Clinical frailty as a key characteristic of the patient population of the NHS Nightingale North West COVID-19 temporary emergency field hospital: cohort study April to June 2020

Abstract

Objectives COVID-19 temporary emergency ‘field’ hospitals have been established in the UK to support the surge capacity of the National Health Service while protecting the community from onward infection. We described the population of one such hospital and investigated the impact of frailty on clinical outcomes. Design Cohort study. Setting NHS Nightingale Hospital North West, April–June 2020. Participants All in-patients with COVID-19. Main Outcome Measures Mortality and duration of admission. Methods We analysed factors associated with mortality using logistic regression and admission duration using Cox's regression, and described trends in frailty prevalence over time using linear regression. Results A total of 104 COVID-19 patients were admitted, 74% with moderate-to-severe frailty (clinical frailty score, CFS > 5). A total of 84 were discharged, 14 transferred to other hospitals, and six died on site. High C-reactive protein (CRP) > 50 mg/dL predicted 30-day mortality (adjusted odds ratio 11.9, 95%CI 3.2–51.5, p < 0.001). Patients with CFS > 5 had a 10-day median admission, versus 7-day for CFS ≤ 5 and half the likelihood of discharge on a given day (adjusted hazard ratio 0.51, 95%CI 0.29–0.92, p = 0.024). CRP > 50 mg/dL and hospital-associated COVID-19 also predicted admission duration. As more frail patients had a lower rate of discharge, prevalence of CFS > 5 increased from 64% initially to 90% in the final week (non-zero slope p < 0.001). Conclusions: The NNW population was characterized by high levels of frailty, which increased over the course of the hospital's operation, with subsequent operational implications. Identifying and responding to the needs of this population, and acknowledging the risks of this unusual clinical context, helped the hospital to keep patients safe.

Process and Systems: Experience of using a regional network of hospitals in the care of older inpatients with COVID-19 in spring 2020

“…Further detail on NNW is described elsewhere. 15 Though the sites worked as distinct units, there was a flow of patients between them and other regional hospitals as illustrated wave of the pandemic, between April 2020 and June 2020. A continuous sample of patients was identified at each site; the sample size was pragmatic, incorporating all patients admitted to the temporary hospital between 13 April 2020 and 17 June 2020, a consecutive sample of the patients admitted to the district general hospital COVID-19 unit between 03 April 2020 and 28 May 2020, and a consecutive sample of the patients admitted to the acute hospital who tested positive for COVID-19 from 01 March 2020 to 09 June 2020.…”

“…Although the construction of the temporary hospital in a conference centre offered a large, flexible floorplan, future pandemic planning may consider prioritising natural light and a dedicated physiotherapy area to reduce the risk of delirium and optimise rehabilitation. 15 Additionally, the absence of critical care facilities at the temporary hospital and district general hospital required that patients in need of clinical escalation were transferred to an acute hospital. To minimise the need for urgent transfer, strict admission criteria (such as a threshold for EWS) were essential and enabled screening of patients who could safely be discharged to the district general hospital and temporary hospital.…”

“…14 An analysis of all admissions to the NNW has previously been performed, and identified frailty as a key clinical characteristic of the cohort. 15 There was a clear necessity for a safe place of care for this vulnerable cohort of frail, older patients, both during their acute illness and to allow isolation from other vulnerable people. Here, we will describe a regional service model that aimed to care for frail, older patients with COVID-19 across three settings: a temporary emergency hospital, a district general hospital and an acute teaching hospital.…”