Using the Clinical Frailty Scale (CFS) in geriatric emergency medicine

Abstract

The Clinical Frailty Scale (CFS) uses clinician judgement to quantify the functional impacts of multidimensional health deficits 1. The CFS has become widely adopted in research and clinical settings and has been recommended in the UK for routine administration with adults aged 65+ with unscheduled hospital attendances. Frailty screening at ED triage has been recommended for its potential to alter downstream processes and attune care to the individual. The study by Munir Ehrlington et al yields post-implementation evidence for CFS concordance and patient outcomes in typical clinical emergency care 2. Pragmatically, the methods and ethics approvals allowed for analysis of anonymous routine data without consent, thus widening the representation of older people living with frailty who are so often excluded from the very research vital to improve their care. It is notable that only approximately half of patients attending during the study period had CFS recorded, reflecting expectedly moderate staff adherence and competing tasks 3. Little is known of the missed attenders, who perhaps had different presentation patterns or who had obviously more or less severe frailty than the included cohort. A sub-study of the Frailty in European Emergency Departments (FEED) project is shortly due to provide such insights on the characteristics of people missed by screening 4. Consideration of frailty alongside physiological vital signs has potential to reduce the underperformance of risk-stratification tools in older people 5. While active intervention may seem an appropriate response to an acute problem, having severe underlying frailty remains, for now at least, a largely irreversible situation and consequently there is a need for honed prognostication and decision-making through application of person-centred care principles. If universal prevention of death were to be health services' only aim, then all people with at least severe frailty (CFS 7+) would require resuscitation room care as their in-hospital mortality observed by Munir Ehrlington et al approximated that of sufficiently pathological vital signs (15% in-hospital mortality when NEWS2  5) to warrant urgent response 6. Instead, it serves to identify and orientate care processes around realistic individualised healthcare goals.