Recent international guidance on prognostic indicators to inform decision making on critical care escalation in older people during the COVID-19 pandemic have identified frailty and its measurement based on specific instruments such as the Clinical Frailty Scale (CFS) [Rockwood et al., 2005] as having potential utility (NICE, 2020; BESEDIM, 2020). In order to inform national guidance in the Irish context, an expert group was formed to advise relevant professional bodies and policy.
Frailty is a multi-dimensional, age-related condition characterised by decreased resilience to stressors predisposing individuals to higher risk of adverse outcomes including death [Clegg et al., 2013]. The COVID-19 pandemic has disproportionately affected older adults with high mortality rates reported in Wuhan, China [Chen et al., 2020; Wu et al., 2020] and Italy [Lazzerini and Putoto, 2020]. Frail older adults appear most susceptible, possibly secondary to impaired immune responses [Wu et al., 2020]. The roles of other possible risk factors remain unclear at present, pending urgent research. Preliminary data from Italy suggests that higher mortality rates relate to infections among older and predominantly male patients with co-morbidities [Onder, Rezza & Brusaferro, 2020]. Data are, however, preliminary and pathophysiological mechanisms and the impact of differential management strategies on the course of the disease among older adults remain uncertain [Wu et al., 2020]. Further, the prevalence of frailty among those diagnosed, admitted or dying is not reported at present
Outside the current COVID-19 pandemic, the measurement of frailty in older adults has been shown to potentially inform prognostic outcomes in critical care including mortality and institutionalisation [Muscedere et al., 2017]. Frailty is also a predictor of adverse outcomes from in-hospital cardiopulmonary resuscitation (CPR) (Wharton, 2019).
The CFS [Rockwood et al., 2005] measures frailty on a scale from 1 (very fit) to 9 (terminally ill). Service evaluations and research studies (outside the COVID-19 context) have shown that the CFS is a significant independent predictor of adverse outcomes in older people in emergency and critical care settings, suggesting that this tool may be able to aid decision making by clinicians. However, it is not perfect - acute illness, for example, can lead to overestimates of frailty severity [Flaatten and Clegg, 2018] - and should not be used in isolation to direct clinical decision making (NHS, 2020).
Up to now, the CFS has largely been deployed by those with training in care of older people where the mix of functional decline, comorbidity and / or cognitive change in later life are identified within a multidimensional assessment. However, in an impending COVID-19 scenario with multiple critically ill older patients presenting simultaneously, the availability and access to geriatric-trained staff will be very limited.
The CFS can be undertaken by any healthcare professional (doctor, nurse, healthcare assistant, therapist etc.) with training and support. There are concerns about the potential for over-estimation of frailty when the CFS is applied by inexperienced raters. In particular, it is essential that all using this scale have an understanding of the nuances required in its use and interpretation.
A range of possible care escalation decisions (from hospital admission to and including intubation / ventilation) may need to be made during the current pandemic. In emergency care settings in particular, assessments may need to be made and decisions taken very quickly. Nevertheless, a number of general principles remain important:
Clinical decision making with individual patients should involve consideration of several factors including:
An amalgam or composite picture of these dimensions as they relate to the individual will be more informative and aid discussion more than any single scoring system.
Advanced care planning, based on the principles of shared decision making and requiring proactive, transparent communication with patients, is essential to avoiding unnecessary admissions and cardiac arrest calls (the latter posing potentially the highest risk to healthcare workers during the COVID-19 pandemic).
It is becoming clear that, in those receiving intensive care as a result of COVID-19, prolonged ventilation often in the prone position, is usually required. This needs to be considered in discussions and decision making, especially in frailer cohorts, as there may be significant potential for additional functional decline and worse outcomes in such patients as a result.
Sensitive communication is also key if it is necessary to explain to a patient, or to those close to the patient, that escalation to critical care will not be effective or suitable.
If limitations in the resources available, rather than purely clinical factors, are an important factor in decision making regarding critical care escalation, this should be documented and acknowledged openly.
Decisions regarding escalation of care are sometimes difficult, and it is important that mechanisms are in place to support resolution of differences of opinion where they occur. The importance of contemporaneous documentation remains very important in this regard.
On admission to hospital, clinicians caring for older adults (typically aged 65 and older), irrespective of COVID‑19 status, should naturally continue to obtain the clinical history, collateral history when appropriate, and perform the clinical examination and the relevant functional assessments. This forms the basis of the geriatric assessment required to use frailty tools such as the Clinical Frailty Scale (CFS). If frailty tools are used, the scoring rationale and result should be recorded in the patient’s chart, alongside all the other information gathered (e.g. acuity of illness, patient preferences).
|Assessing patients using the CFS always requires knowledge of their baseline status (usually about 2 weeks) prior to their acute illness. If this information is not immediately available from the patient, an informant who knows the patient well or from the medical records, assessment with the CFS should be deferred.|
The CFS must always be interpreted in the context of underlying pathologies, comorbidities, severity of acute illness and patient preferences and in awareness of the limitations of this tool. Decision makers using the CFS to inform clinical management MUST check the score to ensure that it is accurate. The following rough guidance may be helpful:
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