Geriatric Screening, Triage Urgency, and 30-Day Mortality in Older Emergency Department Patients

Abstract

Background: Urgency triage in the emergency department (ED) is important for early identification of potentially lethal conditions and extensive resource utilization. However, in older patients, urgency triage systems could be improved by taking geriatric vulnerability into account. We investigated the association of geriatric vulnerability screening in addition to triage urgency levels with 30-day mortality in older ED patients.

Design: Secondary analysis of the observational multicenter Acutely Presenting Older Patient (APOP) study.

Setting: EDs within four Dutch hospitals.

Participants: Consecutive patients, aged 70 years or older, who were prospectively included.

Measurements: Patients were triaged using the Manchester Triage System (MTS). In addition, the APOP screener was used as a geriatric screening tool. The primary outcome was 30-day mortality. Comparison was made between mortality within the geriatric high- and low-risk screened patients in every urgency triage category. We calculated the difference in explained variance of mortality by adding the geriatric screener (APOP) to triage urgency (MTS) by calculating Nagelkerke R² .

Results: We included 2,608 patients with a median age of 79 (interquartile range = 74-84) years, of whom 521 (20.0%) patients were categorized as high risk according to geriatric screening. Patients were triaged on urgency as standard (27.2%), urgent (58.5%), and very urgent (14.3%). In total, 132 (5.1%) patients were deceased within a period of 30 days. Within every urgency triage category, 30-day mortality was threefold higher in geriatric high-risk compared to low-risk patients (overall = 11.7% vs 3.4%; P < .001). The explained variance of 30-day mortality with triage urgency was 1.0% and increased to 6.3% by adding the geriatric screener.

Conclusion: Combining triage urgency with geriatric screening has the potential to improve triage, which may help clinicians to deliver early appropriate care to older ED patients. J Am Geriatr Soc 68:1755-1762, 2020.

Keywords: emergency department; geriatric assessment; geriatric emergency medicine; risk stratification; triage.

Figure 1

The 30‐day mortality by Manchester Triage System (MTS) category and Acutely Presenting Older Patient (APOP) screening result separately. A, The 30‐day mortality rate for patients stratified by MTS category standard, urgent, or very urgent. The χ² test was used to compare differences in mortality between the MTS categories. B, The 30‐day mortality rate for patients stratified by APOP low‐risk or high‐risk screening result. The χ² test was used to compare differences in mortality between the APOP low‐risk and high‐risk screened patients. The upper 95% confidence intervals for proportion are shown.

Figure 2

The 30‐day mortality by Manchester Triage System (MTS) category and Acutely Presenting Older Patient (APOP) screening result combined. The 30‐day mortality percentages for patients stratified by MTS category and APOP screening result combined. The upper 95% confidence intervals (CIs) for proportion are shown. Relative risks (RRs) were calculated to compare differences in mortality between APOP low‐risk and high‐risk screened patients within all three MTS categories, resulting in significant differences within the standard category (RR = 2.8; 95% CI = 1.2‐6.5; P = .021), the urgent category (RR = 3.4; 95% CI = 2.3‐5.1; P < .001), and the very urgent category (RR = 3.4; 95% CI = 1.7‐7.1; P = .001). Nagelkerke R² was calculated for MTS alone (R² = 0.010), APOP alone (R² = 0.056), and MTS and APOP combined (R² = 0.063).

Figure 3

Reclassification concept: upgrade of one Manchester Triage System (MTS) category for Acutely Presenting Older Patient (APOP) high‐risk patients. A reclassification concept for the primary outcome, 30‐day mortality, in which every patient with an APOP high‐risk screening result is upgraded one MTS category. Very urgent patients with an APOP high‐risk result remained in the same very urgent category.