Evaluation of Prioritized Assessment for Older Patients Living With Frailty Presenting to the Emergency Department

Plain-language summary

The older population is getting older and growing in size worldwide. This requires healthcare to adapt to meet the complex medical and nursing needs of the older patient group. As older patients have varying health conditions with different levels of functions, their premise to handle acute, unexpected illness differs as well. This complicates matters for healthcare, especially emergency departments (ED) where resource allocation and identifying patients that are at greatest risk of negative health outcomes must be prioritized in a limited time. When patients present to the ED, initial triage information such as vital signs and reason for visit determines the triage acuity for the patient. In Linköping, and large parts of Sweden, the triage tool RETTS (Rapid Emergency Triage and Treatment System) is used, where the highest priority is red (priority 1), then orange (priority 2), yellow (priority 3), green (priority 4) and blue (priority 5). However, this can be misleading when assessing older patients due to altered physiology with natural ageing and older patients are known to be under-triaged with existing triage systems. The variation in functional capacity in older patients does not necessarily correlate with comorbidities and age and has been condensed to the term 'frailty'. It has been proposed that the frailty level corresponds more to biological age rather than chronological age. Frailty increases the risk of adverse outcomes such as falls, the need of in-hospital care, institutionalization, and mortality in which the risk is increased even in low acuity illnesses. Frailty can be assessed by various means and based on the theory of cumulative deficit, frailty assessment instruments have been developed where frailty level increases with the amount of help needed from others. Different instruments have been compared in the ED and the Clinical Frailty Scale (CFS) have been deemed fit due to it being practical in a busy environment. The scale consists of 9 points where 9 is the highest level of frailty and the scale is usually dichotomized into "robust" and "living with frailty" where 5 points or above constitutes frailty. The prognostic value of CFS has previously been studied in the ED of University hospital of Linköping in Sweden with results indicating that the instrument should be used as an additional risk assessment in the ED. Older patients often present with vague and complex symptoms to th ED, which could lead to prolonged ED stay due to the need of extensive medical workup or therapy. Long ED stays have been shown to increase both morbidity and mortality in older patients as well as risk of delirium and complications relating to care, especially in individuals living with frailty. In order to decrease the adverse events, aim to shorten ED length of stay (ED LOS) should therefore be a reasonable goal in clinical improvement work. Early identification of frailty in the ED may lead to rapid assessments and streaming of care for older patients which have shown to statistically significantly decrease ED LOS, which is why an early assessment by a physician potentially could decrease overall ED LOS. However, it is unknown how early assessed frailty could affect the ED visit itself. In the beginning of 2025, the Emergency department of University hospital of Linköping launched a local guideline which recommended that patients aged 65 years or older visiting the ED should be assessed with CFS as early as possible, preferably in connection to triage. If the patients were assessed as living with frailty, the frailty score should be stated in the electronical overview of ED patients. The patient's needs of care should be induvidualized according to frailty level and the responsible clinical team should aim to decrease the ED length of stay for older patients living with frailty. This study focuses on the outcomes of this newly implemented routine and aims to answer if recommended prioritization of older ED patients living with frailty leads to decreased ED LOS. Furthermore the study investigates if the clinical guidelines have an impact on time to the first assessment by a physician, admission rate, in-hospital length of stay, and mortality at 90 days

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