1
|
Hultink D, Souwer ETD, Bastiaannet E, Dekker JWT, Steup WH, Hamaker ME, Sonneveld DJA, Consten ECJ, Neijenhuis PA, Portielje JEA, van den Bos F. The prognostic value of a geriatric risk score for older patients undergoing emergency surgery of colorectal cancer: A retrospective cohort study. J Geriatr Oncol 2024; 15:101711. [PMID: 38310662 DOI: 10.1016/j.jgo.2024.101711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 12/24/2023] [Accepted: 01/22/2024] [Indexed: 02/06/2024]
Abstract
INTRODUCTION Emergency surgery of colorectal cancer is associated with high mortality rates in older patients. We investigated whether information on four geriatric domains has prognostic value for 30-day mortality and postoperative morbidity including severe complications. MATERIALS AND METHODS All consecutive patients aged 70 years or older who underwent emergency colorectal cancer surgery in six Dutch hospitals (2014-2017) were studied. Presence of geriatric risk factors was scored prior to surgery as either 0 (risk absent) or 1 (risk present) in each of four geriatric domains and summed up to calculate a sumscore with a value between 0 and 4. In addition, we separately investigated the use of a mobility aid. Primary outcome was 30-day mortality. Secondary outcomes were any postoperative complications and severe complications. Multivariable logistic regression model was used to evaluate the sumscore and outcomes. RESULTS Two hundred seven patients were included. Median age was 79.4 years. One hundred seventy-five patients (76%) presented with obstruction, 22 (11%) with a perforation, and 17 (8%) with severe anemia. Mortality rates were 2.9%, 13.6%, and 29.6% for patients with a sumscore of 0, 1-2, and 3-4 respectively, with odds ratio (OR) 4.8 [95% confidence interval (CI) 1.03-22.95] and OR 10.6 [95% CI 1.99-56.34] for a sumscore of 1-2 and 3-4 respectively. Use of a mobility aid was associated with increased mortality OR 8.0 [95% CI 2.74-23.43] and severe complications OR 2.31 [95% CI 1.17-4.55]. DISCUSSION This geriatric sumscore and the use of a mobility aid have strong association with 30-day mortality after emergency surgery of colorectal cancer. This could provide better insight into surgical risk and help select high-risk patients for alternative strategies.
Collapse
Affiliation(s)
- Daniëlle Hultink
- Department of Internal Medicine, Haga Hospital, The Hague, the Netherlands.
| | - Esteban T D Souwer
- Department of Internal Medicine, Haga Hospital, The Hague, the Netherlands; Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Esther Bastiaannet
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - W H Steup
- Department of Surgery, Haga Hospital, The Hague, the Netherlands
| | - Marije E Hamaker
- Department of Geriatric Medicine, Diakonessenhuis, Utrecht, the Netherlands
| | | | - Esther C J Consten
- Department of Surgery, Meander Medisch Centrum, Amersfoort, the Netherlands
| | | | - Johanna E A Portielje
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederiek van den Bos
- Department of Geriatric Medicine, University Medical Center Leiden, Utrecht, the Netherlands
| |
Collapse
|
2
|
Hörlin E, Munir Ehrlington S, Toll John R, Henricson J, Wilhelms D. Is the clinical frailty scale feasible to use in an emergency department setting? A mixed methods study. BMC Emerg Med 2023; 23:124. [PMID: 37880591 PMCID: PMC10601295 DOI: 10.1186/s12873-023-00894-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/14/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The Clinical Frailty Scale (CFS) is a frailty assessment tool used to identify frailty in older patients visiting the emergency department (ED). However, the current understanding of how it is used and accepted in ED clinical practice is limited. This study aimed to assess the feasibility of CFS in an ED setting. METHODS This was a prospective, mixed methods study conducted in three Swedish EDs where CFS had recently been introduced. We examined the completion rate of CFS assessments in relation to patient- and organisational factors. A survey on staff experience of using CFS was also conducted. All quantitative data were analysed descriptively, while free text comments underwent a qualitative content analysis. RESULTS A total of 4235 visits were analysed, and CFS assessments were performed in 47%. The completion rate exceeded 50% for patients over the age of 80. Patients with low triage priority were assessed to a low degree (24%). There was a diurnal variation with the highest completion rates seen for arrivals between 6 and 12 a.m. (58%). The survey response rate was 48%. The respondents rated the perceived relevance and the ease of use of the CFS with a median of 5 (IQR 2) on a scale with 7 being the highest. High workload, forgetfulness and critical illness were ranked as the top three barriers to assessment. The qualitative analysis showed that CFS assessments benefit from a clear routine and a sense of apparent relevance to emergency care. CONCLUSION Most emergency staff perceived CFS as relevant and easy to use, yet far from all older ED patients were assessed. The most common barrier to assessment was high workload. Measures to facilitate use may include clarifying the purpose of the assessment with explicit follow-up actions, as well as formulating a clear routine for the assessment. REGISTRATION The study was registered on ClinicalTrials.gov 2021-06-18 (identifier: NCT04931472).
Collapse
Affiliation(s)
- Erika Hörlin
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Samia Munir Ehrlington
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Rani Toll John
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Joakim Henricson
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Daniel Wilhelms
- Department of Emergency Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
3
|
Arnold I, Busch JM, Terhalle L, Nickel CH, Bingisser R. Throughput delays: causes, predictors, and outcomes - observational cohort in a Swiss emergency department. Swiss Med Wkly 2023; 153:40084. [PMID: 37245118 DOI: 10.57187/smw.2023.40084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND Optimal throughput times in emergency departments can be adjudicated by emergency physicians. Emergency physicians can also define causes of delays during work-up, such as waiting for imaging, clinical chemistry, consultations, or exit blocks. For adequate streaming, the identification of predictors of delays is important, as the attribution of resources depends on acuity, resources, and expected throughput times. OBJECTIVE This observational study aimed to identify the causes, predictors, and outcomes of emergency physician-adjudicated throughput delays. METHODS Two prospective emergency department cohorts from January to February 2017 and from March to May 2019 around the clock in a tertiary care centre in Switzerland were investigated. All consenting patients were included. Delay was defined as the subjective adjudication of the responsible emergency physician regarding delay during emergency department work-up. Emergency physicians were interviewed for the occurrence and cause of delays. Baseline demographics, predictor values, and outcomes were recorded. The primary outcome - delay - was presented using descriptive statistics. Univariable and multivariable logistic regression analyses were performed to assess the associations between possible predictors and delays and hospitalization, intensive care, and death with delay. RESULTS In 3656 (37.3%) of 9818 patients, delays were adjudicated. The patients with delays were older (59 years, interquartile range [IQR]: 39-76 years vs 49 years, IQR: 33-68 years) and more likely had impaired mobility, nonspecific complaints (weakness or fatigue), and frailty than the patients without delays. The main causes of delays were resident work-up (20.4%), consultations (20.2%), and imaging (19.4%). The predictors of delays were an Emergency Severity Index of 2 or 3 at triage (odds ratio [OR]: 3.00; confidence interval [CI]: 2.21-4.16; OR: 3.25; CI: 2.40-4.48), nonspecific complaints (OR: 1.70; CI: 1.41-2.04), and consultation and imaging (OR: 2.89; CI: 2.62-3.19). The patients with delays had an increased risk for admission (OR: 1.56; CI: 1.41-1.73) but not for mortality than those without delays. CONCLUSION At triage, simple predictors such as age, immobility, nonspecific complaints, and frailty may help to identify patients at risk of delay, with the main reasons being resident work-up, imaging, and consultations. This hypothesis-generating observation will allow the design of studies aimed at the identification and elimination of possible throughput obstacles.
Collapse
Affiliation(s)
- Isabelle Arnold
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jeannette-Marie Busch
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Lukas Terhalle
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| |
Collapse
|
4
|
Oud FMM, Schut MC, Spies PE, van der Zaag-Loonen HJ, de Rooij SE, Abu-Hanna A, van Munster BC. Interaction between geriatric syndromes in predicting three months mortality risk. Arch Gerontol Geriatr 2022; 103:104774. [PMID: 35849976 DOI: 10.1016/j.archger.2022.104774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/03/2022] [Accepted: 07/07/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Capturing frailty using a quick tool has proven to be challenging. We hypothesise that this is due to the complex interactions between frailty domains. We aimed to identify these interactions and assess whether adding interactions between domains improves mortality predictability. METHODS In this retrospective cohort study, we selected all patients aged 70 or older who were admitted to one Dutch hospital between April 2015 and April 2016. Patient characteristics, frailty screening (using VMS (Safety Management System), a screening tool used in Dutch hospital care), length of stay, and mortality within three months were retrospectively collected from electronic medical records. To identify predictive interactions between the frailty domains, we constructed a classification tree with mortality as the outcome using five variables: the four VMS-domains (delirium risk, fall risk, malnutrition, physical impairment) and their sum. To determine if any domain interactions were predictive for three-month mortality, we performed a multivariable logistic regression analysis. RESULTS We included 4,478 patients. (median age: 79 years; maximum age: 101 years; 44.8% male) The highest risk for three-month mortality included patients that were physically impaired and malnourished (23% (95%-CI 19.0-27.4%)). Subgroups had comparable three-month mortality risks based on different domains: malnutrition without physical impairment (15.2% (96%-CI 12.4-18.6%)) and physical impairment and delirium risk without malnutrition (16.3% (95%-CI 13.7-19.2%)). DISCUSSION We showed that taking interactions between domains into account improves the predictability of three-month mortality risk. Therefore, when screening for frailty, simply adding up domains with a cut-off score results in loss of valuable information.
Collapse
Affiliation(s)
- F M M Oud
- Department of Geriatrics and Centre of Excellence for Old Age Medicine, Gelre Ziekenhuizen Apeldoorn and Zutphen, the Netherlands; Department of Internal Medicine, University Medical Centre Groningen, Groningen, the Netherlands.
| | - M C Schut
- Department of Medical Informatics, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - P E Spies
- Department of Geriatrics and Centre of Excellence for Old Age Medicine, Gelre Ziekenhuizen Apeldoorn and Zutphen, the Netherlands
| | - H J van der Zaag-Loonen
- Department of Internal Medicine, University Medical Centre Groningen, Groningen, the Netherlands
| | - S E de Rooij
- Department of Medical Informatics, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands; Amstelland Hospital, Amstelveen, the Netherlands
| | - A Abu-Hanna
- Department of Medical Informatics, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - B C van Munster
- Department of Internal Medicine, University Medical Centre Groningen, Groningen, the Netherlands
| |
Collapse
|
5
|
The feasibility and acceptability of frailty screening tools in the Emergency Department and the additional value of clinical judgment for frailty detection. Eur J Emerg Med 2022; 29:301-303. [PMID: 35773203 DOI: 10.1097/mej.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
6
|
van Dam CS, Trappenburg MC, Ter Wee MM, Hoogendijk EO, de Vet R, Smulders YM, Nanayakkara PB, Muller M, Peters ML. The Prognostic Accuracy of Clinical Judgment Versus a Validated Frailty Screening Instrument in Older Patients at the Emergency Department: Findings of the AmsterGEM Study. Ann Emerg Med 2022; 80:422-431. [PMID: 35717270 DOI: 10.1016/j.annemergmed.2022.04.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/23/2022] [Accepted: 04/28/2022] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE To compare the prognostic accuracy of clinical judgment for frailty in older patients at the emergency department with a validated screening instrument and patient-perceived frailty. METHODS A prospective cohort study in patients 70 years of age and older in 2 Dutch EDs with a follow-up of 3 months. A dichotomous question was asked to the physician and patient: "Do you consider the patient / yourself to be frail?" The Identification of Seniors At Risk-Hospitalized Patients (ISAR-HP) was used as a validated screening instrument. The primary composite outcome consisted of either functional decline, institutionalization, or mortality. RESULTS A total of 736 patients were included. The physician identified 59% as frail, compared with 49% by ISAR-HP and 43% by patients themselves. The level of agreement was fair (Fleiss Kappa, 0.31). After 3 months, 31% of the patients experienced at least 1 adverse health outcome. The sensitivity was 79% for the physician, 72% for ISAR-HP, 61% for the patient, and 48% for all 3 combined. The specificity was 50% for the physician, 63% for ISAR-HP, 66% for the patient, and 85% for all 3 positive. The highest positive likelihood ratio was 3.03 (physician, ISAR-HP, patient combined), and the lowest negative likelihood ratio was 0.42 (physician). The areas under the receiver operating curves were all poor: 0.68 at best for ISAR-HP. CONCLUSION Clinical judgment for frailty showed fair agreement with a validated screening instrument and patient-perceived frailty. All 3 instruments have poor prognostic accuracy, which does not improve when combined. These findings illustrate the limited prognostic value of clinical judgment as a frailty screener in older patients at the ED.
Collapse
Affiliation(s)
- Carmen S van Dam
- Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands.
| | - Marijke C Trappenburg
- Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Marieke M Ter Wee
- Department of Epidemiology and Data Science, Amsterdam Public Health research institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Emiel O Hoogendijk
- Department of Epidemiology and Data Science, Amsterdam Public Health research institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Riekie de Vet
- Department of Epidemiology and Data Science, Amsterdam Public Health research institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Yvo M Smulders
- Department of Internal Medicine and Vascular Medicine, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Prabath B Nanayakkara
- Section General Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Majon Muller
- Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Mike L Peters
- Department of Internal Medicine and Geriatrics, Amsterdam Cardiovascular Sciences research institute, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands; Department of Internal Medicine and Vascular Medicine, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands; Department of Internal Medicine and Geriatrics, University Medical Center Utrecht, the Netherlands
| |
Collapse
|
7
|
The Accuracy of Four Frequently Used Frailty Instruments for the Prediction of Adverse Health Outcomes Among Older Adults at Two Dutch Emergency Departments: Findings of the AmsterGEM Study. Ann Emerg Med 2021; 78:538-548. [PMID: 34304915 DOI: 10.1016/j.annemergmed.2021.04.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Older adults presenting to the emergency department (ED) are at high risk of adverse health outcomes. This study aimed to evaluate the accuracy of 4 frequently used screening instruments for the prediction of adverse health outcomes among older adults in the ED. METHODS This was a prospective cohort study in patients ≥70 years of age presenting to the ED in 2 hospitals in the Netherlands. Screening instruments included the acutely presenting older patient screening program (APOP) (providing 2 risk scores-functional decline [APOP1] and mortality [APOP2]), the International Resident Assessment Instrument Emergendy Department screener (InterRAI ED), the Identification of Seniors At Risk-Hospitalized Patients (ISAR-HP), and the safety management system (VMS). The primary outcome measure was a composite outcome encompassing functional decline, institutionalization, and mortality at 3 months after ED presentation. Other follow-up time points were 1 and 6 months. Analyses were performed to assess prognostic accuracy. RESULTS In total, 889 patients were included. After 3 months, 267 (31%) patients experienced at least 1 adverse outcome. The positive likelihood ratio ranged from 1.67 (VMS) to 3.33 (APOP1), and the negative likelihood ratio ranged from 0.41 (ISAR-HP) to 0.88 (APOP2). Sensitivity ranged from 17% (APOP2) to 74% (ISAR-HP), and specificity ranged from 63% (ISAR-HP) to 94% (APOP2). The area under the curve ranged from 0.62 (APOP2) to 0.72 (APOP1 and ISAR-HP). Calibration was reasonable for APOP1 and VMS. The prognostic accuracy was comparable across all outcomes and at all follow-up time points. CONCLUSION The frailty screening instruments assessed in this study showed poor to moderate prognostic accuracy, which brings into question their usability in the prediction of adverse health outcomes among older adults who present to the ED.
Collapse
|