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.Päivystyksen kiireellisyysluokituksen (triagen) tarkoitus on tunnistaa kriittisesti sairaat potilaat ja jakaa resurssit tarkoituksenmukaisesti. Yhdestäkään kiireellisyysluokittelumenetelmästä ei ole vahvaa näyttöä, erityisesti iäkkäiden potilaiden kohdalla, sillä iän mukanaan tuoma haurastuminen heikentää kiireellisyysluokitusten osuvuutta. Väestön ikääntyessä ja päivystyspoliklinikoiden ruuhkautuessa tarvitaan luotettavampia työkaluja kiireellisyyden arvioimiseksi. Tässä tutkimuksessa pyritään osoittamaan kansainvälisesti käytössä olevan Emergency severity indexin (ESI) luotettavuus suomalaisessa väestössä, erityisesti iäkkäiden potilaiden osalta. Pyritään selvittämään, paranisiko sen osuvuus, jos luokitusta muutettaisiin iän mukaan. Toisena tavoitteena on selvittää ennustavatko paikallinen triagemenetelmä tai poikkeavat peruselintoiminnot iäkkäiden päivystyspotilaiden selviytymistä. Lisäksi esitetään systemaattinen kirjallisuuskatsaus yleistilan lasku - potilaiden ennusteesta päivystyksessä. Ensimmäisessä osatyössä vertaillaan ESI:n osuvuutta yli ja alle 65-vuotiailla päivystyspotilailla. Tulosten mukaan ESI ennusti teho- ja valvontahoidon tarvetta sekä 3:n päivän kuolleisuutta iäkkäillä potilailla. Toisessa osatyössä havaittiin, että ESI:n osuvuus oli parempi kuin paikallisen 3-portaisen kiireellisyysluokituksen. Luokitusta iän perusteella muuttamalla pystyttiin parantamaan kummankin kiireellisyysluokituksen osuvuutta. Kolmannessa osatyössä tarkasteltiin peruselintoimintojen pisteytyksen (NEWS2) ja paikallisen kolmeportaisen luokituksen osuvuutta erityisen haurailla iäkkällä potilailla. Kummankin osuvuus oli melko heikko. Neljännessä osatyössä tehtiin systemaattinen kirjallisuuskatsaus ja meta-analyysi yleistilan lasku -potilaista päivystyksessä. Tulosten mukaan yleistilan lasku -potilaiden sairaalakuolleisuus oli korkeampi ja he tarvitsivat enemmän resursseja päivystyksessä verrattuna muihin potilaisiin. Silti heidät yleensä luokiteltiin hoidon tarpeen arviossa vähemmän kiireellisiksi. Yhteenvetona voidaan todeta, että ESI:n käyttöönotto saattaisi parantaa hoidon tarpeen arviota Suomessa. Yleistilan lasku -potilaiden ennuste on heikompi kuin muiden potilaiden, mikä tulisi ottaa huomioon päivystyksen hoitopolkujen suunnittelussa

A common definition should be used in future studies of NSC

Non peer reviewe

Effect of age adjustment on two triage methods

Background Most emergency departments rely on acuity assessment, triage, to recognize critically ill patients that need urgent treatment, and to allocate resources according to need. The accuracy of commonly used triage instruments such as the Emergency Severity Index (ESI) is lower for older adults compared to young patients. We aim to examine, whether adjusting the triage category by age leads to improvement in sensitivity without excessive increase in patient numbers in the higher triage categories. The primary outcome measure was 3-day mortality and secondary outcomes were 30-day mortality, hospital admission, and HDU/ICU admissions. Methods We gathered data of all adult patients who had an unscheduled visit to any of our three emergency departments within one month. The data was analysed for 3-day mortality, 30-day mortality, hospital admission, and high dependency unit or intensive care unit (HDU/ICU) admission. The analysis was run for both the standard ESI triage method and a local 3-level Helsinki University Hospital (HUH) method. A further analysis was run for both triage methods with age adjustment. Net reclassification improvement values were calculated to demonstrate the effect of age adjustment. Results Thirteen thousand seven hundred fifty-nine patients met the study criteria, median age was 57. 3-day mortality AUCs for unadjusted HUH and ESI triage were 0.77 (0.65-0.88) and 0.72 (0.57-0.87); 30-day mortality AUCs were 0.64 (0.59-0.69) and 0.69 (0.64-0.73); hospital admission AUCs were 0.60 (0.68-0.71) and 0.66 (0.65-0.68) and HDU/ICU admission AUCs were 0.67 (0.64-0.70) and 0.82 (0.79-0.86), respectively. Age adjustment improved accuracy for 30-day mortality and hospital admission. With the threshold age of 80, AUCs for 30-day mortality were 0.73 (0.68-0.77) and 0.77 (0.73-0.81) and for hospital admission, 0.66 (0.65-0.67) and 0.72 (0.71-0.73) for the HUH and ESI triage. The effect was similar with all cut off ages. Conclusion Moving older adults into a more urgent triage category based on age, improved the triage instruments' performance slightly in predicting 30-day mortality and hospital admission without excessive increase in patient numbers in the higher triage categories. Age adjustment did not improve HDU/ICU admission or 3-day mortality prediction.Peer reviewe

Accuracy of Emergency Severity Index in older adults

Background and importance Emergency Severity Index is a five-level triage tool in the emergency department that predicts the need for emergency department resources and the degree of emergency. However, it is unknown whether this is valid in patients aged greater than or equal to 65 years. Objective The aim of the study was to compare the accuracy of the Emergency Severity Index triage system between emergency department patients aged 18-64 and greater than or equal to 65 years. Design, settings, and participants This was a retrospective observational cohort study of adults who presented to a Finnish emergency department between 1 February 2018 and 28 February 2018. All data were collected from electronic health records. Outcome measures and analysis The primary outcome was 3-day mortality. The secondary outcomes were 30-day mortality, hospital admission, high dependency unit or ICU admission, and emergency department length of stay. The area under the receiver operating characteristic curve and cutoff performances were used to investigate significant associations between triage categories and outcomes. The results of the two age groups were compared. Main results There were 3141 emergency department patients aged 18-64 years and 2370 patients aged greater than or equal to 65 years. The 3-day mortality area under the curve in patients aged greater than or equal to 65 years was greater than that in patients aged 18-64 years. The Emergency Severity Index was associated with high dependency unit/ICU admissions in both groups, with moderate sensitivity [18-64 years: 61.8% (50.9-71.9%); greater than or equal to 65 years: 73.3% (63.5-81.6%)] and high specificity [18-64 years: 93.0% (92.0-93.8%); greater than or equal to 65 years: 90.9% (90.0-92.1%)]. The sensitivity was high and specificity was low for 30-day mortality and hospital admission in both age groups. The emergency department length of stay was the longest in Emergency Severity Index category 3 for both age groups. There was no significant difference in accuracy between age groups for any outcome. Conclusion Emergency Severity Index performed well in predicting high dependency unit/ICU admission rates for both 18-64 years and greater than or equal to 65-year-old patients. It predicted the 3-day mortality for patients aged greater than or equal to 65 years with high accuracy. It was inaccurate in predicting 30-day mortality and hospital admission for both age groups.Peer reviewe

Red cell distribution width and mortality in older patients with frailty in the emergency department

Peer reviewe

Low body temperature and mortality in older patients with frailty in the emergency department

Purpose The aim of this study was to assess the association between low body temperature and mortality in frail older adults in the emergency department (ED). Methods Inclusion criteria were: >= 75 years of age, Clinical Frailty Scale (CFS) score of 4-8, and temperature documented at ED admission. Patients were allocated to three groups by body temperature: low = 38.1. Odds ratios (OR) for 30-day and 90-day mortality were analysed. Results 1577 patients, 61.2% female, were included. Overall mortalities were 85/1577 (5.4%) and 144/1557 (9.2%) in the 30-day and 90-day follow-ups, respectively. The ORs for low body temperature were 3.03 (1.72-5.35; P < 0.001) and 2.71 (1.68-4.38; P < 0.001) for 30-day and 90-day mortality, respectively. This association remained when adjusted for age, CFS score and gender. Mortality of the high-temperature group did not differ significantly when compared to the normal-temperature group. Conclusions Low body temperature in frail older ED patients was associated with significantly higher 30- and 90-day mortality.Peer reviewe

National Early Warning Score 2 (NEWS2) and 3-Level Triage Scale as Risk Predictors in Frail Older Adults in the Emergency Department

Background The aim of the emergency department (ED) triage is to recognize critically ill patients and to allocate resources. No strong evidence for accuracy of the current triage instruments, especially for the older adults, exists. We evaluated the National Early Warning Score 2 (NEWS2) and a 3-level triage assessment as risk predictors for frail older adults visiting the ED. Methods This prospective, observational study was performed in a Finnish ED. The data were collected in a six-month period and included were >= 75-year-old residents with Clinical Frailty Scale score of at least four. We analyzed the predictive values of NEWS2 and the three-level triage scale for 30-day mortality, hospital admission, high dependency unit (HDU) and intensive care unit (ICU) admissions, a count of 72-h and 30-day revisits, and ED length-of-stay (LOS). Results A total of 1711 ED visits were included. Median for age, CFS, LOS and NEWS2 were 85 years, 6 points, 6.2 h and 1 point, respectively. 30-day mortality was 96/1711. At triage, 69, 356 and 1278 of patients were assessed as red, yellow and green, respectively. There were 1103 admissions, of them 31 to an HDU facility, none to ICU. With NEWS2 and triage score, AUCs for 30-day mortality prediction were 0.70 (0.64-0.76) and 0.62 (0.56-0.68); for hospital admission prediction 0.62 (0.60-0.65) and 0.55 (0.52-0.56), and for HDU admission 0.72 (0.61-0.83) and 0.80 (0.70-0.90), respectively. The NEWS2 divided into risk groups of low, medium and high did not predict the ED LOS (p = 0.095). There was a difference in ED LOS between the red/yellow and as red/green patient groups (p <0.001) but not between the yellow/green groups (p = 0.59). There were 48 and 351 revisits within 72 h and 30 days, respectively. With NEWS2 AUCs for 72-h and 30-day revisit prediction were 0.48 (95% CI 0.40-0.56) and 0.47 (0.44-0.51), respectively; with triage score 0.48 (0.40-0.56) and 0.49 (0.46-0.52), respectively. Conclusions The NEWS2 and a local 3-level triage scale are statistically significant, but poor in accuracy, in predicting 30-day mortality, and HDU admission but not ED LOS or revisit rates for frail older adults. NEWS2 also seems to predict hospital admission.Peer reviewe

Systematic geriatric assessment for older patients with frailty in the emergency department: a randomised controlled trial

BackgroundComprehensive geriatric assessment provided in hospital wards in frail patients admitted to hospital has been shown to reduce mortality and increase the likelihood of living at home later. Systematic geriatric assessment provided in emergency departments (ED) may be effective for reducing days in hospital and unnecessary hospital admissions, but this has not yet been proven in randomised trials.MethodsWe conducted a single-centre, randomised controlled trial with a parallel-group, superiority design in an academic hospital ED.ED patients aged >= 75 years who were frail, or at risk of frailty, as defined by the Clinical Frailty Scale, were included in the trial. Patients were recruited during the period between December 11, 2018 and June 7, 2019, and followed up for 365 days.For the intervention group, systematic geriatric assessment was added to their standard care in the ED, whereas the control group received standard care only.The primary outcome was cumulative hospital stay during 365-day follow-up. The secondary outcomes included: admission rate from the index visit, total hospital admissions, ED-readmissions, proportion of patients living at home at 365 days, 365-day mortality, and fall-related ED-visits.ResultsA total of 432 patients, 63% female, with median age of 85 years, formed the analytic sample of 213 patients in the intervention group and 219 patients in the control group.Cumulative hospital stay during one-year follow-up as rate per 100 person-years for the intervention and control groups were: 3470 and 3149 days, respectively, with rate ratio of 1.10 (95% confidence interval, 0.55-2.19, P=.78). Admission rates to hospital wards from the index ED visit for the intervention and control groups were: 62 and 70%, respectively (P=.10). No significant differences were observed between the groups for any outcomes.ConclusionSystematic geriatric assessment for older adults with frailty in the ED did not reduce hospital stay during one-year follow-up. No statistically significant difference was observed for any secondary outcomes. More coordinated, continuous interventions should be tested for potential benefits in long-term outcomes.Trial registrationThe trial was registered in the ClinicalTrials.gov (registration number and date NCT03751319 23/11/2018).Peer reviewe

Genome-wide association study of primary tooth eruption identifies pleiotropic loci associated with height and craniofacial distances

Twin and family studies indicate that the timing of primary tooth eruption is highly heritable, with estimates typically exceeding 80%. To identify variants involved in primary tooth eruption we performed a population based genome-wide association study of ‘age at first tooth’ and ‘number of teeth’ using 5998 and 6609 individuals respectively from the Avon Longitudinal Study of Parents and Children (ALSPAC) and 5403 individuals from the 1966 Northern Finland Birth Cohort (NFBC1966). We tested 2,446,724 SNPs imputed in both studies. Analyses were controlled for the effect of gestational age, sex and age of measurement. Results from the two studies were combined using fixed effects inverse variance meta-analysis. We identified a total of fifteen independent loci, with ten loci reaching genome-wide significance (p<5x10−8) for ‘age at first tooth’ and eleven loci for ‘number of teeth’. Together these associations explain 6.06% of the variation in ‘age of first tooth’ and 4.76% of the variation in ‘number of teeth’. The identified loci included eight previously unidentified loci, some containing genes known to play a role in tooth and other developmental pathways, including a SNP in the protein-coding region of BMP4 (rs17563, P= 9.080x10−17). Three of these loci, containing the genes HMGA2, AJUBA and ADK, also showed evidence of association with craniofacial distances, particularly those indexing facial width. Our results suggest that the genome-wide association approach is a powerful strategy for detecting variants involved in tooth eruption, and potentially craniofacial growth and more generally organ development