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OBJECTIVES To evaluate, in a cohort of adults ≥80 years old, the frailty status at the emergency department (ED) admission, for the in-hospital death risk stratification of patients needing major surgical procedures. DESIGN Single-center prospective observational cohort study. SETTING AND PARTICIPANTS The study was conducted in the ED of a teaching hospital. We enrolled all patients ≥80 years old consecutively admitted to the ED for conditions requiring urgent surgical procedures, between 2018 and 2021. METHODS Clinical variables and frailty status assessed in the ED were evaluated for the association with all-cause in-hospital death. The parameters evaluated were frailty [assessed by the Clinical Frailty Scale (CFS)], comorbidities, physiological parameters, type of surgery needed, laboratory values at admission. Cox regression analysis was used to identify independent risk factors for poor outcomes. RESULTS The study enrolled 1039 patients aged ≥80 years [median age 85 years (interquartile range 82-89); 445 males (42.8%)]. Overall, 127 patients (12.2%) were classified as nonfrail (CFS score 1-3), 722 (69.5%) as mild frail (CFS score 4-6), and 190 (18.3%) as frail (CFS score 7-9). The covariate-adjusted analysis revealed that severe frailty [hazard ratio (HR) 12.55, 95% CI 2.96-53.21, P = .016], ≥3 comorbidities (HR 2.08, 95% CI 1.31-3.31, P = .002), shock at ED presentation (HR 3.58, 95% CI 2.16-5.92, P < .001), anemia (HR 1.88, 95% CI 1.17-3.04, P = .009), and neurosurgery procedures (HR 3.97, 95% CI 1.98-7.96, P < .001) were independent risk factors for in-hospital death. CONCLUSIONS AND IMPLICATIONS In patients aged ≥80 years undergoing urgent surgical procedures, the evaluation of functional status in the ED could predict the risk of in-hospital death. Frail patients have an increased risk of death and major complications, whereas those with mild frailty have a similar prognosis compared with the more fit ones. Nonsurgical management should be considered in the case of severely frail and comorbid patients aged ≥80 years needing neurosurgery or abdominal surgery.