Impact of early rehabilitation on the functional quality of life of the critically ill at one year

Introduction: ICU-acquired weakness (ICUAW) is a long-recognised phenomenon, featuring a prevalence of 25-80%. Early mobilisation is anaccepted intervention that may attenuate ICUAW and improve outcomes [1, 2]. Method(s): Prospective observational study in polyvalent ICU analysing the effect of early rehabilitation (eRHB) on quality of life one year after discharge (D/C).Patients who required invasive mechanical ventilation > 24 h and survived SARS-CoV2 respiratory infection between 5/3/2020 and 12/01/2022 were included. Patients were classified into two groups: eRHB or not eRHB. Demographic and clinical data were collected, and a telephone survey was conducted one year after D/C. Clinical Frailty Scale at ICU admission (T1) and one year after D/C (T5);Medical Research Council (MRC) at the start of rehabilitation (T2) and hospital D/C (T4);Barthel Index at ICU D/C (T3), T4 and T5;and the SF-36 health questionnaire at T5 were also collected. Statistical analysis was performed between subgroups: Pearson's Chi-square test or Mann-Whitney U test to find significant differences. ART-ANOVA was used to analyse the survey results. Result(s): Of 99 patients, 64.6% belonged to the eRHB group. There were no statistically significant differences in the analysis of clinicdemographic variables. We observed a significant improvement of the MRC, a better Barthel Index in the eRHB group, and a statistically significant positive impact on several components of the SF-36 in the eRHB group (physical functioning, vitality, social functioning, bodily pain, general health, and self-reported health transition). Conclusion(s): Patients who received eRHB had better physical functioning and higher vitality recovery. In addition, they suffered less impact on their social life, had better pain control, and reported improved general health. All this emphasises the need for eRHB protocols in the ICU, promoting multidisciplinary care of our patients.

The impact of pre-existing chronic heart failure on the intensive care treatment and outcome of old intensive care patients suffering from COVID-19

Background: Patients suffering from COVID-19 with pre-existing chronic heart failure (CHF) are considered to have a significant risk regarding morbidity and mortality. Similarly, older patients on the intensive care unit (ICU) constitute another vulnerable subgroup. This study investigated the association between pre-existing CHF and clinical practice in critically ill older ICU patients with COVID-19. Method(s): Patients with severe COVID-19 and who were >=70 years old were recruited from this prospective multicenter international study. Patients' treatment, follow-up, and pre-existing heart failure data were collected during ICU stay. Univariate and multivariate logistic regression analyses examined the association between pre-existing heart failure and the primary endpoint of 30-day mortality. Result(s): The study included 3,917 patients, with 407 patients (17%) evidencing pre-existing CHF. These patients were older (77+/-5 versus 76+/-5, p<0.001) and more frail (Clinical Frailty Scale 4+/-2 versus 3+/-2, p<0.0001). The other comorbidities were also significantly more common in CHF patients. Before hospital admission, CHF patients suffered fewer days from symptoms (5 days (3-8) versus 7 days (4-10), p<0.001), but there was no difference in the days in the hospital before ICU admission (2 days (1-5) versus 2 (1-5) days, p=0.21). At ICU admission, disease severity assessed by SOFA scores was significantly higher in CHF patients (7+/-3 versus 5+/-3). During ICU-stay, intubation, mechanical ventilation, and tracheostomy occurred significantly more often in patients without CHF (63% versus 69%, p=0.017;and 13% versus 18%, p=0.002, respectively). In contrast, there was no difference regarding non-invasive ventilation (28% versus 27%, p=0.20), and the need for vasoactive drugs (66% versus 64, p=0.30). Regarding the limitation of life-sustaining therapy, therapy was significantly more often withheld (32% versus 25%, p=0.001) but not withdrawn (18% versus 17%, p=0.21) in CHF patients. Length of ICU stay was significantly shorter in CHF patients (166 (72-336) hours versus 260 hours (120-528), p<0.001). CHF patients had significantly higher ICU-(52% versus 46%, p=0.007), 30-day mortality (60% vs. 48%, p<0.001;OR 1.87, 95% CI 1.5- 2.3) and 3-month mortality (69% vs. 56%, p<0.001). In the univariate regression analysis, having pre-existing CHF was significantly associated with 30-day mortality (OR 1.89, 95% CI 1.5-2.3;p<0.001), but after adjusting for confounders (SOFA, age, gender, frailty), heart failure was not independently associated any more (aOR 1.2, 95% CI 0.5-1.5;p=0.137). Conclusion(s): In critically ill old COVID-19 patients, pre-existing chronic heart failure is associated with significantly increased short-and long-term mortality, but heart failure is not independently associated with increased 30-day mortality when adjusted for confounders.

Memory T cell responses in seronegative older adults following SARS-CoV-2 vaccination

Generating memory T cell responses besides humoral immune responses is essential when it comes to the efficacy of a vaccine. In this study, the presence of memory T cell responses after aluminum-adjuvanted inactivated whole-virion SARS-CoV-2 vaccine (CoronaVac) in seronegative and seropositive elderly individuals were examined. CD4+ and CD8+ memory T cell proliferation and IFN-gamma production capacities were evaluated. Additionally, clinical frailty scale (CFS) and FRAIL scales of the individuals were scored. CD4+ memory T cell responses more prominent than CD8+ memory T cells. In seronegative individuals, 80% of them had memory CD4+ and IFN-gamma, whereas 50% of them had memory CD4+ and all of them had IFN-gamma responses. Additionally, 40% of seronegative patients and 50% of seropositive patients had memory CD8+ responses. To sum up, humoral immune responses are not associated with memory T cell responses, and in seronegative individuals, memory T cell responses can be detected.Copyright © 2022

COVID-19 Sequelae and Their Implications on Social Services.

BACKGROUND: The impact of persistent coronavirus disease 2019 (COVID-19) symptoms on quality of life remains unclear. This study aimed to describe such persistent symptoms and their relationships with quality of life, including clinical frailty and subjective health status. METHODS: A prospective longitudinal 3-month follow-up survey monitored symptoms, health quality, support needs, frailty, and employment. RESULTS: A total of 82 patients with a mean age of 52 years (ranging from 23-84 years) were enrolled, including 48 (58.6%) men, and 34 (41.5%) women. The fully active status decreased from 87.8% before admission to 78.1% post discharge. Two patients (2.4%) were ambulatory and capable of all self-care but unable to carry out any work-related activities 12 weeks after discharge. Clinical frailty scale (CFS) levels 1, 2, 3 and 4 changed drastically between admission and 12 weeks later after discharge. Just after admission, the median EuroQol visual analogue scales (EQ-VAS) was 82.23 (± 14.38), and it decreased to 78.10 (± 16.02) 12 weeks after discharge; 62 (75.6%) of patients reported at least one symptom 12 weeks after discharge. The most frequent symptom was fatigue followed by smell disorder, anxiety, sleep disorder, headache, depressive mood, dyspnea, and taste disorder. CFS was definitively associated with fatigue. Decreased EQ-VAS was associated with fatigue and palpitation, cough, taste disorder, and chest pain. EQ-VAS was worse in women (28%) than in men. Compared with regular outpatient clinic visits before admission, 21 patients (25.6%) reported increased outpatient clinic visits, one (1.4%) reported readmission, and one (1.4%) reported emergency room visits. Six of the 54 (77.1%) patients who were employed before admission lost their jobs. And most vulnerable type was self-employed, because three self-employed job workers were not working at 12 weeks after discharge. CONCLUSION: COVID-19 sequelae should not be underestimated. We find a decrease in health quality and increase in psychological problems in discharged COVID-19 patients, and some patients experience unemployment. The number of patients suffering from COVID-19 sequelae would not be negligible considering there are more than one million COVID-19 infection cases in Korea. Hence, the government should start a systematic monitoring system for discharged patients and prepare timely medical and social interventions accordingly.

Clinical Frailty Scale (CFS) indicated frailty is associated with increased in-hospital and 30-day mortality in COVID-19 patients: a systematic review and meta-analysis.

BACKGROUND: The concept of frailty provides an age-independent, easy-to-use tool for risk stratification. We aimed to summarize the evidence on the efficacy of frailty tools in risk assessment in COVID-19 patients. METHODS: The protocol was registered (CRD42021241544). Studies reporting on frailty in COVID-19 patients were eligible. The main outcomes were mortality, length of hospital stay (LOH) and intensive care unit (ICU) admission in frail and non-frail COVID-19 patients. Frailty was also compared in survivors and non-survivors. Five databases were searched up to 24th September 2021. The QUIPS tool was used for the risk of bias assessment. Odds ratios (OR) and weighted mean differences (WMD) were calculated with 95% confidence intervals (CI) using a random effect model. Heterogeneity was assessed using the I2 and χ2 tests. RESULTS: From 3640 records identified, 54 were included in the qualitative and 42 in the quantitative synthesis. Clinical Frailty Scale (CFS) was used in 46 studies, the Hospital Frailty Risk Score (HFRS) by 4, the Multidimensional Prognostic Index (MPI) by 3 and three studies used other scores. We found that patients with frailty (CFS 4-9 or HFRS ≥ 5) have a higher risk of mortality (CFS: OR: 3.12; CI 2.56-3.81; HFRS OR: 1.98; CI 1.89-2.07). Patients with frailty (CFS 4-9) were less likely to be admitted to ICU (OR 0.28, CI 0.12-0.64). Quantitative synthesis for LOH was not feasible. Most studies carried a high risk of bias. CONCLUSIONS: As determined by CFS, frailty is strongly associated with mortality; hence, frailty-based patient management should be included in international COVID-19 treatment guidelines. Future studies investigating the role of frailty assessment on deciding ICU admission are strongly warranted.

Scottish Society of Physicians 63rd Annual Meeting

The proceedings contain 12 papers. The topics discussed include: COVID-19 in a district general hospital: does CPAP improve outcomes?;plasma desmosine, a biomarker of elastin degradation, predicts outcomes in acute myocardial infarction;managing human factors that influence the care of medical boarding patients: improving the quality and consistency of discharge communication with primary care;venous thromboembolism prescription in cardiology patients - a quality improvement project;real-life toxicity of low-dose methotrexate - what the general physician needs to know;introducing MR fact: an audit to assess the standards of safe medical admissions in the medical admission unit (MAU) at the borders general hospital;clinical frailty scale as a point of care prognostic indicator of mortality in COVID-19: a systematic review and meta-analysis;and a review of the current research priorities in dementia with a focus on the Scottish landscape.

Lack of Benefit of High Flow Nasal Oxygen Therapy as Ceiling of Treatment for Severe COVID-19 Pneumonitis in Elderly Frail Patients: A Single Centre Observational Study

Background: Severe COVID-19 pneumonitis in elderly frail patients is associated with poor outcomes, and therefore invasive mechanical ventilation is often deemed an inappropriate course of action. Some evidence suggests high-flow nasal oxygen (HFNO) may prevent the need for invasive ventilation in other groups of patients, but whether it is an appropriate ceiling of care for older frail patients is unknown. Method(s): We retrospectively identified patients with severe COVID-19 pneumonitis requiring FiO2 >60% who were deemed inappropriate for invasive ventilation or non-invasive continuous positive airway pressure ventilation (CPAP). Our local protocol based on national guidance suggested these patients should be considered for HFNO. We observed whether the patients received HFNO or standard oxygen therapy (SOT) and compared mortality and survival time in these groups. Result(s): We identified 81 patients meeting the inclusion criteria. From this group, 24 received HFNO and 57 received SOT. The HFNO group was similar in age, BMI and co-morbidities to the SOT group but less frail, as determined by the Clinical Frailty Scale (CFS). All 24 patients that received HFNO died in comparison to 46 patients (80.7%) in the SOT group. Mortality in the HFNO group was significantly higher than in the SOT group. Conclusion(s): Elderly frail patients with severe COVID-19 pneumonitis deemed inappropriate for invasive ventilation and did not benefit from HFNO. Further, HFNO may have been associated with harm in this group. Copyright © 2022 Merchant et al.

Long-Term Effects of Hospitalization for COVID-19 on Frailty and Quality of Life in Older Adults ≥80 Years.

Objectives: This study aimed to assess the effects of frailty and the perceived quality of life (QOL) on the long-term survival (at least 1 year) of patients ≥ 80 years hospitalized for COVID-19 and the predictors of frailty and QOL deterioration in survivors. Design: This is a single-center, prospective observational cohort study. Setting and Participants: The study was conducted in a teaching hospital and enrolled all COVID-19 patients ≥80 years old consecutively hospitalized between April 2020 and March 2021. Methods: Clinical variables assessed in the Emergency Department (ED), and during hospitalization, were evaluated for association with all-cause death at a follow-up. Frailty was assessed by the clinical frailty scale (CFS), and the QOL was assessed by the five-level EuroQol EQ-5d tool. Multivariate Cox regression analyses and logistic regression analyses were used to identify independent factors for poor outcomes. Results: A total of 368 patients aged ≥80 years survived the index hospitalization (age 85 years [interquartile range 82-89]; males 163 (44.3%)). Compared to non-frail patients (CFS 1-3), patients with CFS 4-6 and patients with CFS 7-9 had an increased risk of death (hazard ratio 6.75 [1.51, 30.2] and HR 3.55 [2.20, 5.78], respectively). In patients alive at the 1-year follow-up, the baseline QOL was an independent predictor of an increase in frailty (OR 1.12 [1.01, 1.24]). Male sex was associated with lower odds of QOL worsening (OR 0.61 [0.35, 1.07]). Conclusions and Implications: In older adults ≥80 years hospitalized for COVID-19, the frailty assessment by the CFS could effectively stratify the risk of long-term death after discharge. In survivors, the hospitalization could produce a long-term worsening in frailty, particularly in patients with a pre-existing reduced baseline QOL. A long-term reduction in the perceived QOL is frequent in ≥80 survivors, and the effect appears more pronounced in female patients.

Impact of frailty on clinical outcomes in patients with and without COVID-19 pneumonitis admitted to intensive care units in Australia and New Zealand: a retrospective registry data analysis.

BACKGROUND: It is unclear if the impact of frailty on mortality differs between patients with viral pneumonitis due to COVID-19 or other causes. We aimed to determine if a difference exists between patients with and without COVID-19 pneumonitis. METHODS: This multicentre, retrospective, cohort study using the Australian and New Zealand Intensive Care Society Adult Patient Database included patients aged ≥ 16 years admitted to 153 ICUs between 01/012020 and 12/31/2021 with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome, and Clinical Frailty Scale (CFS). The primary outcome was hospital mortality. RESULTS: A total of 4620 patients were studied, and 3077 (66.6%) had COVID-19. The patients with COVID-19 were younger (median [IQR] 57.0 [44.7-68.3] vs. 66.1 [52.0-76.2]; p < 0.001) and less frail (median [IQR] CFS 3 [2-4] vs. 4 [3-5]; p < 0.001) than non-COVID-19 patients. The overall hospital mortality was similar between the patients with and without COVID-19 (14.7% vs. 14.9%; p = 0.82). Frailty alone as a predictor of mortality showed only moderate discrimination in differentiating survivors from those who died but was similar between patients with and without COVID-19 (AUROC 0.68 vs. 0.66; p = 0.42). Increasing frailty scores were associated with hospital mortality, after adjusting for Australian and New Zealand Risk of Death score and sex. However, the effect of frailty was similar in patients with and without COVID-19 (OR = 1.29; 95% CI: 1.19-1.41 vs. OR = 1.24; 95% CI: 1.11-1.37). CONCLUSION: The presence of frailty was an independent risk factor for mortality. However, the impact of frailty on outcomes was similar in COVID-19 patients compared to other causes of viral pneumonitis.

Mental, physical, and cognitive impairments of COVID-19 patients admitted to intensive care during the pandemic in Chile: An observational, multicentre study

Introduction: Mental, physical, and cognitive impairments are common after an intensive care unit (ICU) stay. It remains unknown to what extent the extraordinary increase in bed occupancy during the pandemic could be linked to the severity and frequency of patient's impairments. Objective: To determine the frequency, severity, and risk factors for mental, physical, and cognitive impairments at ICU discharge during high and low bed occupancy periods. Methods: Prospective cohort study in seven Chilean ICUs (ClinicalTrials.gov Identifier: NCT04979897). We included adults, mechanically ventilated >48 hours in the ICU who could walk independently prior to admission. Trained physiotherapists assessed the Medical Research Council Sum-Score (MRC-SS), Montreal Cognitive Assessment (MOCA-blind), Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale-Revised (IES-R), and the World Health Organization Disability Assessment Schedule (WHODAS 2.0) at ICU discharge. Pre-admission employment status, educational level, and Clinical Frailty Scale (CFS) were also collected. We compared periods of low and high bed-occupancy, defined as less or more than 90% of staffed ICU beds occupied. We used t-test for normally distributed, Mann-Whitney for those not normally distributed, and chi-square for categorical variables. We explored risk factors for mental, physical, and cognitive impairments using logistic regression adjusted for age, sex, educational level, and bed occupancy. Analyses were performed in Stata/SE 16.0. Results: We included 192 patients with COVID-19 of which 126 [66%] were admitted during a high bedoccupancy period (January to April 2021). Majority were male (137 [71%]) and worked full-time (127 [66%]). Median [P25-P75] age was 57 [47-67], length of ICU stay was 15[ 11-27] days, and duration of mechanical ventilation (MV) was 9 [6-16.5] days. Seven (4%) patients were clinically frail, 65 (34%) had ICUacquired weakness (ICU-AW), 134(70%) had cognitive impairment, 122 (64%) had post-traumatic stress symptoms (PTSS), 53 (28%) had depressive symptoms, 106 (55%) had anxiety symptoms, and 148 (77%) had severe disability. Table 1 shows the combined prevalence of physical and mental health problems. Patients admitted during the high-occupancy period were younger (mean 54, 95% confidence interval [47, 61] vs 61 [58, 64]), more likely to have a higher education qualification(HEQ) (OR 1.67 [0.9, 3.06]), and had a shorter duration of MV (8 [6-13] vs 13 [8-34];p<0.001) and ICU stay (13 [10-19] vs 21.5 [13-42];p<0.001). Mental, physical, and cognitive impairments were similar in low and high occupancy periods. Patients with a HEQ were less likely to have ICU-AW (OR 0.23 [0.11, 0.46]), cognitive impairments (OR 0.26 [0.11, 0.6]), symptoms of depression (OR 0.45 [0.22, 0.9]) or anxiety (OR 0.26 [0.13, 0.5]), and severe disability (OR 0.4 [0.18, 0.94]). Females were more likely to have ICU-AW (OR 2.4 [1.13, 4.93]). Older patients were less likely to suffer PTSS (OR 0.97 [0.94, 0.99] per year old). Conclusions: Majority of patients had at least one mental, physical or cognitive impairment being similar by bed occupancy. Having a higher education qualification was the main protective factor for impairments at ICU discharge. Preventative treatments programmes should target patients with <12 years of education.

The Prognostic and Discriminatory Utility of the Clinical Frailty Scale and Modified Frailty Index Compared to Age.

Background: There is no consensus on the optimal method for the assessment of frailty. We compared the prognostic utility of two approaches (modified Frailty Index [mFI], Clinical Frailty Scale [CFS]) in older adults (≥65 years) hospitalised with COVID-19 versus age. Methods: We used a test and validation cohort that enrolled participants hospitalised with COVID-19 between 27 February and 30 June 2020. Multivariable mixed-effects logistic modelling was undertaken, with 28-day mortality as the primary outcome. Nested models were compared between a base model, age and frailty assessments using likelihood ratio testing (LRT) and an area under the receiver operating curves (AUROC). Results: The primary cohort enrolled 998 participants from 13 centres. The median age was 80 (range:65-101), 453 (45%) were female, and 377 (37.8%) died within 28 days. The sample was replicated in a validation cohort of two additional centres (n = 672) with similar characteristics. In the primary cohort, both mFI and CFS were associated with mortality in the base models. There was improved precision when fitting CFS to the base model +mFI (LRT = 25.87, p < 0.001); however, there was no improvement when fitting mFI to the base model +CFS (LRT = 1.99, p = 0.16). AUROC suggested increased discrimination when fitting CFS compared to age (p = 0.02) and age +mFI (p = 0.03). In contrast, the mFI offered no improved discrimination in any comparison (p > 0.05). Similar findings were seen in the validation cohort. Conclusions: These observations suggest the CFS has superior prognostic value to mFI in predicting mortality following COVID-19. Our data do not support the use of the mFI as a tool to aid clinical decision-making and prognosis.

USING FRAILTY REVIEWS TO MANAGE THE COVID-19 PANDEMIC IN AN EVIDENCE-BASED AND PERSONCENTRED MANNER ACROSS BUCKINGHAMSHIRE CARE HOMES

Aim NICE COVID-19 guidelines NG191 recognise that frailer patients, including those with a higher Rockwood Clinical Frailty Scale1 (CFS), are seldom improved by hospital admission. The project used a collaborative approach to undertake frailty reviews, aiming to reduce inappropriate hospital admissions. The reviews included discussing residents' preferred place of care and options in the event of deterioration, a Treatment Escalation Plan (TEP). Method A collaborative was formed between care home managers, pharmacists and geriatricians to review frailty factors in residents over 65 years, excluding those with Learning Disabilities. Care homes with high risk of COVID-19 were prioritised. A Standard Operational Procedure was approved within one month. Using existing resources only, the project was delivered over 3 months. Communication was sent to GP practices, care homes and residents/families and consent was obtained. Templates were developed and education delivered. Results Review outcomes were recorded electronically onto the GP clinical system. Care homes kept a copy and informed residents/ families of the outcome. 595 residents were reviewed in 21 care homes. Preliminary analysis for 71 residents reviewed May 2020 to April 2021 show: • 42 survivors, 33 with severe frailty (CFS 7-9), 9 not severely frail (CFS<7). Out of total 28 residents with TEP indicating avoidance of hospital admission, 23 were not admitted and 5 had single hospital admission. 14 residents TEP included hospital management of whom 7 were admitted. • 26 of the 29 deceased residents were severely frail. 96% died in their preferred place of death. Conclusion Clinical leadership demonstrated courage and capacity to challenge the status quo, improve organisational processes and innovate practice. This helped staff morale at a difficult time of immense pressure and positively enhanced care homes' profile and residents' experience.

Disability, Frailty, and Outcomes After Hospitalization for Covid-19: Results from the PETAL Network BLUE CORAL Study

Rationale: The relationship between disability and outcomes after COVID-19 hospitalization remains largely unexplored. We hypothesized that patients with pre-COVID disability would have poorer hospital outcomes, and that COVID-19 hospitalization would be associated with increased disability at hospital discharge. Methods: Between August 2020 and July 2021, NHLBI PETAL Network hospitals prospectively enrolled patients hospitalized with symptomatic SARS-CoV2 infection (fever and/or respiratory signs or symptoms) confirmed by molecular testing. Patients or their surrogates reported pre-COVID ability to perform activities of daily living (ADL) and degree of frailty using standardized surveys at study entry (Katz's ADLs and Rockwood's Clinical Frailty Scale (CFS)). Study staff collected detailed clinical data throughout hospitalization. We examined bivariate and multivariable associations between pre-COVID disability and hospital outcomes and reported risk factors for increased disability at hospital discharge among patients surviving to hospital discharge. In analyses exploring factors associated with returning home to living independently or walking at discharge, we excluded patients not living independently or walking prior to COVID admission, respectively. Results: We enrolled 1369 patients across 44 US hospitals. Demographics are presented in the table, along with clinical management and outcomes. Most patients lived at home without help prior to hospitalization (n=1130, 84%), while 14% were dependent in 1-3 ADLs and 14% were dependent in 4 or more. Before hospitalization, 15% of patients were frail (CFS>4) and 15% were vulnerable (CFS=4). Most patients did not receive critical care (“acute illness”);389 patients (28%) were cared for in ICUs (“critical illness”), and 192 (14%) received mechanical ventilation. Overall, 100 (7%) patients died during their COVID-19 hospitalization. Median hospital length of stay was 6 days (IQR 4-8) for acutely ill patients, 14 days (IQR 9-24 days) for critically ill patients. Pre-COVID frailty was independently associated with hospital mortality (OR 3.5, 95% CI 1.9-6.5), adjusting for age and critical illness. Many patients experienced inability to walk and/or return home independently at hospital discharge, which were associated with baseline disability (OR 2.1, 95% CI 1.1-4.1 for inability to walk, OR 1.9, 95% 1.1-3.4 for inability to return home), adjusting for age and critical illness. Conclusion: Disability and frailty are common among patients hospitalized with SARS-CoV2 infection and associated with poorer outcomes. Additionally, COVID hospitalization is associated with increased disability and loss of independence, especially among critically ill patients. Improving recovery and patient centered outcomes after severe SARS-CoV2 hospitalization will likely require careful discharge planning, post-hospital follow-up, and additional research.

THE CLINICAL FRAILTY SCALE IS USEFUL FOR ICU TRIAGE IN DIALYSIS PATIENTS WITH COVID-19-AN ERACODA ANALYSIS

BACKGROUND AND AIMS: during the COVID-19 pandemic, several guidelines have recommended the use of the Clinical Frailty Scale (CFS) for triage of critically ill patients with COVID-19 in case of shortage in ICU resources. However, no data on using CFS assessment for ICU triage for dialysis patients is yet available. This study evaluates whether CFS is associated with mortality rates in a cohort of hospitalized dialysis patients with COVID-19. METHOD: the analyses are based on data of the European Renal Association COVID-19 Database (ERACODA). Dialysis patients who presented with COVID-19 between 1 February 2020 and 30 April 2021 and with complete information on CFS and vital status at 3 months were included. Study outcomes were hospital and ICU admission rates and hospital and ICU mortality at 3 months after hospital admission. Cox regression analyses were performed to assess the association of CFS category (≤5 versus ≥ 6) and study outcomes in line with Dutch ICU triage guidelines for COVID-19. Furthermore, additional subgroup analyses were performed to assess the association between CFS and 3-month mortality by age category (<65, 65-75 and >75 years). RESULTS: among a total of 2206 dialysis patients (mean age = 67.2 (14.1) years, male sex = 61%), 1694 (77%) had CFS ≤ 5 and 514 (23%) had CFS ≥ 6. Hospitalization rate was comparable in patients with CFS ≤ 5 and in patients with CFS ≥ 6 (67 and 71%, respectively), whereas the rate of ICU admission was higher in patients with CFS ≤ 5 than in patients with CFS ≥ 6 (16 versus 9%, p = 0.001). Among 1501 hospitalized patients, 3-month mortality was 26% of patients with CFS ≤ 5 and 59% in patients with CFS ≥ 6 (P < 0.001). Multivariate analysis with adjustment for patient demographics, smoking status and BMI revealed that CFS ≥ 6 was associated with hospital mortality [aHR 2.27 (1.88-2.74) versus CFS ≤ 5;P < 0.001) with a significant interaction for age (P = 0.029). aHR was 4.00 (2.56-6.37;CFS ≥ 6 versus CFS ≤ 5;P < 0.001) in patients < 65 years, aHR was 1.87 (1.33-2.64;CFS ≥ 6 versus CFS ≤ 5;P < 0.001) in patients 65-75 years and aHR was 2.12 (1.64-2.75;CFS ≥ 6 versus CFS ≤ 5;P < 0.001) in patients >75 years. Among 219 ICU admitted patients, 3-month mortality was 60% of the patients with CFS ≤ 5 and 91% in the patients with CFS ≥ 6, respectively. Multivariate analysis with adjustment for patient demographics, smoking status and BMI revealed that CFS ≥ 6 was associated with ICU mortality [aHR 1.80 (1.17-2.77);CFS ≥ 6 versus CFS ≤ 5;P = 0.002]. CONCLUSION: more frail dialysis patients with CFS ≥ 6 who are hospitalized for COVID-19 were less often admitted to the ICU, but in case they were admitted to the ICU they have a very high mortality of 91% in this cohort study. In fit to mildly frail dialysis, patients who were admitted to the ICU, mortality rates are lower. The association between frailty and hospital mortality is interacted by age with the strongest association in patients younger than 65 years. These findings suggest that CFS may be a useful complementary triage tool for ICU admission of dialysis patients during the ongoing COVID-19 pandemic.

Clinical Frailty Scale (CFS) indicated frailty is associated with increased in-hospital and 30-day mortality in COVID-19 patients: a systematic review and meta-analysis

BackgroundThe concept of frailty provides an age-independent, easy-to-use tool for risk stratification. We aimed to summarize the evidence on the efficacy of frailty tools in risk assessment in COVID-19 patients.MethodsThe protocol was registered (CRD42021241544). Studies reporting on frailty in COVID-19 patients were eligible. The main outcomes were mortality, length of hospital stay (LOH) and intensive care unit (ICU) admission in frail and non-frail COVID-19 patients. Frailty was also compared in survivors and non-survivors. Five databases were searched up to 24th September 2021. The QUIPS tool was used for the risk of bias assessment. Odds ratios (OR) and weighted mean differences (WMD) were calculated with 95% confidence intervals (CI) using a random effect model. Heterogeneity was assessed using the I2 and χ2 tests.ResultsFrom 3640 records identified, 54 were included in the qualitative and 42 in the quantitative synthesis. Clinical Frailty Scale (CFS) was used in 46 studies, the Hospital Frailty Risk Score (HFRS) by 4, the Multidimensional Prognostic Index (MPI) by 3 and three studies used other scores. We found that patients with frailty (CFS 4–9 or HFRS ≥ 5) have a higher risk of mortality (CFS: OR: 3.12;CI 2.56–3.81;HFRS OR: 1.98;CI 1.89–2.07). Patients with frailty (CFS 4–9) were less likely to be admitted to ICU (OR 0.28, CI 0.12–0.64). Quantitative synthesis for LOH was not feasible. Most studies carried a high risk of bias.ConclusionsAs determined by CFS, frailty is strongly associated with mortality;hence, frailty-based patient management should be included in international COVID-19 treatment guidelines. Future studies investigating the role of frailty assessment on deciding ICU admission are strongly warranted.

Measuring the Impact of COVID-19 Restrictions on Mobility in Older Patients with a Fragility Fracture Using the New Mobility Score

Introduction: The World Health Organization declared COVID-19 a pandemic in March 2020. In Ireland, public health restrictions were implemented with specific measures for older adults who were advised to 'cocoon' or remain at home as much as possible. While this has a positive effect on disease spread, a reduction in physical activity in older individuals even for short periods has been shown to increase the risk of falls and fractures as well as all-cause mortality. The New Mobility Score (NMS) stratifies patients with fractures according to pre-fracture mobility based on the ability to perform three activities;indoor walking, outdoor walking and shopping. The NMS is an independent predictor of in-hospital outcome and a cutoff score of 5 has been found to be a valid predictor of 6-month functional level and 1-year mortality. Using the NMS score, we evaluated patient mobility pre and post implementation of restrictions. We also obtained basic data, information on the frequency of patient falls pre and post restrictions together with Clinical Frailty Scale (CFS). Methods: We prospectively studied 50 patients admitted following a fracture and reviewed by our Orthogeriatric team at our hospital from August-October 2020. Results: The mean age was 80 years [range 53-99], over 80% (41) were over 70 years and 43 (86%) were female. A hip fracture (78%) was the most common reason for admission and the mean CFS was 4 [Range 1-7] classifying our cohort as living with very mild frailty. There was a statistically significant difference in mean NMS with a lower mean NMS post implementation of COVID-19 restrictions compared to pre restrictions;[5 [SD 2.19] vs 6.5 [SD 2.15] [P = 0.0074]]. There was no difference in the mean number of falls pre and post restrictions [pre COVID-19;1.1 [S.D 2.3] and post COVID-19 1.9 [S.D 1.9] [P = 0.0609]. Conclusion: Our study has shown that in a vulnerable cohort of patients, COVID-19 restrictions have significantly impacted patient mobility over a short period of time. Our results show that as result of the reduction in mobility following implementation of COVID-19 restrictions, our patients are less likely to regain pre-fracture functional level and are at a higher risk of all-cause mortality. As further public health restrictions are implemented across the world to control the spread of COVID-19, public health strategies and advice for older people should be prioritised to maintain mobility and physical activity and prevent adverse outcomes.

Orthopaedic Rehabilitation is Associated with Better Outcomes in Orthopaedic Patients with COVID-19

Introduction: The geriatric patient cohort is at high risk of falling and sustaining a fragility fracture, leading to an admission to the orthopaedic rehabilitation ward. Outbreaks of COVID-19 on wards were a common occurrence, with 13% of cases classified as 'healthcare acquired'. This study examines a group in whom these two scenarios coincided, those who sustained a fragility fracture, and later contracted COVID-19 during their rehabilitation stay. The study aims to identify whether access to orthopaedic rehabilitation services during the acute phase of COVID-19 was associated with better patient outcomes. Methods: A retrospective, cohort observational study was carried out. Data from 26 rehabilitation patients aged over 65 years with confirmed COVID-19 at two Irish orthopaedic rehabilitation wards were collected from health records. Symptom profile, COVID-19 severity level based on Irish Thoracic Society guidelines, Clinical Frailty Scale (CFS), Cumulative Illness Rating Scale-Geriatric (CIRS-G) scores and radiological data were reviewed and compared with outcomes from a similar study carried out in the hospital setting. Results: Patient mortality rate was 7.7% (n = 2) in the orthopaedic rehabilitation population compared to 23.2% (n = 16) in the acute hospital orthopaedic population. Median survivor age was 79.5 years (IQR 70-85.5) and 81.5 years (IQR 76.5-86.5), respectively. Mean CFS was 4.15 (SD 1.6) and 5 (SD 1.6), respectively. Mean CIRS-G scores were 10.6 (SD 4.3) and 8.19 (SD 4.4). Most patients were categorised as mild COVID-19 cases (n = 25, 96%), (n = 56, 81.1%). Eight patients (n = 8, 30.8%) in rehabilitation group were asymptomatic compared to five (n = 5, 7%) in the acute hospital group. Atypical symptom presentation was 15.4% (n = 4) and 7% (n = 5) respectively. Delirium was noted in 11.6% (n = 3) of rehabilitation patients compared to 30.4% (n = 21) of acute patients. Non-invasive ventilation was required in 3.8% (n = 1) of rehab patients and 2.9% (n = 2) of acute hospital patients. Conclusion: Orthopaedic rehabilitation patients were younger, less frail, had a milder COVID-19 disease profile and lower mortality rate when compared with orthopaedic patients in the acute hospital setting. Rehabilitation patients had lower rates of reported delirium. Rehabilitation patients' better outcomes may have been associated with an increased accessibility to allied healthcare, increased time between sustaining a fragility fracture and being diagnosed with COVID-19 and a hospital environment more conducive to recuperation.

Multidisciplinary Management of an Outbreak of COVID-19 on an Orthopaedic Rehabilitation Ward: A Description of Outcomes

Introduction: In January 2021, Ireland was undergoing the 'Third Wave' of COVID-19, with almost 2,000 persons hospitalised with COVID-19. Over 50% of all COVID-19-related deaths in the EU have occurred in those aged 80 years and older. The same patient cohort is also at high risk sustaining a fragility fracture, leading to an admission to the orthopaedic rehabilitation ward. This study examines a patient group in whom these two scenarios coincided, describing a patient cohort who having sustained a fragility fracture, later contracted COVID-19. This study aims to describe the characteristics and outcomes of orthopaedic rehabilitation patients with COVID-19 and to examine the response of an orthopaedic rehabilitation ward to an outbreak of COVID-19. Methods: This is a retrospective observational study. Data from 26 hospitalised patients aged over 65 years with COVID-19 at an Irish orthopaedic rehabilitation ward was collected. Symptom profile, degree of COVID-19 severity, Clinical Frailty Scale (CFS), Charleston co-morbidity scores, laboratory and radiological data were reviewed. Individual treatment pathways were recorded for each patient. Infection control records were reviewed to examine the response of the ward to an outbreak of COVID-19. Results: Patient mortality rate was 7.7% (n = 2). Median survivor age was 79.5 years (IQR 70-85.5). Mean CFS and Charleston Co-morbidity scores were 4.15;(SD1.6) and 5.08, respectively. The majority of patients (n = 25, 96%) were categorised as mild COVID-19 cases. Delirium was noted in more than 10% of patients (n = 3, 11.6%). One patient (n = 1, 3.8%) required non-invasive ventilation. In those whose disease was classifies as severe (n = 2, 7.7%), intubation/resuscitation were not deemed appropriate and when they deteriorated, comfort measures were taken. The majority of patients (n = 21, 81%) were able to return home upon discharge. Three patients (11.5%) had increased care needs and required long term care to be arranged. Conclusion: An outbreak of COVID-19 requires a multidisciplinary approach with a focus on not only medical management but also clinical workforce management, patient flow, management of access to the wards and information and communications management. The overall outcomes in this group, including mortality and proportion discharged to long term care, were positive when compared to similar cohorts of elderly hospitalised patients with COVID-19. These outcomes support a multidisciplinary model of care.

The value of qualitative data in Quality Improvement Projects in the care of older adults: the case of frailty scores in the emergency department.

This commentary discusses the role and value of qualitative data when undertaking quality improvement (QI) focussing on the care of older adults. To illustrate this, we reflect on our own experiences of planning a QI project to improve the documentation of Clinical Frailty Scale (CFS) scores in the emergency department (ED) during the coronavirus disease of 2019 (COVID-19) pandemic. National clinical guidance for COVID-19 states that all adults over the age of 65 should be given a CFS at the first point of contact during hospital admission. Therefore, there is a need to improve CFS documentation, specifically in acute care settings. We describe how qualitative methods facilitated an understanding of the barriers to CFS documentation in ED. Staff see the CFS as a useful tool for inter-professional communication, though there are tensions between clinical guidance and their beliefs. Staff had moral concerns about how an ED-allocated CFS might limit available treatment options for older adults. Our findings demonstrate how qualitative methods can illuminate the important social and moral dimensions of why improvement does or does not occur.