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.

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.

Background: The purpose of acuity assessment, triage, in the emergency department is to recognize critically ill patients and to allocate resources. The Emergency Severity Index (ESI) is used widely around the world and has been shown to be at least as good as other 5-level assessment instruments. In this study, we assess validity of the ESI triage system in a Finnish Emergency department for predicting 30-day mortality as primary outcome and hospital admissions, high dependency unit or intensive care unit admissions as secondary outcomes, and efficiency for predicting emergency department length-of-stay and utilized resources as secondary outcomes. Methods: We collected data of all adult patient visits to the emergency department during a one-month period. The data was analyzed for the primary and secondary outcomes stratified by age: younger adults (18-64 years), older adults (65-79 years) and oldest old (>80 years). Results: Of the 5909 visits, 5511 were eligible for analysis, 2725 of them men. Median age was 59 years; 30-day mortality was 150 (2.7%). In all age groups, 30-day mortality was consecutively higher with statistical significance between each step from between categories 1 to 3. There were 2274 admissions, 190 of the to HDU or ICU.  Hospital admission rates were significantly higher between each step between categories 2 to 4 for all adults. HDU/ICU admissions were higher in category 2 than in category 3 in all age groups. Resource utilization was higher in category 3 than in category 4; categories 4 and 5 differed only in the younger adult group. Most patients in categories 4 and 5 required ≥2 and 0 resource, respectively. Median length of stay at the emergency department was 3h 47min. For all patients ED-LOS varied without linearity; LOS was longest in category 3 in all age groups. Conclusions: ESI seems to be a valid tool for acuity assessment in all age groups in our population: it recognized severely ill patients by predicting mortality and hospital admissions in the higher triage categories in all age groups. Having failed to predict both resource consumption and ED-LOS, ESI was not associated with efficiency in our population.