Background: the clinical frailty scale (CFS) was validated as a predictor of adverse outcomes in community-dwelling older people. In our hospital, the use of the CFS in emergency admissions of people aged ≥ 75 years was introduced under the Commissioning for Quality and Innovation payment framework. Aim: we retrospectively studied the association of the CFS with patient characteristics and outcomes. Design: retrospective observational study in a large tertiary university National Health Service hospital in UK. Methods: the CFS was correlated with transfer to specialist Geriatric ward, length of stay (LOS), in-patient mortality and 30-day readmission rate. Results: between 1st August 2013 and 31st July 2014, there were 11 271 emergency admission episodes of people aged ≥ 75 years (all specialties), corresponding to 7532 unique patients (first admissions); of those, 5764 had the CFS measured by the admitting team (81% of them within 72 hr of admission). After adjustment for age, gender, Charlson comorbidity index and history of dementia and/or current cognitive concern, the CFS was an independent predictor of in-patient mortality [odds ratio (OR) = 1.60, 95% confidence interval (CI): 1.48 to 1.74, P < 0.001], transfer to Geriatric ward (OR = 1.33, 95% CI: 1.24 to 1.42, P < 0.001) and LOS ≥ 10 days (OR = 1.19, 95% CI: 1.14 to 1.23, P < 0.001). The CFS was not a multivariate predictor of 30-day readmission. Conclusions: the CFS may help predict in-patient mortality and target specialist geriatric resources within the hospital. Usual hospital metrics such as mortality and LOS should take into account measurable patient complexity.

Frail individuals may be at higher risk of death from a given acute illness severity (AIS), but this relationship has not been studied in an English National Health Service (NHS) acute hospital setting. This was a retrospective observational study in a large university NHS hospital in England. We analyzed all first non-elective inpatient episodes of people aged ≥75years (all specialties) between October 2014 and October 2015. Pre-admission frailty was assessed with the Clinical Frailty Scale (CFS) of the Canadian Study on Health & Aging, and AIS in the Emergency Department was measured with a Modified Early Warning Score (ED-MEWS<4 was considered as low acuity, and ED-MEWS≥4 as high acuity). A survival analysis compared times to 30-day inpatient death between CFS categories (1-4: very fit to vulnerable, 5: mildly frail, 6: moderately frail, and 7-8: severely or very severely frail). There were 12,282 non-elective patient episodes (8202 first episodes, of which complete data was available for 5505). In a Cox proportional hazards model controlling for age, gender, Charlson Comorbidity Index, history of dementia, current cognitive concern, and discharging specialty (medical versus surgical), ED-MEWS≥4 (HR=2.87, 95% CI: 2.27-3.62, p<0.001), and CFS 7-8 (compared to CFS 1-4, HR=2.10, 95% CI: 1.52-2.92, p<0.001) were independent predictors of survival time. We found frailty and AIS independently associated with inpatient mortality after adjustment for confounders. Hospitals may find it informative to undertake large scale assessment of frailty (vulnerability), as well as AIS (stressor), in older patients admitted to hospital as emergencies.

Introduction: interventions to prevent hospital readmission depend on the identification of patients at risk. The LACE index predicts readmission (and death) and is in clinical use internationally. The LACE index was investigated in an older UK population. Methods: randomly selected alive-discharge episodes were reviewed. A LACE score was calculated for each patient and assessed using receiver operator characteristic (ROC) curves. A logistic regression model was constructed, compared with the LACE and validated in a separate population. Results: a total of 507 patients were included with a mean (SD) age of 85 (6.5) years; 17.8% were readmitted and 4.5% died within 30 days. The median LACE score of those readmitted compared with those who were not was 12.5 versus 12 (P = 0.13). The Lace index was only a fair predictor of both 30-day readmission and death with c-statistics of 0.55 and 0.70, respectively. Only the emergency department visit was an independent predictor of readmission, with a c-statistic of 0.61 for readmission. In a validation cohort of 507 cases, the c-statistic of the regression model was 0.57. Conclusion: the LACE index is a poor tool for predicting 30-day readmission in older UK inpatients. The absence of a simple predictive model may limit the benefit of readmission avoidance strategies.

BACKGROUND: Frailty, history of dementia (HoD), and acute confusional states (ACS) are common in older patients admitted to hospital.OBJECTIVE: To study the association of frailty (≥6 points in the Clinical Frailty Scale [CFS]), HoD, and ACS with hospital outcomes, controlling for age, gender, acute illness severity (measured by a Modified Early Warning Score in the emergency department), comorbidity (Charlson Comorbidity Index), and discharging specialty (general medicine, geriatric medicine, surgery).DESIGN: Retrospective observational study.SETTING: Large university hospital in England.PATIENTS: We analyzed 8202 first nonelective inpatient episodes of people aged 75 years and older between October 2014 and October 2015.MEASUREMENTS: The outcomes studied were prolonged length of stay (LOS ≥10 days), inpatient mortality, delayed discharge, institutionalization, and 30‐day readmission. Statistical analyses were based on multivariate regression models.RESULTS: Independently of controlling variables, prolonged LOS was predicted by CFS ≥6: odds ratio (OR) =1.55; 95% confidence interval [CI], 1.36‐1.77; P < 0.001; HoD: OR = 2.16; 95% CI, 1.79‐2.61; P < 0.001; and ACS: OR = 3.31; 95% CI, 2.64‐4.15; P < 0.001. Inpatient mortality was predicted by CFS ≥6: OR = 2.29; 95% CI, 1.79‐2.94; P < 0.001. Delayed discharge was predicted by CFS ≥6: OR = 1.46; 95% CI, 1.27‐1.67; P < 0.001; HoD: OR = 2.17; 95% CI, 1.80‐2.62; P < 0.001; and ACS: OR = 2.29; 95% CI: 1.83‐2.85; P < 0.001. Institutionalization was predicted by CFS ≥6: OR = 2.56; 95% CI, 2.09‐3.14; P < 0.001; HoD: OR = 2.51; 95% CI, 2.00‐3.14; P < 0.001; and ACS: OR 1.93; 95% CI, 1.46‐2.56; P < 0.001. Readmission was predicted by ACS: OR = 1.36; 95% CI, 1.09‐1.71; P = 0.006.CONCLUSIONS: Routine screening for frailty, HoD, and ACS in hospitals may aid the development of acute care pathways for older adults.

Background: Transient ischaemic attacks (TIAs) carry a significant early risk of stroke. New national guidelines state patients should be seen within 7 days of the incident, with higher-risk patients being seen within 24 h. Meeting these targets across the NHS poses a significant challenge. A novel approach to TIA assessment has been developed using a nurse-led rapid-access anterior circulation TIA clinic. Methods: This was a prospective evaluation of all patients attending the FAST-TIA clinic between November 2003 and December 2006. Diagnostic yield of neurovascular events among patients seen through the TIA service and median time from referral to assessment and from event to assessment were measured. Results: 282 patients were eligible for investigation, and seen through the clinic over a period of 38 months. A vascular event was diagnosed in 242 (86%). TIA was diagnosed in 133 (55%), minor ischaemic stroke in 77 (32%), haemorrhagic stroke in three (1%), and an ocular event in 29 (12%). Median time from referral to assessment was 3 days (interquartile range (IQR) 1–7), and from event to assessment it was 7 days (IQR 3–18). 34% of patients were seen within 24 h of referral. Conclusions: This model has a high diagnostic rate of 86% vascular events, significantly higher than current national averages of ∼55%. Current national guidelines for early assessment of patients (published subsequent to this study) are achievable using this service. The FAST-TIA model is an easily reproducible and pragmatic method of improving the diagnostic yield of TIA services, while keeping within national targets.

Background: Routinely collected hospital information could help to understand the characteristics and outcomes of care home residents admitted to hospital as an emergency. Methods: This retrospective 2-year service evaluation included first emergency admissions of any older adult (≥75 years) presenting to Cambridge University Hospital. Routinely collected patient variables were captured by an electronic patient record system. Care home status was established using an official register of care homes. Results: 7.7% of 14,777 admissions were care home residents. They were older, frailer, more likely to be women and have cognitive impairment than those admitted from their own homes. Additionally, 42% presented with an Emergency Department Modified Early Warning Score above the threshold triggering urgent review, compared to 26% of older adults from their own homes. Admission from a care home was associated with higher 30-day inpatient mortality (11.1 vs 5.7%), which persisted after multivariable adjustment (hazard ratio: 1.42; 95% confidence interval: 1.09-1.83; p = 0.008). Conclusion: Care home residents admitted to hospital as an emergency have high illness acuity and inpatient mortality.