Older adults have longer emergency department (ED) length of stay (LOS) and higher odds of admission than younger adults within the same triage category despite being assigned to higher acuity, reveals a Singapore study.
“This highlights a mismatch between triage allocation and care needs, requiring enhanced geriatric-specific risk-stratification approaches,” the researchers said.
Adult patients presenting to a tertiary ED between 1 February 2021 and May 2021 were included in this retrospective observational study. The research team stratified patients into geriatric (aged ≥65 years) and nongeriatric groups. They also performed multivariable analyses to adjust for confounders.
Geriatric patients experienced longer ED LOS overall than nongeriatric patients in both unadjusted (317.4 vs 217.2 min; p<0.05) and adjusted (300.2 vs 223.1 min; p<0.05) analyses. They also had higher admission rates (75.1 percent vs 33.2 percent; p<0.001). [Singapore Med J 2026;67:249-256]
In stratified analysis, ED LOS was significantly longer in Patient Acuity Category Scale (PACS) 2 (346.3 vs 286.7 min; p<0.001) and Emergency Severity Index (ESI) 3 (353.4 vs 281.2 min; p<0.001). Furthermore, higher admission rates were observed in PACS 1‒3 and ESI 1‒4, with the highest likelihood in ESI 1 (odds ratio [OR], 65.9) and PACS 1 (OR, 28.3).
“These findings highlight a mismatch between initial triage categorization and downstream resource utilization among older adults, underscoring the need for geriatric-informed approaches to ED care planning,” the researchers said.
Frailty
Studies validating how existing triage systems perform in older adults and exploring modifications tailored to this group are needed due to the rise in ageing populations worldwide and the lack of research on geriatric-specific triage beyond trauma, according to the researchers.
Some of the proposed approaches are as follows: incorporating age, functional status, and mobility into triage; integrating clinical gestalt; and embedding frailty assessments.
“[T]here have been calls to shift ED focus from disease-based care to frailty-centred care, incorporating comorbidities, geriatric syndromes, functional status, psychosocial needs, and frailty scores, to better identify frail in older adults early and facilitate timely multidisciplinary intervention,” the researchers said. [J Am Geriatr Soc 2020;68:1755-1762; Am J Emerg Med 2023;66:16-21; J Am Med Dir Assoc 2021;22:923-928.e5]
Previous studies have shown the capacity of some frailty measures (eg, Clinical Frailty Scale, Comprehensive Geriatric Assessment, Emergency Geriatric Assessment, Identification of Seniors at Risk, Triage Risk Screening Tool, and Acutely Presenting Older Patient screener) to predict hospitalization, nursing home admission, mortality, prolonged LOS, poor quality of life, and ED reattendance. [Eur J Intern Med 2017;45:5-7; Emergencias (Madr) 2021;33:361-367]
“It has been shown that frailty and triage acuity are independent measures of the severity of a patient’s condition,” the researchers said. “Combining frailty with existing triage tools has shown promise in improving prognostication and reducing under-triage.” [Can J Emerg Med 2019;22:74-81]
Some studies have also suggested the use of artificial intelligence, including machine learning applied to large-scale electronic health records and intelligent decision-support systems, to improve triage accuracy. However, most of these are still in development and early evaluation stages. [JMIR Res Protoc 2022;11:e32911; Artif Intell Med 2020;102:101771]
“There is an urgent and critical gap in the arena of geriatric triage,” the researchers said. “Further studies that assess the utility of modified geriatric-specific triage systems would be beneficial in closing this gap.”
Singapore is seen to become a “super-aged” society by 2026, with an expected rise in geriatric ED attendances, according to the researchers.