Improving the Documentation of Clinical Frailty and Resuscitation Status on a Psychiatric Older Adult Ward: A Quality Improvement Project.

Background  Older adults admitted to psychiatric inpatient wards frequently have significant physical health comorbidities, placing them at elevated risk of deterioration and death. Despite national guidance, documentation of clinical frailty assessments and do not attempt cardiopulmonary resuscitation (DNACPR) decisions in this setting remains inconsistent. This project was therefore implemented to improve the documentation of resuscitation decisions and frailty assessments on The Oaks, which is a 20-bedded acute psychiatric admissions ward for adults over 65 years at Chase Farm Hospital, North London NHS Foundation Trust.  Method  A quality improvement project (QIP) was conducted across four phases between August 2024 and April 2025. Baseline data collection (Phase 1) examined 20 current inpatients for documentation of frailty assessment using the Rockwood Clinical Frailty Scale (RCFS) and DNACPR status in the electronic patient record (RiO). Following multidisciplinary team (MDT) discussion (Phase 2), a standardised pathway was implemented which included routine frailty assessment on admission, MDT safety huddle discussion, patient and family information provision (Phase 3, including a bespoke CPR/DNAR information leaflet), and completion of DNACPR forms at care planning meetings. Re-evaluation (Phase 4) examined notes for all patients admitted over a one-month period (21 January to 21 February 2025).  Results  Following implementation of the intervention, DNACPR form completion increased from 5% to 30% (absolute increase: 25 percentage points; Fisher's exact test: p = 0.095). Documentation of DNACPR discussions increased from 15% to 90% (absolute increase: 75 percentage points; Fisher's exact test: p < 0.001), representing a sixfold relative increase. Where forms were not completed, reasons were clearly documented. Of the two project objectives, DNACPR documentation was measured as the primary re-evaluation outcome. Frailty documentation was not formally re-evaluated; however, this will be assessed in future QI cycles to accurately reflect the study findings. Conclusion  This QIP demonstrates that a structured, MDT-driven pathway can produce short-term feasibility and a substantial improvement in DNACPR discussion documentation on a single older adult psychiatric ward. The pathway is low cost and has been adopted as standard practice, with ongoing monitoring planned. Further cycles targeting frailty scoring completion and DNACPR form rates are planned.