
==== Front
Nurs Open
Nurs Open
10.1002/(ISSN)2054-1058
NOP2
Nursing Open
2054-1058
John Wiley and Sons Inc. Hoboken

10.1002/nop2.70024
NOP270024
NOP-2023-Feb-0366.R1
Empirical Research Quantitative
Empirical Research Quantitative
The effectiveness of a modified Manchester Triage System for geriatric patients: A retrospective quantitative study
Li et al.
Li Baiyu https://orcid.org/0000-0001-6985-9516
1
Zhang Zhufeng 1 zzfljq@126.com

Li Keye 1
Deng Yayin 1
1 Department of Emergency Medicine Zhejiang Hospital Hangzhou Zhejiang China
* Correspondence
Zhufeng Zhang, Department of Emergency Medicine, Zhejiang Hospital, No. 1229, Gudun Road, Xihu District, Hangzhou, Zhejiang, China.
Email: zzfljq@126.com

04 9 2024
9 2024
11 9 10.1002/nop2.v11.9 e7002406 2 2024
01 3 2023
04 8 2024
© 2024 The Author(s). Nursing Open published by John Wiley & Sons Ltd.
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Abstract

Aim

Geriatric patients are increasingly dominating the daily routine in emergency department (ED). The atypical clinical presentation of disease, multimorbidity, frailty and cognitive impairment of geriatric patients pose particular challenges for triage in the ED. Efficient and accurate emergency triage plays a key role in differentiating between geriatric patients who need timely treatment and those who can wait safely. The purpose of this study was to evaluate the performance of the modified Manchester Triage System (mMTS) in classifying geriatric patients.

Design

An observational retrospective study.

Methods

A retrospective study of 18,796 geriatric patients (≥65 years) attending the ED of a tertiary care hospital in Zhejiang province between 1 June 2020 and 30 June 2022. Baseline information on patients was collected and divided into two different study groups according to triage level: high priority (red/orange) and low priority (yellow/green). The sensitivity and specificity of the mMTS were estimated by verifying the triage classification received by the emergency geriatric patients and their survival at 7 days or the need for acute surgery within 72 h.

Results

The study included a total of 17,764 geriatric patients with a median age of 72 years in ED. 10.7% (1896/17,764) of the geriatric patients were assigned to the high priority code group (red/orange) and 89.3% (15,868/17,764) were in the low priority code group (yellow/green). The sensitivity of the mMTS associated with death within 7 days was 85.7% (77.5–91.4), specificity was 89.8% (89.3–90.2), and accuracy was 89.8% (89.3–90.2). 1.8% of patients required surgery within 72 h. The sensitivity was 62.6% (57.0–67.9), specificity was 90.3% (89.8–90.7), and negative predictive value was 99.2% (99.0–99.4).

Conclusions

The mMTS has good specificity, accuracy and negative predictive value for geriatric patients. However, its incorrect prediction of triage in high‐priority code patients results in lower sensitivity, which may serve as a protective strategy for these individuals. The current emergency triage system does not completely screen geriatric patients with severe acute illness who present to the ED, and it is necessary to add comprehensive assessment tools that match the characteristics of geriatric patients to improve triage outcomes.

emergency department
geriatric patients
modified Manchester Triage System
nurse triage
triage
source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:04.09.2024
Li, B. , Zhang, Z. , Li, K. , & Deng, Y. (2024). The effectiveness of a modified Manchester Triage System for geriatric patients: A retrospective quantitative study. Nursing Open, 11 , e70024. 10.1002/nop2.70024
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pmc1 INTRODUCTION

As the number of geriatric population continues to grow. It is estimated that the global geriatric population (≥65 years) will reach 2 billion by 2050 (Clegg et al., 2013). In China, there are 260 million geriatric people over the age of 60, accounting for 18.70% of the total population (National Bureau of Statistics, 2021). Population ageing has become a major public health issue in China and even globally. The growing geriatric population will affect emergency department (ED) settings. Compared to younger patients, geriatric patients suffer from physiological decline, often associated with cognitive impairment (e.g. delirium or dementia), frailty and polypharmacy. It makes emergency triage of geriatric patients more challenging (Groening & Wilke, 2020; Rossi et al., 2010).

Emergency triage has played a key role in prioritising patient access to the ED, determining urgency and waiting times prior to medical examination (Maillard, 2018). Correct and effective triage is essential to the operation and development of the entire ED. Over the past 30 years, as emergency medicine has evolved more mature emergency triage systems have emerged, including the Manchester Triage System (MTS) (Santos et al., 2014), the Emergency Severity Index (ESI) (Green et al., 2012), the Australian Triage Scale (ATS) (Ebrahimi et al., 2015), the Canadian ED Triage and Acuity Scale (CTAS) (Bullard et al., 2017), have shown high validity and reliability in practice (Zachariasse et al., 2019). However, emergency triage criteria do not take into account the presence of differences in disease characteristics, vital signs, atypical disease manifestations or different reference values for cognitive impairment in geriatric and younger patients. This makes the commonly used emergency triage system susceptible to certain biases in disease judgement and ineffective in assigning urgency to geriatric patients. Undertriage rates increase with increasing age with a rate of approximately 30% among adults aged between 55 and 70 and a dramatically higher rate in excess of 60% among 90 years old (Lehmann et al., 2009). This ultimately leads to prolonged emergency length of stay for geriatric patients, missing the optimal time for treatment and increasing the clinical incidence of adverse outcomes (Blomaard et al., 2020; Brouns et al., 2019).

The Manchester Triage System (MTS) is one of the most popular triage systems in the world (Pinto et al., 2012). The Modified Manchester Triage System (mMTS) is a triage strategy that is now widely used in general hospitals in China. It was developed by the Emergency Nursing Professional Committee of the Chinese Nursing Association in accordance with the single‐patient management requirements of the National Ministry of Health, based on the Manchester Triage System in combination with the Modified Early Warning Score (MEWS). mMTS categorises emergency patients into four levels based on the patient's chief complaint, symptoms and vital signs. Including red (immediate, 0 min), orange (very urgent, 10 min), yellow (urgent, 30 min) and blue (non‐urgent, 240 min) (Emergency Nursing Committee of Chinese Nursing Association, 2020; Zhiting et al., 2020). mMTS combined green (normal, 120 min), blue (non‐urgent, 240 min) in the MTS for emergency patients into green (non‐urgent). The effectiveness of the current mMTS has not been evaluated. Therefore, this study assessed the effectiveness of the mMTS for triage of geriatric patients in the ED by surgery within 72 h and death within 7 days. It provides a reference for optimising emergency triage of geriatric patients.

2 METHODS

This study was a single‐centre retrospective study with data from the mMTS. Triage system records of geriatric emergency patients included in the cohort were examined and assessed by at least two nursing researchers and baseline information on the patient (gender, age and department visited), triage assessment (primary symptoms, secondary symptoms and triage level), patient length of stay in the ED and outcomes were collected for inclusion in the study data set. The triage data for this study were obtained from a clinically validated emergency triage system. This study was conducted and reported in accordance with the Strengthening Observational Research Reports in Epidemiology (STROBE) statement.

2.1 Study design

The study population was all patients receiving care in the ED of a tertiary hospital in Zhejiang province between 1 June 2020 and 30 June 2022 (120,000 ED visits per year, including the emergency resuscitation unit, EICU, emergency ward and emergency infusion unit). We have used mMTS to triage emergency patients since 2020. Triage in ED is a standardised process organised according to the mMTS. Each patient admitted in the ED is evaluated by a trained registered nurse using the process described by mMTS to define the priority code and the possible waiting time until the medical examination. Our triage nurses have at least 3 years of experience in emergency medicine and have completed training related to triage, including professional skills, use of resuscitation equipment, and communication and coordination skills. Patient triage information is recorded in the electronic nursing record, which is stored in the ED database.

2.2 Participants

All patients admitted to the ED between 1 June 2020 and 30 June 2022 were included in this study. Data integrity was ensured by the extraction of data from the mMTS by professional staff from the hospital information management centre. A group of researchers from the ED performed an assessment after data acquisition. After team discussion, geriatric patients aged ≥65 years were finally included and other exclusion criteria were patients with incomplete information, self‐discharge (difficult to determine patient outcomes), patients transferred for treatment (untraceable).

2.3 Determination study groups

We dichotomised the emergency triage system as has been done in other studies examining the effectiveness of the Manchester triage system (Nishi et al., 2018; Zaboli et al., 2021). Emergency geriatric patients with red and orange codes were included in the ‘high priority’ study group and patients with yellow and green codes were included in the ‘low priority’ study group.

2.4 Outcomes

The study included two primary outcomes, the predictive performance of the mMTS for death within 7 days and surgery within 72 h for geriatric patients in the ED. A 2 × 2 column high priority/low priority (row) linkage was established between patient outcomes (columns) and the mMTS, classifying patients into correct triage predictions (true positives and true negatives) and incorrect triage predictions (false positives and false negatives). Baseline characteristics, classification codes and distribution of patient outcomes were compared between these two groups and performance was judged by assessing the sensitivity and specificity of the mMTS for geriatric patients. The effect of triage class on the length of stay in the ED for geriatric patients was a secondary outcome.

2.5 Ethical considerations

This study was approved by the Ethics Committee of Zhejiang Hospital (2023 Clinical Audit No.8k). The Department of Nursing of Zhe jiang Hospital agreed to conduct this study in accordance with the Declaration of Helsinki on ethical principles for medical research involving humans.

2.6 Statistical methods

Data were analysed using SPSS 26.0 software, and continuous variables were described by median and interquartile descriptions being described (IQR, 25th and 75th percentile). The Mann–Whitney test was used between two groups and the Kruskal–Wallis test was used for multiple data groups. Categorical variables were expressed as percentages, used chi‐square test. The validity of the mMTS was assessed through a 2 × 2 contingency table by comparing emergency surgery (72 h) and short‐term mortality (7 days) with mMTS codes (high priority/low priority) of geriatric patients in ED. Through 2 × 2 contingency‐table mMTS, sensitivity, specificity and negative predictive value were calculated. The ability of the mMTS (four levels) to discriminate death within 7 days was also assessed by the area under the receiver operating characteristic (ROC) curve. p < 0.05 was considered statistically significant.

3 RESULTS

3.1 Participant general information

The study included a total of 17,764 geriatric emergency patients, whose median age was 72 years (67–80 years) and 50.1% were male. 10.7% (1896/17,764) of patients with orange or red codes were assigned to high priority codes and the remaining patients with yellow or green codes were assigned to low priority codes (Figure 1).

FIGURE 1 Flowchart of patient enrolment. A total of 254,456 patients were treated in the emergency department during the study and 18,796 participants who met the criteria were enrolled in the study. 1032 patients were excluded due to untraceable outcomes, leaving 17,764 participants according to the classification level of the mMTS, 1896 patients were assigned to the high priority code group and 15,868 patients were assigned to the low priority code group. A final retrospective analysis of the 17,764 patients was performed.

In our study, we found that those patients with high priority codes were older than those with low priority codes (p < 0.001). The triage nurses were more likely to give high priority codes to geriatric patients presenting with symptoms such as altered consciousness or weakness of the limbs at the time of consultation (p < 0.001), whereas they were more likely to give low priority codes to patients with cough, bloating and abdominal pain as their main clinical presentation (p < 0.001). It is easy to see that patients with high priority codes spent more time in the ED (p < 0.001). In addition, patients assigned to the high priority code group had a high hospitalisation rate of 65.8% (1247/1896) compared to only 12.9% (2045/15868) of patients in the low priority code group who required hospitalisation. For geriatric patients requiring emergency surgery within 72 h, 62.6% (201/321) were allocated to the high priority code group. 85.7% of geriatric patients who died within 7 days were correctly assigned to the high priority code group. The mortality rate within 7 days was 0.1% in the low priority code group and 5.1% in the high priority code group (Table 1).

TABLE 1 Characteristics of all enrolled patients divided according to triage code.

Variables	Red	Orange	Yellow	Green	p	High priority	Low priority	p	
Patients	673 (3.8)	1223 (6.9)	4632 (26.1)	11,236 (63.3)		1896 (10.7)	15,868 (89.3)		
Age, years, median (IQR)	81 (71–86)	77 (71–84)	82 (72–86)	69 (67–74)	<0.001 a	78 (71–85)	71 (67–78)	<0.001 a	
Gender, n (%)	<0.001 b		<0.001 b	
Female	318 (47.3)	540 (44.2)	2193 (47.3)	5856 (52.1)	858 (45.3)	8049 (50.7)	
Male	355 (52.7)	683 (55.8)	2439 (52.7)	5380 (47.9)	1038 (54.7)	7819 (49.3)	
Patient's symptoms	
Disorders of consciousness	109 (16.2)	65 (5.3)	31 (0.7)	0 (0.0)	<0.001 b	174 (9.2)	31 (0.2)	<0.001 b	
Weakness of limbs	60 (8.9)	87 (7.1)	98 (2.1)	2 (0.0)	<0.001 b	147 (7.8)	100 (0.6)	<0.001 b	
Chest tightness, chest pain	124 (18.4)	185 (15.1)	293 (6.3)	54 (0.5)	<0.001 b	309 (16.3)	347 (2.2)	<0.001 b	
Cough	35 (5.2)	48 (3.9)	82 (1.8)	113 (1.0)	<0.001 b	83 (4.4)	195 (1.2)	<0.001 b	
Abdominal pain, bloating	9 (1.3)	36 (2.9)	286 (6.2)	318 (2.8)	<0.001 b	45 (2.4)	604 (3.8)	<0.001 b	
Dizziness, headache	44 (6.5)	128 (10.5)	468 (10.1)	524 (4.7)	<0.001 b	172 (9.1)	992 (6.3)	0.002	
Fever	50 (7.4)	85 (7.0)	169 (3.6)	49 (0.4)	<0.001 b	135 (7.1)	218 (1.4)	<0.001 b	
Abnormal urination	7 (1.0)	13 (1.1)	98 (2.1)	164 (1.5)	0.005 b	20 (1.1)	262 (1.7)	0.05	
Post‐traumatic pain	12 (1.8)	43 (3.5)	443 (9.6)	1406 (12.5)	<0.001 b	55 (2.9)	1849 (11.7)	<0.001 b	
Disease subspecialties	<0.001 b		<0.001 b	
Emergency medicine	670 (99.6)	1197 (97.9)	3686 (79.6)	6933 (61.7)	1867 (98.5)	10,619 (66.9)	
Emergency surgery	1 (0.1)	14 (1.1)	526 (11.4)	1865 (16.6)	15 (0.8)	2391 (15.1)	
Emergency orthopaedics	2 (0.3)	7 (0.6)	216 (4.7)	548 (4.9)	9 (0.5)	764 (4.8)	
Emergency department of five organs	0 (0.0)	4 (0.3)	159 (3.4)	813 (7.2)	4 (0.2)	972 (6.1)	
Length of stay, minutes, median (IQR)	256 (132–567)	295 (168–650)	188 (57–371)	29 (10–98)	<0.001 a	284 (154–610)	50 (13–182)	<0.001 a	
Outcome	<0.001 b			<0.001 b	
Discharged from hospital	78 (11.6)	286 (23.4)	2732 (58.9)	10,963 (97.6)	358 (18.9)	13,673 (86.2)	
Hospitalisation	420 (62.4)	828 (67.7)	1776 (38.3)	271 (2.4)	1247 (65.8)	2045 (12.9)	
Surgery within 72 h	98 (14.6)	103 (8.4)	119 (2.6)	1 (0.0)	201 (10.6)	120 (0.8)	
Death within 7 days	77 (11.4)	19 (1.6)	14 (0.3)	2 (0.0)	96 (5.1)	16 (0.1)	
a Kruskal–Wallis test.

b Chi‐square test.

3.2 Accuracy of the modified Manchester triage system

Overall, for emergency surgery within 72 h in geriatric patients, the specificity of the mMTS was 90.3% (89.8–90.7), the NPV was 99.2% (99.0–99.4), and the accuracy was 89.8% (89.3–90.2), and the sensitivity was 62.6% (57.0–67.9). In addition, for the secondary outcome—patient death within 7 days—the mMTS demonstrated a specificity of 89.8% (89.3–90.2), NPV of 99.9% (99.8–99.9), accuracy of 89.8% (89.3–90.2) and sensitivity of 85.7% (77.5–91.4) (Table 2).

TABLE 2 2 × 2 triage contingency tables used with mMTS in the evaluation of Geriatric patients, first with surgery within 72 h and second death within 7 days.

mMTS (low priority) versus mMTS (high priority)	
	No	Yes	
Surgery within 72 h	
Low priority (yellow/green)	15,748	120	
High priority (red/orange)	1695	201	
Sensitivity	62.6 (57.0–67.9)		
Specificity	90.3 (89.8–90.7)		
NPV	99.2 (99.0–99.4)		
PPV	10.7 (10.2–11.1)		
Accuracy	89.8 (89.3–90.2)		
Overtriage	9.5 (9,1–9.9)		
Under‐triage	0.7 (0.6–0.8)		
Death within 7 days	
Low priority (yellow/green)	15,852	16	
High priority (red/orange)	1800	96	
Sensitivity	85.7 (77.5–91.4)		
Specificity	89.8 (89.3–90.2)		
NPV	99.9 (99.8–99.9)		
PPV	5.1 (4.1–6.2)		
Accuracy	89.8 (89.3–90.2)		
Overtriage	10.1 (9.7–10.6)		
Under‐triage	0.1 (0.1–0.1)		
Abbreviations: NPV, negative predictive value; PPV, positive predictive value.

Based on risk classification for emergency surgery within 72 h, 89.8% of patients were correctly classified (true positive + true negative), whilst only 10.2% had incorrect classification predictions (false positive + false negative). Similarly, the emergency triage system performed equally well in the classification of death within 7 days, with 89.8% correct triage predictions and 10.2% incorrect triage predictions. In total, there was a significant association between groups of mMTS (high versus low priority groups) and emergency surgery within 72 h and death within 7 days (p < 0.001). Triage predictions for patients with low priority codes were correct for both death within 7 days and emergency surgery within 72 h (99.9%, 92.4%). In contrast, 89.4% of patients with high priority codes had incorrect triage predictions for surgery within 72 h and over 85% of patients did not require emergency surgery within 72 h. 99.9% of patients with high priority codes had incorrect triage predictions for death within 7 days and over 95% of patients did not die within 7 days. This indicates the presence of a large number of false positive patients. Patients in both groups with incorrect triage predictions were geriatric (p < 0.001) and spent more time in the ED (p < 0.001). Patients presenting with symptoms such as impaired consciousness (p < 0.001), limb weakness (p < 0.001), chest tightness and chest pain (p < 0.001) had a higher rate of incorrect triage prediction for risk of surgery within 72 h, and a similar phenomenon was observed in triage prediction for risk of death within 7 days (Table 3).

TABLE 3 Association between mMTS performance in relation to surgery within 72 h and death within 7 days.

Variables	Surgery within 72 h	p	Death within 7 days	p	
Incorrect triage prediction (FP + FN) n (%)	Correct triage prediction (TP + TN) n (%)	Incorrect triage prediction (FP + FN) n (%)	Correct triage prediction (TP + TN) n (%)	
Patients	1815 (10.2)	15,949 (89.8)		1816 (10.2)	15,948 (89.8)		
Age, years, median (IQR)	78 (71–85)	71 (67–78)	<0.001	78 (71–85)	71 (67–78)	<0.001	
Female	804 (44.3)	8103 (50.7)	<0.001	999 (55.0)	8090 (50.7)	0.001	
Male	1011 (55.7)	7846 (49.3)	817 (44.9)	7858 (49.3)	
mMTS priority code	
Low priority	120 (7.6)	15,748 (92.4)	<0.001	16 (0.1)	15,852 (99.9)	<0.001	
High priority	1695 (89.4)	201 (10.6)	1800 (99.9)	96 (0.1)	
Patient's symptoms	
Disorders of consciousness	145 (70.7)	60 (29.3)	<0.001	139 (67.8)	66 (32.2)	<0.001	
Weakness of limbs	127 (51.4)	120 (48.6)	<0.001	149 (60.3)	98 (39.7)	<0.001	
Chest tightness, chest pain	278 (42.4)	378 (57.6)	<0.001	311 (47.4)	345 (52.6)	<0.001	
Cough	82 (29.5)	196 (70.5)	<0.001	82 (29.5)	196 (70.5)	<0.001	
Abdominal pain, bloating	60 (9.2)	589 (90.8)	0.429	47 (7.2)	602 (92.8)	0.01	
Dizziness, headache	142 (12.2)	1022 (87.8)	0.021	140 (12.0)	1024 (88.0)	0.036	
Fever	136 (38.5)	217 (61.5)	<0.001	130 (36.8)	223 (63.2)	<0.001	
Length of stay, minutes, median (IQR)	299 (175–650)	51 (13–180)	<0.001	286 (160–603)	51 (13–184)	<0.001	
Outcome	
Discharged from hospital	364 (2.6)	13,695 (97.4)	<0.001	361 (2.6)	13,698 (97.4)	<0.001	
Hospitalisation	1248 (37.9)	2048 (62.1)	1250 (37.9)	2046 (62.1)	
Surgery within 72 h	
No	1695 (9.7)	15,748 (90.3)	<0.001	1615 (9.3)	15,828 (90.7)	<0.001	
Yes	120 (37.4)	201 (62.6)	200 (62.3)	121 (37.7)	
Death within 7 days	
No	1720 (9.7)	15,932 (90.3)	<0.001	1800 (10.2)	15,852 (89.8)	0.158	
Yes	95 (84.8)	17 (15.2)	16 (14.3)	96 (85.7)	
Abbreviations: FN, false negative; FP, false positive; TN, true negative; TP, true positive.

The ROC curves for mMTS priority codes that death within 7 days. The individual performance of each priority code is also highlighted. The risk of death within 7 days was 0.936 (95% CI: 0.914–0.957) (Figure 2).

FIGURE 2 ROC curves for mMTS priority codes that death within 7 days. The individual performance of each priority code is also highlighted. LR+, positive likelihood ratio; LR‐, negative likelihood ratio.

4 DISCUSSION

In this large retrospective study we found good sensitivity, specificity and NPV for the mMTS in predicting the need for emergency surgery within 72 h and death within 7 days in geriatric patients. Although the PPV was low, this may be due to patient protection strategies. The mMTS is safe and reliable in geriatric patients and is similar to the results of the MTS triage urgency for 30‐day mortality in a recent study of geriatric emergency patients (Blomaard et al., 2020).

As with other papers exploring the performance of the MTS, a dichotomous classification (high‐priority code versus low‐priority code) was chosen to assess its effectiveness in identifying high‐risk geriatric patients (Ausserhofer et al., 2020; Gräff et al., 2017; Nishi et al., 2018; Zaboli et al., 2021). The best method for assessing triage systems is still controversial (Kuriyama et al., 2017). Some authors suggest choosing expert assessment results for comparison, but actual clinical outcomes (emergency surgery or short and intermediate‐term mortality) in some patients seem to be a better assessment of the validity and accuracy of triage. In previous studies it was found that patients with high priority codes (orange and red) had higher rates of emergency surgery and intermediate mortality within 72 h of entering the ED, but the selection of short‐term mortality to assess the validity of the emergency classification system appeared to be better than intermediate mortality. For geriatric emergency patients despite medical advances in surgery and anaesthesia geriatric emergency surgery patients continue to have poor postoperative outcomes and high mortality rates (Cinar et al., 2021). Therefore, it is feasible to select emergency surgery rates and short‐term mortality rates within 72 h for geriatric emergency patients in our study to explore the effectiveness and safety of the mMTS.

In previous studies, it has been found that geriatric emergency patients account for approximately 12% to 24% of all ED visits. This number is likely to increase with global ageing (Pines et al., 2013; Salvi et al., 2007). However, geriatric patients (age ≥ 65 years) accounted for 7.4% of all ED visits in our study. This may be related to the geographical location of the hospital. The hospital is adjacent to a combined Chinese and Western geriatric hospital some geriatric patients will choose to attend specialist hospitals resulting in a lower proportion of geriatric patients in the ED. The rate of acute surgery within 72 h in geriatric patients was 1.8%, and the rate of acute surgery within 72 h was higher in patients with high‐priority codes than in patients with low‐priority codes. Also, geriatric patients with high‐priority codes had a much higher 7‐day mortality rate than those with low‐priority codes. the proportion of patients who died within 7 days was lower than the 1.8% in another retrospective study of emergency geriatric patients in India (Kaeley et al., 2021). To explain this phenomenon I have to refer to the Chinese cultural context. In China, patients and family members want to minimise the patient's suffering at the end of life. They do not want to be treated in hospital in a hopeless and painful way. Therefore, most geriatric emergency patients want to return home to spend the last part of their lives in the company of their loved ones. These customs result in many geriatric emergency patients arriving at the ED for brief treatment and then abandoning further treatment and being discharged automatically. This group of patients was excluded from the study because the final time of death could not be determined, resulting in a low statistical mortality rate within 7 days. However, this did not affect the results of the study as this group of patients came to the hospital with a high priority classification and its exclusion did not adversely affect the accuracy of the mMTS in triaging geriatric patients. In addition, geriatric patients with high priority codes stayed longer in the ED, similar to previous studies (Latham & Ackroyd‐Stolarz, 2014; Lee et al., 2018; Ogliari et al., 2022). First, geriatric patients often present with a lack of typical symptoms compared to younger patients who may also have geriatric syndromes including cognitive impairment, delirium, mood disorders, polypharmacy, frailty and falls (Huang et al., 2021). Various reasons why history taking and medical assessment of geriatric patients can be complex and also require more thorough investigations lead to increased length of stay in the ED. In turn, longer stays in the ED are associated with an increased risk of adverse clinical outcomes including delirium, falls, bed sores, hospital‐acquired infections, longer hospital stays and may even include a higher risk of death (Ackroyd‐Stolarz et al., 2011; Guttmann et al., 2011).

This study demonstrates that the mMTS has good sensitivity, specificity and negative predictive values for emergency surgery within 72 h and death within 7 days in geriatric patients. Both previous and our findings suggest that even among low priority patients the emergency triage system is good at identifying patients at low risk of undergoing acute surgery and low risk of death within 72 h, with a 99.9% probability of geriatric patients without life‐threatening conditions being triaged as a low priority code, close to 100%. Almost all patients with a low priority code had a correct triage prediction. This suggests that the mMTS we used is safe for geriatric emergency patients and enables good stratification of geriatric patients in the ED. (Zaboli et al., 2021; Ausserhofer et al., 2020; Zachariasse et al., 2017; Zaboli et al., 2022. Zaboli et al., 2020).

However, a problem with both previous studies and our study was the poor PPV of the emergency triage system. 89.4% of patients with high priority codes incorrectly predicted surgery within 72 h and 99.9% of patients with high priority codes incorrectly predicted death within 7 days. This suggests that there is over triage in the high priority group with a large number of false positives. Firstly, in the high‐priority group, in addition to emergency surgery within 72 h and death within 7 days, the elderly in acute care had other symptomatic acute and critical illnesses, such as airway obstruction or asphyxia, status epilepticus, diabetic ketoacidosis, glycaemic coma, ischemic stroke, heart failure, and exacerbation of chronic obstructive pulmonary disease (COPD), accompanied by some abnormal vital signs. For example, hypothermia or hyperthermia (<32°C or >41°C), slow or rapid heart rate (<40/min or >180/min), slow or rapid respiratory rate (≤8/min or ≥36/min), low or excessive systolic blood pressure (<70 mmHg or >220 mmHg) or excessively low blood oxygen saturation (SpO2 < 80%). These acute or critical conditions do not require emergency surgery within 72 h and often have a positive clinical outcome with hospitalisation after aggressive emergency management (Covino et al., 2018; Expert Consensus Group on Emergency Pretest Triage, 2018). In addition, triage nurses give high priority codes for patient protection purposes, which will allow geriatric emergency patients to be treated as soon as possible, thus avoiding possible adverse outcomes. As a result, the mortality rate of patients with high priority codes did not exceed 10%. On the one hand, this suggests that reversible disease exists even in high‐priority codes (Becker et al., 2015), and on the other hand, it suggests that we are treating patients effectively. In addition we can see that in false negative cases involving low priority codes some geriatric patients have insidious disease and lack typical disease presentation. Many of the conditions that lead to death or surgery may not present with serious clinical signs when they arrive in the ED. This undoubtedly confuses triage nurses and thus underestimates the severity of illness in geriatric patients (Hendin et al., 2018). Previous studies have combined emergency triage tools with geriatric screening tools to improve the prediction of early death in geriatric patients. Adding geriatric screening to geriatric emergency triage to adjust classification may improve early risk stratification whilst reducing underclassification of geriatric patients (Blomaard et al., 2020; Lucke et al., 2019; Rhodes et al., 2017).

4.1 Limitations

In this study, the performance of the mMTS was assessed by patient outcomes rather than reassessment of triage levels by a panel of emergency triage experts. Analysing the discrepancy between the reassessment by the emergency triage expert panel and the actual data would allow for a more accurate assessment. However, it would be impractical to provide such a large amount of data for expert panel reassessments. On balance, our study chose to analyse actual data obtained by the mMTS in practice. Therefore, this study has some limitations: firstly, as a retrospective study, only records with complete information on data and outcomes were included in the study, which is prone to an inherent selectivity bias. Second, the inclusion of only older adults (≥65 years) makes the characteristics of the triage hierarchy also limited by the population. Third, this study was a single‐centre study, as there are variations in treatment and care between hospital facilities, and more multi‐centre use will be needed to report results in the future. Fourthly, the best way to assess the accuracy of emergency triage remains controversial, and we chose to assess only two patient outcomes, emergency surgery within 72 h and death within 7 days. It may be possible to assess the accuracy of triage level by whether a patient is admitted to the intensive care unit. However, this could not be analysed due to lack of relevant data. Finally, we did not assess the reliability of triage accuracy for emergency patients. This limitation could be reduced somewhat if triage outcomes were audited annually to validate their accuracy.

5 CONCLUSION

With this large single‐centre retrospective observational study, we aimed to evaluate the effectiveness of mMTS for geriatric patients in the ED. Our study showed excellent specificity, NPV and accuracy in clinical endpoints, including emergency surgery within 72 h and death within 7 days. This indicates that the use of the mMTS for triage of geriatric patients is safe, reliable and performs well The low PPV of the mMTS for emergency surgery within 72 h and death within 7 days may result from overtriage, as triage nurses tend to prioritize patients based on their conditions at the moment, ensuring that treatment is provided as quickly as possible to avoid potential adverse outcomes and maximize patient protection. In the future, while ensuring the safety of geriatric patients, diverse methods can be employed to assess these patients in the emergency department and to develop targeted triage criteria, which will positively impact the optimization of resource allocation for emergency care.

AUTHOR CONTRIBUTIONS

All authors contributed to the article design and acquisition of data. Zhufeng Zhang was involved in the selection of the topic and helped to obtain the data. Baiyu Li and Yayin Deng were involved in data collation and analysis. Baiyu Li and Keye Li were involved in drafting and critical revision of the manuscript.

FUNDING INFORMATION

This research did not receive any specific grant from funding agencies in the public, commercial or non‐profit sectors.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ACKNOWLEDGEMENTS

We would like to thank the medical and nursing team of the emergency department of Zhejiang Hospital for their help and support in the extraction and analysis of the data, as well as the nursing department for their strong support and other teachers who gave recognition and encouragement in this study.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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