ASA or CFS for ICU Prediction in Geriatric Hip Fracture

Comparative Analysis of ASA Score and Clinical Frailty Scale in Predicting Postoperative Intensive Care Requirements in Geriatric Hip Fracture Surgery

The aim of this retrospective study is to compare the efficacy of the American Society of Anesthesiologists (ASA) physical status classification and the Clinical Frailty Scale (CFS) in predicting postoperative intensive care unit (ICU) requirements in geriatric patients undergoing hip fracture surgery. The investigators will analyze medical records of patients aged 65 and older. The study will evaluate whether the CFS provides better predictive value for ICU admission compared to the traditional ASA score in this specific surgical population.

Study Overview

• Status: Active, not recruiting
• Conditions: Intensive Care; Geriatric Assessment; Frailty at Older Adults; Hip Fracture Surgeries
• Intervention / Treatment: Other: Routine Surgical and Anesthetic Mnagement.

Detailed Description

Study Title Comparative analysis of American Society of Anesthesiologists (ASA) physical status classification and Clinical Frailty Scale (CFS) in predicting postoperative intensive care unit (ICU) admission in geriatric hip fracture surgery Introduction With the rapid increase in the elderly population worldwide, geriatric hip fracture cases have become one of the most critical health issues in anesthesia and surgical practice. This patient group is characterized not only by surgical trauma but also by reduced physiological reserve, multiple chronic diseases, and high frailty levels. Major complications following hip fracture surgery extend hospital stays, increase healthcare costs, and lead to high mortality rates. Therefore, predicting which patients will require intensive care unit (ICU) support in the preoperative period is vital for both patient safety and efficient hospital resource management.

The American Society of Anesthesiologists (ASA) physical status classification, widely used in traditional anesthesia practice, successfully defines a patient's systemic disease burden but does not fully reflect the biological resistance and functional capacity of an elderly individual against surgical stress. It is reported in the literature that patients with the same ASA score can have significantly different clinical outcomes; even with similar chronic disease burdens, patients defined as "frail" face worse postoperative results. The Clinical Frailty Scale (CFS), developed by Kenneth Rockwood, measures "biological aging" based on a patient's mobility level and independence in activities of daily living, revealing the "reserve depletion" that traditional scoring systems overlook.

The primary rationale for this study is to directly compare the success of the ASA score and the CFS in predicting the need for postoperative ICU admission in a geriatric hip fracture population. While both scores are known to have predictive value, their superiority over each other and their combined use in clinical decision-making remain controversial in acute trauma groups like hip fractures. This research will provide a scientific basis for anesthesiologists to use more sensitive tools in preoperative risk assessment and to develop appropriate triage strategies for patients in the "hidden risk" group (low ASA but high CFS scores).

Materials and Methods This study is a retrospective cohort study examining the data of patients aged 65 and older who underwent surgery for a hip fracture (femur neck, intertrochanteric, or subtrochanteric fracture) between November 2023 and December 2025. Approval was obtained from the relevant ethics committee, and the data of 243 patients with complete operative records were evaluated. Cases transferred to another center before surgery, those with inaccessible surgical data, or those followed conservatively were excluded. Demographic information such as age and gender, as well as comorbidities (hypertension, diabetes, coronary artery disease, dementia), preoperative laboratory values (hemoglobin, albumin, creatinine), and echocardiography findings, were obtained through the hospital information management system.

Among the parameters used for risk assessment, ASA scores were recorded directly from preoperative anesthesia forms. Clinical Frailty Scale (CFS) scores were retrospectively calculated based on the Rockwood scale by scoring functional data such as mobility levels, domestic independence, and history of assistive device use found in nursing follow-up notes. Intraoperative variables, including anesthesia technique (general or spinal), surgical duration, and the requirement for vasoactive drugs, were also included. The primary endpoint of the study is the requirement for postoperative ICU admission, while secondary endpoints include total ICU stay, development of delirium in the first 48 hours, myocardial injury after non-cardiac surgery (MINS), acute kidney injury (AKI), and in-hospital mortality.

Inclusion and Exclusion Criteria

Inclusion Criteria

Age: Patients aged 65 years and older.

Diagnosis: Acute traumatic hip fracture (femoral neck, intertrochanteric, or subtrochanteric).

Surgical Intervention: Patients scheduled for and undergoing surgery (arthroplasty, osteosynthesis, etc.) for a hip fracture.

Data Integrity: Complete records of preoperative ASA score, laboratory findings, and postoperative follow-up notes.

Functional Information: Sufficient clinical notes to allow for retrospective CFS scoring.

Exclusion Criteria

Pathological and Periprosthetic Fractures: Fractures due to bone metastasis/tumors or fractures occurring around an existing prosthesis.

Multi-trauma: Presence of other major organ injuries or additional extremity fractures.

Conservative Follow-up: Patients not undergoing surgery due to medical contraindications or preference.

Missing Data: Patients with incomplete records or those transferred to another center immediately post-op.

• Study Type: Observational
• Enrollment (Estimated): 200

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • Ankara, Turkey (Türkiye), 06630
    • Abdurrahman yurtarslan onkoloji eğitim ve araştırma hastanesi

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Probability Sample

Study Population

The study population consists of approximately 243 geriatric patients aged 65 years and older who underwent surgery for acute traumatic hip fracture (femoral neck, intertrochanteric, or subtrochanteric) at the Department of Anesthesiology and Reanimation, University of Health Sciences, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, between November 2023 and December 2025. The population includes patients with complete preoperative anesthesia records, ASA physical status scores, and sufficient clinical documentation for retrospective Clinical Frailty Scale (CFS) scoring

Description

Inclusion Criteria:Age: Patients aged 65 years and older.

Diagnosis: Patients diagnosed with acute traumatic hip fracture, including femoral neck, intertrochanteric, or subtrochanteric fractures.

Surgical Intervention: Patients who have undergone or are scheduled for surgical treatment (e.g., arthroplasty, internal fixation/osteosynthesis) for hip fracture.

Data Integrity: Availability of complete electronic health records, including preoperative anesthesia evaluation forms and ASA physical status scores.

Functional Assessment: Presence of sufficient clinical and nursing documentation to retrospectively determine the Clinical Frailty Scale (CFS) score based on preoperative functional status.

-

Exclusion Criteria:Pathological and Periprosthetic Fractures: Fractures resulting from bone metastases or those occurring around an existing prosthesis.

Multiple Trauma: Patients with concomitant major organ injuries or additional limb fractures that could impact clinical outcomes.

Conservative Management: Patients who did not undergo surgical intervention and were managed non-surgically.

Incomplete Data: Cases with missing ASA scores, laboratory results, or postoperative clinical follow-up data in the hospital records.

Insufficient Functional Documentation: Patients whose clinical or nursing notes are inadequate for retrospective determination of the Clinical Frailty Scale (CFS) score.

Patient Transfer: Patients transferred to another healthcare facility preoperatively or in the immediate postoperative period, leading to incomplete data follow-up.

-

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort

Intervention / Treatment

Geriatric Hip Fracture Cohort; This cohort includes retrospective data from approximately 200 patients aged 65 and older who underwent surgery for hip fractures (femoral neck, intertrochanteric, or subtrochanteric) between November 2023 and November 2025. The study evaluates the requirement for Intensive Care Unit (ICU) admission following routine surgical and anesthesia (general or spinal) interventions. The primary focus is to comparatively analyze the predictive value of preoperative ASA physical status classification and Clinical Frailty Scale (CFS) scores on patients' postoperative ICU needs and clinical outcomes

Other: Routine Surgical and Anesthetic Mnagement.; Since this is a retrospective record review, no new intervention is administered. The intervention name represents the standard surgical (arthroplasty or osteosynthesis) and anesthetic (general or spinal) management received by patients for hip fractures according to institutional protocols. The study analyzes the relationship between these routine clinical processes and preoperative ASA and CFS scores

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Postoperative Intensive Care Unit (ICU) Admission Requirement	Assessment of whether the patient required immediate postoperative admission to the intensive care unit due to clinical necessity, physiological instability, or the need for advanced monitoring.	Within 24 hours postoperatively

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Length of Stay in the Intensive Care Unit and Total Hospital Stay	Calculation of the total duration of stay in the intensive care unit (recorded in days) and the total hospital stay from the date of surgery until hospital discharge.	From the day of surgery until hospital discharge, up to 1 year
Postoperative Delirium	Assessment of clinical signs of delirium (such as acute confusion, disorientation, or agitation) as documented in medical and nursing follow-up notes.	Up to 48 hours postoperatively
Major Postoperative Complications	Frequency of major adverse events based on laboratory results and clinical findings, specifically including myocardial injury after non-cardiac surgery (MINS) and acute kidney injury (AKI).	From the end of surgery until hospital discharge, up to 30 days
In-hospital Mortality	Assessment of the all-cause mortality rate occurring during the patient's hospital stay following the surgical procedure.	From the day of surgery until hospital discharge, up to 30 days

Collaborators and Investigators

• Sponsor: Dr Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital

Publications and helpful links

General Publications

• Saetang M, Kunapaisal T, Chatmongkolchart S, Yongsata D, Sukitpaneenit K. Assessing frailty to predict surgical risk: a comparative study of three tools in older non-cardiac surgery patients. BMC Geriatr. 2025 Nov 21;25(1):941. doi: 10.1186/s12877-025-06683-1.
• Becerra-Bolanos A, Hernandez-Aguiar Y, Rodriguez-Perez A. Preoperative frailty and postoperative complications after non-cardiac surgery: a systematic review. J Int Med Res. 2024 Sep;52(9):3000605241274553. doi: 10.1177/03000605241274553.

Study record dates

Study Major Dates

• Study Start (Actual): March 30, 2026
• Primary Completion (Estimated): July 1, 2026
• Study Completion (Estimated): August 1, 2026

Study Registration Dates

• First Submitted: April 1, 2026
• First Submitted That Met QC Criteria: April 8, 2026
• First Posted (Actual): April 13, 2026

Study Record Updates

• Last Update Posted (Actual): May 28, 2026
• Last Update Submitted That Met QC Criteria: May 24, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Keywords: Risk Assessment; Geriatrics; Intensive Care Units; Postoperative Complications; Hip Fractures; Clinical Frailty Scale
• Additional Relevant MeSH Terms: Wounds and Injuries; Pathologic Processes; Leg Injuries; Fractures, Bone; Femoral Fractures; Hip Injuries; Pathological Conditions, Signs and Symptoms; Hip Fractures; Postoperative Complications
• Other Study ID Numbers: 2026-03/69

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: The datasets generated during the current study are not publicly available due to institutional regulations and the sensitive nature of patient medical records but are available from the corresponding author on reasonable request

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No