BACKGROUND AND OBJECTIVES The progressive ageing of the population has led to a growing number of older patients presenting to Emergency Departments (ED). This subgroup is characterised by multiple comorbidities, polypharmacy, functional and cognitive decline, and frequently atypical presentations. This medical and social complexity, combined with the reduced efficiency of conventional triage systems in the older population, makes accurate initial assessment challenging. Respiratory complaints are among the leading causes of ED visits in the geriatric population; acute dyspnoea is often the consequence of multiple overlapping conditions, making attribution to a single diagnosis difficult. The study objectives are: to describe the epidemiological, clinical and process characteristics of patients aged 65 years or older presenting with respiratory complaints to the ED of the Policlinico di Modena, to identify factors associated with hospital admission, and to quantify the discordance between the assigned triage code and the actual clinical outcome. METHODS Single-centre retrospective observational study (N=207, March 2023). Variables analysed: age, sex, mode of arrival, triage code, diagnostic group (Cardiovascular, COPD/Respiratory Failure, Respiratory Infections, Sepsis and Other Infections, Signs/Symptoms and Other (SSO)), Charlson Comorbidity Index (CCI), Length of Stay (LOS) and outcome (admission vs discharge). Patients with a low-priority code (Green/Yellow) subsequently admitted were defined as under-triaged; those with a high-priority code (Orange/Red) subsequently discharged as over-triaged. Statistical analysis: Wilcoxon rank-sum, Pearson Chi-square, Kruskal-Wallis and Firth penalised logistic regression. RESULTS 207 patients (51% female; mean age 80.75±8.44; mean CCI 5.87±2.45); 62.8% admitted. 49.8% arrived by ambulance, with an admission rate of 80.6% compared to 45.2% for other means (p<0.001). Admitted patients compared to discharged patients had higher CCI and age (82.52±8.60 vs 77.77±7.31 years, 6.34±2.51 vs 5.09±2.14, both p<0.001), shorter LOS (4.03±3.24 vs 5.14±2.79 hours, p=0.005), predominantly Orange and Red triage codes, and belonged mainly to the Cardiovascular group (admission rate 86.2%); the SSO group had the lowest admission rate (16.2%) and a predominantly low triage profile. Two models were constructed to identify factors associated with hospital admission: Model A identified diagnostic group (ORs 4.67 to 24.71), ambulance arrival (OR=3.94, p<0.001), male sex (OR=2.19, p=0.041) and age (OR=1.05, p=0.035) as significant; Model B identified Red triage code (OR=382.40, p<0.001), Orange (OR=35.89, p=0.023) and ambulance arrival (OR=2.48, p=0.023). Both models showed comparable discriminative capacity (R²Tjur=0.375 vs 0.412). Triage-outcome discordance was observed in 20.3% of cases: 15 under-triaged (7.2%) and 27 over-triaged (13.0%). Under-triaged and over-triaged patients differed from concordant-admitted and concordant-discharged patients respectively only in LOS (6.5 vs 3.9 hours, p<0.001 and 3.95 vs 5.78 hours, p=0.004). CONCLUSIONS The difficulty in assessing geriatric patients can be explained by their clinical complexity, characterised by multimorbidity, polypharmacy, cognitive and functional impairment, and other complex geriatric conditions that produce a range of alterations not routinely considered in the ED setting. These factors are associated with longer ED stays, inappropriate use of resources, and worse clinical outcomes. The integration of geriatric screening tools and dedicated pathways for older patients is hypothesised to improve the quality of care for the elderly population in the emergency setting.
ABSTRACT BACKGROUND E OBIETTIVI L’invecchiamento della popolazione determina un crescente afflusso di pazienti anziani al Pronto Soccorso (PS). Questo sottogruppo si caratterizza per multiple comorbidità, polifarmacoterapia, declino funzionale e cognitivo e presentazioni spesso atipiche. Questa complessità medica e sociale, unito al fatto che i sistemi di triage sono meno efficienti per l’anziano, rende difficile una valutazione iniziale accurata. Le problematiche respiratorie sono tra le principali cause di accesso al PS nella popolazione geriatrica; la dispnea acuta è spesso la conseguenza di molteplici condizioni sovrapposte, rendendo difficile l’attribuzione a una singola diagnosi. Gli obiettivi sono: descrivere le caratteristiche epidemiologiche, cliniche e di processo dei pazienti anziani (≥65 anni) con accesso per problematiche respiratorie al PS del Policlinico di Modena, identificare i fattori associati al ricovero ospedaliero e quantificare la discordanza tra triage assegnato e esito clinico effettivo. METODI Studio osservazionale retrospettivo monocentrico (N=207, marzo 2023). Le variabili analizzate sono: età, sesso, mezzo di presentazione, codice triage, gruppo diagnostico (Cardiovascolare, BPCO/Insufficienza Respiratoria, Infezioni Respiratorie, Sepsi e Altre Infezioni, Segni/Sintomi e Altro (SSA)), Charlson Comorbidity Index (CCI), Length of Stay (LOS) ed esito (ricovero vs dimissione). Definiti “sottotriaggiati” i pazienti con codice Verde/Azzurro poi ricoverati, “sovratriaggiati” quelli con codice Arancione/Rosso poi dimessi. Analisi statistica: Wilcoxon rank-sum, Chi-quadro di Pearson, Kruskal-Wallis e regressione logistica penalizzata di Firth. RISULTATI 207 pazienti (51% femmine; età media 80,75 ± 8,44; CCI medio 5,87 ± 2,45); 62,8% ricoverati. Il 49,8% è arrivato in ambulanza con tasso di ricovero del 80,6% rispetto al 45,2% degli altri mezzi (p<0,001). I pazienti ricoverati, rispetto ai dimessi, presentavano CCI e età maggiori (82,52±8,60 vs 77,77± 7,31 anni, 6,34± 2,51 vs 5,09± 2,14, entrambi p<0,001), una LOS minore (4,03± 3,24 vs 5,14± 2,79 ore, p=0,005), per lo più codici Arancioni e Rossi ed appartenevano per lo più al gruppo Cardiovascolare (tasso di ricovero del 86,2%); mentre il gruppo SSA presentava il tasso di ricovero più basso (16,2%) e profilo di triage basso. Per i fattori associati al ricovero sono stati creati due modelli: nel modello A sono risultati significativi il gruppo diagnostico (OR da 4,67 a 24,71), arrivo in ambulanza (OR=3,94, p<0,001), sesso maschile (OR=2,19, p=0,041) ed età (OR=1,05, p=0,035); nel modello B erano significativi il codice triage Rosso (OR=382,40, p<0,001), Arancione (OR=35,89, p=0,023) e arrivo in ambulanza (OR=2,48, p=0,023). I due modelli mostravano capacità discriminativa comparabile (R2Tjur=0,375 vs 0,412). È stata misurata una discordanza triage-esito del 20,3%: 15 sottotriaggiati (7,2%) e 27 sovratriaggiati (13,0%). I sottotriaggiati e i sovratriaggiati differivano rispettivamente dai concordanti-ricoverati e concordanti-dimessi solo per la LOS (6,5 vs 3,9 ore, p<0,001 e 3,95 vs 5,78 ore, p=0,004). CONCLUSIONI La difficoltà nell’inquadramento del paziente geriatrico può essere spiegata dalla sua complessità clinica, data dalla multimorbilità, dalla politerapia, dal quadro cognitivo e funzionale e da tutte le altre problematiche geriatriche complesse che portano ad una serie di alterazioni che non vengono usualmente considerate nell’ambito del PS. Questi fenomeni si associano a tempi di permanenza maggiori, utilizzo improprio di risorse ed esiti clinici peggiori. L’integrazione di strumenti di screening e percorsi dedicati al paziente geriatrico si ipotizza possano permettere una migliore qualità delle cure per la popolazione anziana nell’ambito dell’emergenza-urgenza.
Emergency care in the older population: a retrospective study
CAVALLINI, FRANCESCO
2025/2026
Abstract
BACKGROUND AND OBJECTIVES The progressive ageing of the population has led to a growing number of older patients presenting to Emergency Departments (ED). This subgroup is characterised by multiple comorbidities, polypharmacy, functional and cognitive decline, and frequently atypical presentations. This medical and social complexity, combined with the reduced efficiency of conventional triage systems in the older population, makes accurate initial assessment challenging. Respiratory complaints are among the leading causes of ED visits in the geriatric population; acute dyspnoea is often the consequence of multiple overlapping conditions, making attribution to a single diagnosis difficult. The study objectives are: to describe the epidemiological, clinical and process characteristics of patients aged 65 years or older presenting with respiratory complaints to the ED of the Policlinico di Modena, to identify factors associated with hospital admission, and to quantify the discordance between the assigned triage code and the actual clinical outcome. METHODS Single-centre retrospective observational study (N=207, March 2023). Variables analysed: age, sex, mode of arrival, triage code, diagnostic group (Cardiovascular, COPD/Respiratory Failure, Respiratory Infections, Sepsis and Other Infections, Signs/Symptoms and Other (SSO)), Charlson Comorbidity Index (CCI), Length of Stay (LOS) and outcome (admission vs discharge). Patients with a low-priority code (Green/Yellow) subsequently admitted were defined as under-triaged; those with a high-priority code (Orange/Red) subsequently discharged as over-triaged. Statistical analysis: Wilcoxon rank-sum, Pearson Chi-square, Kruskal-Wallis and Firth penalised logistic regression. RESULTS 207 patients (51% female; mean age 80.75±8.44; mean CCI 5.87±2.45); 62.8% admitted. 49.8% arrived by ambulance, with an admission rate of 80.6% compared to 45.2% for other means (p<0.001). Admitted patients compared to discharged patients had higher CCI and age (82.52±8.60 vs 77.77±7.31 years, 6.34±2.51 vs 5.09±2.14, both p<0.001), shorter LOS (4.03±3.24 vs 5.14±2.79 hours, p=0.005), predominantly Orange and Red triage codes, and belonged mainly to the Cardiovascular group (admission rate 86.2%); the SSO group had the lowest admission rate (16.2%) and a predominantly low triage profile. Two models were constructed to identify factors associated with hospital admission: Model A identified diagnostic group (ORs 4.67 to 24.71), ambulance arrival (OR=3.94, p<0.001), male sex (OR=2.19, p=0.041) and age (OR=1.05, p=0.035) as significant; Model B identified Red triage code (OR=382.40, p<0.001), Orange (OR=35.89, p=0.023) and ambulance arrival (OR=2.48, p=0.023). Both models showed comparable discriminative capacity (R²Tjur=0.375 vs 0.412). Triage-outcome discordance was observed in 20.3% of cases: 15 under-triaged (7.2%) and 27 over-triaged (13.0%). Under-triaged and over-triaged patients differed from concordant-admitted and concordant-discharged patients respectively only in LOS (6.5 vs 3.9 hours, p<0.001 and 3.95 vs 5.78 hours, p=0.004). CONCLUSIONS The difficulty in assessing geriatric patients can be explained by their clinical complexity, characterised by multimorbidity, polypharmacy, cognitive and functional impairment, and other complex geriatric conditions that produce a range of alterations not routinely considered in the ED setting. These factors are associated with longer ED stays, inappropriate use of resources, and worse clinical outcomes. The integration of geriatric screening tools and dedicated pathways for older patients is hypothesised to improve the quality of care for the elderly population in the emergency setting.| File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.14251/6724