We acknowledge that Zaboli et al. 1 highlight conceptual and operational concerns regarding our FRED (age-friendly Emergency Department) study protocol 2, specifically age-friendly triage. We appreciate the opportunity to address three issues raised. First, high-quality triage involves more than scoring a triage instrument: The current triage definition states that the function of triage is to sort and assign the right patient to the right resources in the right place at the right time 3. Hence, the aim of triage is not to make patients wait in one “care production line.” Quite the contrary, the aim of (age-friendly) triage is to initiate multiple “care production lines” 4. This differentiation is a strength of our FRED program, as triage will initiate care trajectories early, for example, streaming to an observation unit, which is equipped to satisfy the needs of older adults 5, 6. Timely allocation of patients to the appropriate stream facilitates emergency department (ED) throughput and output. Triage tools in general are not perfectly accurate, especially when used in older adults 7, 8. A central challenge for triage systems is accurately identifying patients with time-sensitive conditions who present without obvious signs of severe illness or injury. A substantial proportion of ED patients who later become critically ill or die are not initially triaged as high acuity 9. Advanced age is associated with undertriage, and the specific risks of this age group (disease presentation, subtle vital sign abnormalities, etc.) seem to be insufficiently recognized by triage clinicians 10 putting older adults at risk of prolonged waiting times. This suggests the addition of supporting tools such as National Early Warning Score (NEWS) an aggregated vital sign score, and the Clinical Frailty Scale (CFS), as adjuncts for decision making 11, 12. While it may be correct that NEWS and CFS were originally not designed as triage tools, these scores can very well contribute to the triage process and potentially reduce undertriage of older adults. Triage is usually based on symptoms and vital signs. Attention to vital signs, particularly in older adults, seems to improve triage decision-making 13. Of note, the Emergency Severity Index (ESI), which is used in FRED, was updated already 2 years ago 14. In its current fifth version, ESI mandates the assessment of a complete set of vital signs. In case of abnormalities, “reassessment” of the patient's acuity is recommended. Similarly, we suggest that vital sign abnormalities “can escalate” a patient's status to “should not wait.” However, the ESI version 5 handbook does not clearly define what constitutes a full set, when it should be obtained, or cutoff values beyond HR, RR, and SpO2. An aggregated vital-sign score, for example, NEWS, is valuable in this situation, as it assists with efficient recording of vital signs 15, 16 and can therefore serve as an adjunct to the ESI. Regarding frailty assessment at triage, we disagree with Zaboli et al. Complex but presumably non-time-critical vulnerable presentations in a traditional triage paradigm can be very well time-critical presentations and should not be left waiting. Detecting frailty as early as triage thereby allows for considering risks early and potentially preventing harm (e.g., risk and onset of delirium). Consideration of frailty supports decision-making regarding diagnostics and treatment and thereby supports patient-centered care/value-based care principles. Additionally, assessing frailty is important in time-critical situations as well 17. The aim of frailty screening with the CFS is not to override intrinsic heterogeneity of ED populations, but rather to help unravel this heterogeneity and optimize patient care 18. To date, the CFS seems to be one of the best available instruments 19, 20. There are recent compelling data for the use of the CFS at triage (or within 30 min of ED presentation) for prediction of adverse outcomes 21. Issues regarding accuracy and reliability of CFS scorings might be addressed by algorithm-assisted assessment 22. Second, patients aged younger than 65 might have frailty and might benefit from the FRED intervention/approach. For methodological purposes, we used an age cut-off to define the target population 23. In addition, the CFS has not been widely validated in populations younger than 65. This sounds counterintuitive in a field where it is more about biological than chronological age. Therefore, if considered relevant, we make sure that these younger patients can benefit from the FRED intervention elements (i.e., deliver them clinically), although we will not include these patients in our study due to a selection criteria mismatch. Hence, we do comply with equity principles. In addition, Zaboli et al. lump concepts of disability, comorbidity, and frailty together, but they are distinct entities 24. Third, while contexts can vary greatly, a single organizational model may not suit all EDs worldwide 6. This is why an implementation science approach is chosen 25. We acknowledge that FRED is being developed in a high-resource setting and may therefore be transferable only to similar contexts. On the other hand, the theoretical knowledge resulting from the FRED intervention (what works for whom in which circumstances?) will hopefully support lower-resourced EDs in the process to “geriatricize” the ED and build upon developed knowledge 26, 27. Lastly, we believe, in line with the Geriatric Emergency Department Accreditation (GEDA) program and the Geriatric Emergency Department Collaborative (GEDC), that accessible and equitable emergency care is a right for all persons, including the older population 28. Three levels of accreditation exist to recognize that EDs vary in resources, staffing, and patient volume. P.H. and C.H.N. drafted the manuscript; T.D.-H., C.R.C., A.C.F., F.Z. and F.G. critically revised; all authors gave final approval of this reply letter and agree to be accountable for all aspects of the work. Pieter Heeren: no financial or personal conflicts to disclose. He is a member of the geriatric section of the European Society of Emergency Medicine. Thomas Dreher-Hummel: no conflicts to disclose. Christopher R. Carpenter: no financial or personal conflicts to disclose. He is Associate Editor for the Journal of the American Geriatrics Society, leads the Society for Academic Emergency Medicine Guidelines for Reasonable and Appropriate Care in the Emergency Department Committee, serves on the American College of Emergency Physicians Clinical Policy Committee, is Chair of the American College of Emergency Physician's Geriatric Emergency Department Accreditation Advisory Board, and serves on the Clinician–Scientist Transdisciplinary Aging Research Leadership Core. Florian Grossmann: no conflicts to disclose. Alisa Cantarero Fernandez: no conflicts to disclose. Franziska Zúñiga: no conflicts to disclose. Christian H. Nickel: no financial or personal conflicts to disclose. He is a member of the geriatric sections of the European Society of Emergency Medicine and the International Federation of Emergency Medicine. He is also a member of the Geriatric Emergency Department Guidelines 2.0 writing group. He is an editor of medStandards, an online resource that provides evidence-based emergency medicine protocols. This publication is linked to a related Letter to the Editor by Zaboli and Turcato. To view this article, visit https://doi.org/10.1111/jgs.70325.
Heeren et al. (Thu,) studied this question.