How can Frailty assessment tools be integrated into team triage protocols to reduce undertriage in ED or ICU patients?

Research Protocol: Integration of Frailty Assessment Tools into Team Triage Protocols to Reduce Undertriage

Protocol Objective

This protocol aims to systematically integrate validated frailty assessment tools into emergency department and intensive care unit triage systems to reduce undertriage of elderly and frail patients, thereby decreasing mortality and improving outcomes through early identification and appropriate resource allocation.

Background and Rationale

Undertriage represents a critical failure in trauma and emergency care systems, with elderly patients experiencing the highest rates of undertriage compared to younger populations 1. Elderly trauma patients aged ≥55 years require early trauma protocol activation and careful evaluation to avoid undertriage, as even seemingly minor mechanisms of injury carry significantly elevated mortality risk 1. Current triage systems fail to identify 61% of severely injured older patients despite geriatric-specific protocols, though age-based modifications do capture the highest-risk patients 1. The integration of frailty assessment into triage protocols has demonstrated superior predictive accuracy compared to standard triage alone, with area under the curve improvements from 0.64 to 0.82 2.

Primary Outcome Measures

• Reduction in undertriage rates (target: <5% of patients requiring Level I or Level II trauma center care) 1
• In-hospital mortality rates 1, 2
• ICU admission rates among initially undertriaged patients 2
• 30-day and 180-day mortality 1, 3

Secondary Outcome Measures

• Hospital length of stay 1, 2
• ED revisit rates within 30 and 180 days 3
• Functional decline at discharge 3
• Time to comprehensive geriatric assessment 4
• Resource utilization (ED medical expenditures, number of orders) 2

Study Population

Inclusion Criteria

• All patients aged ≥55 years presenting to the ED or requiring ICU triage 1
• Patients with trauma (blunt or penetrating) 1
• Patients presenting with acute medical conditions requiring triage decisions 1, 2

Exclusion Criteria

• Patients requiring immediate resuscitation without time for screening (e.g., cardiac arrest, active exsanguination) 1
• Patients with incomplete vital signs or assessment data 1

Frailty Assessment Tool Selection

Primary Screening Tool: Clinical Frailty Scale (CFS)

The Clinical Frailty Scale should be the primary frailty assessment tool integrated into triage protocols, as it demonstrates high accuracy (AUC 0.83) and is specifically recommended by the World Society of Emergency Surgery for all elderly trauma patients 1, 4. The CFS is a 9-point visual scale ranging from 1 (very fit) to 9 (terminally ill) that can be rapidly administered at triage 2, 4.

Alternative Tool: PRISMA-7

The Programme on Research for Integrating Services for the Maintenance of Autonomy 7-item questionnaire (PRISMA-7) demonstrates the highest statistical accuracy (AUC 0.88) for separating frail from non-frail patients in the ED and should be considered when slightly longer assessment time is available 4. PRISMA-7 consists of 7 yes/no questions addressing age, gender, health problems, need for assistance, and use of walking aids 4.

Supplementary Tool: Identification of Seniors at Risk (ISAR)

The ISAR tool shows 94% sensitivity and 63% specificity using a cut-off score of ≥2 and effectively predicts ED revisit, hospitalization, and 6-month mortality 3. ISAR consists of 6 items and can identify high-risk patients requiring geriatric intervention regardless of admission status 3.

Triage Protocol Integration Framework

Step 1: Modified Vital Sign Thresholds

Lower the threshold for trauma protocol activation in patients aged ≥55 years to heart rate >90 bpm and systolic blood pressure <110 mmHg, as standard vital sign parameters underestimate injury severity in elderly patients 1. These modified thresholds account for age-related physiological changes and medication effects (particularly beta-blockers and antihypertensives) that mask compensatory responses to injury 1.

Step 2: Immediate Frailty Screening at Triage

All patients aged ≥55 years should undergo frailty screening using the CFS within the initial triage assessment, with family/care provider participation strongly encouraged 1. The triage nurse or first-contact physician should complete the CFS scoring based on:

• Pre-injury functional status 1
• Need for regular assistance 1
• Recent hospitalizations (within 6 months) 1
• Sensory impairments (vision) 1
• Cognitive function (memory problems) 1
• Polypharmacy (>3 medications daily) 1

Step 3: Risk Stratification and Protocol Activation

Patients with CFS scores ≥4 or PRISMA-7 scores ≥3 should trigger automatic escalation of triage level and early trauma protocol activation, regardless of initial vital signs or apparent injury severity 1, 2, 4. This integration creates a Triage Frailty Acuity Scale (TFAS) that combines traditional triage parameters with frailty assessment 2.

High-Risk Criteria (Immediate Protocol Activation):

• CFS score ≥6 (moderately frail or worse) 1, 4
• Age ≥70 years with CFS ≥4 1, 2
• Any positive response to high-risk screening questions (need for help, recent hospitalization, polypharmacy) 1
• Modified vital sign thresholds met (HR >90, SBP <110) 1

Moderate-Risk Criteria (Enhanced Monitoring):

• CFS score 4-5 (vulnerable to mildly frail) 4
• ISAR score ≥2 3
• Age 55-69 years with any frailty indicators 1

Step 4: Comprehensive Assessment Triggers

All patients identified as frail (CFS ≥4) should receive early blood gas analysis for baseline base-deficit or lactate assessment, as these markers detect occult hypoperfusion that vital signs may not reveal in elderly patients 1. Additional mandatory assessments include:

• Medication reconciliation with specific attention to anticoagulants, antiplatelets, beta-blockers, and antihypertensives 1
• Comorbidity documentation using structured tools 1
• Baseline cognitive assessment for delirium screening 1
• Fall risk assessment if mechanism involves fall 1

Step 5: Imaging and Diagnostic Protocols

Maintain a low threshold for initial contrast-enhanced CT scanning in geriatric trauma patients, as the diagnostic yield outweighs contrast-induced nephropathy risk and the potential consequences of undertriage are severe 1. The decision for advanced imaging should not be delayed by concerns about radiation exposure or contrast administration in frail elderly patients with trauma 1.

Step 6: Disposition Decision-Making

Frail patients (CFS ≥4) meeting any of the following criteria require admission to a Level I or Level II trauma center or geriatric intensive care unit, even if injuries appear minor 1:

• Base deficit >2 mmol/L or lactate >2.0 mmol/L 1
• Any anatomical injury with Abbreviated Injury Score >2 1
• Mechanism of injury suggesting high energy transfer 1
• Inability to return to pre-injury functional status 1

Implementation Protocol

Phase 1: Staff Training and Education (Weeks 1-4)

All triage nurses, emergency physicians, and trauma team members must complete mandatory training on frailty assessment tools, modified vital sign thresholds, and the rationale for reducing undertriage in elderly patients 1. Training should include:

• Recognition of age-related physiological changes 1
• Proper administration and scoring of CFS 2, 4
• Understanding of frailty as distinct from chronological age 1, 5
• Communication strategies with patients and families regarding frailty-based triage 5

Phase 2: Protocol Integration (Weeks 5-8)

Integrate frailty screening into existing electronic health record triage documentation with mandatory fields for:

• CFS score (required for all patients ≥55 years) 1, 2
• Modified vital sign threshold alerts 1
• Automatic escalation triggers based on combined frailty and traditional triage parameters 2
• Decision support tools linking frailty scores to disposition recommendations 1

Phase 3: Pilot Testing (Weeks 9-16)

Conduct pilot implementation in a single ED or trauma bay with:

• Real-time monitoring of undertriage rates 1
• Weekly review of cases where frailty screening altered triage decisions 2
• Assessment of time burden on triage process 4, 6
• Feedback collection from nursing and physician staff 6

Phase 4: Full Implementation (Week 17 onwards)

Roll out protocol hospital-wide with:

• Continuous quality improvement monitoring 1
• Monthly audit of undertriage rates stratified by age and frailty status 1
• Quarterly review of mortality outcomes 1, 2
• Annual protocol revision based on accumulated data 1

Quality Assurance Measures

Process Metrics

• Percentage of eligible patients (≥55 years) receiving frailty screening (target: >95%) 1
• Time from triage to frailty assessment completion (target: <5 minutes) 4, 6
• Concordance between nurse-administered and physician-administered CFS scores (target: >85% agreement) 6
• Protocol activation rate for frail patients (target: 100% for CFS ≥6) 1

Outcome Metrics

• Undertriage rate for patients aged ≥55 years (target: <5%) 1
• Sensitivity of frailty-enhanced triage for predicting ICU admission or in-hospital mortality (target: >90%) 2, 3
• Reduction in mortality among previously undertriaged elderly patients 1
• Overtriage rate (acceptable range: 25-50%) 1

Safety Monitoring

• Review of all elderly patient deaths within 30 days of ED visit to identify missed frailty indicators 3
• Analysis of patients who deteriorated after initial low-acuity triage assignment 2
• Tracking of adverse events potentially related to undertriage (delayed diagnosis, delayed intervention, preventable complications) 1

Data Collection and Analysis

Required Data Elements

• Demographics (age, sex) 2, 4
• Initial vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) 1
• CFS score and individual component responses 2, 4
• Traditional triage level assignment 2
• Frailty-adjusted triage level assignment 2
• Time stamps (arrival, triage, assessment, disposition decision) 4
• Laboratory values (base deficit, lactate, hemoglobin) 1
• Imaging performed and findings 1
• Disposition (discharge, admission, ICU admission, transfer) 2, 3
• Outcomes (in-hospital mortality, 30-day mortality, 180-day mortality, ED revisit, functional decline) 1, 2, 3

Statistical Analysis Plan

• Compare undertriage rates before and after protocol implementation using chi-square tests 1, 2
• Calculate sensitivity, specificity, positive predictive value, and negative predictive value of frailty-enhanced triage 2, 4, 3
• Generate receiver operating characteristic curves comparing traditional triage versus frailty-enhanced triage 2, 4
• Perform multivariable logistic regression to identify independent predictors of critical events (ICU admission, in-hospital mortality) 2
• Conduct subgroup analyses stratified by age categories (55-64,65-74,75-84, ≥85 years) 1

Ethical Considerations

Frailty-based triage does not constitute unjust discrimination on the grounds of age or disability when applied consistently to all patients and based on probability of survival, longevity, and quality of life outcomes 5. The protocol must ensure:

• Consistent assessment of frailty criteria in all patients aged ≥55 years referred for triage 5
• Explicit documentation of the ethical basis for triage decisions (survival probability, resource optimization) 5
• Application of triage equivalence principles to ensure fair treatment across patient populations 5
• Transparent communication with patients and families regarding how frailty influences triage decisions 5

Common Pitfalls and Mitigation Strategies

Pitfall 1: Confusing Frailty with Chronological Age

Frailty is a physiological state of decreased reserve and resistance to stressors, distinct from age alone 1, 5. Many elderly patients are robust and non-frail, while some younger patients may be frail due to chronic disease 1. Mitigation: Mandatory use of validated frailty assessment tools rather than age cutoffs alone 1, 4.

Pitfall 2: Inadequate Time for Screening

Emergency physicians may perceive frailty screening as time-consuming and complex 6. Mitigation: Use the CFS, which requires <2 minutes to administer, and integrate scoring into electronic triage workflows with pre-populated fields 2, 4.

Pitfall 3: Inconsistent Application Across Providers

Variability in frailty assessment between nurses and physicians can reduce protocol effectiveness 6. Mitigation: Standardized training, use of visual CFS reference cards at triage stations, and regular inter-rater reliability assessments 4, 6.

Pitfall 4: Failure to Adjust for Medication Effects

Beta-blockers and other cardiovascular medications mask tachycardia and hypotension in elderly trauma patients 1. Mitigation: Mandatory medication history collection at triage with automatic alerts for medications affecting vital signs 1.

Pitfall 5: Overtriage Concerns Leading to Protocol Non-Adherence

Clinicians may resist frailty-based escalation due to concerns about resource utilization 1, 5. Mitigation: Education on acceptable overtriage rates (25-50%) and emphasis that undertriage carries higher mortality risk than overtriage 1, 5.

Resource Requirements

Personnel

• Dedicated triage officer with critical care experience for high-volume periods 1
• Geriatric consultation team availability within 24 hours 1
• Palliative care team for early involvement in frail patients with severe injuries 1

Equipment and Supplies

• Point-of-care blood gas analyzers for rapid base deficit and lactate measurement 1
• Laminated CFS visual reference cards at all triage stations 4
• Electronic health record modifications with mandatory frailty screening fields 2

Infrastructure

• Geriatric intensive care units or dedicated geriatric trauma beds 1
• Enhanced monitoring capabilities for serial vital sign and laboratory assessment 1
• Quiet, well-lit triage areas to facilitate accurate cognitive and functional assessment 1

Protocol Revision and Continuous Improvement

Establish a multidisciplinary review committee meeting quarterly to evaluate protocol performance, analyze undertriage cases, and implement modifications based on accumulated evidence 1. The committee should include:

• Emergency medicine physicians 1
• Trauma surgeons 1
• Geriatricians 1
• Critical care specialists 1
• Nursing leadership 1
• Quality improvement specialists 1

Annual protocol updates should incorporate new evidence on frailty assessment tools, modified triage thresholds, and outcome data from the institution's experience 1.