Background Risk stratification for older people based on aggregated vital signs lack the accuracy to predict mortality at presentation to the Emergency Department (ED). We aimed to develop and internally validate the Frailty adjusted Prognosis in ED tool (FaP‐ED) for 30‐day mortality combining frailty and aggregated vital signs. Methods Single‐center prospective cohort of undifferentiated ED patients aged 65 or older, consecutively sampled upon ED presentation from a tertiary Emergency Center. Vital signs were aggregated using the National Early Warning Score (NEWS) as a measure of illness or injury severity and frailty was assessed with the Clinical Frailty Scale (CFS). The FaP‐ED was constructed by combining NEWS and CFS in multivariable logistic regression. The primary outcome was 30‐day mortality. Measures of discrimination and calibration were assessed to evaluate predictive performance and internally validated using bootstrapping. Results 2250 patients were included, 67 (1.8%) were omitted from analyses due to missing CFS, loss to follow‐up, or terminal illness. Thirty‐day mortality rate was 5.4% (N = 122, 95% CI = 4.5%–6.4%). Median NEWS was 1 (Inter‐Quartile Range (IQR): 0–3) and median CFS was 4 (IQR: 3–5). The Area Under Receiver Operating Characteristic (AUROC) for FaP‐ED was 0.86 (95% CI = 0.83–0.90). This was significantly higher than NEWS (0.81, 95% CI = 0.77–0.85, DeLong: Z = 3.5, p < 0.001) or CFS alone (0.82, 95% CI = 0.78–0.86, DeLong: Z = 4.4, p < 0.001). Bootstrapped estimates of FaP‐ED AUROC, calibration slope, and intercept were 0.86, 0.95, and −0.09, respectively, suggesting internal validity. A decision‐threshold of CFS 5 and NEWS 3 was proposed based on qualitative comparison of positive Likelihood Ratio at all relevant FaP‐ED cutoffs. Conclusion Combining aggregated vital signs and frailty accurately predicted 30‐day mortality at ED presentation and illustrated an important clinical interaction between frailty and illness severity. Pending external validation, the Fap‐ED operationalizes the concept of such “geriatric urgency” for the ED setting.

Background. Prognostication is an important component of medical decision-making. A patients’ general prognosis can be difficult to measure. The Simple Prognostic Score (SPS) was designed to include patients’ age, mobility, aggregated vital signs, and the treating physician’s decision to admit to aid prognostication. Study Aim. Our study aim is to validate the SPS, compare it with the Emergency Severity Index (ESI) regarding its prognostic performance, and test the interrater reliability of the subjective variable of the decision to admit. Methods. Over a period of 9 weeks all patients presenting to the ED were included, routinely interviewed, final disposition registered, and followed up for one year. The C-statistics of discrimination was used to compare SPS and ESI predictions of 7-day, 30-day, and 1-year mortality. Youden J Statistics and Odds ratio, using logistical regression, were calculated for the Simple Prognostic Score. In a subset, a chart review was performed by senior physicians for a secondary assessment of the decision to admit. Interrater reliability was calculated using percentages and Cohens Kappa. Results. Out of 5648 patients, 3272 (57.9%) had a low SPS (i.e., ≤ 1); none of these patients died within 7 days, 2 (0.1%) died within 30 days after presentation and 19 (0.6%) died within a year. The area under the curve for 1-year mortality of the Simple Prognostic Score was 0.848. Secondary analysis of the interrater agreement for the decision to admit was 92%. Conclusion. In a prospective study of unselected ED patients, the Simple Prognostic Score was validated as a reliable predictor of short- and long-term mortality.

Emergency care for asthma is provided by general practitioners, pulmonologists, and emergency departments (EDs). Although it is known that patients presenting to EDs with acute asthma exacerbations are a vulnerable population and that this mode of presentation is a risk marker for more severe complications, research on this population is scarce. We conducted a retrospective study on patients with asthma exacerbations who presented to the ED of the University Hospital Basel, Switzerland, during 2017–2020. Of the last 200 presentations, 100 were selected and analyzed to assess demographic information, the use of previous and ED-prescribed asthma medication, and clinical outcomes after a mean period of time of 18 months. Of these 100 asthma patients, 96 were self-presenters, and 43 had the second highest degree of acuity (emergency severity index 2). Global Initiative for Asthma (GINA) step 1 and step 3 were the most common among patients with known GINA levels, accounting for 22 and 18 patients, respectively. A total of 4 patients were undergoing treatment with oral corticosteroids at presentation, and 34 were at discharge. At presentation, 38 patients used the combination therapy of inhaled corticosteroid/long-acting β2-agonist (ICS/LABA), and 6 patients underwent ICS monotherapy. At discharge, 68 patients were prescribed with ICS/LABA. At entry to the ED, about one-third of patients did not use any asthma medication. In total, 10 patients were hospitalized. None of them needed invasive or non-invasive ventilation. A follow-up for the study was precluded by the majority of patients. This group of asthma patients seemed particularly vulnerable as their asthma medication at presentation was often not according to guidelines or even lacking, and almost all the patients had self-presented to the ED without any reference from a physician. The majority of patients did not give consent to the collection of any follow-up information. These medical shortcomings reflect an urgent medical need to improve care for patients at high risk of asthma exacerbations.