Prevalence of Frailty in European Emergency Departments (FEED): an international flash mob study

Prevalence and severity of frailty amongst middle-aged and older adults conveyed to hospital by ambulance between 2010 and 2017 in Wales

BACKGROUND

Ambulance services are commonly used by older adults. The scope of services continues to adapt in response to more non-life-threatening calls, often due to the acute consequences of chronic illness. Frailty increases with increasing age, but it is not known how common or severe it is within patients conveyed to hospital by ambulance.

METHODS

Open cohort of people aged ≥50 living in Wales between 2010 and 2017. Routinely collected electronic data on ambulance attendances resulting in conveyance were linked to primary care data within the Secure Anonymised Information Linkage databank, and the electronic Frailty Index was calculated. The prevalence and severity of frailty according to patient and incident characteristics was described.

RESULTS

Of 1 264 094 individuals within the cohort, 23.8% were taken to hospital between 2010 and 2017, of which frailty was present in 84.3% of patients. There was an upward trend in the number of conveyances for patients with moderate and severe frailty across the years in all age groups. The distribution of frailty was similar across call categories, deprivation quintiles and out-of-hours incidents. Patients conveyed from residential homes had a higher level of frailty and comprised 8.7% of the total conveyances.

CONCLUSIONS

The high prevalence of frailty within adults aged ≥50 with emergency conveyances suggests upskilling ambulance crews with frailty training to enhance their assessment and decision making may improve patient outcomes. The high proportion of conveyances from residential homes indicates scope for increasing integration of community services to provide more patient-centred care pathways.

From triage to departure: Older adults' ED journey. A mixed methods study

BACKGROUND

Rising Emergency Department (ED) demand strains resources to assess and manage frail older adults. Allied health supports comprehensive care, disposition planning and patient safety in the ED but often intervenes late. This study investigated factors affecting allied health referrals and co-designed an early allied health frailty service.

METHODS

An explanatory sequential mixed-methods approach was used. Patient journey mapping of low acuity older ED patients was followed by stakeholder focus groups.

RESULTS

From triage, 20 older ED patients waited a mean of 110 minutes (SD 83 minutes) for doctor assessment, 123 minutes (SD 116 minutes) for an ED bed and 355 minutes (SD 297 minutes) for allied health assessment with a mean ED length of stay (LOS) of 685 minutes (SD 444 minutes). Qualitative analysis of focus group discussions identified perceived benefits of an early allied health service including shorter LOS, earlier disposition planning, increased staff confidence and streamlined decision making. Perceived barriers were lack of space, competing assessments with doctors and incomplete investigations. Perceived solutions were refining the inclusion criteria and staff education.

CONCLUSION

Allied health assessment occurred six hours post presentation, outside national targets. Opportunities and barriers identified supported the development of an earlier allied health frailty service.

Concordance with routine Clinical Frailty Scale screening in the frailty in European emergency departments (FEED) study

BACKGROUND

Frailty screening determines who receive geriatric emergency medicine interventions that are of high importance for patient outcomes. However, post-implementation evaluations show around 50% older Emergency Department (ED) attenders to receive screening. Why and who are omitted from screening remains largely unstudied. This study gave opportunity to compare normal screening status to data from a targeted screening study.

METHODS

The parent Frailty in European Emergency Departments (FEED) study administered the Clinical Frailty Scale (CFS) to consecutive ED attenders on 04 July 2023. This present study considered a subset of sites which provided retrievable CFS data from a "normal day" two weeks prior. Symmetry and dependency of missing CFS entries with observed variables were assessed. The frailty distribution was then compared with the parent FEED study data.

RESULTS

A minority of sites (5/62) recorded CFS in retrievable format. 55 % "normal day" CFS entries were missing compared with 14 % consecutive attenders during the parent FEED study. While no pattern was evident in the FEED cohort, "normal day" CFS entries were more frequently missing with non-white ethnic group (76 %, vs 52 % with white group), self-presentation (68 %), and discharge home from ED (59 %). CFS distributions differed between the routine and research day datasets (p = 0.009).

CONCLUSION

Our findings suggest systematic, non-random omission of CFS in normal screening practice, disproportionately affecting people with non-white ethnic group and self-presentation. This raises concern for limitations when routine CFS data are analysed and prompts study and improvement of concordance with screening.

Person-centred decisions in emergency care for older people living with frailty: principles and practice

Older people living with frailty are frequent users of emergency care and have multiple and complex problems. Typical evidence-based guidelines and protocols provide guidance for the management of single and simple acute issues. Meanwhile, person-centred care orientates interventions around the perspectives of the individual. Using a case vignette, we illustrate the potential pitfalls of applying exclusively either evidence-based or person-centred care in isolation, as this may trigger inappropriate clinical processes or place undue onus on patients and families. We instead advocate for delivering a combined evidence-based, person-centred approach to healthcare which considers the person's situation and values, apparent problem and available options.

FI-lab in the emergency department and adverse outcomes among acutely hospitalized older adults

BACKGROUND

The emergency department is treating a growing number of older patients with frailty, which has been linked to poorer outcomes. Urgency is generally emphasized in the emergency department based on indicators such as triage scores and early warning scores for decision-making. However, this approach may not be sufficient for frail older people. The Frailty Index-laboratory (FI-lab) has been used as a simple assessment tool for frailty, but it may also reflect disease severity and predict adverse outcomes in the emergency care setting. Therefore, we aimed to evaluate the association between FI-lab in the emergency room and adverse outcomes during hospitalization through comparison with assessments using triage and early warning scores.

METHODS

This was a retrospective cohort study conducted in a tertiary hospital. The study included patients aged 65 years or older who were admitted to the general internal medicine ward after being initially evaluated in the emergency department. FI-lab was calculated using 24 laboratory parameters from blood tests. The National Early Warning Score (NEWS), the Japan Triage and Acuity Scale (JTAS), and the modified JTAS were also used as prognostic indicators, and their association with adverse outcomes was compared with that of FI-lab.

RESULTS

In total, 872 patients (mean age, 80.9 years; male, 52.6 %) were analyzed. Patients who died during hospitalization had a higher FI-lab than those who survived. In multiple regression analysis, FI-lab, NEWS, and the modified JTAS were significantly associated with in-hospital death and prolonged length of hospital stay. In contrast, none of these indices were associated with in-hospital falls. The FI-lab was independently associated with the likelihood of discharge to home.

CONCLUSIONS

FI-lab evaluated in the emergency department reflected the severity of illness in acutely hospitalized older adults, similarly to NEWS and JTAS, and was a useful indicator for predicting adverse outcomes. These results may indicate the value of FI-lab for older adults in the acute care setting.

AEGIS-AcutE Geriatric Intervention Study: pilot study of frontline acute geriatric assessment to improve quality of care in emergency department

INTRODUCTION

Due to the increasing number of older patients in emergency departments (EDs) with frailty, cognitive impairment and multimorbidity, there is a need for geriatric expertise in EDs.

METHODS

This retrospective study is of older patients visiting Turku University Hospital ED between 2 January and 31 December 2022. Patients aged 75 years of older were screened for frailty using Triage Risk Screening Tool (TRST) and Clinical Frailty Scale (CFS). Nonacute, frail patients (CFS ≥4) suitable for Targeted Geriatric Assessment (TGA) (n = 1096) were scanned for the risk of delirium, cognitive impairment, change in functional status, falls, malnutrition and depression. A comprehensive patient record was made with recommendations for future care.

RESULTS

TRST was completed in 70% of the ED visits, and two-thirds of those were considered high-risk. Among the patients assessed by the geriatric team (TGA), nonspecific complaint (38%) and falls (35%) were the main reasons for ED admission. Cognitive impairment was present in over 60% and orthostatic hypotension in 40% of the patients. The 72-hour revisit rate for TGA-patients was 2.3%. For the real-life control group, the 72-hour revisit rate was 4.6% (P = .001). Thirty-day revisit rates were 10% and 16%, respectively (P < .001). The need for rehabilitation, cognitive evaluation and intensifying home care were the main recommendations for future care.

CONCLUSIONS

TGA approach provides structured and accurate information on older patients' background. This may lead to more precise diagnostics, a thorough consideration of hospital intake and a secure discharge from the ED. Ensuring continuity of care may help to reduce readmissions to EDs.