Screening of the frail patient in the emergency department: A systematic review

doi:10.1016/j.ejim.2017.09.036

European Journal of Internal Medicine

Volume 45, November 2017, Pages 71-73

https://doi.org/10.1016/j.ejim.2017.09.036 Get rights and content

Highlights

•
Frail elders in need of further geriatric assessment should be identified in the ED.
•
Frailty Screening predicts risk of mortality and admission to hospital/nursing home.
•
Increased risk of 30 day ED revisit is not predicted by frailty screening.
•
To assess validity of frailty screening in EDs randomized clinical trials are needed.

Abstract

Background

Several frailty rating scales have been developed to detect and screen for the level of frailty. It is uncertain what diagnostic value screening of frailty level have in the emergency department.

Aim

To assess the accuracy of the screening tools used in the emergency department to detect frailty in patients ≥ 65 years by their ability to identify the risk of adverse outcomes.

Methods

An extensive medical literature search of Embase and PubMed was conducted, to identify studies using frailty screening scales in the emergency department. Data was subsequently extracted and evaluated from the results of the included studies.

Results

Four studies met the exact inclusion criteria. Four different frailty screening scales: Clinical Frailty Scale, Deficit Accumulation Index, Identification of Seniors At Risk and The Study of Osteoporotic Fracture frailty index used in the emergency department were described and compared. Predictive values for various outcomes are represented and discussed.

Conclusions

The results suggest that frailty successfully predicts increased risk of hospitalization, nursing home admission, mortality and prolonged length of stay after an initial emergency department visit. Frailty does however not predict increased risk of 30 day emergency department revisit. Further research highlighting the value of screening for frailty level in elderly emergency department patients is needed.

Learning points

Although frail elders in need of further geriatric assessment should be identified as soon as possible, this systematic review only identified four cohort studies of frailty assessment in emergency departments.

Although frailty screening appeared to predict the risk of mortality and of admission to hospital/nursing home, these four studies did not show that it could predict return visits to emergency departments within 30 days.

Randomized clinical trials of frailty screening tools compared to usual care or other methods of assessment are clearly needed.

Introduction

The total number of people aged over 65 years attending emergency departments (EDs) is increasing [1], [2], with the result that emergency physicians have less time to manage them [3], [4]. Elderly patients are generally more demanding with a greater number of co-morbidities and communication problems. A substantial number of people ≥ 65 years are considered frail, the percentages have been reported to vary between 5 and 15% at the age of 65, increasing to 20–25% at the age of 85 [5], [6]. Frailty is a geriatric syndrome where patients are more vulnerable to adverse outcomes such as hospital admission and death. More than one operational definition exists [7]; these are difficult to use in everyday clinical practice because of their complexity.

Frailty screening tools that can identify elderly patients at greater risk of adverse outcomes and in need of further geriatric assessment and treatment would be of great clinical value in EDs [8], [9], [10], [11]. Rapid accurate risk stratification would allow for a more focused use of time and resources to the patients that need it the most. This systematic review assessed those screening tools that have been used in EDs to identify frail patients aged over 65 years.

Section snippets

Methods

Since the current concepts of frailty are relatively recent, this systematic review of the literature confined itself only to studies published in either English or Danish the last 10 years. PRISMA guidelines were followed [12]. PubMed and Embase were searched using the following terms:

•
Population: Frail OR Frail Elder etc. AND ED OR Emergency Department OR Emergency Room etc.
•
Intervention: Frailty Screening OR Frailty Assessment etc.

The quality of selected studies was assessed using described

Results

A literature search performed in March 2016 of PubMed and Embase yielded 794 unique papers reporting frailty and ED. After titles, abstracts and full text were screened to exclude those papers that only reported the use of a comprehensive geriatric assessment by a geriatric specialist and those not taking place in EDs, 790 papers were excluded. Only four papers dealt specifically with the assessment of frailty in patients at the time of presentation to an ED. All four papers were prognostic

Discussion

Given the small number of studies it is difficult to draw firm conclusions from their results. Moreover, the four studies identified were all cohort studies. Cohort studies do not provide the highest level of evidence [21]. This systematic review clearly identifies the need for randomized clinical trials of frailty screening tools compared to usual care or other methods of assessment. Nevertheless the four studies show that the use of frailty screening in the ED can be successful in predicting

Conclusion

This systematic review only identified four cohort studies of frailty assessment in EDs. There is clearly a need for randomized clinical trials of frailty screening tools compared to usual care or other methods of assessment.

References (26)

D.C. Roberts et al.
Increasing rates of emergency department visits for elderly patients in the United States, 1993 to 2003
Ann Emerg Med
(2008)
C.R. Carpenter et al.
Evolving prehospital, emergency department, and “inpatient” management models for geriatric emergencies
Clin Geriatr Med
(2013)
P.D. Friedmann et al.
Early revisit, hospitalization, or death among older persons discharged from the ED
Am J Emerg Med
(2001)
J. McCusker et al.
Prediction of hospital utilization among elderly patients during the 6 months after an emergency department visit
Ann Emerg Med
(2000)
F. Salvi et al.
Screening for frailty in elderly emergency department patients by using the Identification of Seniors At Risk (ISAR)
J Nutr Health Aging
(2012)
M.E. Charlson et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chronic Dis
(1987)
A. Kulminski et al.
Cumulative index of health disorders as an indicator of aging-associated processes in the elderly: results from analyses of the National Long Term Care Survey
Mech Ageing Dev
(2007)
J.M. Pines et al.
National trends in emergency department use, care patterns, and quality of care of older adults in the United States
J Am Geriatr Soc
(2013)
U. Hwang et al.
The geriatric emergency department
J Am Geriatr Soc
(2007)
L.P. Fried et al.
Frailty in older adults: evidence for a phenotype
J Gerontol A Biol Sci Med Sci
(2001)

C.Y. Chen et al.

The prevalence of subjective frailty and factors associated with frailty in Taiwan

Arch Gerontol Geriatr

(2010)

D.B. Hogan et al.

Models, definitions, and criteria of frailty

Aging Clin Exp Res

(2003)

J. McCusker et al.

Return to the emergency department among elders: patterns and predictors

Acad Emerg Med Off J Soc Acad Emerg Med

(2000)

Cited by (63)

Frailty Knowledge, Use of Screening Tools, and Educational Challenges in Emergency Departments in Ireland: A Multisite Survey
2024, Journal of Emergency Nursing
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.
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.
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.
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.
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.
Frailty and mortality: Utility of Frail-VIG index in ED short-stay units for older adults
2023, Archives of Gerontology and Geriatrics
Frailty assessment allows the identification of patients at risk of death. The aim here was to study the ability of Frail-VIG Index (FI-VIG) in order to discriminate frailty groups of older adults and garner its correlation with mortality in an Emergency-Department Short-Stay Unit (ED-SSU).
Our observational, single-center, prospective study consecutively included patients over 65-years-old admitted between March 1, 2021, and April 30, 2021.
302 patients were included (56 % women), mean age 83 ± 8 years, and 39.1 % of them had a functional disability whilst 16.5 % of them had dementia. A total of 174 patients (58 %) met the frailty criteria (FI-VIG ≥ 0.2): 111 (63.8 %) had mild frailty (FI-VIG 0.2–0.36), 52 (29.9 %) had moderate frailty (FI-VIG 0.36–0.55), and 11 (6.3 %) had advanced frailty (FI-VIG > 0.55). Mortality at 30 days, 6 months, and 1 year was analyzed: no frailty was 6.3 %, 10.8 %, and 12.5 %, respectively; mild frailty was 10.8 %, 22.5 %, and 22.5 %, respectively; moderate frailty was 25 %, 34.6 %, and 42.3 %, respectively; advanced frailty was 36.4 %, 54.5 %, and 3.6 %, respectively. This shows the significant differences between the groups (1-year mortality p < 0.001). Mild frailty vs. non-frail HR was 2.47 (95 %CI 1.12–5.46), moderate frailty vs. non-frail HR was 6.93 (95 %CI 3.16–15.23), and advanced frailty vs. non-frail HR was 11.29 (95 %CI 3.54–36.03). The mean test time was 7 min.
There was a strong correlation between frailty degree and mortality at 1, 6, and 12 months. FI-VIG is fast and easy-to-use in this setting. It is routine implementation in ED-SSUs could enable early risk stratification.
Impact of Frailty on Emergency Department Encounters for Cardiovascular Disease: A Retrospective Cohort Study
2023, American Journal of Cardiology
Data are limited on whether the causes of emergency department (ED) encounters for cardiovascular diseases (CVDs) and associated clinical outcomes vary by frailty status. Using the United States Nationwide ED Sample, selected CVD encounters (acute myocardial infarction [AMI], ischemic stroke, atrial fibrillation [AF], heart failure [HF], pulmonary embolism, cardiac arrest, and hemorrhagic stroke) were stratified by hospital frailty risk score (HFRS). Logistic regression was used to determine the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of ED mortality among the different frailty groups. A total of 8,577,028 selected CVD ED encounters were included. A total of 5,120,843 (59.7%) had a low HFRS (<5), 3,041,699 (35.5%) had an intermediate HFRS (5 to 15), and 414,485 (4.8%) had a high HFRS (>15). Ischemic stroke was the most common reason for the encounter in the high HFRS group (66.9%), followed by hemorrhagic stroke (11.7%) and AMI (7.2%). For the low HFRS group, AF was the most common reason for the encounter (30.2%), followed by AMI (23.6%) and HF (16.8%). Compared with the low-risk group, high-risk patients had a decreased ED mortality and an increased overall mortality across most CVD encounters (p <0.001). The strongest association with overall mortality was observed among patients with a high HFRS admitted for AF (aOR 27.14, 95% CI 25.03 to 29.43) and HF (aOR 13.71, 95% CI 12.95 to 14.51) compared with their low-risk counterparts. In conclusion, patients presenting to the ED with acute CVD have a significant frailty burden, with different patterns of CVD according to frailty status. Frailty is associated with an increased all-cause mortality in patients for most CVD encounters.
Assessing Physiologic Reserve and Frailty in the Older Emergency Department Patient: Should the Paradigm Change?
2023, Clinics in Geriatric Medicine
Integrating the clinical frailty scale with emergency department triage systems for elder patients: A prospective study
2023, American Journal of Emergency Medicine
This prospective study investigated whether integrating the Clinical Frailty Scale (CFS) with a triage system would improve triage for older adult emergency department (ED) patients.
We enrolled ED patients aged 65 years or older at 5 study sites in Taiwan between December 2020 and April 2021. All eligible patients were assigned a triage level by using the Taiwan Triage and Acuity Scale (TTAS) in accordance with usual practice. A CFS score was collected from them. The primary outcome was critical events, defined as ICU admission or in-hospital mortality. The secondary outcomes were ED medical expenditures, number of orders in the ED, and length of hospital stay (LOS). We applied a reclassification concept and integrated the CFS and TTAS to create the Triage Frailty Acuity Scale (TFAS). We compared the outcomes achieved between the TTAS and TFAS.
Of 1023 screened ED patients, 890 were enrolled. The majority were assigned to TTAS level 3 (73.26%) and had CFS scores of 4 to 9 (55.96%). The primary outcomes were better predicted by the TFAS than the TTAS (area under the curve [AUC] 0.82 vs. 064). Using multivariable approach, TTAS level 1 (odds ratio [OR], 4.8; 95% confidence interval [CI], 1.7–13.4) and CFS score (OR, 5.8; 95% CI, 1.9–17.2) were significantly associated with the primary outcomes. For older adults at the highest triage level, the TFAS was not associated with an increase in the primary outcomes compared with the TTAS; however, the TFAS was associated with a significant decrease in the number of older ED patients assigned to triage levels 3 to 5. In addition, TFAS had a longer average LOS but did not have a higher average number of orders or ED medical expenditures compared to TTAS.
The TFAS identified more older ED patients who had been triaged as less emergent but proceeded to need ICU admission or in-hospital death. Incorporating the CFS into triage may reduce the under-triage of older adults in the ED.
Models of care for frail older persons who present to the emergency department: A scoping review of the literature
2023, International Emergency Nursing
People aged ≥65 years comprise approximately 20 % of all emergency department (ED) presentations. Frailty amongst this cohort is common yet can go undetected.
To summarise the evidence regarding models of care for frail older people in the ED.
The Joanna Briggs Institute scoping review framework was used. Literature searches were conducted in five electronic databases published from 2009 to 2022. Original research that met the criteria: frail older people aged ≥65 years, models of care and ED were included.
A total of thirteen articles met the criteria for inclusion in this review. These comprised four studies of frailty care models and nine studies of care models using different assessment tools to identify frail older people. Care models were comprised of various specialist team members (e.g., geriatrician/ED physician and nurse). Processes underpinning these models included tools to support clinicians in the assessment of frail older adults, particularly around functional status, comorbidities, symptom distress, quality of life, cognition/delirium, and social aspects. Outcomes of care models for frail older people included: shorter ED length of stay, lower hospital admission rates, cost savings and increased patient satisfaction rates.
A variety of models, supported by a variety of assessment tools, exist to identify and guide care delivery for frail older people in the ED. Careful consideration of existing policies, guidelines and models is required before implementing new service models.

View all citing articles on Scopus

View full text

Original ArticleScreening of the frail patient in the emergency department: A systematic review

Highlights

Abstract

Background

Aim

Methods

Results

Conclusions

Learning points

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Ann Emerg Med

Clin Geriatr Med

Am J Emerg Med

Ann Emerg Med

J Nutr Health Aging

J Chronic Dis

Mech Ageing Dev

National trends in emergency department use, care patterns, and quality of care of older adults in the United States

J Am Geriatr Soc

The geriatric emergency department

J Am Geriatr Soc

Frailty in older adults: evidence for a phenotype

J Gerontol A Biol Sci Med Sci

The prevalence of subjective frailty and factors associated with frailty in Taiwan

Arch Gerontol Geriatr

Models, definitions, and criteria of frailty

Aging Clin Exp Res

Return to the emergency department among elders: patterns and predictors

Acad Emerg Med Off J Soc Acad Emerg Med

Original Article
Screening of the frail patient in the emergency department: A systematic review