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.authorCardona, Magnolia
dc.contributor.authorO'Sullivan, Michael
dc.contributor.authorLewis, Ebony T.
dc.contributor.authorTurner, Robin M.
dc.contributor.authorGarden, Frances
dc.contributor.authorAlkhouri, Hatem
dc.contributor.authorAsha, Stephen
dc.contributor.authorMackenzie, John
dc.contributor.authorPerkins, Margaret
dc.contributor.authorSuri, Sam
dc.contributor.authorHoldgate, Anna
dc.contributor.authorWinoto, Luis
dc.contributor.authorChang, David C. W.
dc.contributor.authorGallego-Luxan, Blanca
dc.contributor.authorMcCarthy, Sally
dc.contributor.authorHillman, Ken
dc.contributor.authorBreen, Dorothy
dc.contributor.funderNational Health and Medical Research Council, Australiaen
dc.date.accessioned2019-11-23T06:28:17Z
dc.date.available2019-11-23T06:28:17Z
dc.date.issued2018-11-14
dc.description.abstractAbstract 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.description.statusPeer revieweden
dc.description.versionPublished Versionen
dc.format.mimetypeapplication/pdfen
dc.identifier.citationCardona, 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.13664en
dc.identifier.doi10.1111/acem.13664en
dc.identifier.eissn1553-2712
dc.identifier.endpage620en
dc.identifier.issn1069-6563
dc.identifier.issued6en
dc.identifier.journaltitleAcademic Emergency Medicineen
dc.identifier.startpage610en
dc.identifier.urihttps://hdl.handle.net/10468/9183
dc.identifier.volume26en
dc.language.isoenen
dc.publisherBlackwell Publishing Inc.en
dc.relation.projectinfo:eu-repo/grantAgreement/NHMRC/Program Grants/1054146/AU/Creating safe, effective systems of care: the translational challenge/en
dc.relation.urihttps://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.urihttps://creativecommons.org/licenses/by/4.0/en
dc.subjectShort-term deathen
dc.subjectOlder patientsen
dc.subjectEmergency departmenten
dc.subjectCriSTALen
dc.subjectRisk predictionen
dc.titleProspective validation of a checklist to predict short-term death in older patients after emergency department admission in Australia and Irelanden
dc.typeArticle (peer-reviewed)en
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