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Seniors slighted for emergency care reports new study

Robin Wulffson MD's picture
emergency care, emerncy department, triage, seniors, missed diagnosis

BASEL, SWITZERLAND - For a variety of reasons, all patients are not treated equally when they present at an emergency department. These patients have medical conditions ranging from minor to life-threatening. A basic function of these facilities is triage: deciding between which patients need immediate attention and those who have less urgent problems. According to a new study, emergency department triage nurses underestimated the severity of the conditions of 22.5% of seniors. The findings were published online on March 9 in the Annals of Emergency Medicine.

University Hospital of Basel (Basel, Switzerland) is an urban, 700-bed primary (basic) and tertiary (high level) facility that receives 42,000 emergency department visits a year. Researchers at the hospital reviewed the records of 519 seniors aged 65 or older who were triaged by a method known as the Emergency Severity Index. An index level of 1 represents a condition in need of lifesaving intervention. The predictive validity of the index was evaluated by examining its relationship to resources, disposition, length of stay, and mortality. Resources were defined as the number of tests, procedures, consultation with a specialist, or interventions that were "beyond the physician history and examination." Disposition was defined as "discharge, admission to normal ward, or admission to intensive care." The diagnostic accuracy of the Emergency Severity Index was tested by calculating sensitivity (detecting the degree of emergency) and specificity (diagnosing the medical problem correctly. of Emergency Severity Index level 1 for the prediction of a lifesaving intervention. Two experts independently reviewed the triage nurses' notes.

A total of 519 seniors were included in the study. Florian F. Grossmann, MNS, RN and her colleagues found that 117 patients were under-triaged and 15 were over-triaged. In 13 of the under-triaged patients, lifesaving interventions were ultimately performed, including airway and breathing support and/or emergency medication. The authors concluded that under-triage was more likely due to an inappropriate application of the index rather than a deficiency with the index itself.

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According to the study, seniors comprise 12-21% of all emergency department visits. Study author Christian Nickel stated in a news release: "Elderly patients make up a significant portion of emergency patients but they may come to the [emergency department] with atypical symptoms, making it more difficult for them to be accurately assessed." He added, "The often complex combination of social and medical problems in older patients can complicate the triage process."

The researchers calculated that the sensitivity of the index was 0.462 (1 being perfect) and the specificity was 0.998. The investigators examined the inter-rater reliability (agreement) between the two experts who triaged patients, using triage nurse's notes. Agreement was found to be high (0.917). In contrast, agreement between the experts and the triage nurses was only moderate (0.746). The authors reviewed the reasons for inadequate triage. They found that the most common reason for under-triage was the failure to recognize a high-risk situation, sometimes in combination with abnormal vital signs, or in combination with severe pain or distress. The second most common reason for under-triage was inappropriate interpretation of vital signs, sometimes in combination with severe pain or distress, high-risk situations, or an altered mental status.

The authors concluded that seniors were at risk for under-triage; however, they also noted that their results suggested that the Emergency Severity Index is reliable and valid for triage of older patients. They explained that inadequate triaged appeared to be due to “a lack of adherence to the Emergency Severity Index algorithm rather than to an inherent deficit of the algorithm itself."

Take home message:
An ongoing problem with emergency departments throughout the U.S., and most likely most developed nations is that a large percentage of the patients who percent at them have minor problems or chronic conditions that could be better handled at a regular physician’s office visit. This situation increases the risk of a healthcare specialist overlooking a severely ill patient. Any individual with increased vulnerability (often a child or a senior) should present at an emergency department with an advocate. This advocate should inform the staff of the symptoms and stress their importance. Of course, an advocate should not demand immediate attention for a problem that is not extremely urgent. If you present at an emergency department without an advocate and feel that your situation is more urgent than the staff appears to recognize, speak out andinsist on further evaluation.

Reference: Annals of Emergency Medicine