The impact of frailty Screening of Older adults with muLtidisciplinary assessment of those At Risk during emergency hospital attendance on the quality, safety and cost-effectiveness of care (SOLAR): a randomised controlled trial

A frailty census of older adults in the emergency department and acute inpatient settings of a model 4 hospital in the Mid-West of Ireland

BACKGROUND

Frailty is a risk factor for presentation to the ED, in-hospital mortality, prolonged hospital stays and functional decline at discharge. Profiling the prevalence and level of frailty within the acute hospital setting is vital to ensure evidence-based practice and service development within the construct of frailty. The aim of this cross-sectional study was to establish the prevalence of frailty and co-morbidities among older adults in an acute hospital setting.

METHODS

Data collection was undertaken by clinical research nurses and advanced nurse practitioners experienced in assessing older adults. All patients aged ≥ 65 years and admitted to a medical or surgical inpatient setting between 08:00 and 20:00 and who attended the ED over a 24-h period were screened using validated frailty and co-morbidity scales. Age and gender demographics, Clinical Frailty Scale (CFS), Charlson Co-morbidity Index (CCI) and admitting specialty (medical/surgical) were collected. Descriptive statistics were used to profile the cohort, and p values were calculated to ascertain the significance of results.

RESULTS

Within a sample of 413 inpatients, 291 (70%) were ≥ 65 years and therefore were included in the study. 202 of these 291 older adults (70%) were ≥ 75 years. Frailty was investigated using validated clinical cut-offs on the CFS (not frail < 5; frail ≥ 5). Comorbidities were investigated using the Charlson Comorbidity Index (mild 1-2; moderate 3-4; severe ≥ 5). The median CFS was 6 indicating moderate frailty levels, and the median CCI score was 3 denoting moderate co-morbidity. In the inpatient cohort, 245 (84%) screened positive for frailty, while 223 (75%) had moderate-severe co-morbidity (CCI Mod 3-4, severe ≥ 5). No significant differences were observed across genders for CFS and CCI. In the ED, 81 patients who attended the ED were ≥ 65 years. The median CFS was 6 (moderate frailty), and the median CCI was 5 (severe co-morbidity level). Seventy-four percent (60) of participants screened positively for frailty (CFS ≥ 5), and 31% (25) had a CFS of 7 or greater (severely frail). Ninety-six percent (78) of patients had a moderate-severe level of comorbidity. No significant associations were found between the CFS and CCI and ED participants age, gender, and medical/surgical speciality usage.

CONCLUSION

There is a high prevalence of frailty and co-morbidity among older adults who present to the ED and require inpatient care. This may contribute to increased waiting times, lengths of stay, and the need for specialist intervention. With an increased focus on the integration of care for older adults across care transitions, there is a clear need for expansion of frailty-based services, staff training in frailty care and multidisciplinary team resources across the hospital and community setting.

Core requirements of frailty screening in the emergency department: an international Delphi consensus study

INTRODUCTION

Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study.

METHODS

A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August-September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors.

RESULTS

In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include.

CONCLUSIONS

Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

Frailty Knowledge, Use of Screening Tools, and Educational Challenges in Emergency Departments in Ireland: A Multisite Survey

BACKGROUND

Recognizing frailty and providing evidenced-based management in busy emergency departments is challenging. Understanding the knowledge and educational needs of ED staff is important to design training that might improve patient outcomes.

OBJECTIVE

This study aimed to explore frailty knowledge of ED staff, use of frailty screening instruments in Irish emergency departments, and educational challenges in the emergency department.

METHODS

A multisite survey of ED staff (different specialties) was conducted between April and September 2021. An anonymous online survey was distributed via email. Free-text sections were analyzed using content analysis.

RESULTS

In total, 168 staff (nursing, medical and allied health) participated, representing 9 of 26 Irish emergency departments (35%). Most respondents were nurses (n = 78, 46%). Less than half of respondents had received frailty identification training (n = 81, 48%). One-fifth of emergency doctors and nurses (20%) were unsure how to define frailty. Major barriers to ED frailty screening were resource deficits, insufficient diagnostic pathways from the emergency departments, and lack of education on suitable instruments.

CONCLUSIONS

Most of the ED staff surveyed relied on clinical judgment rather than formal training in frailty identification. A high proportion reported poor knowledge and low confidence in recognizing frailty. Dedicated staff with frailty management expertise, bespoke education initiatives, and clearly defined frailty screening pathways may help address the issues identified.

Diagnostic Accuracy of Frailty Screening Instruments Validated for Use among Older Adults Attending Emergency Departments: A Systematic Review and Meta-Analysis

Early identification of frailty can prevent functional decline. Although multiple frailty screens exist for use in Emergency Departments (EDs), few are validated against diagnostic standards such as comprehensive geriatric assessment. To examine the diagnostic accuracy of ED screens for frailty, scientific databases were searched for prospective diagnostic accuracy test studies from January 2000 to September 2022. Studies were assessed for risk of bias using QUADAS-C. Psychometric properties were extracted and analysed using R. Six studies involving 1,663 participants describing seven frailty screening instruments (PRISMA-7, CFS, VIP, FRESH, BPQ, TRST, and ISAR), representing 13 unique data points, were included. The mean age of participants ranged from 76 to 86 years. The proportion that was female ranged from 45 to 60%. The pooled prevalence rate of frailty was high at 59%. The pooled estimate for sensitivity was 0.85 (95% CI: 0.76-0.91) versus 0.77 (95% CI: 0.62-0.88) for specificity. Pooled accuracy based on area under the ROC curve was 0.89 (95% CI: 0.86-0.90). Although few studies were found, limiting the ability to conduct a meta-analysis of individual instruments, available frailty screens can accurately diagnose frailty in older adults attending the ED. As specificity was comparatively low, additional assessment may be required to identify those requiring inpatient management or onward community referral. Further study is therefore required.

Comprehensive geriatric assessment and multidisciplinary team interventions for hospitalized older adults: A scoping review

BACKGROUND/OBJECTIVES

Comprehensive geriatric assessment (CGA) is a multidisciplinary diagnostic and treatment process to evaluate medical, psychosocial, and functional capability. It is useful to develop a coordinated and integrated plan for frail older patients. This study aimed to examine the current scope of CGA based multidisciplinary team interventions in acute care setting to improve the health outcomes for older adults.

METHODS

We searched electronic databases: PubMed, Ovid, PsychINFO, Scopus, RISS and KoreaMed from 2011 to 2021. The selected articles were extracted by three reviewers and cross checked by the fourth reviewer to resolve any conflicts. Data were synthesized and analyzed descriptively and thematically. Articles are nested three themes: inpatient (IN), emergency room (ER) and oncology patient (ONCO).

RESULTS

Of the 1830 articles that were screened, 710 were potentially eligible. Finally, 26 articles were selected and categorized as IN (n=8), ER (n=7) and ONCO (n=11). Geriatricians and nurses participated in most of the multidisciplinary teams followed by other health professionals. The most effective primary outcomes were focused and retrieved across five domains, screening, prevention, treatment, quality of care, and rehabilitation. The subdomains are problem lists which is common and problematic among hospitalized older patients and retrieved from the most commonly used multidisciplinary interventions according to each domain.

CONCLUSION

CGA based multidimensional intervention (MDI) are likely to be an effective in care of older adults. There is remarkable paradigm shift required to improve better health outcomes for hospitalized older adults. It also suggests that there is a need to design the CGA based MDI to build a standardized protocol for older adults to maintain functional capacity and increase likelihood of living in their own home.

Frailty Network in an Acute Care Setting: The New Perspective for Frail Older People

The incidence of elderly patients who come to the emergency room is progressively increasing. The specialization of the physician units might not be adequate for the evaluation of this complexity. The present study aimed to present a standard procedure, called ‘The Geriatric Frailty Network’, operating at the Policlinico Gemelli IRCCS Foundation, which is configured specifically for the level II assessment of frail elderly patients. This was a retrospective study in 1191 patients aged over 65, who were evaluated by the Geriatric Frailty Unit directly after emergency department admission for one year. All patients underwent multidimensional geriatric evaluation. Data were collected on demographics, co-morbidity, disease severity, and Clinical Frailty Scale. Among all patients, 723 were discharged directly from the emergency room with early identification of continuity of care path. Globally, 468 patients were hospitalized with an early assessment of frailty that facilitated the discharge process. The geriatric frailty network model aims to assist the emergency room and ward doctor in the prevention of the most common geriatric syndromes and reduce the number of incongruous hospitalizations.