Content uploaded by Robert Crouch
Author content
All content in this area was uploaded by Robert Crouch on Apr 02, 2021
Content may be subject to copyright.
O R I G I N A L R E S E A R C H Open Access
Feasibility and accuracy of ED frailty
identification in older trauma patients: a
prospective multi-centre study
Heather Jarman
1*
, Robert Crouch
2
, Mark Baxter
2
, Chao Wang
3
, George Peck
4
, Dhanupriya Sivapathasuntharam
5
,
Cara Jennings
6
and Elaine Cole
7
Abstract
Background: The burden of frailty on older people is identifiable by its adverse effect on mortality, morbidity and
long term functional and health outcomes. In patients suffering from a traumatic injury there is increasing evidence
that it is frailty rather than age that impacts greatest on these outcomes and that early identification can guide
frailty specific care. The aim of this study was to evaluate the feasibility of nurse-led assessment of frailty in older
trauma patients in the ED in patients admitted to major trauma centres.
Methods: Patients age 65 years and over attending the Emergency Departments (ED) of five Major Trauma Centres
following traumatic injury were enrolled between June 2019 and March 2020. Patients were assessed for frailty
whilst in the ED using three different screening tools (Clinical Frailty Scale [CFS], Program of Research to Integrate
Services for the Maintenance of Autonomy 7 [PRIMSA7], and the Trauma Specific Frailty Index [TSFI]) to compare
feasibility and accuracy. Accuracy was determined by agreement with geriatrician assessment of frailty. The primary
outcome was identification of frailty in the ED using three different assessment tools.
Results: We included 372 patients whose median age was 80, 53.8% of whom were female. The most common
mechanism of injury was fall from less than 2 m followed by falls greater than 2 m. Completion rates for the tools
were variable, 31.9% for TSFI, compared to 93% with PRISMA7 and 98.9% with the CFS. There was substantial
agreement when using CFS between nurse defined frailty and geriatrician defined frailty. Agreement was moderate
using PRISMA7 and slight using TSFI.
Conclusions: This prospective study has demonstrated that screening for frailty in older major trauma patients
within the Emergency Department is feasible and accurate using CFS.
Trial registration: ISRCTN, ISRCTN10671514. Registered 22 October 2019
Keywords: Frailty, Major trauma, Older people, Nursing
© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: Heather.jarman@stgeorges.nhs.uk
1
Emergency Department Clinical Research Unit, St George’s University
Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK
Full list of author information is available at the end of the article
Jarman et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
(2021) 29:54
https://doi.org/10.1186/s13049-021-00868-4
Introduction
Background
Frailty is a condition characterised by a cumulative
decline of physiological resilience across several body
systems [1–3]. The ageing population is increasing and
so is the prevalence of frailty, with estimates ranging
from 4.0–59.1% [4].
In the UK, national trauma registry data show that
more older people are sustaining major trauma, with a
rise in those aged 75 and over from 8.1% of cases in
1990 to 53.8% in 2013 [5]. Older trauma patients are
more likely to suffer adverse outcomes compared to
younger patients despite similar injury severity [6,7].
Frailty has been linked to worse outcomes, such as
longer hospital stay and mortality in a variety of clinical
situations, including in emergency surgery and patients
with fractured neck of femur [8,9]. Considering older
people as one population may be misleading due to het-
erogeneity in pre-injury functional status, comorbidities
and physiologic condition. Although there is overlap
with multi-morbidity and chronological age, frailty is dif-
ferent. Older trauma patients fall into one of two groups
–those who are functioning well prior to injury, and
those with more complex health needs, sometimes
referred to as geriatric syndromes, including frailty. It is
this pre-injury frailty, as well as age, that appears to
influence outcome with those who are frail suffering
worse outcomes and increased mortality [10,11].
There are broadly two overlapping models of frailty,
the cumulative deficit model and the phenotype model
[12,13]. The cumulative deficit model considers frailty
as a number of ‘deficits’(variables including symptoms,
disease states and abnormal laboratory findings) where
the more variables that a person has the more likely that
they are frail [12]. The frailty phenotype model presents
five variables associated with frailty: unintentional weight
loss, self-reported exhaustion, low energy expenditure,
slow gait speed, weak grip strength [13]. Key to both
these models is frail patients are at risk of significant
functional, physical and cognitive decline following an
episode of illness or injury [4. Clegg]. Despite the char-
acterisation of frailty in these models, patients with
frailty represent a heterogeneous group requiring indi-
vidual adaptations to their assessment and treatment.
This makes recognition of frailty in the emergency care
environment challenging.
There is increasing recognition of the benefit of early
identification of frailty to predict outcome or guide re-
source use in older emergency surgery and trauma pa-
tients [14,15]. Despite this there is a lack of consensus
of how and when frailty should be identified in patients
with major traumatic injuries [16]. In the UK, the British
Geriatric Society makes recommendation that frailty as-
sessment occurs across all healthcare settings and in
patients with different clinical conditions but do not
recommend a specific tool for use in major trauma [1].
The identification of major trauma patients who are
frail or are at risk of frailty should lead to frailty specific
major trauma pathways initiated in the ED which may
lead to an improvement in patient outcomes. However,
a recent international scoping review reported only 14%
of patients were frailty screened during this phase of
care [17], and a systematic mapping review found a lack
of consensus evidence on how to identify frail older
people in the ED [18]. In UK Major Trauma Centres a
quality measure leading to a payment subsidy has
recently been introduced requiring that all patients aged
≥65 years have a Clinical Frailty Scale completed within
72 h of admission by a geriatrician rather than within
the ED [19]. The timing of this assessment at this stage
in the admission process has been designed to promote
diversion of geriatrician resource to major trauma
patients, but may not be optimum in providing early
frailty specific care to those most in need and earlier
identification could lead to better targeting of multi-
disciplinary resource.
The prevalence of frailty in the UK major trauma
population is not currently known, nor do we know
whether it is feasible to carry out accurate frailty assess-
ment in the ED in this patient group. To address this,
we performed a prospective study to determine the
accuracy of frailty assessment undertaken by ED nurses
using three scoring tools against the reference standard
of a geriatrician assessment (GA). The overall aim was
to evaluate the feasibility of nurse-led assessment of
frailty in the ED in patients aged 65 years or over admit-
ted to major trauma centres. Primarily we aimed to
assess and compare the performance of different tools in
identifying frailty. We also sought to determine the
prevalence of frailty in this population of trauma
patients, and examine the outcomes associated with
frailty.
Methods
Study design
This is a prospective observational study carried out
between June 2019 and March 2020. The methods of
this study have been previously published [20]. The
study was approved by the UK Social Care Research
Ethics Committee (REC no 19/IEC08/0006) in March
2019, trial registration number: ISRCTN12345678.The
study was prospectively registered on the National In-
stitute for Health Research (NIHR) portfolio (reference
UK CRN 41047).
Setting
The study was carried out at five Major Trauma Centres
(Level 1 equivalent hospitals) in the south of England.
Jarman et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:54 Page 2 of 9
The population covered by the study was approximately
2.2 million people, with characteristics of each of the
MTCs shown in Table 1. The EDs treated a total of 714,
655 patients in 2019.
Participants
Patients were eligible to participate if they were aged 65
or over, required activation of the trauma team at the
receiving hospital and were subsequently admitted.
Patients were enrolled if they met the eligibility criteria
and there was a nurse trained to consent and use the
frailty assessment tools available. Patients who were
unable to consent to take part in the study initially due
to injury or existing cognitive impairment were enrolled
using consultee consent procedures and subsequently
withdrawn if patient or next of kin consent could not be
gained.
All study data were prospectively collected from either
patient or relative information or the clinical records by
a research nurse using a standardised reporting form.
Patients were anonymised and identified using a study
identification number. Data were uploaded to a secure
online database, REDCap (Research Electronic Data
Capture, Vanderbilt University hosted by St George’s,
University of London).
Variables
The primary outcome is identification of frailty. Second-
ary outcomes included in-hospital mortality, critical care
and hospital length of stay and discharge to the usual
place of residence.
Data were collected on patient demographics (age,
gender, usual place of residence), pre-injury comorbidi-
ties and medications, mechanism of injury, admission
vital signs, injuries and the need for critical care admis-
sion (Level 3). Preinjury polypharmacy was defined as
five or more regular medications [21]. Traumatic Brain
Injury (TBI) was defined as a head abbreviated injury
score (AIS) ≥3 and injury severity was calculated using
the Injury Severity Score (ISS) [22].
Data sources / measurement
To compare feasibility and accuracy of ED frailty
assessment three tools with potential utility in major
trauma patients were chosen. Tools were selected by
an expert panel of clinicians including ED and trauma
specialists, geriatricians, nursing staff and patients
based clinical application to an emergency setting.
ToolswereconsideredfeasibleforuseintheEDif
they were able to be fully completed using the infor-
mation available at time of assessment, and accurate
if there was agreement with the ‘gold standard’of a
geriatrician assessment of frailty (Additional file 1).
1. Trauma Specific Frailty Index (TSFI) is a scale
composed of 15 variables designed to predict the
presence of frailty in the trauma setting. It requires
knowledge of functional state and pre-existing med-
ical conditions. A TSFI score of > 0.27 is found to
be an independent predictor of unfavourable out-
comes after trauma [23].
2. Program of Research to Integrate Services for the
Maintenance of Autonomy 7 (PRISMA7) is a self-
report questionnaire comprising of 7 unambiguous
questions aimed at identifying frail older adults. It
utilises closed questions, ‘yes’or ‘no’answers, and a
score of three or more is indicative of frailty [24].
3. Clinical Frailty Scale (CFS) is a 9-point scale using
patient report or clinical judgement to assess func-
tional capacity. It uses nine pictorial representations
alongside a short descriptor to assign a frailty score:
1 (very fit) to 9 (terminally ill). Participants scoring
5 or more are considered frail [25].
Clinical and research nurses were trained in the use of
each tool. Frailty assessment was performed in the ED
using information available from the patient and/or
carer, medical records, and clinical judgement. The
geriatrician assessment was performed by a Consultant
(Attending) or Specialist Registrar within 72 h of admis-
sion to hospital using CFS or as part of the Comprehen-
sive Geriatric Assessment.
Table 1 Characteristics of sites
Major Trauma
Centre
Trauma
population
served
Total ED
attendances
2019
a
Total trauma team activations based
on hospital criteria 2019
Total team activations based on
hospital criteria ≥65y 2019
Kings College Hospital 5 million 186, 137 2142 393
Royal London Hospital 4.3 million 128, 904 3095 490
Southampton University Hospital 3.5 million 116, 010 594
b
Not available
St George’s Hospital 3.5 million 161, 369 2407 692
St Mary’s Hospital 3.9 million 122, 235 3032 692
Data source: local hospital data except
a
from https://www.england.nhs.uk/statistics/statistical-work-areas/ae-waiting-times-and-activity.
b
TARN eligible
patients only
Jarman et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:54 Page 3 of 9
Sample size
Prior data from the London Major Trauma system sug-
gested that frailty affects 37% of major trauma patients
aged 65 years and over. Based on this, the estimated
number of patients required was 372, with 97% probabil-
ity to achieve a 10% width of 95% confidence interval as
the desired level of precision.
Statistical analysis
Data were analysed using Stata (version 16.1). Compari-
sons of continuous data in frail and non-frail patients
were conducted using t-tests. Due to the differing vari-
ables and defining scores in each tool we applied a
dichotomous frailty measure (frail or non-frail) based on
the clinically recommended scores in each of the tools.
Analysis of categorical data was conducted using Fisher’s
exact test. All tests are two-sided. Kappa statistic was
used to measure the interrater agreement between ED
assessed frailty according to TSFI, PRISMA7 and CFS
with that of the geriatricians. A p-value of < 0.05 is con-
sidered statistically significant, and its corresponding
false discovery rate using the Benjamini–Hochberg
method is reported to account for multiplicity.
Patient and public involvement
Members of a patient and public research expert group
were involved in the design of the study and provided
advice on consent procedures, content of the patient
information material, and on acceptability (timing in the
ED and number) of the frailty assessment tools used.
Results
A total of 1278 patients aged 65 or older admitted to
hospital following major trauma were screened for inclu-
sion into the study, 813 where not enrolled (Fig. 1). Of
the remainder, 93 were withdrawn after enrolment as
they declined to give consent, did not have a consultee
or lacked capacity leaving 372 patients enrolled into the
study.
The median age of the cohort was 80 years, more
than half of patients were female and the majority
lived in their own homes prior to the injury (Table 2).
On average, patients had two pre-existing comorbidi-
ties and over a third took more than five regular medi-
cations daily. Low-level falls from less than 2 m were
the leading mechanism of injury (56.7%) and one fifth
of patients sustained a TBI (20.6%). A minority of pa-
tients were admitted to critical care as a result of their
injuries (10.7%). Deaths in hospital occurred in 9.4%
of cases and more than half of survivors were able to
return to their usual place of residence from the MTC
(Table 2).
The completion of frailty screening tools in the ED
was variable. TSFI was completed in 31.9% of patients,
compared to 93% with PRISMA7 and 98.9% with the
CFS. Incidence of frailty also differed between tools. In
patients with completed scores the TSFI identified the
highest proportion of frail patients (95.0%), whereas just
over half of the patients were frail according to PRIS
MA7 (57.1%) and a third with the CFS (31.8%). Of the
279 patients assessed by a geriatrician within 72 h of
Fig. 1 Flowchart of recruitment
Jarman et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:54 Page 4 of 9
admission, 104 (37.2%) were considered to be frail
(Fig. 2). Inter-rater agreement between the identification
of frailty in the ED and that of the GA differed between
tools. There was substantial agreement between CFS de-
fined frailty and GA defined frailty (Kappa 0.637, p<
0.001). The agreement between PRISMA7 and the GA
was moderate (Kappa 0.458, p< 0.001) but between the
TSFI and GA agreement was slight (Kappa 0.103, p=
0.017).
Irrespective of screening tool, frail patients were sig-
nificantly older than those deemed to be non-frail (p=
0.0012 for TSFI; p< 0.001 for others). PRISMA7 and
CFS frail patients had a greater number of comorbidities
compared to non-frail (p< 0.001) and were less likely to
live in their own home prior to their injury (p< 0.05).
Those taking more than five pre-injury medications were
more likely to be frail across all tools (p< 0.05) but in
higher proportions with PRISMA7 and CFS (Table 3).
The incidence of falls < 2 m was greater in frail pa-
tients, with significantly higher rates in PRISMA7
(69.8%) and CFS (75.2%) cohorts compared to TSFI
(54.9%). Rates of TBI and severity of injury did not
differ significantly between frail and non-frail groups
across the tools. Frail patients were significantly less
likely to be admitted to critical care in all screening
groups (p< 0.001). The greatest difference was ob-
served in TSFI frailty where there was an 11-fold de-
crease in critical care admission for frail patients
(66.6% vs. 6.1%, p< 0.001). Of the frail patients ad-
mitted to critical care, the stay length was shorter in
all screening tool groups with the largest difference
seen in the TSFI cohort (Non-Frail 10.5 days vs. Frail
0.64 days p<0.001).
Mortality was greatest in all frail cohorts but rates
differed between screening tool groups (Fig. 3). TSFI
frailty had the lowest proportion of deaths (Non-frail 0%
vs. Frail 10.6%, p= 1.000) compared to PRISMA7 (Non-
frail 3.4% vs. Frail 13.6%, p= 0.001) and CFS (Non-frail
6.0% vs. Frail 17.1%, p= 0.002) respectively. Irrespective
of tool, there were few differences between frail and
non-frail groups for critical care and hospital length of
stay or discharge back to their previous place of
residence (Table 3).
Table 2 Demographic and clinical characteristics
n 372
Age, years, (median, IQR) 80 (73–86)
Female (n,%) 200 (53.8)
Pre-admission residential status:
Own home (n,%) 338 (90.9)
Residential facility with nursing (n,%) 16 (4.3)
Residential facility without nursing (n,%) 11 (3.0)
Warden controlled accommodation (n,%) 6 (1.6)
Unknown (n,%) 1 (0.3)
Comorbidities, (median, IQR) 2 (1–3)
Number of pre-injury medications
1–5 (n,%) 189 (50.8)
> 5 (n,%) 139 (37.4)
Predominant mechanisms of injury:
Fall < 2 m (n,%) 211 (56.7)
Fall > 2 m (n,%) 79 (21.2)
Pedestrian vs vehicle (n,%) 36 (9.7)
Admission SBP mmHg, (median, IQR) 145 (125–166)
Admission GCS, (median, IQR) 15 (14–15)
TBI (n,%) 77 (20.6)
ISS, median (IQR) 16 (9–21)
Critical care (n,%) 40 (10.7)
Outcomes
In-hospital mortality (n,%) 35 (9.4)
Critical care stay, days, (mean, SD) 1.06 (5.2)
Total MTC LOS, days, (median, IQR) 12 (5–20)
Discharge to usual place of residence (n,%) 210 (56.5)
SBP Systolic Blood Pressure, GCS Glasgow Coma Scale, TBI Traumatic Brain
Injury, ISS Injury Severity Score, MTC Major Trauma Centre, LOS Length of Stay.
Missing data: SBP: 4, GCS: 2, ISS: 39, LOS: 35
Fig. 2 Bar graph represents proportion of frailty according to each
tool: TSFI (Trauma Specific Frailty Index): 95%; PRISMA7 (Program of
Research to Integrate Services for the Maintenance of Autonomy):
57%; CFS (Clinical Frailty Scale): 32%; GA (Geriatrician
Assessment): 37%
Jarman et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:54 Page 5 of 9
Discussion
This prospective study has demonstrated that screening
for frailty in older major trauma patients within the ED
is feasible and accurate. However this appears to depend
on which tool is used and our results suggest that frailty
determined by the Clinical Frailty Scale had the stron-
gest agreement with specialist geriatrician assessment.
Frailty was associated with increased age and previously
defined characteristics of frail syndromes were best iden-
tified by PRISMA7 and CFS. Critical care resource use
differed between frail and non-frail patients, and mortal-
ity was increased in those identified as frail, greatest in
the CFS defined group.
The three tools used within this study represent differ-
ent approaches to the ED assessment of frailty in major
trauma patients. Each of the screening tools needs to be
completed fully for a score to be derived and there were
significant differences in the completion rates across
Table 3 Characteristics and outcomes per frailty tool groups (n = 372)
TSFI Non-
Frail
TSFI Frail PRISMA7 Non-
Frail
PRISMA7
Frail
CFS Non-
Frail
CFS Frail
n (%) 6 (4.2) 113 (95.0) 147 (42.4) 199 (57.1) 251 (68.2) 117 (31.8)
Age, years (median, IQR) 69 (67–71) 81 (74–86)** 75 (70–80) 84 (77–89)** 78 (71–82) 87 (81–91)**
Female (n,%) 1 (16.7) 60 (53.1) 76 (51.7) 107 (53.8) 117 (46.6) 79 (67.5)
Pre-admission residential status:
Own home (n,%) 5 (83.3) 104 (92.0) 142 (96.6) 174 (87.4)* 238 (94.8) 96 (82.1)**
Residential facility with nursing (n,%) 0 (0.0) 5 (4.4) 1 (0.7) 13 (6.5) 2 (0.8) 14 (12.0)
Residential facility without nursing (n,%) 1 (16.7) 3 (2.7) 3 (2.0) 7 (3.5) 7 (2.8) 4 (3.4)
Warden controlled accommodation (n,%) 0 (0.0) 1 (0.9) 1 (0.7) 5 (2.5) 3 (1.2) 3 (2.6)
Unknown (n,%) –– – – 1 (0.4) 0 (0.0)
Comorbidities (median, IQR) 1 (1–3) 2 (1–3) 2 (1–3) 3 (2–4)** 2 (1–3) 3 (2–4)**
> 5 pre-injury medications (n,%) 0 (0.0) 46 (40.7)* 30 (20.4) 101 (50.8) ** 70 (27.9) 69 (59.0) **
Predominant Mechanism of Injury:
Fall < 2 m (n,%) 0 (0.0) 62 (54.9)* 62 (42.2) 139 (69.8)** 123 (49.0) 88 (75.2)**
Fall > 2 m (n,%) 4 (66.7) 27 (23.9) 39 (26.5) 32 (16.1) 57 (22.7) 19 (16.2)
Pedestrian vs vehicle (n,%) 0 (0.0) 14 (12.4) 21 (14.3) 13 (6.5) 31 (12.4) 5 (4.3)
Admission SBP mmHg (median, IQR) 124 (96–149) 143 (129–162) 139 (120–164) 148 (130–170)* 141 (120–164) 150 (133–170)**
Admission GCS (median, IQR) 15 (15–15) 15 (14–15) 15 (14–15) 15 (14–15) 15 (14–15) 15 (14–15)
TBI (n,%) 0 (0.0) 7 (6.1) 15 (10.2) 24 (12.0) 26 (10.3) 17 (14.5)
ISS (median, IQR) 23 (20–29) 17 (9–26) 16 (9–22) 13 (9–20) 16 (9–22) 13 (9–20)
Critical Care (n,%) 4 (66.6) 7 (6.1)** 24 (16.3) 10 (5.0)** 37 (14.7) 2 (1.7)**
Outcomes
In-hospital mortality (n,%) 0 (0) 12 (10.6) 5 (3.4) 27 (13.6)* 15 (6) 20 (17.1)*
Critical care stay, days (mean, SD) 10.5 (17.9) 0.64 (4.22)** 1.8 (6.2) 0.55 (4.6)* 1.5 (6.3) 0.03 (0.29)*
Total MTC LOS, days (median, IQR) 24 (8–28) 9 (3–19) 12 (4–21) 12 (5–19) 12 (4–20) 13 (6–21)
Discharge to usual place of residence (n,%) 2 (33.3) 62 (62.8) 106 (75.6) 119 (69.1) 169 (71.6) 66 (68.0)
MOI Mechanism of Injury, SBP Systolic Blood Pressure, GCS Glasgow Coma Scale, TBI Traumatic Brain Injury, ISS Injury Severity Score, MTC Major Trauma Centre,
LOS Length of Stay. ** p≤0.001; * p< 0.05 comparing non-frail and frail groups (t-test for continuous variables; Fisher’s exact test for categorical variables). False
discovery rate =0.066. Missing data: TSFI Frail ISS:50; PRISMA7 Non-Frail: ISS: 71, LOS: 5; PRISMA7 Frail: SBP: 1, GCS: 1, ISS: 78, LOS: 27; CFS Non-Frail: SBP: 3, GCS: 1,
ISS: 92, LOS: 15; CFS Frail: GCS: 1, ISS: 46, LOS: 20
Fig. 3 Bar graph represents mortality for non-frail and frail cohorts
(n= 372). TSFI non-frail 0% vs. frail 10% p= 1.000; PRISMA7 non-frail
3% vs. frail 13% *p= 0.001; CFA non-frail 6% vs. frail 17% *p= 0.002
Jarman et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:54 Page 6 of 9
tools. The 15-point TSFI completion rate was less than
32%, rising to 93% (PRISMA7) and nearly 99% (CFS).
Studies that compare the ability of different frailty tools
to prognosticate or identify resource use do not report
completion rates as these patients are usually excluded
from any analysis. Measurement of frailty in the ED is
known to be challenging as the information required to
make the assessment may not be available or the
patient’s clinical condition may leave them unable to
answer questions directly. Previous studies have identi-
fied the optimal characteristics of frailty tools appropri-
ate for use in ED patients as those which can be applied
quickly, do not require the use of complex equipment
and use objective parameters [26–28]. The variation in
the levels of completion could be explained by the de-
gree of complexity in the tools. The TSFI requires know-
ledge of social history and physical and sexual activity
that may not be readily available or appropriate to ques-
tion in the acute phases of trauma care, whereas CFS
relies on patient report or clinical judgement to assess a
single indicator (functional capacity). The low comple-
tion rate of the TSFI in this study indicates that it is not
a feasible tool to use in the ED phase of older trauma
management.
Screening using the different tools resulted in a wide
variation in the percentage of patients identified as frail
compared to the ‘gold standard’geriatrician assessment
of frailty. We used dichotomous scores (frail / not frail)
to allow for comparison across tools and a greater pro-
portion of patients were assessed as frail using the TSFI
compared to the PRISMA7 and CSF. Our findings differ
from previous reports in major trauma patients age 65
or over with prevalence of frailty ranging from 14 to
44% dependent on the tool used [11,23]. However, dir-
ect comparison of frailty prevalence across existing stud-
ies is hampered by the large number of tools reported
and the differences in their application (assessor type,
comparator, timing of assessment).
Frailty defined by CFS in our study was similar to that
in other major trauma studies using the Clinical Frailty
Scale [29,30]. However we found that ED CFS had the
strongest agreement with geriatrician assessed frailty,
whereas a recent study of patients with medical condi-
tions only observed a weak agreement between ED clin-
ical frailty scale assessment and that of in-hospital
physicians [31]. PRISMA7 frailty was higher than in
other studies of older major trauma patients but showed
moderate agreement between the ED and geriatrician
scores [23,28,29]. PRISMA7 use in major trauma pa-
tients is unreported although in a recent non-selective
ED population was found to have a higher accuracy in
separating frail from non-frail compared to CFS and
Identification of Seniors at Risk Tool [32]. Whilst TSFI
identified the greatest proportion of patients as being
frail it had the weakest agreement with GA. The tool
relies less on clinical judgement and more on objective
measures in comparison to CFS, which should make it
more accurate in differentiating frail from non-frail
trauma patients, but was not the case in our study.
We are unable to account for the high rates of frailty
scored using TSFI, which were over twice or three
times that found in other older trauma in-patient
populations [23,30,33].
In line with other studies, frailty was characterised by
increased age, comorbidity, polypharmacy and low level
falls across all tools in this study [25,33–36]. Frail
patients were less severely injured across the cohorts
and this may be due to lower energy mechanisms associ-
ated with reduced mobility and activity levels. However
the lower ISS observed in frail patients may have impli-
cations for the levels of geriatric specialist input
required. A recent single site study of geriatrician-
defined frailty reported concerns that frail patients with
an ISS < 15 would not qualify for the best practice pay-
ment given in UK and the financial incentive to support
geriatrician review would be lost [29]. In our multi-site
study the median ISS in both PRISMA7 and CFS frail
groups fell below the ISS severe injury definition and
may not have been triggered a geriatrician review. This
underpins the need for accurate, early identification of
frailty to ensure ED initiated frailty specialist pathways
in older trauma patients, irrespective of ISS.
Whilst mortality differed across tools, rates were simi-
lar for those reported in other frail trauma populations
[29,37,38]. The greatest proportion of deaths were in
those who were frail according to CSF and PRISMA7,
which may mean these tools identified the frailest pa-
tients. Frailty is a predictor of mortality in older trauma
patients [29,37,39]. Our findings suggest that ED as-
sessment using CFS may enable early specialist geriatric
pathways to improve outcomes and enhance survival.
Whilst overall hospital length of stay and home dis-
charge did not differ across groups, the proportion of
patients identified as frail were less likely to be admitted
to critical care. In those that were, the length of stay for
survivors was shorter than for the non-frail group. It is
not clear from our work why the admission rate to crit-
ical care is low for the majority of frail patients but a
similar trend was reported in older major trauma pa-
tients with an ISS > 15 [7,40]. It may be due to appro-
priate step down from critical care to ward-based care
for patients following a period of optimization or where
a ceiling of care is identified.
Limitations
This study has a number of limitations. TSFI was com-
pleted in just under a third of the patients and this small
sample size may have affected statistical power and may
Jarman et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:54 Page 7 of 9
not accurately reflect the utility of this tool in non ED set-
tings. In addition, this study only looks at simple associa-
tions between frailty and various factors using unadjusted
analysis without controlling confounding factors, so the re-
sults do not indicate causal relationships. If the geriatricians
assessed frailty using a tool then CFS was utilised, which
may have positively influenced the agreements with ED
CFS assessment. However the expert geriatrician ‘diagnosis’
of frailty was deemed to be the gold standard within this
study. Ideally the geriatricians would have assessed all of
the patients with all of the tools however this was not feas-
ible within geriatric clinical workloads.
Formal validation was not performed however bias
was minimised using standardised measures and the
provision of consistent face to face training with the
nurses on the use of the tools.
We acknowledge that older trauma patients are also
admitted to Trauma Units (Level 2–3 hospitals) and
findings in these settings may differ to that of an MTC.
Finally, whilst this study was conducted in the UK our
findings may not be applicable to all emergency health
settings, although may be of interest to those with simi-
lar trauma systems.
Conclusions
Our findings suggest that the CFS is the most suitable
screening tool to identify frailty in older major trauma
patients in the ED when compared to both the PRIS
MA7 and TSFI tools. The results provide evidence that
the CFS is reliable and feasible to complete early in the
major trauma patient’s pathway prior to admission to an
in-patient area. We provide further evidence of agree-
ment between ED nurses and subsequent physician as-
sessment of frailty suggesting CFS can be used to
distinguish between frail and non-frail major trauma pa-
tients in the ED [41]. We propose that as the largest
healthcare workforce within major trauma care that
nursing staff are ideally placed at the bedside to identify
frailty early in this patient group. This early identifica-
tion of frailty should be followed by improved frailty
specific clinical pathways and interventions that posi-
tively impact on health and longer term recovery.
Abbreviations
AIS: Abbreviated Injury Scale; CFS: Clinical Frailty Scale; ED: Emergency
Department; GCS: Glasgow Coma Scale; ISS: Injury Severity Score;
LOS: Length of Stay; MTC: Major Trauma Centre; PRISMA7: Program of
Research to Integrate Services of Autonomy; TBI: Traumatic Brain Injury;
TSFI: Trauma specific frailty index
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s13049-021-00868-4.
Additional file 1.
Acknowledgements
We would like to thank members of the Centre for Public Engagement, part
of the Faculty of Health, Social Care and Education, Kingston University and
St George’s, University of London, London, United Kingdom for their
contribution to the development of the protocol and data collection tools.
In addition to the authors, the following members of the Pan-London Elderly
Major Trauma Group provided advice and consensus opinions on the use of
frailty tools and the recruitment processes: Trish Burton, Dr. Rhonda Sturley,
and Jane Tippett.
Thanks also to the clinical and research staff at the recruiting sites and to the
study coordinator Bebhinn Dillane.
Authors’contributions
HJ, RC, MB, and EC contributed to the conception and design of the study.
HJ, EC and CW drafted the manuscript. CW and EC completed the data
analysis section of the manuscript. All authors read, provided comment and
approved the final manuscript.
Authors’information
Heather Jarman is a National Institute for Health Research (NIHR) Senior
Nurse and Midwife Research Leader. The views expressed in this article are
those of the author(s) and not necessarily those of the NIHR, or the
Department of Health and Social Care.
Funding
This work was supported by The Burdett Trust for Nursing. The funder was
not involved in the design of the study, collection, analysis, or interpretation
of data or in writing the manuscript.
Availability of data and materials
The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The study obtained an ethical opinion for conduct by the UK Social Care
Research Ethics Committee (REC no 19/IEC08/0006). Consent guidance for
undertaking research in emergency settings and with patients lacking
capacity was followed.
Consent for publication
Not applicable.
Competing interests
None.
Author details
1
Emergency Department Clinical Research Unit, St George’s University
Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, UK.
2
University Hospital Southampton NHS Foundation Trust, Southampton, UK.
3
Faculty of Health, Social Care and Education, Kingston University and St
George’s, University of London, London, UK.
4
Imperial College Healthcare
NHS Trust, London, UK.
5
Bart’s Health NHS Trust, London, UK.
6
King’s College
Hospital NHS Foundation Trust, London, UK.
7
Blizard Institute, Queen Mary’s,
University of London, London, UK.
Received: 23 December 2020 Accepted: 15 March 2021
References
1. British Geriatric Society. Fit for frailty part 1 - consensus best practice
guidance for the care of older people living in community and outpatient
settings - a report from the British geriatrics society; 2014. http://www.bgs.
org.uk/sites/default/files/content/resources/files/2018-05-23/fff_full.pdf.
Accessed 22 Dec 2020
2. Dent E, Kowal P, Hoogendijk E. Frailty measurement in research and clinical
practice: a review. Eur J Intern Med. 2016;31:3–10. https://doi.org/10.1016/j.
ejim.2016.03.007.
3. Junius-Walker U, Onder G, Soleymani D, Wiese B, et al. The essence of frailty:
a systematic review and qualitative synthesis on frailty concepts and
Jarman et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:54 Page 8 of 9
definitions. Eur J Intern Med. 2018;56:3–10. https://doi.org/10.1016/j.ejim.201
8.04.023.
4. Clegg A, Young J, Iliffe S, Rickert M, Rockwood K. Frailty in elderly people.
Lancet. 2013;381(9868):752–62. https://doi.org/10.1016/S0140-6736(12)621
67-9.
5. Kehoe A, Smith JE, Edwards A, Yates D, Lecky F. The changing face of major
trauma in the UK. Emerg Med J. 2015;32(12):911–5. https://doi.org/10.1136/
emermed-2015-205265.
6. Caterino JM, Valasek T, Werman HA. Identification of an age cut-off for
increased mortality in patients with elderly trauma. Am J Emerg Med. 2010;
28(2):151–8. https://doi.org/10.1016/j.ajem.2008.10.027.
7. TARN. Major trauma in older people; 2017. www.tarnacuk/content/downloa
ds/3793/Major%20Trauma%20in%20Older%20People%202017pdf Accessed
22 Dec 2020
8. Chan S, Wong EKC, Ward SE, Kuan D, Wong CL. The predictive value of the
clinical frailty scale on discharge destination and complications in older hip
fracture patients. J Orthop Trauma. 2019;33(10):497–502. https://doi.org/10.1
097/BOT.0000000000001518.
9. Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes
in older surgical patients: a systematic review. BMC Geriatr. 2016;16(1):157.
https://doi.org/10.1186/s12877-016-0329-.
10. Maxwell CA, Patel MB, Suarez-Rodriguez LC, Miller RS. Frailty and
prognostication in geriatric surgery and trauma. Clin Geriatr Med. 2019;35(1):
13–26. https://doi.org/10.1016/j.cger.2018.08.002.
11. Cheung A, Haas B, Ringer TJ, McFarlan A, Wong CL. Canadian study of
health and aging clinical frailty scale: does it predict adverse outcomes
among geriatric trauma patients? J Am Coll Surg. 2017;225:658–665.e3.
12. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J
Gerontol A Biol Sci Med Sci. 2007;62(7):722–7. https://doi.org/10.1093/
gerona/62.7.722.
13. Fried L, Tangen C, Walston J, Newman AB, Hirsch C, Gottdiener J, et al.
Frailty in older adults:evidence for a phenotype. J Gerontol A Biol Sci Med
Sci. 2001;56(3):M146–56. https://doi.org/10.1093/gerona/56.3.M146.
14. Engelhardt K, Reuter Q, et al. Frailty screening and a frailty pathway
decrease length of stay, loss of independence, and 30-day readmission rates
in frail geriatric trauma and emergency general surgery patients. J Trauma
Acute Care Surg. 2018;85(1):167–73. https://doi.org/10.1097/TA.
0000000000001931.
15. Bryant EA, Tulebaev S, Castillo-Angeles M, Moberg E, Senglaub SS, O'Mara L,
et al. Frailty identification and care pathway: an interdisciplinary approach
to Care for Older Trauma Patients. J Am Coll Surg. 2019;228:852–859.e1.
16. Cubitt M, Downie E, Shakerian R, Lange PW, Cole E. Timing and methods of
frailty assessments in geriatric trauma patients: a systematic review. Injury.
2019;50(11):1795–808. https://doi.org/10.1016/j.injury.2019.07.026.
17. Theou O, Squires E, Mallery K, Lee JS, Fay S, Goldstein J, et al. What do we
know about frailty in the acute care setting? A scoping review. BMC Geriatr.
2018;18(1):139. https://doi.org/10.1186/s12877-018-0823-2.
18. Preston L, Chambers D, Campbell F, Cantrell A, Turner J, Goyder E. What
evidence is there for the identification and management of frail older
people in the emergency department? A systematic mapping review.
Southampton: NIHR Journals Library; 2018. https://www.journalslibrary.nihr.a
c.uk/hsdr/hsdr06160/#/abstract Accessed 22 Dec 2020
19. NHS England and NHS Improvement. National Tariff Payment System; 2019.
Available at https://improvement.nhs.uk/resources/national-tariff/ Accessed
22 Dec 2020
20. Jarman H, Crouch R, Baxter M, Cole E, Dillane B, Wang C. Frailty in major
trauma study (FRAIL-T): a study protocol to determine the feasibility of
nurse-led frailty assessment in elderly trauma and the impact on outcome
in patients with major trauma. BMJ Open. 2020;10(8):e038082. https://doi.
org/10.1136/bmjopen-2020-038082.
21. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A
systematic review of definitions. BMC Geriatr. 2017;17(1):230. https://doi.
org/10.1186/s12877-017-0621-2.
22. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: a
method for describing patients with multiple injuries and evaluating
emergency care. J Trauma. 1974;14(3):187–96. https://doi.org/10.1097/
00005373-197403000-00001.
23. Joseph B, Pandit V, Zangbar B, Kulvatunyou N, Tang A, O'Keeffe T, et al.
Validating trauma-specific frailty index for geriatric trauma patients: a
prospective analysis. J Am Coll Surg. 2014;219(1):10–7. https://doi.org/10.101
6/j.jamcollsurg.2014.03.020.
24. Raîche M, Hébert R, Dubois M-F. PRISMA-7: a case-finding tool to identify
older adults with moderate to severe disabilities. Arch Gerontol Geriatr.
2008;47(1):9–18. https://doi.org/10.1016/j.archger.2007.06.004.
25. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I,
et al. A global clinical measure of fitness and frailty in elderly people. CMAJ.
2005;173(5):489–95. https://doi.org/10.1503/cmaj.050051.
26. Lewis ET, Dent E, Alkhouri H, Kellett J, Williamson M, Asha S, et al. Which
frailty scale for patients admitted via emergency department? A cohort
study. Arch Gerontol Geriatr. 2019;80:104–14. https://doi.org/10.1016/j.a
rchger.2018.11.002.
27. Elliott A, Hull L, Conroy SP. Frailty identification in the emergency
department—a systematic review focussing on feasibility. Age Ageing.
2017;46(3):509–13. https://doi.org/10.1093/ageing/afx019.
28. Shah SP, Penn K, Kaplan SJ, Vrablik M, Jablonowski K, Pham TN, et al.
Comparison of bedside screening methods for frailty assessment in older
adult trauma patients in the emergency department. Am J Emerg Med.
2019;37(1):12–8. https://doi.org/10.1016/j.ajem.2018.04.028.
29. Rickard F, Ibitoye S, Deakin H, Walton B, Thompson J, Shipway BP. The
clinical frailty scale predicts adverse outcome in older people admitted to a
UK major trauma Centre. Age Ageing. 2020:1–7. https://doi.org/10.1093/a
geing/afaa180.
30. Hamidi M, Haddadin Z, Zeeshan M, Saljuqi AT, Hanna K, Tang A, et al.
Prospective evaluation and comparison of the predictive ability of different
frailty scores to predict outcomes in geriatric trauma patients. J Trauma
Acute Care Surg. 2019;87(5):1172–80. https://doi.org/10.1097/TA.
0000000000002458.
31. Shrier W, Dewar C, Parrella P, Hunt D, Hodgson LE. Agreement and
predictive value of the Rockwood clinical frailty scale at emergency
department triage. Emerg Med J. 2020:emermed-2019-208633. https://doi.
org/10.1136/emermed-2019-208633.
32. O’Caoimh R, Costello M, Small C, Spooner L, Flannery A, O’Reilly L, et al.
Comparison of frailty screening instruments in the emergency department.
Int J Environ Res Public Health. 2019;16(19):3626. https://doi.org/10.3390/
ijerph16193626.
33. Joseph B, Phelan H, Hassan A, Orouji Jokar T, O'Keeffe T, Azim A, et al. The
impact of frailty on failure-to-rescue in geriatric trauma patients: a
prospective study. J Trauma Acute Care Surg. 2016;81(6):1150–5. https://doi.
org/10.1097/TA.0000000000001250.
34. Hammami S, Zarrouk A, Piron C, Almas I, Sakly N, Latteur V. Prevalence and
factors associated with frailty in hospitalized older patients. BMC Geriatr.
2020;20(1):144. https://doi.org/10.1186/s12877-020-01545-4.
35. McMahon CG, Cahir CA, Kenny RA, et al. Inappropriate prescribing in older
fallers presenting to an Irish emergency department. Age Ageing. 2014;
43(1):44–50. https://doi.org/10.1093/ageing/aft114.
36. Hatcher VH, Galet C, Lilienthal M, Skeete DA, Romanowski KS. Association of
Clinical Frailty Scores with hospital readmission for falls after index
admission for trauma-related injury. JAMA Netw Open. 2019;2(10):e1912409.
https://doi.org/10.1001/jamanetworkopen.2019.12409.
37. Poulton A, Shaw J, Nguyen F, Wong C, Lampron J, Tran A, et al. The
Association of Frailty with adverse outcomes after multisystem trauma: a
systematic review and meta-analysis. Anesth Analg. 2020;130(6):1482–92.
https://doi.org/10.1213/ANE.0000000000004687.
38. Hashmi A, Ibrahim-Zada I, Rhee P, Aziz H, Fain MJ, Friese RS, et al. Predictors
of mortality in geriatric trauma patients a systematic review and meta-
analysis. J Trauma Acute Care Surg. 2014;76(3):894–901. https://doi.org/10.1
097/TA.0b013e3182ab0763.
39. Curtis E, Romanowski K, Sen S, Hill A, Cocanour C. Frailty score on admission
predicts mortality and discharge disposition in elderly trauma patients over
the age of 65 y. J Surg Res. 2018;230:13–9. https://doi.org/10.1016/j.jss.2018.
04.017.
40. Pecheva M, Phillips M, Hull P, Carrothers AOR, Queally J. The impact of
frailty in major trauma in older patients. Injury. 2020;51(7):1536–42. https://
doi.org/10.1016/j.injury.2020.04.045.
41. Lo A, Heinemann A, Gray E, Lindquist L, Kocherginsky M, Post LA, et al.
Inter-rater reliability of clinical frailty scores for older patients in the
emergency department. Ac Emer Med. 2020;28(1):110–3. https://doi.org/1
0.1111/acem.13953.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Jarman et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:54 Page 9 of 9
