Reply to “Comment on ‘Frailty Alerts Reduce Waiting Time and Length of Stay in the Emergency Department’”

We appreciate the commentary by Putra, who raises the question of whether social vulnerability should be incorporated into emergency department (ED) frailty alert systems. The argument that clinical frailty assessment without social context may lead to operationally efficient but potentially unsafe disposition decisions merits consideration, and we agree that Putra identifies a genuine gap between what frailty screening instruments formally capture and what ultimately influences post-discharge outcomes. Social factors, including living situation, caregiver availability, and social isolation, are relevant to clinical decision-making for older ED patients and are conceptually linked to the broader construct of frailty 1. We concur that a purely biomedical frailty assessment risks overlooking determinants that shape the safety and feasibility of discharge plans. We would note, however, that much of this social information is already elicited during emergency care encounters, albeit informally. In a recent qualitative study from our group, older patients described sharing details about their home situations, partner support, and functional capacity during Clinical Frailty Scale (CFS) assessment, prompted by relational communication from ED staff. Staff routinely inquired whether patients lived alone, had access to home care services, or had family members available—information that both guided the CFS rating and invited disclosure of contextual information beyond what the instrument strictly requires 2. Separate work on CFS feasibility in the ED has similarly shown that the nature of the assessment may help in adapting the care process beyond the point of ED care 3. Thus, social context is not absent from current practice; it is gathered inconsistently and without structured documentation, but may still contribute to improved quality of care. We agree with Putra that this information should be captured more systematically and that doing so need not demand substantial additional resources. The more fundamental question, however, is how such information should be operationalized. Social isolation and loneliness, for instance, are conceptually distinct constructs with different measurement properties and different relationships to health outcomes 4. Translating a patient's report that they “live alone” into a modifiable risk that meaningfully alters the ED workup or disposition requires validated instruments and interventions—neither of which currently exist in the ED setting. Before additional dimensions are incorporated into frailty screening, it is important to note that patients need to understand the consequences of the assessment 2, and that staff, in turn, require actionable pathways to make the assessment clinically meaningful 3. Importantly, many potential interventions related to social vulnerability may exist on the societal level, outside the scope of the ED, making both operationalization and generalizability challenging. Without operationalization, however, adding social data points risks creating an illusion of comprehensiveness without changing clinical decisions. Future research should therefore address not only whether social vulnerability can be assessed at triage but also how it should be measured, at what threshold it should trigger actions, and—most importantly—which actions are effective. This is also a prerequisite for meaningful integration into frailty alert systems. We agree with Putra regarding patient-centered outcomes being a cardinal aspect; hence, our recommendation is to focus future research on how frailty-attuned routines in the ED impact patient experience and patient-related outcomes. The data that support the findings of this study are available from the corresponding author upon reasonable request.