Prognostic association of frailty with post-arrest outcomes following cardiac arrest: A systematic review and meta-analysis

Accuracy of frailty instruments in predicting outcomes following perioperative cardiac arrest

BACKGROUND

Frailty is associated with increased 30-day mortality and non-home discharge following perioperative cardiac arrest. We estimated the predictive accuracy of frailty when added to baseline risk prediction models.

METHODS

In this retrospective cohort study using 2015-2020 NSQIP data for 3048 patients aged 50+ undergoing non-cardiac surgery and resuscitation on post-operative day 0 (i.e., intraoperatively or postoperatively on the day of surgery), baseline models including age, sex, ASA physical status, preoperative sepsis or septic shock, and emergent surgery were compared to models that added frailty indices, either RAI or mFI-5, to predict 30-day mortality and non-home discharge. Predictive accuracy was characterized by area under the receiver operating characteristic curve (AUC-ROC), integrated calibration index (ICI), and continuous net reclassification index (NRI).

RESULTS

1786 patients (58.6%) died in the study cohort within 30 days, and 38.6% of eligible patients experienced non-home discharge. The baseline model showed good discrimination (AUC-ROC 0.77 for 30-day mortality and 0.74 for non-home discharge). AUC-ROC and ICI did not significantly change after adding frailty for 30-day mortality or non-home discharge. Adding RAI significantly improved NRI for 30-day mortality and non-home discharge; however, the magnitude was small and difficult to interpret, given other results including false positive and negative rates showing no difference in predictive accuracy.

CONCLUSIONS

Incorporating frailty did not significantly improve predictive accuracy of models for 30-day mortality and non-home discharge following perioperative resuscitation. Thus, demonstrated associations between frailty and outcomes of perioperative resuscitation may not translate into improved predictive accuracy. When engaging patients in shared decision-making regarding do-not-resuscitate orders perioperatively, providers should acknowledge uncertainty in anticipating resuscitation outcomes.

Association of Frailty and Cardiopulmonary Resuscitation Outcomes in Older U.S. Veterans

Objectives: Determine the association between frailty and immediate survival of cardiopulmonary resuscitation (CPR) in older Veterans. Secondary outcomes: compare in-hospital mortality, duration of resuscitation efforts, hospital and intensive care unit (ICU) length of stay, neurologic outcomes, and discharge disposition between frail and non-frail Veterans. Methods: Retrospective cohort study including Veterans 50 years and older, who were "Full Code" and had in-hospital cardiac arrest between 7/1/2017 and 6/30/2020, at the Miami VAMC. Frailty Index for the VA (VA-FI) was used to determine frailty status. Immediate Survival was determined by return of spontaneous circulation (ROSC) and in-hospital mortality was determined by all-cause mortality. We compared outcomes between frail and non-frail Veterans using chi-square test. After adjusting for age, gender, race, and previous hospitalizations, we used multivariate binomial logistic regression with 95% confidence intervals to analyze the relationship between immediate survival and frailty, and in-hospital mortality and frailty. Results: 91% Veterans were non-Hispanic, 49% Caucasian, 96% male, mean age 70.7 ± 8.5 years, 73% frail and 27% non-frail. Seventy-six (65.5%) Veterans had ROSC, without difference by frailty status (P = .891). There was no difference based on frailty status of in-hospital mortality, discharge disposition, or neurologic outcomes. Frail and non-frail Veterans had resuscitation efforts lasting the same amount of time. Conclusions and Implications: CPR outcomes were not different depending on frailty status in our Veteran population. With these results, we cannot use frailty - as measured by the VA-FI - as a prognosticator of CPR outcomes in Veterans.

Comprehensive geriatric assessment as an essential tool to register or update DNR codes in a tertiary care hospital

PURPOSE

To investigate the prevalence of Do not Resuscitate (DNR) code registration in patients with a geriatric profile admitted to Antwerp University Hospital, a tertiary care hospital in Flanders, Belgium, and the impact of comprehensive geriatric assessment (CGA) on DNR code registration.

PATIENTS AND METHODS

Retrospective analysis of a population of 543 geriatric patients (mean age 82.4 ± 5.19 years, 46.4% males) admitted to Antwerp University Hospital from 2018 to 2020 who underwent a CGA during admission. An association between DNR code registration status before and at hospital admission and age, gender, ethnicity, type of residence, clinical frailty score (CFS), cognitive and oncological status, hospital ward and stay on intensive care was studied. Admissions before and during the first wave of the pandemic were compared.

RESULTS

At the time of hospital admission, a DNR code had been registered for 66.3% (360/543) of patients. Patients with a DNR code at hospital admission were older (82.7 ± 5.5 vs. 81.7 ± 4.6 years, p = 0.031), more frail (CFS 5.11 ± 1.63 vs. 4.70 ± 1.61, p = 0.006) and less likely to be admitted to intensive care. During the hospital stay, the proportion of patients with a DNR code increased to 77% before and to 85.3% after CGA (p < 0.0001). Patients were consulted about and agreed with the registered DNR code in 55.8% and 52.1% of cases, respectively. The proportion of patients with DNR codes at the time of admission or registered after CGA did not differ significantly before and after the start of the COVID-19 pandemic.

CONCLUSION

After CGA, a significant increase in DNR registration was observed in hospitalized patients with a geriatric profile.

Cardio pulmonary resuscitation (CPR) in the frail and those with multiple health conditions: Outcomes before and during the COVID pandemic

Coronavirus 2019 (COVID-19)-era resuscitation guidelines advised personal protective equipment before chest compressions and proactive advanced care planning. We investigated the impact of COVID-19 on cardiopulmonary resuscitation (CPR) outcomes according to scoring of frailty and of multiple health conditions. A retrospective single-centre analysis of clinical and electronic records for all adult cardiac arrest calls on wards between June 2020 and June 2021 was performed. Data were compared with a cohort pre-COVID (March 2017-March 2018). In total, 62 patients received CPR in 2020-21 compared with 113 in 2017-18. Similar rates of return of spontaneous circulation (ROSC) and a statistically insignificant survival increase from 23.8% to 32.2% (p=0.210). There were linear relationships between Clinical Frailty Scale (CFS) or Charlson Comorbidity Index (CCI) and diminished survival in the pooled data (both p<0.001). Both increasing frailty (measured by CFS) and comorbidity (measured by CCI) were associated with reduced survival from CPR. However, survival and ROSC during COVID-19 were no worse than before the pandemic.

The association between frailty, long-term care home characteristics and COVID-19 mortality before and after SARS-CoV-2 vaccination: a retrospective cohort study

BACKGROUND

The relative contributions of long-term care (LTC) resident frailty and home-level characteristics on COVID-19 mortality has not been well studied. We examined the association between resident frailty and home-level characteristics with 30-day COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination in LTC.

METHODS

We conducted a population-based retrospective cohort study of LTC residents with confirmed SARS-CoV-2 infection in Ontario, Canada. We used multi-level multivariable logistic regression to examine associations between 30-day COVID-19 mortality, the Hubbard Frailty Index (FI), and resident and home-level characteristics. We compared explanatory models before and after vaccine availability.

RESULTS

There were 11,179 and 3,655 COVID-19 cases in the pre- and post-vaccine period, respectively. The 30-day COVID-19 mortality was 25.9 and 20.0% during the same periods. The median odds ratios for 30-day COVID-19 mortality between LTC homes were 1.50 (95% credible interval [CrI]: 1.41-1.65) and 1.62 (95% CrI: 1.46-1.96), respectively. In the pre-vaccine period, 30-day COVID-19 mortality was higher for males and those of greater age. For every 0.1 increase in the Hubbard FI, the odds of death were 1.49 (95% CI: 1.42-1.56) times higher. The association between frailty and mortality remained consistent in the post-vaccine period, but sex and age were partly attenuated. Despite the substantial home-level variation, no home-level characteristic examined was significantly associated with 30-day COVID-19 mortality during either period.

INTERPRETATION

Frailty is consistently associated with COVID-19 mortality before and after the availability of SARS-CoV-2 vaccination. Home-level characteristics previously attributed to COVID-19 outcomes do not explain significant home-to-home variation in COVID-19 mortality.

Frailty is a better predictor than age for shockable rhythm and survival in Out-of-Hospital cardiac arrest in over 16-year-olds

Objective

To determine if the Clinical Frailty Scale (CFS) predicts out-of-hospital cardiac arrest (OHCA) outcomes better than age?Design: The analysed data was collected as part of a larger study run by NCEPOD on hospital admissions for OHCA in 2018. Study selection was OHCA in over 16-year-olds with restoration of spontaneous circulation (ROSC) for >20 mins and who were admitted to hospital, or who died in the emergency department. Patients from hospitals in England, Wales and Northern Ireland were identified using standard coding for cardiac arrest. CFS, age and gender were examined against two binary outcomes (non-shockable rhythm and survival).

Results

304 patients with a known CFS, known original rhythm, and known outcome were included. Younger patients had lower CFSs, as a continuous variable (Pearson correlation coefficient 0.44, p-value < 0.001) and in CFS groupings of 1-3, 4-6, 7-9 (p-value < 0.001). CFSs were higher (p-values < 0.001) for both non-shockable rhythm and death (median CFS was 4 for death and 2 for survivors). Logistic regression analysis of continuous scale CFS showed the association with non-shockable rhythm remained when adjusted for age and sex (odds ratio [95% CI]; age adjustment 1.46 [1.28, 1.68] p-value < 0.001) and remained for survival when adjusted for age alone (odds ratio [95% CI]; 1.60 [1.36, 1.88] p-value < 0.001) and when adjusted for age, sex and initial rhythm combined (1.45 [1.21, 1.73] p-value < 0.001). 3.2% of patients had resuscitation against their advanced-care-directives. 12.9% (23/178) of hospitals had electronic systems which shared advance-care-directives with ambulance services and primary care.

Conclusion

A higher CFS is a prognostic indicator in adult OHCA independent of age. Frail individuals have a lower likelihood of a shockable rhythm and poorer survival. Sensitive sharing of this information with patients when discussing advance-care-directives may enhance shared decision-making.

The association of demographics, frailty and multiple health conditions with outcomes from acute medical admissions to hospitals in England: exploratory analysis of an administrative dataset

Emergency and acute hospital services in England are under increasing pressure. The aim of this study was to investigate the association between key case-mix indicators and outcomes for adults admitted to hospital with an acute medical condition in England. All patients aged ≥16 years admitted to hospital in England as an acute unselected medical admission and who survived to discharge during the financial year 2021-2022 were included. Length of hospital stay was the primary outcome of interest. Data were available for 1,586,168 unique patients. A case-mix index was developed with a score that ranged from 0 to 12. Frailty was the most important variable in the index, followed by multiple health conditions and patient age. The mean case-mix score across hospital trusts in England ranged from 5.3 to 7.8. The case-mix index will support initiatives to better understand factors contributing to outcomes from acute medical admissions to hospital.

Assessing Physiologic Reserve and Frailty in the Older Emergency Department Patient: Should the Paradigm Change?

Older patients are more vulnerable to acute illness or injury because of reduced physiologic reserve associated with aging. Therefore, their assessment in the emergency department (ED) should include not only vital signs and their baseline values but also changes that reflect physiologic reserve, such as mobility, mental status, and frailty. Combining aggregated vitals sign scores and frailty might improve risk stratification in the ED. Implementing these changes in ED assessment may require the introduction of senior-friendly processes to ensure ED treatment is appropriate to the older patients' immediate discomfort, personal goals, and likely prognosis.

Frailty and Neurologic Outcomes of Patients Resuscitated From Nontraumatic Out-of-Hospital Cardiac Arrest: A Prospective Observational Study

STUDY OBJECTIVE

To elucidate the clinical utility of the Clinical Frailty Scale score for predicting poor neurologic functions in patients resuscitated from out-of-hospital cardiac arrest (OHCA).

METHODS

This was a prospective, multicenter, observational study conducted between 2019 and 2021. The study included adults with nontraumatic OHCA admitted to the intensive care unit after return of spontaneous circulation (ROSC). Pre-arrest high Clinical Frailty Scale score was defined as 5 or more. Favorable neurologic outcomes defined as a Cerebral Performance Category score of 2 or less at 30 days after admission were compared between patients with and without high Clinical Frailty Scale scores. Multivariable logistic regression analyses fitted with generalized estimating equations were performed to adjust for patient characteristics, out-of-hospital information, and resuscitation content and account for within-institution clustering.

RESULTS

Of 9,909 patients with OHCA during the study period, 1,216 were included, and 317 had a pre-arrest high Clinical Frailty Scale score. Favorable neurologic outcomes were fewer among patients with high Clinical Frailty Scale scores. The high Clinical Frailty Scale score group showed a lower percentage of favorable neurologic outcomes after OHCA than the low Clinical Frailty Scale score group (6.1% vs 24.4%; adjusted odds ratio, 0.45 [95% confidence interval 0.22 to 0.93]). This relationship remained in subgroups with cardiogenic OHCA, with ROSC after hospital arrival, and without a high risk of dying (Clinical Frailty Scale score of 7 or less), whereas the neurologic outcomes were comparable regardless of pre-arrest frailty in those with noncardiogenic OHCA and with ROSC before hospital arrival.

CONCLUSIONS

Pre-arrest high Clinical Frailty Scale score was associated with unfavorable neurologic functions among patients resuscitated from OHCA. The Clinical Frailty Scale score would help predict clinical consequences following intensive care after ROSC.

1-year functional outcomes after cardiopulmonary resuscitation for older adults with pre-existing long-term care needs

OBJECTIVE

To investigate the 1-year functional outcomes after cardiopulmonary resuscitation (CPR) in adults aged ≥65 years with pre-existing long-term care needs.

METHODS

This population-based cohort study was conducted in Tochigi Prefecture, one of 47 prefectures in Japan. We used medical and long-term care administrative databases, which included data on functional and cognitive impairment that were assessed with the nationally standardised care-needs certification system. Among individuals aged ≥65 years registered between June 2014 and February 2018, patients who underwent CPR were identified. The primary outcome was mortality and care needs at 1 year after CPR. The outcome was stratified by pre-existing care needs before CPR based on the total daily estimated care minutes: no care needs, support levels 1 and 2 and care-needs level 1 (estimated care time 25-49 min), care-needs levels 2 and 3 (50-89 min) and care-needs levels 4 and 5 (≥90 min).

RESULTS

Among 594,092 eligible individuals, 5,086 (0.9%) underwent CPR. The 1-year mortalities after CPR in patients with no care needs, support levels 1 and 2 and care-needs level 1, care-needs levels 2 and 3 and care-needs levels 4 and 5 were 94.6% (n = 2,207/2,332), 96.1% (n = 736/766), 94.5% (n = 930/984) and 95.9% (n = 963/1,004), respectively. Among survivors, most patients had no change in care needs before and at 1 year after CPR. There was no significant association between pre-existing functional and cognitive impairment and 1-year mortality and care needs after adjusting for potential confounders.

CONCLUSION

Healthcare providers need to discuss poor survival outcomes after CPR with all older adults and their families in shared decision making.

Prognostic Association Between Frailty and Post-Arrest Health Outcomes in Patients Receiving Home Care: A Population-Based Retrospective Cohort Study

AIM

To evaluate the association between frailty and post-cardiac arrest survival, functional decline, and cognitive decline, among patients receiving home care METHODS: Frailty was measured using the Clinical Frailty Scale (CFS) and a valid frailty index. We used multivariable logistic regression to measure the association between frailty and post-arrest outcomes after adjusting for age, sex, and arrest setting. Functional independence and cognitive performance were measured using the interRAI ADL Long-Form and Cognitive Performance Scale, respectively. We conducted sub-group analytics of in-hospital and out-of-hospital arrests RESULTS: Our cohort consisted of 7,901 home care clients; most patients arrested out-of-hospital (55.4%) and were 75 years or older (66.3%). Most of the cohort was classified as frail (94.2%), with a CFS score of 5 or greater. The 30-day survival rate was higher for in-hospital (26.6%) than out-of-hospital cardiac arrests (5.2%). Most patients who survived to discharge had declines in post-arrest functional independence (65.8%) and cognitive performance (46.5%). A one-point increase in the CFS decreased the odds of 30-day survival by 8% (aOR=0.92; 95%CI = 0.87-0.97). A 0.1 unit increase in the frailty index reduced 30-day survival odds by 9% (aOR = 0.91; 95%CI = 0.86-0.96). The frailty index was associated with declines in functional independence (OR = 1.16; 95%CI = 1.02-1.31) and cognitive performance (OR = 1.24; 95%CI = 1.09-1.42), while the CFS was not.

CONCLUSION

Frailty is associated with cardiac arrest survival and post-arrest cognitive and functional status in patients receiving home care. Post-cardiac arrest cognitive and functional status are best predicted using more comprehensive frailty indices.

Prognostic models for outcome prediction following in-hospital cardiac arrest using pre-arrest factors: a systematic review, meta-analysis and critical appraisal

BACKGROUND

Several prediction models of survival after in-hospital cardiac arrest (IHCA) have been published, but no overview of model performance and external validation exists. We performed a systematic review of the available prognostic models for outcome prediction of attempted resuscitation for IHCA using pre-arrest factors to enhance clinical decision-making through improved outcome prediction.

METHODS

This systematic review followed the CHARMS and PRISMA guidelines. Medline, Embase, Web of Science were searched up to October 2021. Studies developing, updating or validating a prediction model with pre-arrest factors for any potential clinical outcome of attempted resuscitation for IHCA were included. Studies were appraised critically according to the PROBAST checklist. A random-effects meta-analysis was performed to pool AUROC values of externally validated models.

RESULTS

Out of 2678 initial articles screened, 33 studies were included in this systematic review: 16 model development studies, 5 model updating studies and 12 model validation studies. The most frequently included pre-arrest factors included age, functional status, (metastatic) malignancy, heart disease, cerebrovascular events, respiratory, renal or hepatic insufficiency, hypotension and sepsis. Only six of the developed models have been independently validated in external populations. The GO-FAR score showed the best performance with a pooled AUROC of 0.78 (95% CI 0.69-0.85), versus 0.59 (95%CI 0.50-0.68) for the PAM and 0.62 (95% CI 0.49-0.74) for the PAR.

CONCLUSIONS

Several prognostic models for clinical outcome after attempted resuscitation for IHCA have been published. Most have a moderate risk of bias and have not been validated externally. The GO-FAR score showed the most acceptable performance. Future research should focus on updating existing models for use in clinical settings, specifically pre-arrest counselling. Systematic review registration PROSPERO CRD42021269235. Registered 21 July 2021.

In-hospital cardiac arrest: the state of the art

In-hospital cardiac arrest (IHCA) is associated with a high risk of death, but mortality rates are decreasing. The latest epidemiological and outcome data from several cardiac arrest registries are helping to shape our understanding of IHCA. The introduction of rapid response teams has been associated with a downward trend in hospital mortality. Technology and access to defibrillators continues to progress. The optimal method of airway management during IHCA remains uncertain, but there is a trend for decreasing use of tracheal intubation and increased use of supraglottic airway devices. The first randomised clinical trial of airway management during IHCA is ongoing in the UK. Retrospective and observational studies have shown that several pre-arrest factors are strongly associated with outcome after IHCA, but the risk of bias in such studies makes prognostication of individual cases potentially unreliable. Shared decision making and advanced care planning will increase application of appropriate DNACPR decisions and decrease rates of resuscitation attempts following IHCA.

Peri-procedural code status for transcatheter aortic valve replacement: Absence of program policies and standard practices

BACKGROUND

Little is known about policies and practices for patients undergoing Transcatheter Aortic Valve Replacement (TAVR) who have a documented preference for Do Not Resuscitate (DNR) status at time of referral. We investigated how practices across TAVR programs align with goals of care for patients presenting with DNR status.

METHODS

Between June and September 2019, we conducted semi-structured interviews with TAVR coordinators from 52/73 invited programs (71%) in Washington and California (TAVR volume > 100/year:34%; 50-99:36%; 1-50:30%); 2 programs reported no TAVR in 2018. TAVR coordinators described peri-procedural code status policies and practices and how they accommodate patients' goals of care. We used data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry, stratified by programs' DNR practice, to examine differences in program size, patient characteristics and risk status, and outcomes.

RESULTS

Nearly all TAVR programs (48/50: 96%) addressed peri-procedural code status, yet only 26% had established policies. Temporarily rescinding DNR status until after TAVR was the norm (78%), yet time frames for reinstatement varied (38% <48 h post-TAVR; 44% 48 h-to-discharge; 18% >30 days post-discharge). For patients with fluctuating code status, no routine practices for discharge documentation were well-described. No clinically substantial differences by code status practice were noted in Society of Thoracic Surgeons Predicted Risk of Mortality risk score, peri-procedural or in-hospital cardiac arrest, or hospice disposition. Six programs maintaining DNR status recognized TAVR as a palliative procedure. Among programs categorically reversing patients' DNR status, the rationale for differing lengths of time to reinstatement reflect divergent views on accountability and reporting requirements.

CONCLUSIONS

Marked heterogeneity exists in management of peri-procedural code status across TAVR programs, including timeframe for reestablishing DNR status post-procedure. These findings call for standardization of DNR decisions at specific care points (before/during/after TAVR) to ensure consistent alignment with patients' health-related goals and values.

Outcomes in adults living with frailty receiving cardiopulmonary resuscitation: A systematic review and meta-analysis

Background

Frailty is a clinical expression of adverse ageing which could be a valuable predictor of outcomes from cardiac arrest. The aim of this systematic review was to evaluate survival outcomes in adults living with frailty versus adults living without frailty receiving cardiopulmonary resuscitation (CPR) following cardiac arrest.

Methods

A comprehensive search of MEDLINE, EMBASE, CINAHL, and Web of Science databases was performed using pre-defined search terms, with no date or language restrictions applied. Prospective and retrospective observational studies measuring outcomes from CPR in adults assessed for frailty using an accepted clinical definition were selected.

Results

Eight eligible studies were included. Seven retrospective observational studies presenting high methodological quality were included in a meta-analysis comprising 1704 participants. Frailty was strongly associated with an increased likelihood of mortality after CPR, with moderate inter-study heterogeneity (OR = 3.56, 95% CI = 2.74–4.63, I² = 71%).

Discussion

This review supports the consideration of frailty status in a holistic approach to CPR. The present findings suggest that frailty status provides valuable prognostic information and could complement other known pre-arrest prognostic factors such as comorbidities in the context of Do Not Attempt CPR consideration. Awareness of the poorer outcomes in those living with frailty could support the identification of individuals less likely to benefit from CPR. Validation of our findings and evaluation of quality-of-life in frail individuals surviving cardiac arrest are prerequisites for the future integration of frailty status into CPR clinical decision-making.

Registration

Prospectively registered on PROSPERO: CRD42020223670.

Is frailty associated with long-term survival, neurological function and patient-reported outcomes after in-hospital cardiac arrest? - A Swedish cohort study

BACKGROUND

Frailty is associated with poor 30-days survival after in-hospital cardiac arrests (IHCA). The aim was to assess how pre-arrest frailty was associated with long-term survival, neurological function and patient-reported outcomes in elderly survivors after IHCA.

METHODS

Patients aged ≥65 years with IHCA at Karolinska University Hospital between 2013-2021 were studied. Frailty was assessed by the Clinical Frailty Scale (CFS) based on clinical records and categorised into non-frail (1-4) or frail (5-7). Survival was assessed in days. Neurological function was assessed by the Cerebral Performance Category scale (CPC). A telephone interview was performed six months post-IHCA and included the questionnaires EuroQoL-5 Dimensions-5 Levels and Hospital Anxiety and Depression Scale.

RESULTS

Totally, 232 (28%) out of 817 eligible patients survived to 30-days. Out of 232, 65 (28%) were frail. Long-term survival was better for non-frail than frail patients (6months (92% versus 75%, p-value <0.01), 3 years (74% vs 22%, p-value <0.01)). The vast majority of both non-frail and frail patients had unchanged CPC from admittance to discharge from hospital (87% and 85%, respectively). The 121 non-frail patients reported better health compared to 27 frail patients (EQ-VAS median 70 versus 50 points, p-value <0.01) and less symptoms of depression than frail (16% and 52%, respectively, p-value <0.01).

CONCLUSION

Frail patients suffering IHCA survived with largely unchanged neurological function. Although one in five frail patients survived to three years, frailty was associated with a marked decrease in long-term survival as well as increased symptoms of depression and poorer general health.

Factors influencing prehospital physicians' decisions to initiate advanced resuscitation for asystolic out-of-hospital cardiac arrest patients

BACKGROUND

The decision to initiate or continue advanced life support (ALS) in out-of-hospital cardiac arrest (OHCA) could be difficult due to the lack of information and contextual elements, especially in non-shockable rhythms. This study aims to explore factors associated with clinicians' decision to initiate or continue ALS and the conditions associated with higher variability in asystolic patients.

METHODS

This retrospective observational study enrolled 2653 asystolic patients on whom either ALS was attempted or not by the emergency medical services (EMS) physician. A multivariable logistic regression analysis was performed to find the factors associated with the decision to access ALS. A subgroup analysis was performed on patients with a predicted probability of ALS between 35% and 65%. The single physicians' behaviour was compared to that predicted by the model taking into account the entire agency.

RESULTS

Age, location of event, bystander CPR and EMS-witnessed event were independent factors influencing physicians' choices about ALS. Non-medical OHCA, younger patients, less experienced physicians, presence of breath activity at the emergency call and a longer time for ALS arrival were more frequent among cases with an expected higher variability in behaviours with ALS. Significant variability was detected between physicians.

CONCLUSIONS

Significant inter-physician variability in access to ALS could be present within the same EMS, especially among less experienced physicians, non-medical OHCA and in presence of signs of life during emergency call. This arbitrariness has been observed and should be properly addressed by EMS team members as it raises ethical issues regarding the disparity in treatment.

Sensitivity Analysis: A Method to Promote Certainty and Transparency in Nursing and Health Research

Nursing and health researchers may be presented with uncertainty regarding the utilization or legitimacy of methodological or analytic decisions. Sensitivity analyses are purposed to gain insight and certainty about the validity of research findings reported. Reporting guidelines and health research methodologists have emphasized the importance of utilizing and reporting sensitivity analyses in clinical research. However, sensitivity analyses are underreported in nursing and health research. The aim of this methodological overview is to provide an introduction to the purpose, conduct, interpretation, and reporting of sensitivity analyses, using a series of simulated and contemporary case examples.

Accuracy of prehospital clinicians' perceived prognostication of long-term survival in critically ill patients: a nationwide retrospective cohort study on helicopter emergency service patients

OBJECTIVES

Prehospital critical care physicians regularly attend to patients with poor prognosis and may limit the advanced therapies. The aim of this study was to evaluate the accuracy of poor prognosis given by prehospital critical care clinicians.

DESIGN

Cohort study.

SETTING

We performed a retrospective cohort study using the national helicopter emergency medical services (HEMS) quality database.

PARTICIPANTS

Patients classified by the HEMS clinician to have survived until hospital admission solely because of prehospital interventions but evaluated as having no long-term survival by prehospital clinician, were included.

PRIMARY AND SECONDARY OUTCOME

The survival of the study patients was examined at 30 days, 1 year and 3 years.

RESULTS

Of 36 715 patients encountered by the HEMS during the study period, 2053 patients were classified as having no long-term survival and included. At 30 days, 713 (35%, 95% CI 33% to 37%) were still alive and 69 were lost to follow-up. Furthermore, at 1 year 524 (26%) and at 3 years 267 (13%) of the patients were still alive. The deceased patients received more often prehospital rapid sequence intubation and vasoactives, compared with patients alive at 30 days. Patients deceased at 30 days were older and had lower initial Glasgow Coma Scores. Otherwise, no clinically relevant difference was found in the prehospital vital parameters between the survivors and non-survivors.

CONCLUSIONS

The prognostication of long-term survival for critically ill patients by a prehospital critical care clinician seems to fulfil only moderately. A prognosis based on clinical judgement must be handled with a great degree of caution and decision on limitation of advanced care should be made cautiously.

Hospital Frailty Risk Score Predicts Outcomes in Chronic Obstructive Pulmonary Disease Exacerbations

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) are at high risk for frailty and prone to complications after admission for an acute exacerbation. We aim to investigate the association between frailty risk and functional outcomes in patients with acute exacerbations of COPD, using a nationwide database.

METHODS

This retrospective cohort study included patients with acute exacerbations of COPD who were admitted by ambulance. We assessed frailty using the Hospital Frailty Risk Score (HFRS) and compared the outcomes between low frailty risk (HFRS < 5) and frailty at risk (HFRS ≥ 5) groups. The primary outcome was prolonged hospitalization (≥30 days). The secondary outcomes were in-hospital mortality, readmission (≤90 days), poor activities of daily living (ADL) at discharge, and difficulty in returning home.

RESULTS

There were 3,396 eligible patients (mean age, 75.9 ± 11.2 years; 20.4% female). The rate of frailty at risk patients was 14.0%. Frailty at risk patients were significantly higher rates of prolonged hospitalization (32.9% vs. 17.5%), more in-hospital mortality (16.4% vs. 12.5%), more difficulty in returning home (34.6% vs. 22.9%), and poorer ADL at discharge (8.7% vs. 12.4%) than those of low frailty risk. Multivariate analysis with adjusted covariates showed that HFRS was independently associated with prolonged hospitalization (odds ratio, 2.0; 95% confidence interval, 1.4-2.9).

CONCLUSIONS

HFRS can be used to predict the outcome of patients with acute exacerbations of COPD. This finding supports the validity of using the HFRS in clinical practice with patients with acute exacerbations of COPD.

The clinical frailty scale predicts 1-year mortality in emergency department patients aged 65 years and older

Objective

To validate the Clinical Frailty Scale (CFS) for prediction of 1‐year all‐cause mortality in the emergency department (ED) and compare its performance to the Emergency Severity Index (ESI).

Methods

Prospective cohort study at the ED of a tertiary care center in Northwestern Switzerland. All patients aged ≥65 years were included from March 18 to May 20, 2019, after informed consent. Frailty status was assessed using CFS, excluding level 9 (palliative). Acuity level was assessed using ESI. Both CFS and ESI were adjusted for age, sex and presenting condition in multivariable logistic regression. Prognostic performance was assessed for discrimination and calibration separately. Estimates were internally validated by Bootstrapping. Restricted mean survival time (RMST) was determined for all levels of CFS.

Results

In the final study population of 2191 patients, 1‐year all‐cause mortality was 17% (n = 372). RMST values ranged from 219 days for CFS 8 to 365 days for CFS 1. The adjusted CFS model had an area under receiver operating characteristic of 0.767 (95% confidence interval [CI]: 0.741–0.793), compared to 0.703 (95% CI: 0.673–0.732) for the adjusted ESI model.

Conclusion

The CFS predicts 1‐year all‐cause mortality for older ED patients and predicts survival time in a graded manner. The CFS is superior to the ESI when adjusted for age, sex, and presenting condition.

Born to Age: When Adult Congenital Heart Disease Converges With Geroscience

Advances in imaging, catheter-based interventions, congenital heart disease surgery, and clinical management of congenital heart disease (CHD) have yielded a dramatic change in age distribution of the CHD population. This implores clinicians and researchers to gain a better understanding of aging, as this will be the cornerstone to how we plan and manage this rapidly evolving group of patients. In this article, we first review the demographic changes in the CHD population and then describe the systemic complications of disease observed in young patients with CHD, following which we discuss general concepts in aging that may be transferable to the CHD population. Finally, we review inflammation and its potential impact on aging. We provide a new lens on aging in CHD and its functional consequences in CHD, with the goal of stimulating an exchange of knowledge between geroscientists and CHD.

Resuscitation highlights in 2021

BACKGROUND

This review is the latest in a series of regular annual reviews undertaken by the editors and aims to highlight some of the key papers published in Resuscitation during 2021.

METHODS

Hand-searching by the editors of all papers published in Resuscitation during 2021. Papers were selected based on then general interest and novelty and were categorised into themes.

RESULTS

98 papers were selected for brief mention.

CONCLUSIONS

Resuscitation science continues to evolve and incorporates all links in the chain of survival.