Undertriaged Elders Might Appear Ignored in Chart

Consider age at triage, or face possible suits

When researchers at University Hospital Basel in Switzerland set out to study triage of elderly patients in their ED, they were surprised to find that 22.5% were undertriaged, reports Christian Nickel, MD, one of the study’s authors and an emergency physician (EP).

We were surprised that the rate of undertriage in elderly ED patients was that high in our setting,” he says. Researchers evaluated 519 patient records for patients triaged using the Emergency Severity Index (ESI), and found undertriage in 117 cases. In 13 of the undertriaged patients, life-saving interventions were ultimately performed, including airway and breathing support and/or emergency medication.

Of the undertriaged cases, 25% involved patients with non-specific complaints such as generalized weakness. “The main pitfall was non-adherence to the triage algorithm,” says Nickel. “Regular staff training of both ED physicians and triage nurses should focus on this issue. Triage performance should be regularly monitored.”

See All Elders Promptly

Essentially, any complaint can be a life-threatening one in an older ED patient, emphasizes Robert Suter, DO, professor of emergency medicine at UT Southwestern Medical Center in Dallas, TX. “Any time you have an older patient come into your ED to be triaged, they really need to be taken very seriously,” he says. “With advancing age, that becomes exponentially more true.”

Suter says that there are no good evidence-based guidelines for when the triage level should increase based on a patient’s age, but that it’s reasonable for an ED to have a policy using a cutoff of 65 or 70 years old for when patients should be triaged in part based on their age, not triaged as non-urgent, and seen promptly ahead of other patients.

An older patient with seemingly benign symptoms might appear to suddenly decompensate due to age-related neurologic or cardiovascular changes or medications the patient is taking. “The patient might not be experiencing the same intensity of symptoms that you would expect in a younger patient,” explains Suter. “The patient may have hypertension, and now their dropping blood pressure makes their blood pressure appear normal instead of low. That could fool the triage person.”

Suter notes that the largely subjective triage process used in most EDs is part of the problem. “It’s still common for EDs to do unstructured triage based largely on the triage nurse’s judgment of the complaint,” he says. “Also, some triage systems in common use, such as ESI, actually were designed to predict resource utilization and not necessarily the dangerousness of the patient’s complaint.”

For this reason, Suter says EDs should consider establishing age older than 65 or 70 as a very important red flag that raises the triage level at least one notch, similar to the way a child 28 days of age or younger should be triaged as urgent or emergent regardless of the stated complaint. “Older patients should have their triage category adjusted up because of the higher likelihood that something bad will happen,” he says.

Suter says he has seen a number of claims involving an older patient who presented to an ED with a seemingly benign complaint, waited for a long period to be seen, and then suddenly decompensated either in the waiting room or right after being brought back.

“While a medical reviewer may look at a case like this and see there were not necessarily any alarming symptoms or signs, it’s very different for a layperson on a jury to understand why the ED didn’t recognize that this older patient was about to die,” says Suter.

When an older patient with a trivial complaint dies in the waiting room without having been seen by a physician, the average person will assume something wrong was done and there was a callous disregard for the patient’s safety, says Suter. “It may have been unavoidable, but no one will ever accept that,” he says.

If that same patient was brought back quickly, saw the EP, and the evaluation had begun, it would appear instead that the hospital and the EP were concerned about the patient and doing the right thing, he says. “For example, EPs are trained to have a very low threshold to do an EKG in an older patient,” adds Suter. “If an EKG is obtained and appears normal, when something bad happens a half-hour later, you have that additional evidence that they appeared to be doing O.K. and the arrest couldn’t have been predicted.”

If the patient dies before being seen, the presumption within the legal system will be that the patient’s life could have been saved if they had a more timely evaluation, says Suter. “That may not be the case, but it’s a difficult charge to defend yourself against,” he says. “It really puts you in a difficult position to deal with Monday morning quarterbacking.”

Make Case Defensible

Kathy Dolan, RN, MSHA, CEN, CPHRM, senior risk management consultant at ProAssurance, a professional liability insurance carrier in Birmingham, AL, and former manager of an emergency department at a level II trauma center, regularly sees claims involving elderly patients in the ED alleging failure to recognize, missed diagnosis, inappropriate discharge, failure to refer, and failure to treat.

“Elderly patients are at risk for all of these things because of age, multiple medications, and multiple comorbidities. They can be very poor historians as well,” says Dolan.

“Not going far enough” when obtaining a history from the elderly patient can make a case less defensible, according to Dolan. “Correct medication lists are difficult to obtain. Patients may think some symptoms aren’t as important to mention,” she says.

Failure to explain the physician’s decision-making process is also a problem Dolan commonly sees in charts she reviews, such as charting why a head CT wasn’t done. “We want to see a full circle,” she says. For example, when abnormal test results return, documentation of notification to the patient and change in the treatment plan is important.

Dolan has reviewed several claims involving ED nurses failing to recognize and report a change in an older patient’s status while undergoing testing in the ED. “These patients can be in the department for long periods of time. The EP goes in to provide discharge instructions, and finds the patient in dire condition,” says Dolan. “Everyone is at risk if a lawsuit is filed and documentation doesn’t support the patient’s condition.”


1. Grossmann FF, Zumbrunn T, Frauchiger A, et al. At risk of undertriage? Testing the performance and accuracy of the Emergency Severity Index in older emergency department patients. Ann Emerg Med 2012; 60(3):317-325.


For more information, contact:

  • Kathy Dolan, RN, MSHA, CEN, CPHRM, ProAssurance, Birmingham, AL. Phone: (319) 310-2249. E-mail: kdolan@proassurance.com.
  • Christian Nickel, MD, Emergency Department, University Hospital Basel, Switzerland. E-mail: CNickel@uhbs.ch.
  • Robert Suter, DO, Professor of Emergency Medicine, UT Southwestern Medical Center, Dallas, TX. Phone: (214) 648-4838. E-mail: robert.suter@utsouthwestern.edu.