Prognosis for older people at presentation to emergency department based on frailty and aggregated vital signs

Abstract

Background Risk stratification for older people based on aggregated vital signs lack the accuracy to predict mortality at presentation to the Emergency Department (ED). We aimed to develop and internally validate the Frailty adjusted Prognosis in ED tool (FaP‐ED) for 30‐day mortality combining frailty and aggregated vital signs. Methods Single‐center prospective cohort of undifferentiated ED patients aged 65 or older, consecutively sampled upon ED presentation from a tertiary Emergency Center. Vital signs were aggregated using the National Early Warning Score (NEWS) as a measure of illness or injury severity and frailty was assessed with the Clinical Frailty Scale (CFS). The FaP‐ED was constructed by combining NEWS and CFS in multivariable logistic regression. The primary outcome was 30‐day mortality. Measures of discrimination and calibration were assessed to evaluate predictive performance and internally validated using bootstrapping. Results 2250 patients were included, 67 (1.8%) were omitted from analyses due to missing CFS, loss to follow‐up, or terminal illness. Thirty‐day mortality rate was 5.4% (N = 122, 95% CI = 4.5%–6.4%). Median NEWS was 1 (Inter‐Quartile Range (IQR): 0–3) and median CFS was 4 (IQR: 3–5). The Area Under Receiver Operating Characteristic (AUROC) for FaP‐ED was 0.86 (95% CI = 0.83–0.90). This was significantly higher than NEWS (0.81, 95% CI = 0.77–0.85, DeLong: Z = 3.5, p < 0.001) or CFS alone (0.82, 95% CI = 0.78–0.86, DeLong: Z = 4.4, p < 0.001). Bootstrapped estimates of FaP‐ED AUROC, calibration slope, and intercept were 0.86, 0.95, and −0.09, respectively, suggesting internal validity. A decision‐threshold of CFS 5 and NEWS 3 was proposed based on qualitative comparison of positive Likelihood Ratio at all relevant FaP‐ED cutoffs. Conclusion Combining aggregated vital signs and frailty accurately predicted 30‐day mortality at ED presentation and illustrated an important clinical interaction between frailty and illness severity. Pending external validation, the Fap‐ED operationalizes the concept of such “geriatric urgency” for the ED setting.

Frailty assessment tools in the emergency department: A geriatric emergency department guidelines 2.0 scoping review

“…Combining a frailty assessment tool with physiologic data may also be useful. Kabell Nissen and colleagues 47 attempted to determine the predictive capacity of the Frailty adjusted Prognosis in ED tool (FaP‐ED), which combines CFS and vital signs with the National Early Warning Score (NEWS). The FaP‐ED was more accurate at predicting 30‐day mortality than NEWS or CFS alone (area under the receiver operating characteristic = 0.86; 95% confidence interval, 0.83–0.90).…”

Clinical Frailty Scale at Presentation to the Emergency Department: Interrater Reliability and Use of Electronic Decision Support

“…Demographics (such as age and sex) and the Emergency Severity Index level (ESI), a 5 level triage tool, [37] were collected from the EHR. ESI triage level assignment is mandatory in all patients presenting to the ED, and can therefore be used as a comparator to assess adherence to frailty-adjusted score [10].…”

“…[3] Frailty is associated with a wide range of adverse health outcomes such as delirium, falls, functional decline, prolonged hospitalization and death. [4][5][6][7][8][9][10] Although qualitative assessment using "clinical judgment" is often used to identify frailty, this is not a reliable method and is less accurate than using formal assessment tools. [11] Several assessment tools have been proposed to assist with the identi cation of frailty in the Emergency Department (ED).…”

“…Using the CFS in the ED may be helpful in the early identi cation of patients who may bene t from additional services, and to support clinical decision making. [4,9,17,18] The CFS takes less than a minute to complete and due to its simplicity and ease of use the CFS is well-suited for use in the ED. [13,[19][20][21][22] 1.2 Importance…”

“…[27] It was previously suggested to determine frailty adjusted triage in the ED setting by assessing both acuity (with the Emergency Severity Index, ESI triage tool) and frailty (as measured with the CFS). [4,10,18,[28][29][30][31] Frailty adjusted triage was implemented in our ED prior to the COVID-19 pandemic, [32,33] but to what degree this process is adhered to is unknown.…”