key: cord-1054852-83rgmdh0
authors: Mandora, Elena; Comini, Laura; Olivares, Adriana; Fracassi, Michela; Cadei, Maria Grazia; Paneroni, Mara; Marchina, Lucia; Suruniuc, Adrian; Luisa, Alberto; Scalvini, Simonetta; Corica, Giacomo; Vitacca, Michele
title: Patients recovering from COVID‐19 pneumonia in sub‐acute care exhibit severe frailty: Role of the nurse assessment
date: 2021-02-03
journal: J Clin Nurs
DOI: 10.1111/jocn.15637
sha: eb326cb763a50f50b70935b03ceb57b32e0b6c81
doc_id: 1054852
cord_uid: 83rgmdh0

AIMS AND OBJECTIVES: To document the level of frailty in sub‐acute COVID‐19 patients recovering from acute respiratory failure and investigate the associations between frailty, assessed by the nurse using the Blaylock Risk Assessment Screening Score (BRASS), and clinical and functional patient characteristics during hospitalisation. BACKGROUND: Frailty is a major problem in patients discharged from acute care, but no data are available on the frailty risk in survivors of COVID‐19 infection. DESIGN: A descriptive cross‐sectional study (STROBE checklist). METHODS: At admission to sub‐acute care in 2020, 236 COVID‐19 patients (median age 77 years – interquartile range 68–83) were administered BRASS and classified into 3 levels of frailty risk. The Short Physical Performance Battery (SPPB) was also administered to measure physical function and disability. Differences between BRASS levels and associations between BRASS index and clinical parameters were analysed. RESULTS: The median BRASS index was 14.0 (interquartile range 9.0–20.0) denoting intermediate frailty (32.2%, 41.1%, 26.7% of patients exhibited low, intermediate and high frailty, respectively). Significant differences emerged between the BRASS frailty classes regards to sex, comorbidities, history of cognitive deficits, previous mechanical ventilation support and SPPB score. Patients with no comorbidities (14%) exhibited low frailty (BRASS: median 5.5, interquartile range 3.0–12.0). Age ≥65 years, presence of comorbidities, cognitive deficit and SPPB % predicted <50% were significant predictors of high frailty. CONCLUSIONS: Most COVID‐19 survivors exhibit substantial frailty and require continuing care after discharge from acute care. RELEVANCE TO CLINICAL PRACTICE: The BRASS index is a valuable tool for nurses to identify those patients most at risk of frailty, who require a programme of rehabilitation and community reintegration.

There is wide variation in the clinical presentations of coronavirus disease 2019 infectious disease, ranging from no symptoms at all to pneumonia with Acute Respiratory Failure (ARF; Grasselli et al., 2020; Lian et al., 2020) . ARF is associated with prolonged functional impairment in many individuals, and the recovery from this critical illness is fraught with challenges (Gandotra et al., 2019) .

After severe COVID-19 disease, many patients will experience a variety of problems in normal functioning and will require either rehabilitation to overcome these problems (Brown et al., 2017; Herridge et al., 2016) or continuity of care when at home to improve their self-management, functional ability, physical disability and return to participation in society.

The problem of frailty-defined as a multidimensional loss of reserves, energy, physical ability, cognition and health (Rockwood, 2005) -is a major issue in people following discharge from hospital-and nursing attention worldwide is focused to capture patients' unmet needs (Allen et al., 2014; Blaylock & Cason, 1992; Carroll & Dowling, 2007; Mistiaen et al., 1997; Wolock et al., 1987) . Screening prior to discharge on these problems is a necessary basis for correct discharge planning (DP) to decide when, where and how to discharge frail subjects (Carroll & Dowling, 2007; Wolock et al., 1987) . The Blaylock Risk Assessment Screening Score (BRASS) was designed to identify patients in need of DP (Blaylock & Cason, 1992; Cammilletti et al., 2018) who are 'at risk' of long-term hospitalisation and with a home environment that is challenging. Although clinical recommendations on the use of frailty tools were proposed during the COVID-19 pandemic, mainly to support decision-making about an escalation plan and to avoid ageism (Maltese et al., 2020) , no data are available, on the frailty risk in COVID-19 infectious disease survivors.

The aim of this cross-sectional study was to evaluate the level of frailty in a large cohort of COVID-19 patients with ARF admitted to a subacute unit to stabilise their clinical condition after discharge from acute care. We investigated potential associations between frailty assessed by BRASS and patients' clinical characteristics during hospitalisation. The secondary aim was to re-evaluate, in a subgroup of patients referred to rehabilitation, the BRASS index at admission to the programme.

A descriptive cross-sectional study design was employed to explore the relationships between BRASS index and clinical/functional patient characteristics during hospitalisation ( Figure 1 ). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross-sectional study was used as guideline (File S1).

All consecutive patients with COVID-19 infection and pneumonia transferred from an acute hospital setting to the sub-acute unit of the Lumezzane (Brescia) centre of Istituti Clinici Scientifici (ICS) Maugeri between 10 March-10 June 2020 were screened for inclusion (see study flow chart, Figure 1 ).

At admission to the ICS sub-acute unit, anthropometric measures (age and body mass index), number of comorbidities and presence or not of cognitive deficits (from the medical history) were collected. Information regarding the patient's respiratory conditions such as need of inspiratory fraction of oxygen (FiO 2 ), value of pulsed oxygenation (SpO 2 ), ratio between SpO 2 /FiO 2 , presence of tracheostomy and use during the acute stay of mechanical ventilation (intubation, non-invasive ventilation [NIV] or continuous positive airway pressure [CPAP] ) was also analysed. In addition, at admission, physical performance-that is motor disability, walking ability, muscle leg function and balance-was assessed by the Short Physical Performance Battery (SPPB; Guralnik et al., 1994) and normalised for the predicted normal values (Bergland & Strand, 2019) . SPPB results were expressed as ratio % of predicted.

Patients were also administered the BRASS index to verify risk of frailty and identify patients 'at risk' of long-term hospitalisation and/or a complicated discharge procedure. The BRASS index (see Figure 1 in Appendix 1) investigates the following items: age, functional status, cognitive status, social support and living conditions, number of previous hospitalisations/emergency room visits, number of active clinical problems, behavioural model, mobility, sensory deficits and number of medications. Predicted validity and reliability of BRASS Index were investigated in a large population What does this paper contribute to the wider global community?

• The majority of COVID-19 survivors exhibit substantial frailty after discharge from acute hospital and require continuity of care.

• Predicting high-risk patients and identifying them early for optimal discharge planning and rehabilitative needs should be one of the aims of post-acute care.

• BRASS index could be a valuable tool in directing nurses' attention to patients at highest risk of frailty.

of Italian patients by Dal Molin et al. (2014) . Patients are classified into three risk classes: low risk (score from 0-10), that is individuals with limited disability not requiring special efforts to organise their discharge; medium risk (score 11-19) , that is patients with complex clinical situations requiring discharge planning, but probably without risk of institutionalisation; and high risk (score ≥20), that is patients with problems probably requiring continuity of care in a rehabilitation facility or institution (Blaylock & Cason, 1992; Cammilletti et al., 2018) .

During their stay in the sub-acute unit, patients underwent medical and nursing care according to their needs with the aim to stabilise their clinical condition and wean them from oxygen and mechanical ventilation if present. Mobilisation and callisthenic/walking exercises were also proposed by physiotherapists. The BRASS index was evaluated at admission to the sub-acute unit.

At discharge from the sub-acute unit, when signs of COVID-19 infection were negative, patients were evaluated to determine whether they could be discharged home or should be referred for rehabilitation.

Criteria for inpatient rehabilitation in our institute were residual disability, multi-comorbidity, hypoxaemia and/or dyspnoea during exercise or at rest, and a reduced exercise tolerance (Vitacca, Lazzeri, et al., 2020) .

In the subgroup of patients referred to rehabilitation, the BRASS index was repeated on admission to inpatient rehabilitation, and the score was compared with the previous test. The length of stay in the subacute unit (approximately three weeks) was similar in this subgroup of patients; thus, the pre-to post-BRASS comparison was applicable.

The study was approved by Local Review Board and Ethics Committee (2440 CEC, 26 May 2020). All evaluations were in conformity with the Declaration of Helsinki. All patients signed an informed written consent prior to participation. 

Of 271 and 34% were bedridden, 43% had sensory deficits, and more than 85% had had at least 1 hospitalisation in the 3 months prior. All patients presented medical problems (56% had more than 5 problems) and 65% were taking more than 5 drugs. However, the distribution of patients belonging to the classes significantly changed, as shown in Table 3 (p < .0001). The medium-risk class was the most unstable one and showed the highest rate of worsening with respect to the other two classes, and the rate of improvement in the high-risk class was greater than the rate of worsening observed in the low-risk class.

These findings show that frailty is highly prevalent in patients with the health service and reinforces the sense of teamwork in all care conditions. Assessment of an individualised, progressive treatment plan which focuses on function, disability and return to participation in society would help each patient to maximise his/her functional ability and quality of life (Allen et al., 2014; Blaylock & Cason, 1992; Carroll & Dowling, 2007; Mistiaen et al., 1997; Wolock et al., 1987) . Careful consideration of the frailty risk is a mandatory need for nursing care (Allen et al., 2014; Blaylock & Cason, 1992; Carroll & Dowling, 2007; DʼSouza et al., 2020) .

After severe COVID-19 disease, many patients experience a deficit in self-management, functional ability and participation (Brown et al., 2017; Herridge et al., 2016) : a continuity of care plan to improve these handicaps would be welcome. In a recent nursing consensus on caring for patients with COVID-19, the authors stressed the need to assess the health needs of patients using scales to evaluate and find abnormalities during this process, and intervene early to improve connections with the community, hospitals, and other institutions to provide extended care for the patient. During the first pandemic wave of COVID-19, many rehabilitative services had, like ours, to be re-adapted (Simonelli et al., 2020; Vitacca, Migliori, et al., 2020) to sustain health care in patients coming from the acute wards. Since there is no validated generic checklist for all conditions, our nurses used the BRASS index to classify the frailty condition of each patient with COVID-19. The BRASS index may present low specificity (Mistiaen et al., 1999) but it has good sensitivity (Chaboyer et al., 2002; Signorini et al., 2016) and

it is easy to use (Dal Molin et al., 2014) . The BRASS index meets three fundamental psychometric criteria. It is (a) multidimensional (outcomes are measured by a range of parameters, both clinic-functional and psycho-social); (b) multi-axial (outcomes are measured from different points of view, that is the patient's, doctor's, nurse's, physiotherapist's, social worker's and caregiver's); and (c) longitudinal (the outcomes should be measured at repeated points across a protracted period of time).

As expected, the BRASS items found to be most frequently pathological related to both physical and cognitive dysfunctions:

impairment in ADLs such as bathing/grooming and transferring, altered behaviour, confusion, limitation in mobilisation, sensory deficit, history of previous hospitalisation, medical problems and need of >5 drugs. Variables that predicted a pathological value of the BRASS index were age, multi-comorbidity, disability and cognitive deficits.

The findings of impaired physical function status related to frailty in our study population validate recommendations to refer COVID-19 survivors to individualised and multicomponent assessment.

Accordingly, an alert score for the early detection of frailty should be considered for all patients, but in particular for those with comorbidities. Undoubtedly, patients with comorbidities usually take a longer period to return to their former condition (Gandotra et al., 2019) . It is not surprising that patients with comorbidities are also those with higher frailty. However, of note, even amongst patients without comorbidities, we found that 31.4% had an intermediate or high level of frailty.

It is of particular interest that the patients with the greatest frailty were those who also had least recourse to mechanical ventilation during their period of stay in the acute hospital. In contrast, patients with low frailty had greater access to mechanical ventilation. These patients were also of younger age and had no or few comorbidities, so they were ideal candidates for intensive care therapies (i.e. they had more chance of a good outcome) especially in a period of health catastrophe re-organisation such as that during the dramatic COVID spread.

Another important finding of our study is that the BRASS index may be a useful tool to apply when one suspects the need to transfer the patient to an acute hospital or to a structured rehabilitation programme. Indeed, patients at medium and high risk required admission to a rehabilitation facility in more than half of the cases (Table 1) .

Traditionally, the BRASS index is used to 'move' a patient from hospital to home, but it has also been used to transfer patients from one hospital structure to another (Allen et al., 2014 target patients' needs more precisely. Using the BRASS index as a process rather than as an isolated event seems the best modality to combine shared decisions between health staff and patient/family.

Two methodological considerations could limit the strength and interpretation of our findings. First, the presence of cognitive deficits was derived from the patient's medical history, collected in the acute hospital, and was not available for the whole sample due to the COVID-19 emergency. Second, the change in BRASS index between the two admission points (sub-acute unit and rehabilitation)

was assessed only in a select group of patients and not in the overall sample.

The majority of COVID-19 survivors exhibit substantial frailty after discharge from acute hospital and require continuity of care. Such a care programme could be better planned if based on the needs identified by the BRASS index as this is a valuable tool in directing nurses' attention to patients at highest risk of frailty and can indicate the need for rehabilitation and community reintegration.

Our study shows that patients with COVID-19 may experience a wide variety of limitations and problems shortly after discharge from hospital and have unmet needs. It is consequently important for nurses to look critically at the information strategies they currently use and find ways to improve them. Predicting high-risk patients and identifying them early for optimal discharge planning and rehabilitative needs seems the most useful strategy.

We thank all doctors, nurses and physiotherapists employed in the ICS Maugeri Hospital of Lumezzane (Bs) Italy involved in the COVID-19 crisis for their tireless dedication (see Appendix 2). We thank Rosemary Allpress for the English revision of the manuscript.

The authors have no conflict of interest to declare.

Data: MV; Data integrity: GC; Accuracy of the data analysis: LC and AO. Study design, data analysis and interpretation, investigation on the accuracy and integrity of the contents, approval of the final version and writing of the manuscript: All authors; Guarantor of the paper, taking responsibility for the integrity of the work as a whole, from inception to published article: MV.

The data that support the findings of this study are available from the corresponding author upon reasonable request. FIGURE 1 BRASS scale reproduced as reported in Blaylock and Cason (1992) 

Circle all that apply and total. Refer to scoring index for recommendations regarding discharge planning. • 0-10 = At risk for home care resources • 11-19 = At risk for extended discharge planning • Greater than 20 = At risk for placement other than home. If score is 10 or greater, refer the patient for discharge coordination or discharge planning team

See in details all doctors, nurses and physiotherapists employed in the ICS Maugeri Hospital of Lumezzane (Bs) Italy and involved in the

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