Inter-team Variability in Clinical Frailty Scale Scoring Within a Major Trauma Pathway: A Quality Improvement Study

Introduction

Frailty assessment is increasingly embedded within acute care pathways and informs escalation decisions, peri-operative risk stratification and orthogeriatric referral. Although the Clinical Frailty Scale (CFS) is widely used, it remains uncertain whether different clinical teams assign the same score to the same patient during routine care.

Variation in CFS documentation and scoring was suspected between the Emergency Department (ED) and Major Trauma Service (MTS). We aimed to evaluate documentation, inter-team agreement and the potential impact of score discordance on trauma-orthogeriatric referral decisions.

Method

We conducted a retrospective quality improvement audit of patients aged ≥65 years discussed at MTS between December 2025 and January 2026. Documentation rates within ED, pre-MTS and MTS records were assessed, together with inter-rater agreement and clinically significant discordance (CFS ≥4 referral threshold).

Results

Of 135 patients reviewed, 122 were included.

MTS documentation was 96.8%. Pre-MTS documentation was 45.9%, increasing to 60.4% among patients assessed within the ED pathway.

Among patients with documented CFS scores in both teams, exact agreement occurred in only 30.4%. Referral-threshold discordance suggested potential under-referral in 30.3% of included patients. Among 56 comparable Pre-MTS–MTS pairs, 25.0% showed potential unnecessary referral, equivalent to 11.5% of all included patients, indicating differences in referral classification.

Most undocumented ED frailty assessments occurred in patients aged ≥75 years despite this group representing the principal target population for ED frailty screening initiatives.

Our audit identified substantial inter-observer variation in CFS scoring between teams assessing the same patient during the same admission episode.

Conclusion(s)

Previous studies have focused on CFS implementation and inter-rater reliability, predominantly within ED. Our study extends this by examining agreement between ED and MTS in routine practice and the potential impact of score discordance on trauma-orthogeriatric referral decisions. These findings suggest that implementation should be evaluated not only by documentation rates, but also by agreement between clinical teams and the potential consequences of score discordance for patient management.