Exploration of frailty screening instruments used in the emergency department and development of a new, short frailty screening instrument, the Quick Frailty Screen (QFS)

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Date
2023
Authors
Moloney, Elizabeth
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University College Cork
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Abstract
Introduction: Research comparing frailty screening instruments against a gold-standard comprehensive geriatric assessment, is lacking. A knowledge gap also exists regarding the core requirements for an ideal frailty screening instrument for use in ED, as well as frailty knowledge and use of instruments among emergency department (ED) staff. Aims and Objectives: • To provide an overview of frailty screening in the emergency department • To undertake a systematic review and metanalysis of the diagnostic accuracy of frailty screening instruments validated for use with older adults attending emergency departments. • To complete a multi-site survey of all grades of ED staff in Ireland regarding frailty knowledge, use of frailty screening instruments and educational challenges in ED • To undertake an international Delphi consensus study examining the core requirements of frailty screening in the emergency department The objective was to use the information collected from these stages to develop and validate a new frailty screening instrument for use in ED. This new instrument is called the Quick Frailty Screen (QFS). Methods: This MD thesis comprised four parts: 1)A systematic review was conducted to identify studies that have validated frailty screening instruments among older adults in ED settings. Scientific databases were searched for prospective diagnostic accuracy studies from January 2000-September 2022. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-Comparative (QUADAS-C). 2) A multi-site survey of ED staff (all grades) working in Irish EDs, was conducted between April-September 2021. An anonymous online survey was distributed via email, using the Irish Association of Emergency Medicine (IAEM)as the contact point for survey site details. 3) A two round, modified electronic Delphi consensus was undertaken involving 37 international frailty experts 4) A new frailty screening tool, the Quick Frailty Screen (QFS) was created from data generated in steps 1-3. Older adults aged ≥70 years presenting consecutively to a single, urban Irish university hospital ED over an eight-week period between December 2021-February 2022, were screened for frailty. Four frailty screening instruments were used in the validation study. The QFS was included along with the Variable Indicator of Placement (VIP), Programme of Research on Integration of Services for the Management of Autonomy (PRISMA 7) and Clinical Frailty Scale (CFS). A dedicated multi-disciplinary frailty team (MDT) completed a Comprehensive Geriatric Assessment (CGA) on all those screened, blind to the screening test scores. Results: 1)Six studies involving 1,350 participants describing seven frailty screening instruments were included in the systematic review (PRISMA-7, Clinical Frailty Scale, Variable Indicator of Placement Risk, FRESH, Bergman Paris Question, Triage Risk Screening Tool and Identification of Seniors At Risk). 2)168 staff, representing 9/26 (35%) of Irish EDs, were surveyed. Less than half of respondents had received training on frailty identification (n=81, 48%). 3) 37 participants from 10 countries completed the Delphi consensus. It was agreed that ideal frailty screens should be short (<5mins), multi-dimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4 weeks before presentation. 4) The QFS had an optimal cut-off score of ≥3, which produced a sensitivity of 84% (CI: 0.77-0.89) and specificity of 88% (CI: 0.81- 0.93). The QFS had an AUC of 0.92 (95% CI: 0.89-0.95), indicating it had excellent diagnostic accuracy for frailty. Conclusion: Available short screens for frailty are sensitive, specific and had good to excellent accuracy for frailty as measured by CGA. Bespoke education initiatives may help address many of the issues identified in the ED staff survey. An ideal ED frailty screening instrument should ideally take less than five minutes to score, reflecting baseline status 2-4 weeks before presentation. The validation study places the QFS in a strong position as a viable option when considering a quick and accurate frailty screening instrument to use in ED.
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Keywords
Frailty , Screening , Tool , Older adult , Emergency department
Citation
Moloney, E. J. 2023. Exploration of frailty screening instruments used in the emergency department and development of a new, short frailty screening instrument, the Quick Frailty Screen (QFS). MD Thesis, University College Cork.
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