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Frailty and Associated Outcomes and Resource Utilization Among Older ICU Patients With Suspected Infection

Fernando, Shannon M. MD, MSc1,2; McIsaac, Daniel I. MD, MPH3,4,5; Perry, Jeffrey J. MD, MSc2,4,5; Rochwerg, Bram MD, MSc6,7; Bagshaw, Sean M. MD, MSc8; Thavorn, Kednapa PhD4,5; Seely, Andrew J. E. MD, PhD1,4,5,9; Forster, Alan J. MD, MSc4,5,10; Fiest, Kirsten M. PhD11; Dave, Chintan MD10; Tran, Alexandre MD, MSc4,9; Reardon, Peter M. MD1,2; Tanuseputro, Peter MD, MHSc4,5,12,13; Kyeremanteng, Kwadwo MD, MHA1,5,13

doi: 10.1097/CCM.0000000000003831
Online Clinical Investigations
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Objectives: Suspected infection and sepsis are common conditions seen among older ICU patients. Frailty has prognostic importance among critically ill patients, but its impact on outcomes and resource utilization in older patients with suspected infection is unknown. We sought to evaluate the association between patient frailty (defined as a Clinical Frailty Scale ≥ 5) and outcomes of critically ill patients with suspected infection. We also evaluated the association between frailty and the quick Sequential Organ Failure Assessment score.

Design: Analysis of a prospectively collected registry.

Setting: Two hospitals within a single tertiary care level hospital system between 2011 and 2016.

Patients: We analyzed 1,510 patients 65 years old or older (at the time of ICU admission) and with suspected infection at the time of ICU admission. Of these, 507 (33.6%) were categorized as “frail” (Clinical Frailty Scale ≥ 5).

Interventions: None.

Measurements and Main Results: The primary outcome was in-hospital mortality. A total of 558 patients (37.0%) died in-hospital. Frailty was associated with increased risk of in-hospital death (adjusted odds ratio, 1.81 [95% CIs, 1.34–2.49]). Frailty was also associated with higher likelihood of discharge to long-term care (adjusted odds ratio, 2.06 [95% CI, 1.50–2.64]) and higher likelihood of readmission within 30 days (adjusted odds ratio, 1.83 [95% CI, 1.38–2.34]). Frail patients had increased ICU resource utilization and total costs. The combination of frailty and quick Sequential Organ Failure Assessment greater than or equal to 2 further increased the risk of death (adjusted odds ratio, 7.54 [95% CI, 5.82–9.90]).

Conclusions: The presence of frailty among older ICU patients with suspected infection is associated with increased mortality, discharge to long-term care, hospital readmission, resource utilization, and costs. This work highlights the importance of clinical frailty in risk stratification of older ICU patients with suspected infection.

1Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.

2Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.

3Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada.

4School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.

5Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.

6Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.

7Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.

8Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.

9Department of Surgery, University of Ottawa, Ottawa, ON, Canada.

10Department of Medicine, University of Ottawa, Ottawa, ON, Canada.

11Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.

12Bruyere Research Institute, Ottawa, ON, Canada.

13Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.

Drs. Fernando, McIsaac, Perry, Rochwerg, Bagshaw, and Kyeremanteng designed the study. Drs. Fernando, Dave, and Kyeremanteng gathered the data. Drs. Fernando, McIsaac, Perry, Rochwerg, Bagshaw, Thavorn, Seely, Forster, Fiest, Tran, Reardon, Tanuseputro, and Kyeremanteng analyzed the data. All authors wrote the manuscript.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Dr. Bagshaw is supported by a Canada Research Chair in Critical Care Nephrology. Dr. Seely holds patents related to multiple organ variability analysis and has shares in Therapeutic Monitoring Systems. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: sfernando@qmed.ca

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