinical nurse specialist lead; and APRN project manager preceptor. The project manager met with physician and nursing leadership to discuss practice implications. Expanding the CFS to other clinical groups is planned once unit/service line staffing stability and acuity allows. Executive leadership review of practice proposals in situation, background, assessment, and recommendation (SBAR) format for widespread practice implementation will occur with the expansion of the CFS.

Conclusion
This EBP project sought to determine whether the Clinical Frailty Scale implementation influenced personalized patient care plans for different frailty scores. Geriatric frailty is associated with a negative impact on function, quality of life, and harm. Aligned with best practices, geriatric frailty screening influenced patient care through objective frailty scoring and influencing interprofessional interventions. Screening for geriatric frailty presents an opportunity to identify vulnerable and frail individuals to maximize access to health and comfort expertise to improve healthcare outcomes and streamline service costs.
https://doi.org/10.1097/TA.0000000000002583  Step 1: Recruit interprofessional team Consult interprofessional clinical leaders for geriatric frailty current practices and opportunity to implement evidence-based practice. Stakeholders identified nurses, physicians, physical therapy, occupational therapy, social work, nutrition.
Step 2: Define the problem Step 3: Develop and refine the EBP question Step 4: Identify stakeholders Step 5: Determine responsibility for project leadership Step 6: Schedule team meetings Evidence Step 7: Conduct internal and external search for evidence Review and synthesis of current literature with recommendation to interprofessional stakeholders to pilot inpatient geriatric frailty screening by a group of clinicians.
Step 8: Appraise the level and quality of each piece of evidence Step 9: Summarize the individual evidence Step 10: Synthesize overall strength + quality of evidence Step 11: Develop recommendations for change based on evidence synthesis Translation Step 12: Determine fit, feasibility, and appropriateness of recommendation(s) for translation path Action plan developed and geriatric frailty screening pilot implemented on acute care general medicine unit by group of clinicians to evaluate influence frailty identification and personalized plans of care. Results reported to interprofessional stakeholders for interprofessional practice implications and dissemination to organization leadership.

Change
Step 13: Create action plan Step 14: Secure support and resources to implement action plan Step 15: Implement action plan Step 16: Evaluate outcomes Step 17: Report outcomes to stakeholders Step 18: Identify next steps Refreeze Step 19: Disseminate findings Note: This table reflects the EBP project's steps aligned with the three stages of change in Lewin's change theory and the JHNEBP three-step process and activities (Lewin, 1951;Dang & Dearholt, 2017).       Fried Frailty Phenotype: three or more of self-reported weight loss (>4.5 kg) in the last 12 months, low physical activity, exhaustion, weak grip strength, and slow gait speed. ***Frail-VIG/IF-VIG: 22 question multidimensional index addressing 25 different deficits with frail/not frail scoring.