Methods to improve acuity assessment for older adults in the emergency department

The purpose of acuity assessment, or triage, in the emergency department (ED) is to recognize critically ill patients and to allocate resources according to need. Evidence of validity regarding currently used triage instruments is limited, especially regarding older adults. With a rapidly ageing population and crowded ED’s, more precise acuity assessment instruments for older ED patients are needed. The main objective of this thesis was to assess the accuracy of the Emergency Severity Index (ESI) for older adults and to see if it can be improved by age adjustment. The secondary objectives were to explore the associations of an early warning score and local three level triage instrument with outcomes for older ED patients and to summarize and review current knowledge regarding patients presenting to the ED with nonspecific complaints. Study I compares the accuracy of the ESI for adults under 65 and 65 years or over in a Finnish ED. Results suggest that the ESI is associated with high dependency unit/intensive care unit (HDU/ICU) admission and 3-day mortality for older ED patients. Study II explores the effect of age adjustment on two triage methods for patients presenting in three Finnish ED’s. According to the results, age adjustment improves accuracy in predicting 30-day mortality and hospital admission. Study III assesses the accuracy of an early warning score (NEWS2) and a local three-level triage methods for frail older ED patients. Both methods were poor to moderate in predicting ED outcomes for older adults. Study IV is a systematic review and meta-analysis of patients presenting to the ED with nonspecific complaints. These patients have a higher in-hospital mortality rate, and their care require more time and resources than patients presenting with a specific complaint (SC). Yet NSC patients are triaged less often as urgent than SC patients. In conclusion, the ESI seems to be sufficiently accurate in our population in all age groups. Its predictive performance was superior to our local three-level method. Age adjustment improved the performance of both tools without excessive overtriage. These findings indicate that the ESI can be used in our population, including for older adults, to improve standards of acuity assessment. Patients presenting to the ED with an NSC have a higher risk of mortality and their care requires more time and resources than patients presenting with an SC. Increasing awareness and knowledge about this common syndrome can be utilized when creating treatment protocols and patient pathways for these patients.