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Agreement and predictive value of the Rockwood Clinical Frailty Scale at emergency department triage
  1. William Shrier1,
  2. Colin Dewar1,
  3. Piervirgilio Parrella2,
  4. David Hunt3,
  5. Luke Eliot Hodgson4,5
  1. 1Emergency Department, Western Sussex Hospitals NHS Foundation Trust, Worthing Hospital, Worthing, UK
  2. 2Patient First Kaizen Improvement, Western Sussex Hospitals NHS Foundation Trust, Worthing, UK
  3. 3Department of Medicine for the Elderly, Western Sussex Hospitals NHS Foundation Trust, Worthing, UK
  4. 4Anaesthetics Department, Western Sussex Hospitals NHS Foundation Trust, Worthing, UK
  5. 5Faculty of Health and Medical Sciences, Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
  1. Correspondence to Dr William Shrier, Emergency Department, Western Sussex Hospitals NHS Foundation Trust, Worthing Hospital, Worthing BN11 2DH, West Sussex, UK; willshrier{at}


Aim To determine the agreement and predictive value of emergency department (ED) triage nurse scoring of frailty using the Rockwood Clinical Frailty Scale (CFS) when compared with inpatient medical assessment using the same scale.

Methods Prospective, dual-centre UK-based study over a 1-year period (1 April 2017 to 31 March 2018) of CFS recorded digitally at nursing triage on ED arrival and on hospital admission by a medical doctor. Inclusion criteria were emergency medical admission in those aged ≥65 staying at least one night in hospital with a CFS completed in both ED and at hospital admission. Agreement between ED triage nurse and inpatient hospital physician was assessed using a weighted Kappa statistic and Spearman’s correlation coefficient. The ability of the ED to diagnose frailty (defined by a CFS ≥5) was assessed using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and receiver operating characteristic (ROC) curves. At both time points the ability of the CFS to predict inpatient mortality was also assessed.

Results From 29 211 admissions aged ≥65 who stayed at least one night in hospital, 12 385 (42.3%) were referred from the ED. Of the ED referrals, 8568 cases (69.2%) were included with paired CFS performed. Median age was 84 (IQR 77 to 89) with an inpatient mortality of 6%. Median CFS in ED was 4 (3 to 5) and on hospital admission 5 (4 to 6). Agreement between the ED CFS and admission CFS was weak (Kappa 0.21, 95% CI 0.19 to 0.22, rs 0.366). The area under the ROC curve (AUC) was 0.67 (95% CI 0.66 to 0.68) for the ED CFS ability to predict an admission CFS ≥5. To predict inpatient mortality the ED CFS AUC was 0.56 (0.53 to 0.59) and admission CFS AUC 0.70 (0.68 to 0.73).

Conclusion Agreement between ED CFS and inpatient CFS was found to be weak. In addition the ability of ED CFS to predict clinically important outcomes was limited. NPV and PPV for ED CFS cut-off value of ≥5 were found to be low. Further work is required on the feasibility, clinical impact and appropriate tools for screening of frailty in EDs.

  • frailty
  • emergency department
  • triage

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  • Handling editor Mary Dawood

  • Contributors WS, CD and LEH were involved in writing the manuscript. CD, LEH and DH were involved in the planning and conduct of the study. WS was involved in submitting the manuscript. PP and LEH were involved in the statistical analysis. DH was involved in the geriatric training session. WS and CD were responsible for the overall content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval was given by NHS South Central—Hampshire B Research Ethics Committee (REC reference 18/SC/0513).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.