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Wretborn J, Munir-Ehrlington S, Hörlin E, Wilhelms DB. Addition of the clinical frailty scale to triage tools and early warning scores improves mortality prognostication at 30 days: A prospective observational multicenter study. J Am Coll Emerg Physicians Open 2024; 5:e13244. [PMID: 39253302 PMCID: PMC11381915 DOI: 10.1002/emp2.13244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 06/17/2024] [Accepted: 06/25/2024] [Indexed: 09/11/2024] Open
Abstract
Objectives Frailty, assessed with clinical frailty scale (CFS), alone or in combination with aggregated vital signs, has been proposed as a measure to better predict mortality of older patients in the emergency department (ED), but the added predictive value to conventional triage is unclear. Methods This was a secondary analysis of a prospective observational study in three EDs in Sweden that evaluated the prognostic performance of the CFS alone or in combination with the national early warning score (NEWS), triage early warning score (TEWS) or the rapid emergency triage and treatment system (RETTS) triage tool using logistic regression. The primary outcome was 30-day mortality with 7- and 90-day mortality and admission as secondary outcomes reported as area under the receiver operating curve (AuROC) scores with 95% confidence intervals (CIs). The sensitivity, specificity, accuracy, predictive values, and likelihood ratios are reported for all models. Results A total of 1832 patients were included with 17 (0.9%), 57 (3.1%), and 121 (6.6%) patients dying within 7, 30, and 90 days, respectively. The admission rate was 43% (795/1832). Frailty (CFS > 4) was significantly associated with 30-day mortality (odds ratio 6, 95% CI 3‒12, p < 0.01). Prognostication of 30-day mortality was similar for all CFS-based models and better compared with models without CFS. The AuROC (95% CI) improved for RETTS from 0.67 (0.61‒0.74) to 0.83 (0.79‒0.88) (p = 0.008), for NEWS from 0.53 (0.45‒0.61) to 0.82 (0.77‒0.87) (p < 0.001), and for TEWS from 0.63 (0.55‒0.71) to 0.82 (0.77‒0.87) (p = 0.002). Conclusion Frailty measured with the CFS in combination with RETTS or structured vital sign assessment using NEWS or TEWS was better at prognosticating 30-day mortality compared to RETTS or early warnings score alone. Improved prognostication provides more realistic expectations and allows for informed discussions with patients and initiation of individualized treatment plans early in the ED process.
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Affiliation(s)
- Jens Wretborn
- Department of Emergency Medicine and Department of Biomedical and Clinical Sciences Linköping University Linköping Sweden
| | - Samia Munir-Ehrlington
- Department of Emergency Medicine and Department of Biomedical and Clinical Sciences Linköping University Linköping Sweden
| | - Erika Hörlin
- Department of Emergency Medicine and Department of Biomedical and Clinical Sciences Linköping University Linköping Sweden
| | - Daniel B Wilhelms
- Department of Emergency Medicine and Department of Biomedical and Clinical Sciences Linköping University Linköping Sweden
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2
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van Oppen JD, Heeren P. Using the Clinical Frailty Scale (CFS) in geriatric emergency medicine. Emerg Med J 2024; 41:512-513. [PMID: 39053971 DOI: 10.1136/emermed-2024-213906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/20/2024] [Indexed: 07/27/2024]
Affiliation(s)
- James D van Oppen
- Centre for Urgent and Emergency Care Research, The University of Sheffield, Sheffield, UK
- College of Life Sciences, University of Leicester, Leicester, UK
| | - Pieter Heeren
- Faculty of Medicine and Life Sciences, Healthcare & Ethics Research Group, UHasselt, Hasselt, Belgium
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
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3
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Fehlmann CA, Mc Loughlin K, Cosgriff EJ, Ferrick JF, van Oppen JD. Service provision for Frailty in European Emergency Departments (FEED): a survey of operational characteristics. Scand J Trauma Resusc Emerg Med 2024; 32:64. [PMID: 39075591 PMCID: PMC11285136 DOI: 10.1186/s13049-024-01234-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 07/14/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND The observational Frailty in European Emergency Departments (FEED) study found 40% of older people attending for care to be living with frailty. Older people with frailty have poorer outcomes from emergency care. Current best practice calls for early identification of frailty and holistic multidisciplinary assessment. This survey of FEED sites explores variations in frailty-attuned service definitions and provision. METHODS This cross-sectional survey included study sites across Europe identified through snowball recruitment. Site co-ordinators (healthcare professionals in emergency and geriatric care) were surveyed online using Microsoft Forms. Items covered department and hospital capacity, frailty and delirium identification methods, staffing, and frailty-focused healthcare services in the ED. Descriptive statistics were reported. RESULTS A total of 68 sites from 17 countries participated. Emergency departments had median 30 (IQR 21-53) trolley spaces. Most defined "older people" by age 65+ (64%) or 75+ (25%). Frailty screening was used at 69% of sites and mandated at 38%. Night-time staffing was lower compared to day-time for nursing (10 [IQR 8-14] vs. 14 [IQR 10-18]) and physicians (5 [IQR 3-8] vs. 10 [IQR 7-15]). Most sites had provision for ED frailty specialist services by day, but these services were rarely available at night. Sites mostly had accessible facilities; however, hot meals were rarely available at night (18%). CONCLUSION This survey demonstrated variability in case definitions, screening practices, and frailty-attuned service provision. There is no unanimous definition for older age, and while the Clinical Frailty Scale was commonly used, this was rarely mandated or captured in electronic records. Frailty services were often unavailable overnight. Appreciation of the variation in frailty service models could inform operational configuration and workforce development.
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Affiliation(s)
- Christophe A Fehlmann
- Division of Emergency Medicine, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland.
| | - Kara Mc Loughlin
- Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, School of Allied Health, University of Limerick, Limerick, Ireland
| | - Emma Jane Cosgriff
- College of Life Sciences, University of Leicester, Leicester, LE1 7HA, UK
| | - John Francis Ferrick
- College of Life Sciences, University of Leicester, Leicester, LE1 7HA, UK
- Belfast Health and Social Care Trust, Royal Victoria Hospital, Belfast, BT12 6BA, UK
| | - James David van Oppen
- College of Life Sciences, University of Leicester, Leicester, LE1 7HA, UK
- Centre for Urgent and Emergency Care Research, The University of Sheffield, Sheffield, S1 4DA, UK
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4
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Lin JW, Lin PY, Wang TY, Chen YJ, Yen DHT, Huang HH. The Association Between Frailty Evaluated by Clinical Frailty Scale and Mortality of Older Patients in the Emergency Department: A Prospective Cohort Study. Clin Interv Aging 2024; 19:1383-1392. [PMID: 39081832 PMCID: PMC11287370 DOI: 10.2147/cia.s472991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 07/16/2024] [Indexed: 08/02/2024] Open
Abstract
Background Frailty epitomizes the most complex consequence of an aging population. This study aimed to evaluate the impact of frailty, measured using the Clinical Frailty Scale (CFS), on outcomes of older people in an emergency department (ED). Methods We conducted a prospective observational study enrolling patients aged 65 years and older in a medical center of Taiwan between March 8, 2021, and November 30, 2021. The primary outcome was 90-day mortality rate. Individuals were categorized into three groups based on the CFS scores. Logistic regression was employed to examine the influence of frailty on clinical outcomes following covariate adjustment. Survival analysis was conducted using Kaplan-Meier curves and Log rank tests. Results A total of 473 individuals were included in the study, with a mean age of 82.1 years, and 60.5% of them were males. The 90-day mortality rate was 10.6%. Among these groups, the CFS score 7-9 group had the highest 90-day mortality rate (15.9%), followed by the CFS score 4-6 group (8.0%) and the CFS score 1-3 group (7.1%). The multiple logistic regression analyses demonstrated a significant impact of CFS score on prognosis, with adjusted odd ratios of 1.24 (95% CI 1.06-1.47) for 90-day mortality, 1.18 (95% CI 1.06-1.31) for hospitalization, and 1.30 (95% CI 1.12-1.52) for 180-day mortality. The Kaplan-Meier curves revealed a significantly higher 90-day mortality rate for patients with high CFS scores (Log rank tests, p = 0.019). Conclusion In the older ED population, the severity of frailty assessed by the CFS emerged as a significant and important prognostic factor for hospitalization, 90-day mortality, and 180-day mortality.
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Affiliation(s)
- Jin-Wei Lin
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Emergency Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Pei-Ying Lin
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Emergency Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tse-Yao Wang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Emergency Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ying-Ju Chen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Emergency Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - David Hung-Tsang Yen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Emergency Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Nursing, Yuanpei University of Medical Technology, Hsinchu, Taiwan
- Chang Bing Show-Chwan Memorial Hospital, Changhua City, Taiwan
| | - Hsien-Hao Huang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Emergency Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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5
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Hamilton MP, Bellolio F, Jeffery MM, Bower SM, Palmer AK, Tung EE, Mullan AF, Carpenter CR, Oliveira J E Silva L. Risk of falls is associated with 30-day mortality among older adults in the emergency department. Am J Emerg Med 2024; 79:122-126. [PMID: 38422753 PMCID: PMC11016374 DOI: 10.1016/j.ajem.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/06/2024] [Accepted: 02/13/2024] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVE Falls in older adults correlate with heightened morbidity and mortality. Assessing fall risk in the emergency department (ED) not only aids in identifying candidates for prevention interventions but may also offer insights into overall mortality risk. We sought to examine the link between fall risk and 30-day mortality in older ED adults. METHODS Observational cohort study of adults aged ≥ 75years who presented to an academic ED and who were assessed for fall risk using the Memorial Emergency Department Fall Risk Assessment Tool (MEDFRAT), a validated, ED-specific screening tool. The fall risk was classified as low (0-2 points), moderate (3-4 points), or high (≥5) risk. The primary outcome was 30-day mortality. Hazard ratios (HR) with 95% confidence intervals (CIs) were calculated. RESULTS A total of 941 patients whose fall risk was assessed in the ED were included in the study. Median age was 83.7 years; 45.6% were male, 75.6% lived in private residences, and 62.7% were admitted. Mortality at 30 days among the high fall risk group was four times that of the low fall risk group (11.8% vs 3.1%; HR 4.00, 95% CI 2.18 to 7.34, p < 0.001). Moderate fall risk individuals had nearly double the mortality rate of the low-risk group (6.0% vs 3.1%), but the difference was not statistically significant (HR 1.98, 95% CI 0.91 to 4.32, p = 0.087). CONCLUSION ED fall risk assessments are linked to 30-day mortality. Screening may facilitate the stratification of older adults at risk for health deterioration.
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Affiliation(s)
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Division of Community Internal Medicine, Geriatric Medicine and Palliative Care, Section of Senior Services and Geriatric Medicine, Mayo Clinic, Rochester, MN, USA; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA.
| | - Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Susan M Bower
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Nursing, Mayo Clinic, Rochester, MN, USA
| | - Allyson K Palmer
- Department of Medicine, Division of Community Internal Medicine, Geriatric Medicine and Palliative Care, Section of Senior Services and Geriatric Medicine, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ericka E Tung
- Department of Medicine, Division of Community Internal Medicine, Geriatric Medicine and Palliative Care, Section of Senior Services and Geriatric Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aidan F Mullan
- Department of Quantitative Health Sciences, Division of Biostatistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Christopher R Carpenter
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Division of Community Internal Medicine, Geriatric Medicine and Palliative Care, Section of Senior Services and Geriatric Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lucas Oliveira J E Silva
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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6
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Aguirre NL, Gutiérrez SG, Miro O, Aguiló S, Jacob J, Alquézar-Arbé A, Burillo G, Fernandez C, Llorens P, Alonso CR, Lopez IT, Cañete M, Asensio PR, Díaz BP, Pizarro TP, Navarro RJDR, Viola NP, Hernández-Castells L, Soler AC, Sánchez Fernández-Linares E, Serrano JÁS, Ezponda P, Lorenzo AM, Liarte JVO, Ramón SS, Aranda AR, Martín-Sánchez FJ, del Castillo JG. Older Adult Patients in the Emergency Department: Which Patients should be Selected for a Different Approach? Ann Geriatr Med Res 2024; 28:9-19. [PMID: 37963716 PMCID: PMC10982447 DOI: 10.4235/agmr.23.0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/05/2023] [Accepted: 11/08/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND While multidimensional and interdisciplinary assessment of older adult patients improves their short-term outcomes after evaluation in the emergency department (ED), this assessment is time-consuming and ill-suited for the busy environment. Thus, identifying patients who will benefit from this strategy is challenging. Therefore, this study aimed to identify older adult patients suitable for a different ED approach as well as independent variables associated with poor short-term clinical outcomes. METHODS We included all patients ≥65 years attending 52 EDs in Spain over 7 days. Sociodemographic, comorbidity, and baseline functional status data were collected. The outcomes were 30-day mortality, re-presentation, hospital readmission, and the composite of all outcomes. RESULTS During the study among 96,014 patients evaluated in the ED, we included 23,338 patients ≥65 years-mean age, 78.4±8.1 years; 12,626 (54.1%) women. During follow-up, 5,776 patients (24.75%) had poor outcomes after evaluation in the ED: 1,140 (4.88%) died, 4,640 (20.51) returned to the ED, and 1,739 (7.69%) were readmitted 30 days after discharge following the index visit. A model including male sex, age ≥75 years, arrival by ambulance, Charlson Comorbidity Index ≥3, and functional impairment had a C-index of 0.81 (95% confidence interval, 0.80-0.82) for 30-day mortality. CONCLUSION Male sex, age ≥75 years, arrival by ambulance, functional impairment, or severe comorbidity are features of patients who could benefit from approaches in the ED different from the common triage to improve the poor short-term outcomes of this population.
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Affiliation(s)
- Nere Larrea Aguirre
- Research Unit, Galdakao-Usansolo University Hospital, Vizcaya, Spain. Kronikgune Institute for Health Services Research, Barakaldo, Spain
| | - Susana García Gutiérrez
- Research Unit, Galdakao-Usansolo University Hospital, Vizcaya, Spain. Kronikgune Institute for Health Services Research, Barakaldo, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), Faculty of Health Sciences, Medicine Department, University of Deusto, Bilbo, Spain
| | - Oscar Miro
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Sira Aguiló
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Javier Jacob
- Emergency Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Catalonia, Spain
| | - Aitor Alquézar-Arbé
- Emergency Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Guillermo Burillo
- Emergency Department, Hospital Universitario de Canarias, University of La Laguna, Tenerife, Spain
| | - Cesáreo Fernandez
- Emergency Department, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Pere Llorens
- Emergency Department, Hospital General Universitario Dr. Balmis de Alicante, Alicante, Spain
| | | | | | - Mónica Cañete
- Emergency Department, Hospital Nuestra Señora del Prado de Talavera de la Reina, Toledo, Spain
| | | | | | | | | | | | | | | | | | | | - Patxi Ezponda
- Emergency Department, Hospital De Zumarraga, Guipuzcoa, Spain
| | | | | | | | | | | | | | - on behalf of the members of the SIESTA Network
- Research Unit, Galdakao-Usansolo University Hospital, Vizcaya, Spain. Kronikgune Institute for Health Services Research, Barakaldo, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), Faculty of Health Sciences, Medicine Department, University of Deusto, Bilbo, Spain
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
- Emergency Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Catalonia, Spain
- Emergency Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Catalonia, Spain
- Emergency Department, Hospital Universitario de Canarias, University of La Laguna, Tenerife, Spain
- Emergency Department, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Emergency Department, Hospital General Universitario Dr. Balmis de Alicante, Alicante, Spain
- Emergency Department, Hospital del Nalón, Langreo, Asturias, Spain
- Emergency Department, Hospital Virgen de Altagracia, Ciudad Real, Spain
- Emergency Department, Hospital Nuestra Señora del Prado de Talavera de la Reina, Toledo, Spain
- Emergency Department, Hospital Universitario Vinalopó, Alicante, Spain
- Emergency Department, Hospital Universitario de Móstoles, Madrid, Spain
- Emergency Department, Hospital Virgen del Rocio, Sevilla, Spain
- Emergency Department, Hospital General Universitario Dr. Peset, Valencia, Spain
- Emergency Department, Hospital Universitario Son Espases, Mallorca, Spain
- Emergency Department, Clinica Universitaria Navarra, Madrid, Spain
- Emergency Department, Clinico Universitario de Valencia, Valencia, Spain
- Emergency Department, Hospital Alvaro Cunqueiro, Pontevedra, Spain
- Emergency Department, Hospital Universitario de Salamanca, Salamanca, Spain
- Emergency Department, Hospital De Zumarraga, Guipuzcoa, Spain
- Emergency Department, Hospital Virxe Da Xunqueira, A Coruña, Spain
- Emergency Department, Hospital Universitario Los Arcos del Mar Menor, San Javier, Murcia, Spain
- Emergency Department, Hospital Universitario Río Ortega, Valladolid, Spain
- Emergency Department, Hospital Juan Ramón Jiménez, Huelva, Spain
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Iozzo P, Spina N, Cannizzaro G, Gambino V, Patinella A, Bambi S, Vellone E, Alvaro R, Latina R. Association between Boarding of Frail Individuals in the Emergency Department and Mortality: A Systematic Review. J Clin Med 2024; 13:1269. [PMID: 38592117 PMCID: PMC10932317 DOI: 10.3390/jcm13051269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/13/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: Older patients who attend emergency departments are frailer than younger patients and are at a high risk of adverse outcomes; (2) Methods: To conduct this systematic review, we adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. We systematically searched literature from PubMed, Embase, OVID Medline®, Scopus, CINAHL via EBSCOHost, and the Cochrane Library up to May 2023, while for grey literature we used Google Scholar. No time restrictions were applied, and only articles published in English were included. Two independent reviewers assessed the eligibility of the studies and extracted relevant data from the articles that met our predefined inclusion criteria. The Critical Appraisal Skills Program (CASP) was used to assess the quality of the studies; (3) Results: Evidence indicates that prolonged boarding of frail individuals in crowded emergency departments (Eds) is associated with adverse outcomes, exacerbation of pre-existing conditions, and increased mortality risk; (4) Conclusions: Our results suggest that frail individuals are at risk of longer ED stays and higher mortality rates. However, the association between the mortality of frail patients and the amount of time a patient spends in exposure to the ED environment has not been fully explored. Further studies are needed to confirm this hypothesis.
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Affiliation(s)
- Pasquale Iozzo
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Via Montpellier, 1, 00133 Rome, Italy; (E.V.); (R.A.)
| | - Noemi Spina
- Anesthesia and Intensive Care Unit, Emergency Department, Azienda Ospedaliera Universitaria Policlinico “Paolo Giaccone”, Via del Vespro, 129, 90127 Palermo, Italy; (N.S.); (G.C.); (V.G.); (A.P.)
| | - Giovanna Cannizzaro
- Anesthesia and Intensive Care Unit, Emergency Department, Azienda Ospedaliera Universitaria Policlinico “Paolo Giaccone”, Via del Vespro, 129, 90127 Palermo, Italy; (N.S.); (G.C.); (V.G.); (A.P.)
| | - Valentina Gambino
- Anesthesia and Intensive Care Unit, Emergency Department, Azienda Ospedaliera Universitaria Policlinico “Paolo Giaccone”, Via del Vespro, 129, 90127 Palermo, Italy; (N.S.); (G.C.); (V.G.); (A.P.)
| | - Agostina Patinella
- Anesthesia and Intensive Care Unit, Emergency Department, Azienda Ospedaliera Universitaria Policlinico “Paolo Giaccone”, Via del Vespro, 129, 90127 Palermo, Italy; (N.S.); (G.C.); (V.G.); (A.P.)
| | - Stefano Bambi
- Department of Health Sciences, University of Florence, Viale GB Morgagni, 48, 50134 Florence, Italy;
| | - Ercole Vellone
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Via Montpellier, 1, 00133 Rome, Italy; (E.V.); (R.A.)
- Department of Nursing and Obstetrics, Wroclaw Medical University, 51-618 Wrocław, Poland
| | - Rosaria Alvaro
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Via Montpellier, 1, 00133 Rome, Italy; (E.V.); (R.A.)
| | - Roberto Latina
- Department of Health Promotion Science, Maternal and Infant Care, Internal Medicine, and Medical Specialities (PROMISE), University of Palermo, Piazza delle Cliniche, 2, 90127 Palermo, Italy;
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8
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Liew CQ, Chen YC, Sung CW, Ko CH, Ku NW, Huang CH, Cheng MT, Tsai CL. A novel scale for triage assessment of frailty in the emergency department (ED-FraS): a prospective videotaped study. BMC Geriatr 2024; 24:137. [PMID: 38321397 PMCID: PMC10848459 DOI: 10.1186/s12877-024-04724-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 01/18/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Rapid recognition of frailty in older patients in the ED is an important first step toward better geriatric care in the ED. We aimed to develop and validate a novel frailty assessment scale at ED triage, the Emergency Department Frailty Scale (ED-FraS). METHODS We conducted a prospective cohort study enrolling adult patients aged 65 years or older who visited the ED at an academic medical center. The entire triage process was recorded, and triage data were collected, including the Taiwan Triage and Acuity Scale (TTAS). Five physician raters provided ED-FraS levels after reviewing videos. A modified TTAS (mTTAS) incorporating ED-FraS was also created. The primary outcome was hospital admission following the ED visit, and secondary outcomes included the ED length of stay (EDLOS) and total ED visit charges. RESULTS A total of 256 patients were included. Twenty-seven percent of the patients were frail according to the ED-FraS. The majority of ED-FraS was level 2 (57%), while the majority of TTAS was level 3 (81%). There was a weak agreement between the ED-FraS and TTAS (kappa coefficient of 0.02). The hospital admission rate and charge were highest at ED-FraS level 5 (severely frail), whereas the EDLOS was longest at level 4 (moderately frail). The area under the Receiver Operating Characteristic curve (AUROC) in predicting hospital admission for the TTAS, ED-FraS, and mTTAS were 0.57, 0.62, and 0.63, respectively. The ED-FraS explained more variation in EDLOS (R2 = 0.096) compared with the other two methods. CONCLUSIONS The ED-Fras tool is a simple and valid screening tool for identifying frail older adults in the ED. It also can complement and enhance ED triage systems. Further research is needed to test its real-time use at ED triage internationally.
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Affiliation(s)
- Chiat Qiao Liew
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yun Chang Chen
- Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Hsinchu, Taiwan
| | - Chih-Wei Sung
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Chia-Hsin Ko
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Nai-Wen Ku
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming-Tai Cheng
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
- Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Hsinchu, Taiwan.
| | - Chu-Lin Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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9
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Wolf LA, Lo AX, Serina P, Chary A, Sri‐On J, Shankar K, Sano E, Liu SW. Frailty assessment tools in the emergency department: A geriatric emergency department guidelines 2.0 scoping review. J Am Coll Emerg Physicians Open 2024; 5:e13084. [PMID: 38162531 PMCID: PMC10755799 DOI: 10.1002/emp2.13084] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 01/03/2024] Open
Abstract
Objective Given the aging population and growing burden of frailty, we conducted this scoping review to describe the available literature regarding the use and impact of frailty assessment tools in the assessment and care of emergency department (ED) patients older than 60 years. Methods A search was made of the available literature using the Covidence system using various search terms. Inclusion criteria comprised peer-reviewed literature focusing on frailty screening tools used for a geriatric population (60+ years of age) presenting to EDs. An additional search of PubMed, EBSCO, and CINAHL for articles published in the last 5 years was conducted toward the end of the review process (January 2023) to search specifically for literature describing interventions for frailty, yielding additional articles for review. Exclusion criteria comprised articles focusing on an age category other than geriatric and care environments outside the emergency care setting. Results A total of 135 articles were screened for inclusion and 48 duplicates were removed. Of the 87 remaining articles, 20 were deemed irrelevant, leaving 67 articles for full-text review. Twenty-eight were excluded for not meeting inclusion criteria, leaving 39 full-text studies. Use of frailty screening tools were reported in the triage, care, and discharge decision-making phases of the ED care trajectory, with varying reports of usefulness for clinical decision-making. Conclusion The literature reports tools, scales, and instruments for identifying frailty in older patients at ED triage; multiple frailty scores or tools exist with varying levels of utilization. Interventions for frailty directed at the ED environment were scant. Further research is needed to determine the usefulness of frailty identification in the context of emergency care, the effects of care delivery interventions or educational initiatives for front-line medical professionals on patient-oriented outcomes, and to ensure these initiatives are acceptable for patients.
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Affiliation(s)
- Lisa A. Wolf
- Emergency Nurses AssociationSchaumburgIllinoisUSA
| | - Alexander X. Lo
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Peter Serina
- Department of Emergency MedicineBrown UniversityProvidenceRhode IslandUSA
| | - Anita Chary
- Department of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
| | - Jiraporn Sri‐On
- Department of Emergency MedicineVajira HospitalBangkokThailand
| | - Kalpana Shankar
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | - Ellen Sano
- Department of Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Shan W. Liu
- Department of Emergency MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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Albrecht R, Espejo T, Riedel HB, Nissen SK, Banerjee J, Conroy SP, Dreher-Hummel T, Brabrand M, Bingisser R, Nickel CH. Clinical Frailty Scale at presentation to the emergency department: interrater reliability and use of algorithm-assisted assessment. Eur Geriatr Med 2024; 15:105-113. [PMID: 37971677 PMCID: PMC10876739 DOI: 10.1007/s41999-023-00890-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/19/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE The Clinical Frailty Scale (CFS) allows health care providers to quickly stratify older patients, to support clinical decision-making. However, few studies have evaluated the CFS interrater reliability (IRR) in Emergency Departments (EDs), and the freely available smartphone application for CFS assessment was never tested for reliability. This study aimed to evaluate the interrater reliability of the Clinical Frailty Scale (CFS) ratings between experienced and unexperienced staff (ED clinicians and a study team (ST) of medical students supported by a smartphone application to assess the CFS), and to determine the feasibility of CFS assignment in patients aged 65 or older at triage. METHODS Cross-sectional study using consecutive sampling of ED patients aged 65 or older. We compared assessments by ED clinicians (Triage Clinicians (TC) and geriatric ED trained nurses (geriED-TN)) and a study team (ST) of medical students using a smartphone application for CFS scoring. The study is registered on Clinicaltrials.gov (NCT05400707). RESULTS We included 1349 patients aged 65 and older. Quadratic-weighted kappa values for ordinal CFS levels showed a good IRR between TC and ST (ϰ = 0.73, 95% CI 0.69-0.76), similarly to that between TC and geriED-TN (ϰ = 0.75, 95% CI 0.66-0.82) and between the ST and geriED-TN (ϰ = 0.74, 95% CI 0.63-0.81). A CFS rating was assigned to 972 (70.2%) patients at triage. CONCLUSION We found good IRR in the assessment of frailty with the CFS in different ED providers and a team using a smartphone application to support rating. A CFS assessment occurred in more than two-thirds (70.2%) of patients at triage.
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Affiliation(s)
- Rainer Albrecht
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Tanguy Espejo
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Henk B Riedel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Søren K Nissen
- Research Unit for Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
| | - Jay Banerjee
- University Hospitals of Leicester NHS Trust, Leicester, UK
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Simon P Conroy
- St Pancras Hospital, Central and North West London NHS Foundation Trust, London, UK
- MRC Unit for Lifelong Health and Ageing, University College London, University College London Hospitals, London, UK
| | - Thomas Dreher-Hummel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Mikkel Brabrand
- Research Unit for Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland.
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11
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Wright R, Regier NG, Booth A, Cotter VT, Hansen BR, Taylor JL, Won S, Witham G. Considerations of Intersectionality for Older Adults with Palliative Care Needs in the Emergency Department: An Integrative Review. CURRENT GERIATRICS REPORTS 2023; 12:195-204. [PMID: 38313361 PMCID: PMC10836610 DOI: 10.1007/s13670-023-00399-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 02/06/2024]
Abstract
Purpose of Review We sought to identify current interventions, research, or non-research evidence that has direct or indirect consideration of intersectionality in the care of older adults in the emergency department (ED). An integrative review informed by Crenshaw's Theory of Intersectionality was conducted in accordance with Whittemore and Knafl's five-stage methodology. A rigorous review process determined appropriateness for inclusion, and articles were analyzed for areas related to direct or indirect relationship to intersectionality. Recent Findings Older adults aged 60 and above in the United States (US) account for more than 20% of ED visits annually, and half of older adults will visit the ED in their last year of life. There has been a growing focus on adapting the ED to meet the palliative care needs of older adults, but relatively little consideration has been given to older adults' intersectional identities. Summary Six articles were identified that provided indirect insights into the status of intersectionality in ED-based palliative care for older adults. Two areas of interest were identified: (1) intersectional elements or reference to such elements embedded within the studies; and (2) the challenges of adapting quantitative methodologies to incorporate variables and approaches that would allow for intersectional analysis. This review highlights areas for future research along with recommendations for adopting an intersectional framing into commonly used methodologies.
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Affiliation(s)
- Rebecca Wright
- Johns Hopkins School of Nursing, Baltimore, MD, USA
- Principal Faculty, Johns Hopkins Center for Equity in Aging, Baltimore, MD, USA
| | - Natalie G. Regier
- Johns Hopkins School of Nursing, Baltimore, MD, USA
- Principal Faculty, Johns Hopkins Center for Equity in Aging, Baltimore, MD, USA
| | - Ashley Booth
- Johns Hopkins School of Nursing, Baltimore, MD, USA
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Valerie T. Cotter
- Johns Hopkins School of Nursing, Baltimore, MD, USA
- Principal Faculty, Johns Hopkins Center for Equity in Aging, Baltimore, MD, USA
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Bryan R. Hansen
- Johns Hopkins School of Nursing, Baltimore, MD, USA
- Principal Faculty, Johns Hopkins Center for Equity in Aging, Baltimore, MD, USA
| | - Janiece L. Taylor
- Johns Hopkins School of Nursing, Baltimore, MD, USA
- Principal Faculty, Johns Hopkins Center for Equity in Aging, Baltimore, MD, USA
| | - Sarah Won
- Johns Hopkins School of Nursing, Baltimore, MD, USA
| | - Gary Witham
- School of Nursing and Public Health, Manchester Metropolitan University, Manchester, UK
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12
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Nickel CH, Kellett J. Assessing Physiologic Reserve and Frailty in the Older Emergency Department Patient: Should the Paradigm Change? Clin Geriatr Med 2023; 39:475-489. [PMID: 37798060 DOI: 10.1016/j.cger.2023.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
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.
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Affiliation(s)
- Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, Basel CH-4031, Switzerland.
| | - John Kellett
- Department of Emergency Medicine, Odense University Hospital, University of Southern Denmark, Denmark
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Hörlin E, Munir Ehrlington S, Toll John R, Henricson J, Wilhelms D. Is the clinical frailty scale feasible to use in an emergency department setting? A mixed methods study. BMC Emerg Med 2023; 23:124. [PMID: 37880591 PMCID: PMC10601295 DOI: 10.1186/s12873-023-00894-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/14/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The Clinical Frailty Scale (CFS) is a frailty assessment tool used to identify frailty in older patients visiting the emergency department (ED). However, the current understanding of how it is used and accepted in ED clinical practice is limited. This study aimed to assess the feasibility of CFS in an ED setting. METHODS This was a prospective, mixed methods study conducted in three Swedish EDs where CFS had recently been introduced. We examined the completion rate of CFS assessments in relation to patient- and organisational factors. A survey on staff experience of using CFS was also conducted. All quantitative data were analysed descriptively, while free text comments underwent a qualitative content analysis. RESULTS A total of 4235 visits were analysed, and CFS assessments were performed in 47%. The completion rate exceeded 50% for patients over the age of 80. Patients with low triage priority were assessed to a low degree (24%). There was a diurnal variation with the highest completion rates seen for arrivals between 6 and 12 a.m. (58%). The survey response rate was 48%. The respondents rated the perceived relevance and the ease of use of the CFS with a median of 5 (IQR 2) on a scale with 7 being the highest. High workload, forgetfulness and critical illness were ranked as the top three barriers to assessment. The qualitative analysis showed that CFS assessments benefit from a clear routine and a sense of apparent relevance to emergency care. CONCLUSION Most emergency staff perceived CFS as relevant and easy to use, yet far from all older ED patients were assessed. The most common barrier to assessment was high workload. Measures to facilitate use may include clarifying the purpose of the assessment with explicit follow-up actions, as well as formulating a clear routine for the assessment. REGISTRATION The study was registered on ClinicalTrials.gov 2021-06-18 (identifier: NCT04931472).
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Affiliation(s)
- Erika Hörlin
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Samia Munir Ehrlington
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Rani Toll John
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Joakim Henricson
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Daniel Wilhelms
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Garcia-Pérez D, Vena-Martínez A, Robles-Perea L, Roselló-Padullés T, Espaulella-Panicot J, Arnau A. Prognostic Value of a New Tool (the 3D/3D+) for Predicting 30-Day Mortality in Emergency Department Patients Aged 75 Years and Older. J Clin Med 2023; 12:6469. [PMID: 37892606 PMCID: PMC10607455 DOI: 10.3390/jcm12206469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
The 3D/3D+ multidimensional geriatric assessment tool provides an optimal model of emergency care for patients aged 75 and over who attend the Emergency Department (ED). The baseline, or static, component (3D) stratifies the degree of frailty prior to the acute illness, while the current, or dynamic, component (3D+) assesses the multidimensional impact caused by the acute illness and helps to guide the choice of care facility for patients upon their discharge from the ED. The objective of this study was to evaluate the prognostic value of the 3D/3D+ to predict short- and long-term adverse outcomes in ED patients aged 75 years and older. Multivariable logistic regression models were used to identify the predictors of mortality 30 days after 3D/3D+ assessment. Two hundred and seventy-eight patients (59.7% women) with a median age of 86 years (interquartile range: 83-90) were analyzed. According to the baseline component (3D), 83.1% (95% CI: 78.2-87.3) presented some degree of frailty. The current component (3D+) presented alterations in 60.1% (95% CI: 54.1-65.9). The choice of care facility at ED discharge indicated by the 3D/3D+ was considered appropriate in 96.4% (95% CI: 93.0-98.0). Thirty-day all-cause mortality was 19.4%. Delirium and functional decline were the dimensions on the 3D/3D+ that were independently associated with 30-day mortality. These two dimensions had an area under receiver operating characteristic of 0.80 (95% CI: 0.73-0.86) for predicting 30-day mortality. The 3D/3D+ tool enhances the provision of comprehensive care by ED professionals, guides them in the choice of patients' discharge destination, and has a prognostic validity that serves to establish future therapeutic objectives.
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Affiliation(s)
- Dolors Garcia-Pérez
- Emergency Service, Althaia Xarxa Assistencial Universitària de Manresa, 08243 Manresa, Spain
- Doctoral Program in Medicine and Biomedical Sciences, Universitat de Vic-Universitat Central de Catalunya (UVIC-UCC), 08500 Vic, Spain
- Faculty of Medicine, Universitat de Vic-Central de Catalunya (UVIC-UCC), 08500 Vic, Spain; (J.E.-P.); (A.A.)
- Central Catalonia Chronicity Research Group (C3RG), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IRIS-CC), 08500 Vic, Spain
| | - Anabelén Vena-Martínez
- UFISS Geriatric Emergncy Service, Hospital Universitari de Santa Maria de Lleida, 25008 Lleida, Spain;
| | - Laura Robles-Perea
- Emergency Service, Hospital de Figueres (Fundació Salut Empordà), 17600 Figueres, Spain;
| | | | - Joan Espaulella-Panicot
- Faculty of Medicine, Universitat de Vic-Central de Catalunya (UVIC-UCC), 08500 Vic, Spain; (J.E.-P.); (A.A.)
- Central Catalonia Chronicity Research Group (C3RG), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IRIS-CC), 08500 Vic, Spain
- Geriatric and Palliative Care Service, Consorci Hospitalari Vic, Fundació Hospital de la Santa Creu de Vic, 08500 Vic, Spain
| | - Anna Arnau
- Faculty of Medicine, Universitat de Vic-Central de Catalunya (UVIC-UCC), 08500 Vic, Spain; (J.E.-P.); (A.A.)
- Central Catalonia Chronicity Research Group (C3RG), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut a la Catalunya Central (IRIS-CC), 08500 Vic, Spain
- Research and Innovation Unit, Althaia Xarxa Assistencial Universitària de Manresa, 08243 Manresa, Spain
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