Development of a Novel Frailty Trigger for Use at Triage in the Emergency Department

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BACKGROUND: Emergency Department (ED) Triage identifies patients with urgent needs. Frailty is not routinely identified and older patients presenting atypically may be inappropriately triaged as low priority. The introduction of a frailty modifier at triage is recommended in international guidelines, but is not yet widely-adopted. METHODS: A Frailty Trigger was developed following a systematic review and two-round eDelphi. To investigate diagnostic test accuracy for frailty, we recruited consecutive adults aged ≥ 70 attending a university hospital ED between December 2021 and February 2022, comparing the Trigger to the Clinical Frailty Scale (CFS), Variable indicative of Placement (VIP), and PRISMA-7. An independent comprehensive geriatric assessment (CGA) determined frailty status. RESULTS: In total, 313 adults aged ≥ 70 years were available, median age 78 ± 9 years and 46% were female. Half (51%) were frail based on the CGA. The Frailty Trigger had excellent diagnostic accuracy for frailty, Area Under the Curve (AUC) of 0.822, 95% confidence interval (CI): 0.780-0.865, similar to the VIP (AUC 0.820, p = 0.937), although significantly lower than the PRISMA-7 (AUC 0.896) and CFS (AUC 0.946). Mean administrative time was 25.5 s (SD ±10.9 s). Scoring positive on the Frailty Trigger was associated with increased length of stay (LOS), median 6.4 versus 2.3 days (p < 0.001). After adjustment for age, sex, and co-morbidity, a positive score was associated with reduced survival at 1 year (Hazard Ratio 2.2; 95% CI 1.15-4.33, p = 0.017). CONCLUSION: When applied as part of ED triage, the Frailty Trigger showed excellent diagnostic accuracy for frailty when compared to validated screens and was quick to use. It predicted LOS and mortality. Studies are required to examine feasibility and its effect on frailty pathways from triage.

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