Prospective Validation of a Checklist to Predict Short‐term Death in Older Patients After Emergency Department Admission in Australia and Ireland

Abstract

Background Emergency departments (EDs) are pressured environment where patients with supportive and palliative care needs may not be identified. We aimed to test the predictive ability of the CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) checklist to flag patients at risk of death within 3 months who may benefit from timely end‐of‐life discussions. Methods Prospective cohorts of >65‐year‐old patients admitted for at least one night via EDs in five Australian hospitals and one Irish hospital. Purpose‐trained nurses and medical students screened for frailty using two instruments concurrently and completed the other risk factors on the CriSTAL tool at admission. Postdischarge telephone follow‐up was used to determine survival status. Logistic regression and bootstrapping techniques were used to test the predictive accuracy of CriSTAL for death within 90 days of admission as primary outcome. Predictability of in‐hospital death was the secondary outcome. Results A total of 1,182 patients, with median age 76 to 80 years (IRE‐AUS), were included. The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% confidence interval [CI] = 7.7–8.6) versus 5.7 (95% CI = 5.1–6.2) and Irish mean of 7.7 (95% CI = 6.9–8.5) versus 5.7 (95% CI = 5.1–6.2). The model with Fried frailty score was optimal for the derivation (Australian) cohort but prediction with the Clinical Frailty Scale (CFS) was also good (areas under the receiver‐operating characteristic [AUROC] = 0.825 and 0.81, respectively). Values for the validation (Irish) cohort were AUROC = 0.70 with Fried and 0.77 using CFS. A minimum of five of 29 variables were sufficient for accurate prediction, and a cut point of 7+ or 6+ depending on the cohort was strongly indicative of risk of death. The most significant independent predictor of short‐term death in both cohorts was frailty, carrying a twofold risk of death. CriSTAL's accuracy for in‐hospital death prediction was also good (AUROC = 0.795 and 0.81 in Australia and Ireland, respectively), with high specificity and negative predictive values. Conclusions The modified CriSTAL tool (with CFS instead of Fried's frailty instrument) had good discriminant power to improve certainty of short‐term mortality prediction in both health systems. The predictive ability of models is anticipated to help clinicians gain confidence in initiating earlier end‐of‐life discussions. The practicalities of embedding screening for risk of death in routine practice warrant further investigation.

A simple prognostic score predicts one‐year mortality of alert and calm emergency department patients: A prospective two‐center observational study

“…Our score was derived from a cohort of alert ED attendees. Although the 1‐year mortality in both cohorts was considerably higher than that of the general population of the same age, the patients were probably far less sick than those in which the “surprise question” and CriSTAL score has been tested. It remains to be demonstrated if this simple prognostic score is more effective in identifying the need for supportive and palliative care than the “surprise question” or the CriSTAL score.…”

“…A modification of the CriSTAL prognostic model has recently been suggested for the assessment of frail older ED patients. 6 However, it is clearly not practical to use complex or inconvenient scores, [7][8][9] or those that require laboratory information, 10,11 or access to large amounts of administrative data 12,13 on every patient attending an ED. The question "Would you be surprised if this patient died within the next 6 to 12 months?"…”

Review article: End‐of‐life care for older people in the emergency department: A scoping review

“…All 14 included studies reported demographic information regarding older people at EOL in the ED. In 11 studies, most older people requiring EOL care in the ED were female, but three studies reported more males than females . Mean/median age ranged from 74 to 84 years .…”

Hot Off the Press: Prospective Validation of a Checklist to Predict Short‐term Death in Older Patients After ED Admission in Australia and Ireland

“…ACEP Geriatric Sect: Question 1 for latest #SGEMHOP authors—[Cardona 2019] notes accuracy of ISAR to CriSTAL, but [Carpenter 2015] highlighted numerous #GeriED instruments to predict mortality yet none displayed LR+ > 10 or LR– < 0.10 (or came close). How does CriSTAL compare to all?…”

“…Basic demographic data alone are insufficient to predict individual patient risk . Therefore, the purpose of this study was to validate a personalized risk score—the Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL)—in older patients presenting to the ED …”