A prospective multi-centre study of feasibility and accuracy of ED frailty identification in older trauma patients (FRAIL-T)

Jarman, Heather, Crouch, Robert, Baxter, Mark, Wang, Chao and Cole, Elaine (2021) A prospective multi-centre study of feasibility and accuracy of ED frailty identification in older trauma patients (FRAIL-T). In: European Emergency Medicine Congress 2021; 27-31 October 2021, Lisbon, Portugal. (Unpublished)


Background Major trauma is a substantial health burden for older patients. The reported incidence of major trauma in those over 65 in the UK nearly doubled between 2008 and 2017. There is increasing evidence that frailty rather than age has the greatest impact on outcomes in this patient group and that early identification should guide frailty specific care. We aimed to establish the feasibility of nurse-led assessment of frailty in the emergency department (ED) in patients admitted to major trauma centres. Methods This was a prospective multi-centre observational study recruiting from five UK major trauma centres between June 2019 and March 2020. Eligible patients were those aged 65 or over requiring activation of the ‘trauma team’ in the ED and were admitted to hospital. Patients were consented or proxy consent was provided by a relative or clinician. We assessed frailty using three different screening tools (Clinical Frailty Scale [CFS], PRIMSA7, and the Trauma Specific Frailty Index [TSFI]) to compare feasibility and accuracy. Accuracy was determined by interrater agreement using Kappa statistic of frailty status with that of a geriatrician. Based on previous prevalence studies in this patient group we estimated the number of patients required was 372, with 97% probability to achieve a 10% width of 95% confidence interval. The primary outcome was identification of frailty in the ED using three different assessment tools. Other variables collected included in-hospital mortality, critical care and hospital length of stay and discharge outcome. Results We analysed data from 372 patients (53.8% female; median age 80 years (IQR 73-86). Most common mechanism was injury was a fall from less than 2 metres (56.7%). Across the 3 frailty tools completion rates were variable: TSFI 31.9%, PRISMA7 93% and CFS 98.9%. Agreement was substantial between nurse defined frailty and geriatrician frailty using the CFS (Kappa 0.637, p<0.001), moderate using PRISMA7 (Kappa 0.458, p<0.001) and slight using TSFI (Kappa 0.103, p=0.017). The incidence of falls was higher in frail patients and the overall in-hospital mortality rate was 9.4% Discussion and Conclusions The tools used within this study represent different approaches to the ED assessment of frailty in major trauma patients. The ability to accurately assess frailty requires relevant information to be available to clinical staff in the ED. The variation in completion rates between tools could be due to complexity – TSFI requires a social and physical activity history which may not be available or appropriate to collect in the ED, whereas CFS is based on patient report or clinical judgement of a single indicator. Our findings suggest that use of the CFS is feasible for identifying frailty in older major trauma patients in the ED when compared to both the PRISMA7 and TSFI tools. The results provide evidence that the CFS provides an accurate way of assessing frailty early in the major trauma patient’s pathway. Trial registration: ISRCTN12345678 Funding: this work was supported by The Burdett Trust for Nursing. Ethical approval: The study was approved by the UK Social Care Research Ethics Committee (REC no 19/IEC08/0006)

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