Cantarero Fernandez et al. describe a sophisticated implementation-science protocol to support the uptake of an age-friendly emergency department (ED) model in a Swiss tertiary hospital (the FRED study). Their work rightly emphasizes the need for systematic strategies to sustain geriatric-oriented interventions in complex ED settings 1. Because this is a study protocol, we believe it is an appropriate moment to highlight several conceptual and operational concerns. The FRED protocol builds on an existing triage system that integrates clinical acuity (Emergency Severity Index ESI), an aggregate vital-sign score based on the National Early Warning Score (NEWS), and frailty measured with the Clinical Frailty Scale (CFS) 1. In this model, each of these three dimensions can escalate a patient to the category “should not wait,” and adults aged ≥ 65 years with ESI ≥ 3, NEWS < 3 but CFS ≥ 5 are streamed to a dedicated age-friendly area 1. While frailty and physiological instability warrant prompt assessment, NEWS and CFS were not designed as triage tools. Their use in the ED is well supported for monitoring, escalation of care and disposition, but the evidence for applying them at the triage desk is heterogeneous and far less robust than for ESI 2-4. Automatically using these prognostic scores to upgrade queue priority risks blurring the distinction between time-critical emergencies and complex but non-time-critical vulnerable presentations. This conceptual mixing is not trivial. ED triage systems were originally developed to prioritize patients according to the urgency of treating a potentially reversible threat to life 4. NEWS and CFS, by contrast, estimate short-term risk of deterioration or overall 2, 3. However, translating frailty or modest vital-sign abnormalities into higher triage categories may inflate the number of “high-priority” patients, dilute the signal for truly time-dependent conditions and paradoxically harm both frail and non-frail patients. This concern is reinforced by recent work indicating that ED staff may not apply these scales reliably, with a non-negligible risk of misclassification 2. Frailty in the ED is unquestionably important, but it cannot override the intrinsic heterogeneity of ED populations, nor the limitations of tools developed and validated in other settings 2, 5. Several studies have reported inconsistent or uncertain results regarding the utility of frailty scales in the ED context 2, 5. We therefore believe the distinction should remain explicit: frailty should guide how we care for non-urgent patients, not whether they bypass others in the initial queue. A second issue concerns equity. The FRED protocol applies frailty-driven prioritization only to adults aged ≥ 65 years 1. Yet frailty and severe disability are not restricted to older adults 6. Evidence shows that frailty is prevalent among younger inpatients and is associated with adverse outcomes, including higher mortality and readmission 6, 7. Younger adults living with major disability or complex multimorbidity may be more clinically vulnerable than an otherwise healthy 70-year-old, yet in the proposed model they would be excluded from the enhanced pathway solely because they fall below the age cut-off. Restricting “frailty-based” priority to those above an age threshold risks introducing systematic age bias. Third, the organizational model is rooted in a high-resource environment: an ED with a dedicated zone and designated staff for older patients 1. While such “gold-standard” centers are invaluable laboratories for innovation, many EDs in high-income countries work under very different conditions, characterized by chronic crowding, prolonged boarding and workforce strain 8, 9. In these settings, carving out a separate geriatric area and assigning dedicated personnel is often unrealistic; for most, it could exacerbate inequities by diverting scarce staff and space from other patients. To be generalizable, age-friendly ED models must be scalable to hospitals without additional space, specialist teams or new funding. Above all, they must respect equity and the core function of triage: treating the sickest and most time-critical patients first 4, 10. Among those who are clinically stable, attention should then shift to those who are more complex or frail, and this logic should apply to all patients, not only those above a specific age threshold. Frailty should therefore act not as an independent axis of triage priority but as a marker of care complexity among non-urgent patients: within this group, frail individuals can reasonably be seen earlier than non-frail peers, while urgent cases remain prioritized on the basis of acute illness. In summary, the FRED protocol represents an important effort to apply implementation science to geriatric emergency care. However, in its current form it risks conflating frailty with emergency, limiting enhanced pathways to older adults while overlooking equally frail younger patients and proposing an organizational model that many EDs will be unable to implement. A.Z. and G.T. conceptualized and drafted the manuscript. Both the authors approved the final version and agree to be accountable for all aspects of the work. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. This publication is linked to a related reply by Heeren et al. To view this article, visit https://doi.org/10.1111/jgs.70326.
Zaboli et al. (Thu,) studied this question.