Examining the relationship between triage acuity and frailty to inform the care of older emergency department patients: Findings from a large Canadian multisite cohort study

Mowbray, Fabrice; Brousseau, Audrey-Anne; Mercier, Éric; Melady, Don; Émond, Marcel; Costa, Andrew P.

doi:10.1017/cem.2019.432

Cited by 33 publications

(31 citation statements)

References 28 publications

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“…We used the Canadian Triage and Acuity Scale (CTAS) to assess illness acuity [ 7 , 20 ]. The CTAS is a descriptive 5-point triage scale, where level 1 is resuscitation, 2 is emergent, 3 is urgent, 4 is less urgent and 5 is non-urgent.…”

Section: Methodsmentioning

confidence: 99%

“…It is strongly associated with increased risks of death and of worsening health status, notably among older patients with acute medical conditions [ 3–7 ]. This relationship is less studied among patients in the emergency department (ED) setting [ 7–10 ], despite its implications for appropriate care planning [ 11 , 12 ].…”

Section: Introductionmentioning

confidence: 99%

“…The increased risk experienced by frail older adults who are acutely ill comes not just from their frailty, but from the severity of their illness [ 7 , 13 , 14 ]. Both frailty and illness acuity can add information about risk [ 5 , 6 , 13 ].…”

Section: Introductionmentioning

confidence: 99%

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The role of illness acuity on the association between frailty and mortality in emergency department patients referred to internal medicine

et al. 2020

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Background we investigated whether two frailty tools predicted mortality among emergency department (ED) patients referred to internal medicine and how the level of illness acuity influenced any association between frailty and mortality. Methods two tools, embedded in a Comprehensive Geriatric Assessment (CGA), were the clinical frailty scale (CFS) and a 57-item deficit accumulation frailty index (FI-CGA). Illness acuity was assessed using the Canadian Triage and Acuity Scale (CTAS). We examined all-cause 30-day and 6-month mortality and time to death. Results in 808 ED patients (mean age ± SD 80.8 ± 8.8, 54.4% female), the mean FI-CGA score was 0.44 ± 0.14, and the CFS was 5.6 ± 1.6. A minority (307; 38%) were classified as having low acuity (CTAS: 1–2). The 30-day mortality rate was 17%; this increased to 34% at 6 months. Compared to well patients with low acuity, the risk of 30-day mortality was 22.5 times (95% CI: 9.35–62.12) higher for severely frail patients with high acuity; 53% of people with very severe frailty (CFS = 8) and high acuity died within 30 days. When acuity was low, the risk for 30-day mortality was significantly higher only among those with very high levels of frailty (CFS 7–9, FI-CGA > 0.5). When acuity was high, even lower levels of frailty (CFS 5–6, FI-CGA 0.4–0.5) were associated with higher 30-day mortality. Conclusions across levels of frailty, higher acuity increased mortality risk. When acuity was low, the risk was significant only when the degree of frailty was high, whereas when acuity was high, even lower levels of frailty were associated with greater mortality risk.

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Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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The role of illness acuity on the association between frailty and mortality in emergency department patients referred to internal medicine

et al. 2020

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“…28 However, prior work has demonstrated that in geriatric populations, frailty and geriatric complexity are what drive health service use and clinical outcomes, rather than patient age. 22,[46][47][48] Though prior reviews report age as an important pre-arrest prognostic factor, we hypothesize that this relationship is likely confounded by frailty. Similarly, older patients without signi cant frailty may be at lower risk of morbidity and mortality than those with frailty, and therefore CPR may provide a greater bene t in this population.…”

Section: Discussionmentioning

confidence: 96%

Examining the Prognostic Utility of Frailty for Post-arrest Outcomes Following the Provision of Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis Protocol

Mowbray

Foroutan

Fernando

et al. 2020

Preprint

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BackgroundAdvanced knowledge of patient prognosis following a cardiac arrest is necessary to determine if resuscitation efforts are futile and ensure value-congruent care. Prior reviews have identified the prognostic factors associated with survival and recovery following cardiac arrest. However, few studies to date have examined the prognostic value of frailty in predicting post-arrest outcomes. The objective of this systematic review is to synthesize the available evidence reporting the association between frailty and patient outcomes following the provision of CPR in-hospital or out-of-hospital MethodsWe searched the following electronic databases from inception until August 2020: Medline Epub Ahead of Print, In-Process and Other Non-Index citations, Pubmed exclusive of Medline citations, EMBASE, CINAHL and Web of Science. We plan to include observational studies that examine the association between frailty and any of the following outcomes: survival to hospital discharge, survival at one, three and twelve months post-arrest, return of spontaneous circulation, functional status at hospital discharge and one-month post-discharge, health-related quality of life at 90 days and one-year post-arrest, and discharge to continuing or long-term care. We plan to conduct a random-effects meta-analysis that pools the effect estimates from all eligible studies to obtain a summary estimate and confidence interval. DiscussionThe findings of this review can be used to determine if the evidence supports the consideration of frailty when discussing advanced directives and care planning with patients, families and caregivers. The findings of this review can also be used to inform future prognostic and clinical prediction models aiming to predict post-resuscitation outcomes. Systematic Review RegistrationThis review has been submitted to the PROSPERO registry (submission ID: 212922)

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“…Neither of these instruments performed well enough to be used as the sole screening tool (7,8). The Canadian ED frailty index tool seemed to predict adverse outcomes in individual studies (9,10).…”

Section: In the Past Other Tools Such As The Identi Cation Of Seniormentioning

confidence: 99%

National Early Warning Score 2 (NEWS2) and 3-Level Triage Scale as Risk Predictors in Frail Older Adults in the Emergency Department

Kemp

Alakare

Harjola

et al. 2020

Preprint

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Background The aim of the emergency department (ED) triage is to recognize critically ill patients and to allocate resources. No strong evidence for accuracy of the current triage instruments, especially for the older adults, exists. We evaluated the National Early Warning Score 2 (NEWS2) and a 3-level triage assessment as risk predictors for frail older adults visiting the ED.Methods This prospective, observational study was performed in a Finnish ED. The data were collected in a six-month period and included were ≥75-year-old residents with Clinical Frailty Scale score of at least four. We analyzed the predictive values of NEWS2 and the three-level triage scale for 30-day mortality, hospital admission, high dependency unit (HDU) and intensive care unit (ICU) admissions, a count of 72-hour and 30-day revisits, and ED length-of-stay (LOS). Results A total of 1711 ED visits were included. Median for age, CFS, LOS and NEWS2 were 85 years, 6 points, 6.2 hours and 1 point, respectively. 30-day mortality was 96/1711. At triage, 69, 356 and 1278 of patients were assessed as red, yellow and green, respectively. There were 1103 admissions, of them 31 to an HDU facility, none to ICU.With NEWS2 and triage score, AUCs for 30-day mortality prediction were 0.70 (0.64-0.76) and 0.62 (0.56-0.68); for hospital admission prediction 0.62 (0.60-0.65) and 0.55 (0.52-0.56), and for HDU admission 0.72 (0.61-0.83) and 0.80 (0.70-0.90), respectively.The NEWS2 divided into risk groups of low, medium and high did not predict the ED LOS (p=0.095). There was a difference in ED LOS between the red/yellow and as red/green patient groups (p<0.001) but not between the yellow/green groups (p=0.59).There were 48 and 351 revisits within 72 hours and 30 days, respectively. With NEWS2 AUCs for 72-hour and 30-day revisit prediction were 0.48 (95% CI 0.40-0.56) and 0.47 (0.44-0.51), respectively; with triage score 0.48 (0.40-0.56) and 0.49 (0.46-0.52), respectively.Conclusions The NEWS2 and a local 3-level triage scale are statistically significant, but poor in accuracy, in predicting 30-day mortality, and HDU admission but not ED LOS or revisit rates for frail older adults. NEWS2 also seems to predict hospital admission

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Examining the relationship between triage acuity and frailty to inform the care of older emergency department patients: Findings from a large Canadian multisite cohort study

Cited by 33 publications

References 28 publications

The role of illness acuity on the association between frailty and mortality in emergency department patients referred to internal medicine

The role of illness acuity on the association between frailty and mortality in emergency department patients referred to internal medicine

Examining the Prognostic Utility of Frailty for Post-arrest Outcomes Following the Provision of Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis Protocol

National Early Warning Score 2 (NEWS2) and 3-Level Triage Scale as Risk Predictors in Frail Older Adults in the Emergency Department

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