Short paperFrailty is associated with adverse outcome from in-hospital cardiopulmonary resuscitation
Introduction
Frailty is a state of increased vulnerability to poor resolution of homeostasis after a stressor event.1 This has been described as a phenotype featuring at least three of: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, and low physical activity.2 Frailty assessment tools include the Clinical Frailty Scale (CFS), Hospital Frailty Risk Score (HFRS) and the Frailty Index.3, 4, 5 The CFS is a validated tool that can easily be applied without specialist training and does not rely on coding data. Information on cognition, function, mobility and co-morbidities gathered from the medical history is used to determine a patient's frailty status on a 9-point ordinal scale (Fig. 1).
Frailty is associated with adverse outcomes including falls, worsening disability, hospitalisation, care home admission and mortality in community studies.2, 6 Patients with frailty have increased risk of complications and mortality after surgery, reduced likelihood of discharge home and increased mortality after ICU admission.7, 8
Survival after out-of-hospital cardiac arrest has been shown to be adversely affected by the presence of frailty.9 When this study was conceived in 2018 there was no comparable data examining an association between frailty and in-hospital cardiac arrests. A recent Australian study of in-hospital cardiac arrests concluded that frailty was associated with reduced likelihood of discharge home, but not with mortality.10
The aim of our study was to assess whether frailty was associated with cardio-pulmonary resuscitation (CPR) outcome in a UK setting. This has the potential to provide critical data to help clinicians and patients when making advanced care planning decisions, as there is evidence that some patients receive CPR inappropriately, and patients may overestimate their likelihood of survival after a resuscitation attempt.11, 12
Section snippets
Methods
The study was carried out at a large UK District General Hospital. The hospital cardiac arrest team consists of a medical registrar, two medical junior doctors, an advanced nurse practitioner and a critical care outreach practitioner. Resuscitation and on-going management is performed in accordance with Resuscitation Council guidelines reflecting UK practice.
The details of cardiac arrest calls are collected prospectively by the hospital resuscitation department and maintained in a database. We
Admission demographics
There were a total of 220 cardiac arrest calls during the study period. After excluding 29 cases which included repeat cardiac arrest in patients already included in the study, non-inpatient or paediatric arrests, and 12 cases where the CFS could not be calculated, 179 cases were included in the study population.
The median age on admission was 74 (mean 71, range 27–102), 110 patients were male and 69 female. In 49% of cases ROSC was achieved and 22% of the study population survived to hospital
Main findings
We analysed the presence of frailty and outcomes of 179 in-hospital cardiac arrests. Moderate to severe frailty affected over 30% of patients, which is similar to previously reported prevalence in hospital populations.8, 10
We found that moderate to severe frailty was associated with reduced likelihood of ROSC and with non-survival to discharge in patients receiving in-hospital CPR. This effect persists after adjusting for age, presenting rhythm and admitting specialty. Survival to hospital
Conclusion
In this retrospective study of in-hospital cardiac arrests we analysed survival to discharge and association with CFS score on admission. We have shown that for patients with a CFS score of greater than 5 there is a significant association with non-survival to discharge after adjusting for age, shockable rhythm and admitting specialty. For those with moderate and severe frailty, so few patients survive to discharge after CPR as to be approaching accepted definitions of futility.18 This should
Conflict of interest
We, the authors, confirm we have no conflicts of interest, financial or otherwise, to disclose.
Acknowledgements
Dr Peter Nightingale PhD, Statistician, University Hospitals Birmingham for providing additional statistical analysis.
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