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Routine Frailty Screening in Critical Illness

A Population-Based Cohort Study in Australia and New Zealand
  • Jai N. Darvall
    Correspondence
    CORRESPONDENCE TO: Jai N. Darvall, PhD
    Affiliations
    Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia

    Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
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  • Rinaldo Bellomo
    Affiliations
    Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia

    Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia

    Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia

    Data Analytics Research & Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
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  • Eldho Paul
    Affiliations
    Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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  • Michael Bailey
    Affiliations
    Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia

    Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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  • Paul J. Young
    Affiliations
    Medical Research Institute of New Zealand, Wellington, New Zealand
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  • Alice Reid
    Affiliations
    Medical Research Institute of New Zealand, Wellington, New Zealand
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  • Kenneth Rockwood
    Affiliations
    Divisions of Geriatric Medicine & Neurology, and the Geriatric Medicine Research Unit, Division of Geriatric Medicine, Department of Medicine, Dalhousie University and Nova Scotia Health Authority, NS, Canada
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  • David Pilcher
    Affiliations
    Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia

    Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia

    Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia
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      Background

      Frailty is associated with poor outcomes in critical illness. However, it is unclear whether frailty screening on admission to the ICU can be conducted routinely at the population level and whether it has prognostic importance.

      Research Question

      Can population-scale frailty screening with the Clinical Frailty Scale (CFS) be implemented for critically ill adults in Australia and New Zealand (ANZ) and can it identify patients at risk of negative outcomes?

      Study Design and Methods

      We conducted a binational prospective cohort study of critically ill adult patients admitted between July 1, 2018, and June 30, 2020, in 175 ICUs in ANZ. We classified frailty with the CFS on admission to the ICU. The primary outcome was in-hospital mortality; secondary outcomes were length of stay (LOS), discharge destination, complications (delirium, pressure injury), and duration of survival.

      Results

      We included 234,568 critically ill patients; 45,245 (19%) were diagnosed as living with frailty before ICU admission. Patients with vs without frailty had higher in-hospital mortality (16% vs 5%; P < .001), delirium (10% vs 4%; P < .001), longer LOS in the ICU and hospital, and increased new chronic care discharge (3% vs 1%; P < .001), with worse outcomes associated with increasing CFS category. Of patients with very severe frailty (CFS score, 8), 39% died in hospital vs 2% of very fit patients (CFS score, 1; multivariate categorical CFS score, 8 [reference, 1]; OR, 7.83 [95% CI, 6.39–9.59]; P < .001). After adjustment for illness severity, frailty remained highly significantly predictive of mortality, including among patients younger than 50 years, with improvement in the area under the receiver operating characteristic curve of the Acute Physiology and Chronic Health Evaluation III-j score to 0.882 (95% CI, 0.879–0.885) from 0.868 (95% CI, 0.866–0.871) with the addition of frailty (P < .001).

      Interpretation

      Large-scale population screening for frailty degree in critical illness was possible and prognostically important, with greater frailty (especially CFS score of ≥ 6) associated with worse outcomes, including among younger patients.

      Graphical Abstract

      Key Words

      Abbreviations:

      ANZICS (Australian and New Zealand Intensive Care Society), ANZROD (Australian and New Zealand Risk of Death), APACHE (Acute Physiology and Chronic Health Evaluation), APD (Adult Patient Database), CFS (Clinical Frailty Scale), LOS (length of stay), mFI (modified frailty index)
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      References

        • Muscedere J.
        • Waters B.
        • Varambally A.
        • et al.
        The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis.
        Intensive Care Med. 2017; 43: 1105-1122
        • De Biasio J.C.
        • Mittel A.M.
        • Mueller A.L.
        • Ferrante L.E.
        • Kim D.H.
        • Shaefi S.
        Frailty in critical care medicine: a review.
        Anesth Analg. 2020; 130: 1462-1473
        • Brummel N.E.
        • Bell S.P.
        • Girard T.D.
        • et al.
        Frailty and subsequent disability and mortality among patients with critical illness.
        Am J Respir Crit Care Med. 2017; 196: 64-72
      1. United Nations, Department of Economic and Social Affairs, Population Division (2017). World Population Ageing 2017 (ST/ESA/SER.A/397). https://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2017_Highlights.pdf. Accessed July 3, 2021.

        • Brummel N.E.
        • Ferrante L.E.
        Integrating geriatric principles into critical care medicine: the time is now.
        Ann Am Thorac Soc. 2018; 15: 518-522
        • Falvey J.R.
        • Ferrante L.E.
        Frailty assessment in the ICU: translation to ‘real-world’ clinical practice.
        Anaesthesia. 2019; 74: 700-703
        • Flaatten H.
        • Clegg A.
        Frailty: we need valid and reliable tools in critical care.
        Intensive Care Med. 2018; 44: 1973-1975
        • Rodriguez-Manas L.
        • Feart C.
        • Mann G.
        • et al.
        Searching for an operational definition of frailty: a Delphi method based consensus statement: the frailty operative definition-consensus conference project.
        J Gerontol A Biol Sci Med Sci. 2013; 68: 62-67
        • Zampieri F.G.
        • Iwashyna T.J.
        • Viglianti E.M.
        • et al.
        Association of frailty with short-term outcomes, organ support and resource use in critically ill patients.
        Intensive Care Med. 2018; 44: 1512-1520
        • Darvall J.N.
        • Pilcher D.
        • Bellomo R.
        • et al.
        Discussion about “Association of frailty with short-term outcomes, organ support and resource use in critically ill patients.
        Intensive Care Med. 2018; 44: 2014-2016
        • Montgomery C.L.
        • Zuege D.J.
        • Rolfson D.B.
        • et al.
        Implementation of population-level screening for frailty among patients admitted to adult intensive care in Alberta, Canada.
        Can J Anesth. 2019; 66: 1310-1319
        • Rockwood K.
        • Song X.
        • MacKnight C.
        • et al.
        A global clinical measure of fitness and frailty in elderly people.
        CMAJ. 2005; 173: 489-495
        • Pugh R.J.
        • Ellison A.
        • Pye K.
        • et al.
        Feasibility and reliability of frailty assessment in the critically ill: a systematic review.
        Crit Care. 2018; 22: 49
        • Darvall J.N.
        • Boonstra T.
        • Norman J.
        • et al.
        Retrospective frailty determination in critical illness from review of the ICU clinical record.
        Anaesth Intensive Care. 2019; 47: 343-348
        • Shears M.
        • Takaoka A.
        • Rochwerg B.
        • et al.
        Assessing frailty in the intensive care unit: a reliability and validity study.
        J Crit Care. 2018; 45: 197-203
        • Pugh R.J.
        • Battle C.E.
        • Thorpe C.
        • et al.
        Reliability of frailty assessment in the critically ill: a multi-centre prospective observational study.
        Anaesthesia. 2019; 74: 758-764
        • Darvall J.N.
        • Greentree K.
        • Braat M.S.
        • Story D.A.
        • Lim W.K.
        Contributors to frailty in critical illness: multi-dimensional analysis of the Clinical Frailty Scale.
        J Crit Care. 2019; 52: 193-199
        • Tipping C.J.
        • Hodgson C.L.
        • Harrold M.
        • Chan T.
        • Holland A.E.
        Frailty in patients with trauma who are critically ill: a prospective observational study to determine feasibility, concordance, and construct and predictive validity of 2 frailty measures.
        Phys Ther. 2019; 99: 1089-1097
        • Australian and New Zealand Intensive Care Society
        Intensive Care Resources and Activity in Australia and New Zealand—Activity Report 2017/2018, ANZICS Melbourne.
        Australian and New Zealand Intensive Care Society, 2019
        • Darvall J.N.
        • Bellomo R.
        • Paul E.
        • et al.
        Frailty in very old critically ill patients in Australia and New Zealand: a population-based cohort study.
        Med J Aust. 2019; 211: 318-323
        • Darvall J.N.
        • Bellomo R.
        • Bailey M.
        • et al.
        Frailty and outcomes from pneumonia in critical illness: a population-based cohort study.
        Br J Anaesth. 2020; 125: 730-738
        • Knaus W.A.
        • Wagner D.P.
        • Draper E.A.
        • et al.
        The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults.
        Chest. 1991; 100: 1619-1636
        • Paul E.
        • Bailey M.
        • Pilcher D.
        Risk prediction of hospital mortality for adult patients admitted to Australian and New Zealand intensive care units: development and validation of the Australian and New Zealand Risk of Death model.
        J Crit Care. 2013; 28: 935-941
        • Paul E.
        • Bailey M.
        • Kasza J.
        • Pilcher D.
        The ANZROD model: better benchmarking of ICU outcomes and detection of outliers.
        Crit Care Resusc. 2016; 18: 25-36
        • Rockwood K.
        • Howlett S.E.
        Age-related deficit accumulation and the diseases of ageing.
        Mech Ageing Dev. 2019; 180: 107-116
        • Bagshaw S.M.
        • Stelfox H.T.
        • McDermid R.C.
        • et al.
        Association between frailty and short- and long-term outcomes among critically ill patients: a multicentre prospective cohort study.
        CMAJ. 2014; 186: E95-E102
        • Pulok M.H.
        • Theou O.
        • van der Valk A.M.
        • Rockwood K.
        The role of illness acuity on the association between frailty and mortality in emergency department patients referred to internal medicine.
        Age Ageing. 2020; 49: 1071-1079
        • Hewitt J.
        • Carter B.
        • Vilches-Moraga A.
        • et al.
        The effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort study.
        Lancet Public Health. 2020; 5: e444-e451
        • Collins J.T.
        • Short R.
        • Carter B.
        • et al.
        The Clinical Frailty Scale: estimating the prevalence of frailty in older patients hospitalised with COVID-19. The COPE Study.
        Geriatrics (Basel). 2020; 5: 58
        • Elliott A.
        • Taub N.
        • Banerjee J.
        • et al.
        Does the clinical frailty scale at triage predict outcomes from emergency care for older people?.
        Ann Emerg Med. 2021; 77: 620-627
        • Pilcher D.
        • Paul E.
        • Bailey M.
        • Huckson S.
        The Australian and New Zealand Risk of Death (ANZROD) model: getting mortality prediction right for intensive care units.
        Crit Care Resusc. 2014; 16: 3-4
        • Zeng A.
        • Song X.
        • Dong J.
        • et al.
        Mortality in relation to frailty in patients admitted to a specialized geriatric intensive care unit.
        J Gerontol A Biol Sci Med Sci. 2015; 70: 1586-1594
        • Le Maguet P.
        • Roquilly A.
        • Lasocki S.
        • et al.
        Prevalence and impact of frailty on mortality in elderly ICU patients: a prospective, multicenter, observational study.
        Intensive Care Med. 2014; 40: 674-682
        • Kizilarslanoglu M.C.
        • Civelek R.
        • Kilic M.K.
        • et al.
        Is frailty a prognostic factor for critically ill elderly patients?.
        Aging Clin Exp Res. 2017; 29: 247-255
        • Heyland D.K.
        • Garland A.
        • Bagshaw S.M.
        • et al.
        Recovery after critical illness in patients aged 80 years or older: a multi-center prospective observational cohort study.
        Intensive Care Med. 2015; 41: 1911-1920
        • Flaatten H.
        • De Lange D.W.
        • Morandi A.
        • et al.
        The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients (>/= 80 years).
        Intensive Care Med. 2017; 43: 1820-1828
        • Sonny A.
        • Kurz A.
        • Skolaris L.A.
        • et al.
        Deficit accumulation and phenotype assessments of frailty both poorly predict duration of hospitalization and serious complications after noncardiac surgery.
        Anesthesiology. 2020; 132: 82-94
        • Ferrante L.E.
        • Pisani M.A.
        • Murphy T.E.
        • Gahbauer E.A.
        • Leo-Summers L.S.
        • Gill T.M.
        The association of frailty with post-ICU disability, nursing home admission, and mortality: a longitudinal study.
        Chest. 2018; 153: 1378-1386
        • Fernando S.M.
        • McIsaac D.I.
        • Perry J.J.
        • et al.
        Frailty and associated outcomes and resource utilization among older ICU patients with suspected infection.
        Crit Care Med. 2019; 47: e669-e676
        • Hicks P.
        • Huckson S.
        • Fenney E.
        • Leggett I.
        • Pilcher D.
        • Litton E.
        The financial cost of intensive care in Australia: a multicentre registry study.
        Med J Aust. 2019; 211: 324-325
        • Zaal I.J.
        • Devlin J.W.
        • Peelen L.M.
        • Slooter A.J.
        A systematic review of risk factors for delirium in the ICU.
        Crit Care Med. 2015; 43: 40-47
        • Sanchez D.
        • Brennan K.
        • Al Sayfe M.
        • et al.
        Frailty, delirium and hospital mortality of older adults admitted to intensive care: the Delirium (Deli) in ICU Study.
        Crit Care. 2020; 24: 609
        • Surkan M.
        • Rajabali N.
        • Bagshaw S.M.
        • Wang X.
        • Rolfson D.
        Interrater reliability of the clinical frailty scale by geriatrician and intensivist in patients admitted to the intensive care unit.
        Can Geriatr J. 2020; 23: 235-241
        • Fried L.P.
        • Tangen C.M.
        • Walston J.
        • et al.
        Frailty in older adults: evidence for a phenotype.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156
        • van Oppen J.D.
        • Thompson D.
        • Tite M.
        • Griffiths S.
        • Martin F.C.
        • Conroy S.
        The Acute Frailty Network: experiences from a whole-systems quality improvement collaborative for acutely ill older patients in the English NHS.
        Eur Geriatr Med. 2019; 10: 559-565