Scientific Papers

Is the clinical frailty scale feasible to use in an emergency department setting? A mixed methods study | BMC Emergency Medicine

A total of 4515 ED visits by patients ≥ 65 years were made during the data collection period. Of these, 280 were excluded, mostly due to missing data. There were 1995 visits with completed assessments and 2240 non-assessed visits, which together comprise the sample of 4235 visits analysed in this study (Fig. 1).

Fig. 1
figure 1

Flow chart describing the inclusion process for ED visits made by patients ≥ 65 years old


The overall completion rate of CFS-based assessments was 47.0%. The completion rate increased with the age of the patients, and for the oldest (≥ 96 years of age) it was 76.9%. The completion rate exceeded 50% for those who arrived by ambulance (56.3%) or by recumbent transport (63.2%). Patients with triage priorities 2 (very urgent) and 3 (urgent) had CFS completion rates of just over 50%, while patients with minor injuries had the lowest proportion of completed assessments (24.0%) (Table 4). There were minor differences in completion rates between the days of the week, with the lowest on Sundays (43.5%). During the day, the completion rate was highest (58.1%) for patients who arrived at the ED between 06:00 and 12:00 am.

Table 4 The completion rate of CFS-assessments in relation to patient- and organisation related factors


In total, 475 ED staff (216 physicians, 148 registered nurses, and 111 assistant nurses) received the survey on perceived user satisfaction, barriers, and facilitators, and 229 (48.0%) responded. Eight declined participation, leaving 221 answers to analyse. The number of respondents was similar between professions, with 78 physicians (divided into 50 emergency physicians, and 28 interns/residents from other specialties), 73 registered nurses, and 70 assistant nurses. The distribution of the percentage of respondents between the hospitals was: UH, 48.9%; CH 1, 28.5% and; CH2, 22.6%. Most participants (70.0%) were women; the all-over median age was 35 years (IQR 17), and median work experience was 8 years (IQR 12).

Information on perceived user satisfaction, barriers, and facilitators was collected using a 7-point Likert scale. Most respondents had positive experiences with the relevance of CFS assessments, relevance to frailty assessments in general, ease of use of the CFS, and perceived time required for CFS assessments (Table 5).

Table 5 Emergency department staff´s responses to their experiences of using the CFS

To identify barriers to using the CFS, we asked: “In cases where you did not assess patients ≥ 65 years of age, what was the reason?”. Participants could select one or more predefined answers, as well as provide free comments regarding other barriers to CFS assessment (Fig. 2). High workload and forgetfulness were the most frequently selected barriers to assessing the patient with CFS, while difficulty understanding the scale or time-consuming assessment were the least reported barriers.

Fig. 2
figure 2

The frequency of ED staff reported barriers to assess patients with CFS. The number of times each barrier was selected. Participants could select all available options that they perceived as a barrier to CFS assessment. The question was answered by 209 respondents

Qualitative analysis

The three open text boxes yielded 194 comments, written by 124 unique ED staff, divided between 41 physicians, 48 registered nurses, and 35 assistant nurses. The questions and subsequent comments were about: additional perceived barriers to CFS assessment; existing or potential facilitators; and perceived importance of identifying frailty (in general) in the ED. The analysis resulted in a total of eight categories and 16 subcategories. The categories and subcategories are illustrated in Fig. 3 and presented in more detail below. Illustrative quotes are marked with profession (Physician = Ph, Registered nurse = RN and Assistant nurse = AN) and hospital (University hospital = UH, Community hospital = CH 1 or CH 2).

Fig. 3
figure 3

The result of the qualitative analysis: the eight categories and 16 subcategories

Additional barriers to CFS-assessment

Unspecific instruction

The description that assessments were not made because the respondents did not feel responsible for it, resulted in the subcategory “Unclear responsibility”. The instruction to the staff was that someone on the team should do the CFS assessment during the patient’s stay in the ED. It may be that the imprecise wording contributed to fewer assessments being made. The subcategory “Time for assessment” was formed by respondents’ descriptions of the fact that the assessments were postponed, which resulted in the patient being discharged without the assessment being carried out.

“…as well as when a patient had been quickly discharged home or to a ward” (AN, CH 1).

Lack of motivation

The subcategory “Preferring clinical judgement” stemmed from the view that the use of a specific assessment tool is unnecessary, as frailty can be assessed using clinical judgement alone. The experience that the use of CFS is challenging was partly based on the need to understand the patient’s usual ability to cope with daily activities, and partly on the difficulty of knowing which questions to ask. This was framed in the subcategory “Challenging Tool”.

“Assessment of frailty is important, but CFS is challenging as there are many questions about the patients´ everyday life…difficult to evaluate the steps in the assessment…” (RN, CH 1).

The third subcategory “Labelling the patient” involves the experience of labelling the patient in a definitive way by grading the person on a scale.

“It feels as if I put a stamp on the patient…that the assessment is definitive in some way” (RN, UH).

Existing or potential facilitators for CFS-assessment

Clear relevance

The category “Clear relevance” was based on the expressions that it was facilitating to maintain, or obtain a sense that a CFS assessment leads to something significant for the patient.

“To continue having the feeling that it is something significant and worth making time for” (Ph, UH).

Tasks assigned to certain ED staff

Another facilitator is described in the subcategory “Defined responsibility”, and would be to dedicate the assessment to specific personnel. Either within each care team (e.g., the registered nurse is always responsible) or at a specific position (e.g. triage). The proposal in the subcategory “Specific geriatric resource” concerned an exclusive geriatric resource that operates on all care teams.

“Assessment could perhaps take place during triage so that it is always done; standardisation often improves this sort of procedures” (Ph, CH 1).

Implementation support

It was further described that continued and additional implementation support would facilitate assessments. Suggestions for verbal or visual reminders formed the “Reminders” subcategory, while integrating the CFS into the EMR formed the “Technical Support” subcategory.

Perceived importance of frailty assessment (in general) in the ED

The perceived importance of frailty assessment in general interacts to a certain degree with the experience of barriers and facilitators. This is illustrated in Fig. 3.

Adapted care process

Those who considered frailty assessment to be important in the ED described it as providing significant information about the patient, leading to an adapted care process. The subcategory “Emergency nursing care” included adapted nursing interventions in the ED. Examples given were increased attention to nutritional and elimination needs; position changes; “real” beds and; more frequent nursing rounds.

“Many older people with frailty are in greater need of nursing rounds as they can rapidly deteriorate, as a result of decreased reserves” (RN, CH 2).

In the subcategory “Emergency medical decisions” the importance of taking frailty into account in medical reasoning was described. Frailty was considered to influence the acute illness, and decisions about: drug treatment; the planned content of care and whether the patient should be admitted to hospital or discharged home.

“…to be extra attentive and think broadly due to underlying frailty” (Ph, CH 2).

Within the subcategory “Shorten the ED length of stay”, the risk of patient harm during waiting times was commented on, as was the importance of rapid care processes for patients living with frailty. Comments in the subcategory “Post-ED process” showed identification of frailty in the ED being considered to influence care, or support, after the emergency visit.

Means of communication

This category involves expressions that frailty assessment is a way to a concordant view of the concept and thus facilitate communication when discussing the patient on the team or at hand-off, but also as a means to follow the degree of frailty over time.

Non-productive assessment

Informants who stated that frailty assessment was unimportant expressed that it did not affect the care provided. In the subcategory “Lack of resources to take action”, respondents voiced a lack of either time or personnel to act on the obtained information. In the subcategory “Irrelevant to emergency care” the perspective was that the information about frailty was of no use in emergency care.

“The patients are here for a short time, and I don’t think that it (frailty assessment) helps the work” (AN, CH 1).

The subcategory “Less important for younger patients” included experiences of that 65 years was too low an age limit, as many people of that age are still fit.

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