Association between preadmission frailty and care level at discharge in older adults undergoing emergency laparotomy
Authors: Carter B , Law J , Hewitt J , Parmar K L , Boyle J M , Casey P , Maitra I , Pearce L , Moug S J , Ross Bryony , Oleksiewicz Julia , Fearnhead Nicola , Jump Christopher , Boyle Jemma , Shaw Alex , Barker Jonathan , Hughes Jane , Randall Jonathan , Tonga Isileli , Kynaston James , Boal Matthew , Eardley Nicola , Kane Elizabeth , Reader Harriet , Mahapatra Sunanda Roy , Garner-Jones Michael , Tan Jessica Juliana , Mohamed Said , George Rina , Whiteman Ed , Malik Kamran , Smart Christopher J , Bogdan Monica , Chaudhury Madhu Parna , Sharma Videha , Subar Daren , Patel Panna , Chok Sok-Moi , Lim Evelyn , Adhiyaman Vedamurthy , Davies Glesni , Ross Ellen , Maitra Rudra , Steele Colin W , Roxburgh Campbell , Griffiths Shelly , Blencowe Natalie S , Kirkham Emily N , Abraham John S , Griffiths Kirsty , Abdulaal Yasser , Iqbal Muhammad Rafaih , Tarazi Munir , Hill James , Khan Azam , Farrell Ian , Conn Gemma , Patel Jugal , Reddy Hyder , Sarveswaran Janahan , Arunachalam Lakshmanan , Malik Afaq , Ponchietti Luca , Pawelec Krystian , Goh Yan Mei , Vitish-Sharma Parveen , Saad Ahmed , Smyth Edward , Crees Amy , Merker Louise , Bashir Nahida , Williams Gethin , Hayes Jennifer , Walters Kelly , Harries Rhiannon , Singh Rahulpreet , Henderson Nikola A , Polignano Francesco M , Knight Ben , Alder Louise , Kenchington Alexandra , Goh Yan Li , Dicurzio Ilaria , Griffiths Ewen , Alani Ahmed , Knight Katrina , MacGoey Patrick , Ng Guat Shi , Mackenzie Naomi , Maitra Ishaan , Moug Susan , Ong Kelly , McGrath Daniel , Gammeri Emanuele , Lafaurie Guillame , Faulkner Gemma , Di Benedetto Gabriele , McGovern Julia , Subramanian Bharathi , Narang Sunil Kumar , Nowers Jennifer , Smart Neil J , Daniels Ian R , Varcada Massimo , Gala Tanzeela , Cornish Julie , Barber Zoe , O'Neill Stephen , McGregor Richard , Robertson Andrew G , Paterson-Brown Simon , Raymond Thomas , Thaha Mohamed A , English William J , Forde Cillian T , Paine Heidi , Morawala Alpa , Date Ravindra , Casey Patrick , Bolton Thomas , Gleaves Xuan , Fasuyi Joshua , Durakovic Sanja , Dunstan Matt , Allen Sophie , Riga Angela , Epstein Jonathan , Pearce Lyndsay , Gaines Emily , Howe Anthony , Choonara Halima , Dewi Ffion , Bennett Joanne , King Emile , McCarthy Kathryn , Taylor Greg , Harris Dean , Nageswaran Hari , Stimpson Amy , Siddiqui Kamran , Lim Lay In , Ray Christopher , Smith Laura , McColl Gillian , Rahman Mohammed , Kler Aaron , Sharma Abhi , Parmar Kat , Patel Neil , Crofts Perry , Baldari Claudio , Thomas Rhys , Stechman Michael , Aldridge Roland , O'Kelly James , Wilson Graeme , Gallegos Nicholas , Kalaiselvan Ramya , Rajaganeshan Rajasundaram , Mackenzie Aliya , Naik Prashant , Singh Kaushiki , Gandraspulli Harinath , Wilson Jeremy , Hancorn Kate , Khawaja Amir , Nicholas Felix , Marks Thomas , Abbott Cameron , Chandler Susan 
Published: January 2020

Abstract

Background
Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.

Methods
The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.

Results
A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.

Conclusion
Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.