Patient Safety Tip of the Week
September 2, 2014
Frailty and the Trauma Patient
Indicators of frailty
are excellent predictors of complications in a variety of surgical settings
(see list of our prior columns on frailty and surgery at the end of today’s column).
In fact, we’ve often stressed that assessment for frailty is probably the most
important pre-op consideration in the geriatric patient undergoing surgery.
Two studies from the
University of Arizona Medical Center have now focused
on use of frailty indices in geriatric trauma patients. The first (Joseph
2014a) was a 2-year prospective study at their level I trauma center of 250
trauma patients aged 65 years and older. The frailty index they used consisted
of 50 variables that could be assessed for preadmission status. Frailty was
present in 40% of the total geriatric trauma population. The frailty score was
an independent predictor of both inhospital
complications and adverse discharge disposition. Urinary tract infections and
pneumonia were the most common complications among the patients with frailty.
Patients with frailty also had longer hospital lengths of
stay (LOS) and ICU lengths of stay and, thus, higher hospital costs. Adverse
discharge dispositions (death or discharge to a nursing home) were also
significantly more common among patients with frailty (37.3% vs. 12.9%). All 5
deaths in their study occurred in patients with frailty. The frailty score was
better than patient age as a predictor of complications and adverse discharge
disposition. In their study the frailty score was also a better predictor of
adverse discharge disposition than the Injury Severity Score.
The authors note that geriatric patients are becoming an
increasing portion of the trauma population and that they have been
historically underrepresented in academic studies of trauma patients.
Use of a frailty index could thus help identify trauma
patients at greatest risk of complications and help us identify patients in
need of additional resources. It should also help us be realistic when
discussing long-term plans with patients’ families and caretakers.
And the frailty index might also be important in stratifying
patient risk. From their results, it would be predictable that use of mortality
rates and complication rates to compare trauma centers could be very misleading
if the proportion of frail patients differs considerably across centers.
The above study utilized the frailty index developed by
Searle et al (Searle 2008),
also known by some as the Rockwood index (named for the senior author of that
paper). That index has 50 variables, most of which can be dichotomized (i.e.
yes or no response), allowing for a summated score. It does, however, utilize
variables that measure a patient’s performance status before their trauma
occurred. While it is unlikely that trauma surgeons would be administering this
frailty index themselves on their patients, it would be very easy to train
other members of the multidisciplinary trauma team to administer it.
Our regular readers know we favor simpler screening for
frailty (see prior columns listed below). The Timed-Up-and-Go Test works
remarkably well as a simple, easy, brief predictor of frailty and can be easily
performed in a physician’s office prior to surgery. However, it’s obvious that
you don’t have that opportunity in the trauma patient.
The University of Arizona Medical Center researchers (Joseph
2014b), cognizant of the challenges in using a 50-variable frailty index,
have developed their own modified 15-variable
Trauma-Specific Frailty Index (TSFI). They performed a 2-year prospective
analysis of all geriatric trauma patients (n = 200) presenting to their Level I
trauma center and showed the TSFI score was an independent predictor of
unfavorable discharge disposition, whereas age was not. The authors conclude
that the Trauma-Specific Frailty Index is an effective tool that can aid
clinicians in planning discharge disposition of geriatric trauma patients.
It should really
come as no surprise that frail patients fare worse after trauma. But the
University of Arizona studies increase our awareness of the magnitude of this
problem in the trauma population and provide use with some very useful tools to
help manage such patients.
Some of our prior
columns on preoperative assessment and frailty:
- March 31, 2009 “Screening
Patients for Risk of Delirium”
- January 26, 2010 “Preventing
Postoperative Delirium”
- June 2010 “The
Frailty Index and Surgical Outcomes”
- August 17, 2010 “Preoperative
Consultation – Time to Change”
- August 31, 2010 “Postoperative
Delirium”
- August 9, 2011 “Frailty
and the Surgical Patient”
- September 2011 “Modified
HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery”)
- October 18, 2011 “High
Risk Surgical Patients”
- November 2011 “Timed
Up-and-Go Test and Surgical Outcomes”
- April 3, 2012 “New
Risk for Postoperative Delirium: Obstructive Sleep Apnea”
- August 7, 2012 “Cognition,
Post-Op Delirium, and Post-Op Outcomes”
- August 14, 2012 “Gait
Speed: A New Vital Sign?”
- September 25, 2012 “Preoperative
Assessment for Geriatric Patients”
- September 3, 2013 “Predicting
Perioperative Complications: Slow and Simple”
- November 2013 “Predicting
Perioperative Complications: Even Simpler!”
- June 2014 “Another
Study Linking Frailty to Surgical Complications”
References:
Joseph B, Pandit V, Zangbar B, et al. Superiority of Frailty Over Age in
Predicting Outcomes Among Geriatric Trauma Patients: A Prospective Analysis.
JAMA Surg 2014; 149(8): 766-772
http://archsurg.jamanetwork.com/article.aspx?articleid=1879845
Searle SD, Mitnitski A, Gahbauer EA, et al. A standard procedure for creating
a frailty index. BMC Geriatr 2008; 8: 24
http://www.biomedcentral.com/1471-2318/8/24
Joseph B, Pandit V, Zangbar B, et al. Validating Trauma-Specific Frailty Index
for Geriatric Trauma Patients: A Prospective Analysis. J Amer
Coll Surg 2014; 219(1):
10–17, July 2014
http://www.journalacs.org/article/S1072-7515%2814%2900260-9/abstract
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