Knight Thomas, Atkin Catherine, Kamwa Vicky, Cooksley Tim, Subbe Chris, Holland Mark, Sapey Elizabeth, Lasserson Daniel
Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, UK.
The Christie NHS Foundation Trust, Manchester, UK.
EClinicalMedicine. 2023 Nov 1;66:102278. doi: 10.1016/j.eclinm.2023.102278. eCollection 2023 Dec.
Frailty is associated with a range of adverse clinical outcomes in the acute hospital setting. We sought to determine whether frailty and related factors affected clinical processes such as time to assessment during emergency hospital admission within the National Health Service (NHS) in the UK.
The Society for Acute Medicine Benchmarking Audit (SAMBA) is an annual cross-sectional day of care survey. SAMBA 2022 was conducted on Thursday 23rd June 2022. We assessed whether the Clinical Frailty Scale (CFS) and presence of a geriatric syndrome affected performance against nationally recognised clinical quality indicators based on time to initial assessment and time to consultant review. CFS was graded into robust (CFS1-3), mild (CFS 4-5), moderate (CFS 6), severe (CFS7-8) and terminal illness (CFS 9). Plausible values were created for missing variables using multi-level multiple imputation. The association was described using mixed effect generalised linear models adjusting for initial National Early Warning Score 2 (NEWS2) and time of arrival.
A total of 152 hospitals provided patient level data relating to 7248 emergency medical admissions. Patients with mild, moderate and severe frailty were less likely to be assessed within 4 h of arrival (adjusted OR, mild 0.79, 95% CI 0.68-0.96, moderate 0.67 95% CI 0.53-0.84, severe, 0.75 95% CI 0.58-0.96, terminally ill 0.59 95% CI 0.23-1.43) and less likely to be achieve the clinical quality indicator for consultant review (adjusted OR, mild 0.69 95% CI 0.58-0.83, moderate 0.55 95% CI 0.44-0.70, severe 0.54 95% CI 0.41-0.69, terminally ill 0.76 95% CI 0.42-1.5). Patients with geriatric syndromes were also less likely to be assessed within 4 h of arrival (adjusted OR 0.66 95% CI 0.56-0.76) or by a consultant within the recommended time frame (adjusted OR 0.45 95% CI 0.39-0.51). The difference was partially explained by differential use of SDEC pathways. Sub-group analysis of 5148 patients assessed outside of SDEC areas demonstrated patients with geriatric syndromes (adjusted OR 0.71, 95% CI 0.60-0.83), but not frailty defined by CFS were less likely to be assessed within 4 h of arrival. Moderate and severe frailty and the presence of a geriatric syndrome were associated with a decreased likelihood of achieving the consultant review standard (moderate, adjusted OR 0.75, 95% CI 0.59-0.94, severe adjusted OR 0.75 95% CI 0.58-0.96, geriatric syndrome adjusted OR 0.59, 95% CI 0.50-0.69).
Frailty is associated with delayed clinical assessment. This association may suggest a systemic issue with clinical prioritisation, with important implications for acute care policy.
The database for SAMBA is funded by the Society for Acute Medicine.
在急性医院环境中，衰弱与一系列不良临床结局相关。我们试图确定衰弱及相关因素是否会影响诸如英国国民医疗服务体系（NHS）内急诊入院时的评估时间等临床流程。
急性医学学会基准审计（SAMBA）是一项年度横断面日间护理调查。SAMBA 2022于2022年6月23日星期四进行。我们根据初始评估时间和会诊医生复查时间，评估临床衰弱量表（CFS）和老年综合征的存在是否会影响针对全国认可的临床质量指标的表现。CFS分为强壮（CFS1 - 3）、轻度（CFS 4 - 5）、中度（CFS 6）、重度（CFS7 - 8）和终末期疾病（CFS 9）。使用多级多重插补法为缺失变量创建合理值。使用混合效应广义线性模型描述这种关联，并对初始国家早期预警评分2（NEWS2）和到达时间进行调整。
共有152家医院提供了与7248例急诊医疗入院患者相关的患者层面数据。轻度、中度和重度衰弱患者在到达后4小时内接受评估的可能性较小（调整后的比值比，轻度为0.79，95%置信区间为0.68 - 0.96，中度为0.67，95%置信区间为0.53 - 0.84，重度为0.75，95%置信区间为0.58 - 0.96，终末期疾病为0.59，95%置信区间为0.23 - 1.43），并且达到会诊医生复查临床质量指标的可能性较小（调整后的比值比，轻度为0.69，95%置信区间为0.58 - 0.83，中度为0.55，95%置信区间为0.44 - 0.70，重度为0.54，95%置信区间为0.41 - 0.69，终末期疾病为0.76，95%置信区间为0.42 - 1.5）。患有老年综合征的患者在到达后4小时内接受评估的可能性也较小（调整后的比值比为0.66，95%置信区间为0.56 - 0.76），或者在推荐时间内由会诊医生评估的可能性较小（调整后的比值比为0.45，95%置信区间为0.39 - 0.51）。这种差异部分可通过对短期评估和治疗单元（SDEC）路径的不同使用来解释。对在SDEC区域外评估的5148例患者进行的亚组分析表明，患有老年综合征的患者（调整后的比值比为0.71，95%置信区间为0.60 - 0.83），但不是由CFS定义的衰弱患者，在到达后4小时内接受评估的可能性较小。中度和重度衰弱以及老年综合征的存在与达到会诊医生复查标准的可能性降低相关（中度，调整后的比值比为0.75，95%置信区间为0.59 - 0.94，重度调整后的比值比为0.75，95%置信区间为0.58 - 0.96，老年综合征调整后的比值比为0.59，95%置信区间为0.50 - 0.69）。
衰弱与临床评估延迟相关。这种关联可能暗示临床优先级存在系统性问题，对急性护理政策具有重要意义。
SAMBA数据库由急性医学学会资助。
