Frailty is associated with adverse outcome from in-hospital cardiopulmonary resuscitation

Abstract

Aim

To assess whether frailty was associated with cardio-pulmonary resuscitation (CPR) outcome in a UK setting.

Method

Retrospective review of prospectively collected data on in-hospital cardio-respiratory arrests between 1/1/17 and 31/12/17. Clinical Frailty Scale (CFS) scores were assigned from notes review, patients with CFS scores ≥6 signified moderate or greater frailty.

Results

There were 179 in-hospital cardiac arrest cases where the CFS could be calculated. The median age on admission was 74 (mean 71, range 27–102), 110 patients were male and 69 female. The initial rhythm was non-shockable in 64% of cases. In 49% of cases return of spontaneous circulation (ROSC) was achieved, 22% of the study population survived to hospital discharge. Moderate or greater frailty was present in 31.3% of patients.

Return of spontaneous circulation (ROSC) was achieved in 56.1% of patients with a CFS score of 1–5 and 32.1% with scores 6–9 (p < 0.001).

Survival to hospital discharge was also associated with frailty, being seen in 31.7% of CFS 1–5 patients but only in 1.8% of CFS 6–9 patients (p < 0.001). In multivariable analysis adjusting for age, presenting rhythm and admitting specialty the effect of frailty on survival to discharge remained significant (p = 0.044).

Conclusion

Patients with moderate or greater frailty as determined by CFS score are unlikely to survive to hospital discharge even if ROSC occurs following CPR. This should be considered when making resuscitation status and ceiling of care decisions in this patient group.

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