What’s New in the Patient Safety World

June 2015

Get a Grip on It!



We’ve done many columns on the impact of frailty on surgical outcomes (see list at the end of today’s column). There exist multiple tools for assessing frailty and there has been continued interest in simplifying those tools. A lot of attention in the past several years has been given to gait speed as a parameter easy to assess and highly predictive of outcomes.


Now there has been renewed attention on another component of many frailty indices: grip strength. And it turns out that grip strength not only predicts surgical complications and outcomes but also predicts risk for stroke, MI, cardiovascular and all-cause death.


In an analysis of 351 consecutive patients undergoing major intra-abdominal operations Revenig and colleagues (Revenig 2015) found that “shrinking” and grip strength alone hold the same prognostic information as the full 5-component Fried Frailty Criteria for 30-day morbidity and mortality. When combined with American Society of Anesthesiologists (ASA) score and serum hemoglobin, they form a simple risk classification system with robust prognostic information.


Shortly after that publication, the results of the Prospective Urban-Rural Epidemiology (PURE) study were released (Leong 2015). This was a longitudinal population study done on approximately 140,000 subjects in 17 countries of diverse cultural and socioeconomic settings. Grip strength was measured with a dynamometer. Grip strength was inversely associated with all-cause mortality (16% increase for each 5 kg reduction in grip strength), cardiovascular mortality (17%), non-cardiovascular mortality (17%), myocardial infarction (7%), and stroke (9%). Grip strength was actually a stronger predictor of all-cause and cardiovascular mortality than systolic blood pressure.


So what do you do now with this information? It’s not like we can say “Your cholesterol is elevated and is a risk factor for heart attack and stroke but we can modify that risk with medications.” Unanswered is the question regarding whether improvement in grip strength through physical therapy, for instance, reduces any of the risks. That is unlikely. Much more likely the reduced grip strength is simply a marker for patients having multiple comorbidities that collectively reduce his/her physiologic reserve and make them more vulnerable to adverse outcomes.


But if you were doing a pre-op evaluation on an elderly patient and found poor grip strength you might communicate the increased likelihood of adverse outcomes to that patient and plan for extended resource use during and after the hospitalization. You might also consider using a program like the Hospital Elder Life Program (HELP). A modified HELP intervention, conducted by a trained nurse and not costly, effectively reduced older surgical patients' functional decline and delirium rates by hospital discharge (Chen 2011).



Some of our prior columns on preoperative assessment and frailty:







Revenig LM, Canter DJ, Kim S, et al. Report of a Simplified Frailty Score Predictive of Short-Term Postoperative Morbidity and Mortality. J Am Coll Surg 2015; 220(5): 904-911




Leong DP, Teo KT, Rangarajan S, et al. Prognostic value of grip strength: Findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet 2015; DOI:10.1016/S0140-6736(14)62000-6. Abstract




Chen CC, Lin MT, Tien YW, et al. Modified hospital elder life program: effects on abdominal surgery patients. J Am Coll Surg 2011; 213(2): 245-52







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