Physiological scoring systems for early identification of critically ill older adults in the emergency department: a prospective observational cohort study.

backgroundEmergency department (ED) overcrowding and the rising proportion of older adults presenting with atypical symptoms pose significant challenges for timely recognition of critical illness. Conventional triage algorithms may fail to reliably identify high-risk geriatric patients, leading to delays in care. To address this issue, this study aimed to evaluate the predictive performance of six commonly used physiological scoring systems—Triage Early Warning Score (TREWS), National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), Worthing Physiological Scoring System (WPS), and Simple Triage Scoring System (STSS)—for identifying critically ill geriatric patients during emergency department triage.

methodsThis prospective observational cohort study was conducted in the ED of a tertiary university hospital between November 1, 2024, and January 31, 2025. All patients aged ≥ 65 years were consecutively enrolled. Patients without vital signs upon arrival, those transferred from other facilities, and those with incomplete data were excluded. Demographics, comorbidities, initial vital signs, and clinical outcomes were recorded. The primary outcome was in-hospital mortality; secondary outcomes included 24-hour, 48-hour, 7-day, and 30-day mortality, as well as ICU admission. The discriminative performance of each score was evaluated using AUROC analysis.

resultsA total of 3,486 patients were included in the final analysis. In-hospital mortality was 4.1% (n = 144). The 24-hour, 48-hour, 7-day, and 30-day mortality rates were 0.7%, 0.9%, 2.2%, and 4.1%, respectively. TREWS and MEWS showed considerable predictive performance for in-hospital mortality (AUROC: 0.815 and 0.803, respectively), while other scores demonstrated poor-to-fair predictive ability. TREWS also showed the highest performance across all outcome measures.

conclusionAmong the evaluated scoring systems, TREWS demonstrated the highest predictive accuracy for in-hospital mortality, and consistent performance in predicting short- and long-term mortality as well as ICU admission among geriatric patients. Given its ease of use and reliance on routine triage data, TREWS may serve as a valuable tool for early identification of high-risk geriatric patients in busy ED settings. Further large-scale, multicenter studies are warranted to validate these findings. CLINICAL TRIAL NUMBER: Not applicable.