Background: For healthcare systems, an ageing population poses challenges in the delivery of equitable and effective care. Frailty assessment has the potential to improve care in the intensive care setting, but applying assessment tools in critical illness may be problematic. The aim of this systematic review was to evaluate evidence for the feasibility and reliability of frailty assessment in critical care. Methods: Our primary search was conducted in Medline, Medline In-process, EMBASE, CINAHL, PsycINFO, AMED, Cochrane Database of Systematic Reviews, and Web of Science (January 2001 to October 2017). We included observational studies reporting data on feasibility and reliability of frailty assessment in the critical care setting in patients 16 years and older. Feasibility was assessed in terms of timing of evaluation, the background, training and expertise required for assessors, and reliance upon proxy input. Reliability was assessed in terms of inter-rater reliability. Results: Data from 11 study publications are included, representing 8 study cohorts and 7761 patients. Proxy involvement in frailty assessment ranged from 58 to 100%. Feasibility data were not well-reported overall, but the exclusion rate due to lack of proxy availability ranged from 0 to 45%, the highest rate observed where family involvement was mandatory and the assessment tool relatively complex (frailty index, FI). Conventional elements of frailty phenotype (FP) assessment required modification prior to use in two studies. Clinical staff tended to use a simple judgement-based tool, the clinical frailty scale (CFS). Inter-rater reliability was reported in one study using the CFS and although a good level of agreement was observed between clinician assessments, this was a small and singlecentre study. Conclusion: Though of unproven reliability in the critically ill, CFS was the tool used most widely by critical care clinical staff. Conventional FP assessment required modification for general application in critical care, and an FIbased assessment may be difficult to deliver by the critical care team on a routine basis. There is a high reliance on proxies for frailty assessment, and the reliability of frailty assessment tools in critical care needs further evaluation. Prospero registration number: CRD42016052073.

Background: Evidence-based interventions may reduce mortality in surgical patients. This study documented the prevalence of sepsis, adherence to guidelines in its management, and timing of source control in general surgical patients presenting as an emergency.Methods: Patients aged 16 years or more presenting with emergency general surgery problems were identified over a 7-day period and then screened for sepsis compliance (using the Sepsis Six standards, devised for severe sepsis) and the timing of source control (whether radiological or surgical). Exploratory analyses examined associations between the mode (emergency department or general practitioner) and time of admission, adherence to the sepsis guidelines, and outcomes (complications or death within 30 days).Results: Of a total of 5067 patients from 97 hospitals across the UK, 911 (18⋅0 per cent) fulfilled the criteria for sepsis, 165 (3⋅3 per cent) for severe sepsis and 24 (0⋅5 per cent) for septic shock. Timely delivery of all Sepsis Six guidelines for patients with severe sepsis was achieved in four patients. For patients with severe sepsis, 17⋅6-94⋅5 per cent of individual guidelines within the Sepsis Six were delivered. Oxygen was the criterion most likely to be missed, followed by blood cultures in all sepsis severity categories. Surgery for source control occurred a median of 19⋅8 (i.q.r. 10⋅0-35⋅4) h after diagnosis. Omission of Sepsis Six parameters did not appear to be associated with an increase in morbidity or mortality. Conclusion:Although sepsis was common in general surgical patients presenting as an emergency, adherence to severe sepsis guidelines was incomplete in the majority. Despite this, no evidence of harm was apparent. * Members of the UK National Surgical Research Collaborative are co-authors of this study and can be found under the heading Collaborators Paper accepted 25 October 2016Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.10432 IntroductionGeneral surgical patients presenting as an emergency account for over 7 per cent of hospital episodes in the USA and 14 000 ICU admissions per year in the UK 1 -3 . Sepsis is prevalent in this patient group. Early diagnosis of severe sepsis and initiation of goal-directed therapy can reduce mortality, irrespective of the need for surgery 4,5 . This evidence was used to develop a care bundle known as the Sepsis Six for managing patients with severe sepsis (Table 1) 6,7 . These standards have been endorsed by many professional organizations, including the Society of Critical Care Medicine, the European Society of Intensive Care Medicine and the Royal Colleges of Surgeons of England and Ireland 1,2,8,9 . Complete application of these interventions is thought to be associated with as much as a one-third reduction in mortality from sepsis, although uptake is uncertain amongst surgical patients presenting as an emergency 4,6 .The main aims of the present study were to assess adherence to the Sepsis Six guidelines and identify the timing of source control in general su...