Hospital Discharge Follow-up Care of ICU Patients with Preadmission Frailty

About the Project

Frailty results from accumulated health problems and manifests as a loss in physical and cognitive function. People living with frailty want to remain active and independent. Frailty can present significant barriers for recovery after complex medical events, and result in the need for admission to the intensive care unit (ICU). Failure to fully recover can translate to new disability and dependence on others for help with daily activities. This is particularly relevant for older patients admitted to ICU.

In Alberta, we routinely assess frailty status at the time of ICU admission. However, at present we do not have a reliable process to ensure patients living with frailty are followed up, assessed and receive customized monitoring and therapy after discharge. We plan to use a frailty measure to ensure patients living with frailty prior to ICU admission receive an appointment at our ICU Survivorship Clinic after discharge from hospital. At the ICU Survivorship Clinic patients will receive a comprehensive assessment and plan to address physical, cognitive and mental health issues acquired during their ICU stay. The plan will be shared with their primary care provider and relevant specialists for ongoing care. We will capture information about these patients to develop frailty-specific strategies to mitigate disability, optimize recovery and preserve long-term functional independence after discharge.

We believe this work will be beneficial to our patients in the short- and long-term serving as a platform for future research to improve patient-centred outcomes and informing on future expansion of the ICU Survivorship Clinic.

Anticipated Findings

We expect that our standardized referral pathway will improve the consistency of post-discharge follow-up of frailty and PICS, with subsequent preservation of independence and reduced need for emergency care and hospital readmission.

Project Team

Principal Investigator:

Carmel Montgomery — University of Alberta


Sean Bagshaw — University of Alberta
Raiyan Chowdhury — University of Alberta
Joanne McPeake — University of Glasgow
Lazar Milovanovic — University of Alberta
Elizabeth Papathanassoglou — University of Alberta
Oleksa Rewa — University of Alberta
Darryl Rolfson — University of Alberta

Knowledge Users:

Samantha Bowker — Alberta Health Services
Sherri Kashuba — Alberta Health Services
Erika MacIntyre — Covenant Health
Evelyn MacKinnon — Covenant Health


Leanne Ellis — Patient Partner

Keywords: ICU; preadmission frailty; survivorship; critical illness

Background & Rationale


Every patient admitted to ICU in Alberta is assessed by an ICU physician and a Clinical Frailty Scale (CFS) score entered into their electronic health record. We recognize that patients admitted to ICU with frailty are likely to experience complications from their ICU stay and should be considered for post-discharge follow-up. Inconsistent communication of patient details during transitions in care from ICU to hospital wards and home present an opportunity for improvement that can benefit patients with frailty.


Post-ICU syndrome (PICS) is a complication of critical illness for ICU survivors. It is associated with new and worsening physical, cognitive and mental health impairment. Frailty has been shown to increase the risk of developing PICS. Both should be measured in ICU survivors. Instruments are available to screen for these syndromes and guide appropriate follow-up. Consistent follow-up of patients with preadmission frailty can ensure appropriate care of pre-ICU conditions and those acquired during critical illness. Edmonton is host to an ICU Survivorship Clinic led by ICU specialists. The clinic was established to help transition patients to primary care by providing comprehensive assessment and appropriate referrals to address PICS.

Research Plan & Hypothesis

Research Plan

We implement a standardized referral pathway for adults with pre-admission frailty admitted to ICU across the Edmonton Zone. We will follow all patients referred to the ICU Survivorship Clinic between January 1 – September 30, 2023, where they will undergo a review of their ICU admission and hospital course, and screening for PICS to initiate appropriate follow-up of care needs.


We hypothesize that patients with pre-admission frailty will achieve higher levels of independence following assessment and care-planning to address PICS at the ICU Survivorship Clinic.


Objective 1: To implement and evaluate a referral pathway for patients living with frailty to be seen in the ICU Survivorship Clinic following hospital discharge when they have had an ICU admission.

Objective 2: To describe the frequent care needs and experiences of patients with frailty referred to an ICU Survivorship Clinic.

Objective 3: To develop a stakeholder co-developed care planning resource to support clear and reliable communication between the ICU Survivorship Clinic, primary care and patients about follow-up after ICU Survivorship Clinic care.