Prospective validation of a checklist to predict short-term death in older patients after emergency department admission in Australia and Ireland

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dc.contributor.author Cardona, Magnolia
dc.contributor.author O'Sullivan, Michael
dc.contributor.author Lewis, Ebony T.
dc.contributor.author Turner, Robin M.
dc.contributor.author Garden, Frances
dc.contributor.author Alkhouri, Hatem
dc.contributor.author Asha, Stephen
dc.contributor.author Mackenzie, John
dc.contributor.author Perkins, Margaret
dc.contributor.author Suri, Sam
dc.contributor.author Holdgate, Anna
dc.contributor.author Winoto, Luis
dc.contributor.author Chang, David C. W.
dc.contributor.author Gallego-Luxan, Blanca
dc.contributor.author McCarthy, Sally
dc.contributor.author Hillman, Ken
dc.contributor.author Breen, Dorothy
dc.date.accessioned 2019-11-23T06:28:17Z
dc.date.available 2019-11-23T06:28:17Z
dc.date.issued 2018-11-14
dc.identifier.citation Cardona, M., O'Sullivan, M., Lewis, E.T., Turner, R.M., Garden, F., Alkhouri, H., Asha, S., Mackenzie, J., Perkins, M., Suri, S. and Holdgate, A. (2018) 'Prospective Validation of a Checklist to Predict Short‐term Death in Older Patients After Emergency Department Admission in Australia and Ireland'. Academic Emergency Medicine, 26 (6), pp. 610-620. doi:10.1111/acem.13664 en
dc.identifier.volume 26 en
dc.identifier.issued 6 en
dc.identifier.startpage 610 en
dc.identifier.endpage 620 en
dc.identifier.issn 1069-6563
dc.identifier.uri http://hdl.handle.net/10468/9183
dc.identifier.doi 10.1111/acem.13664 en
dc.description.abstract 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. en
dc.format.mimetype application/pdf en
dc.language.iso en en
dc.publisher Blackwell Publishing Inc. en
dc.relation.uri https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13664
dc.rights © 2018 The Authors. Academic Emergency Medicine published by Wiley Periodicals, Inc. on behalf of Society for Academic Emergency Medicine (SAEM). This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. en
dc.rights.uri https://creativecommons.org/licenses/by/4.0/ en
dc.subject Short-term death en
dc.subject Older patients en
dc.subject Emergency department en
dc.subject CriSTAL en
dc.subject Risk prediction en
dc.title Prospective validation of a checklist to predict short-term death in older patients after emergency department admission in Australia and Ireland en
dc.type Article (peer-reviewed) en
dc.internal.authorcontactother Michael O'Sullivan, Department of Surgery (Academic), University College Cork, Cork, Ireland. +353-21-490-3000 Email: michaelosullivan@ucc.ie en
dc.internal.availability Full text available en
dc.description.version Published Version en
dc.contributor.funder National Health and Medical Research Council, Australia en
dc.description.status Peer reviewed en
dc.identifier.journaltitle Academic Emergency Medicine en
dc.internal.IRISemailaddress michaelosullivan@ucc.ie en
dc.relation.project info:eu-repo/grantAgreement/NHMRC/Program Grants/1054146/AU/Creating safe, effective systems of care: the translational challenge/ en
dc.identifier.eissn 1553-2712


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© 2018 The Authors. Academic Emergency Medicine published by Wiley Periodicals, Inc. on behalf of Society for Academic Emergency Medicine (SAEM). This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. Except where otherwise noted, this item's license is described as © 2018 The Authors. Academic Emergency Medicine published by Wiley Periodicals, Inc. on behalf of Society for Academic Emergency Medicine (SAEM). This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
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