Clinical impression for identification of vulnerable older patients in the Emergency Department

Objectives To investigate whether the clinical impression of vulnerability (CIV) and the Dutch Safety Management Program (VMS), a screening instrument on four geriatric domains (ADL, falls, malnutrition, delirium), are useful predictors of 1-year mortality in older patients in the Emergency Department (ED).

Methods This was a prospective observational study in the ED of a tertiary care teaching hospital. Patients aged 65 years and older visiting the ED, and their attending physicians and nurses were included. CIV appraised by physician and nurse and the VMS-screening were recorded.

Results We included 196 patients of whom 64.8%, 61.7%, and 52.6% were considered vulnerable based on the CIV of physicians, nurses, and VMS-screening respectively. Agreement between CIV of physicians and nurses, and VMS-screening were both fair (overall agreement 63.3% for both, and respectively kappa 0.32 and kappa 0.31). CIV of physicians, nurses, and VMS-screening had a sensitivity of respectively 94%, 86%, and 73% for predicting 1-year mortality. A positive CIV was associated mostly with factors which can be observed directly during first patient contact after arrival to the ED, such as age, nutritional status and functional impairment.

Conclusion The CIV is a simple dichotomous question which can be used as a first step in the identification of vulnerable older ED patients, whereas the more time-consuming VMS-46 screening is more specific for detection of vulnerability. The CIV is therefore useful in a busy ED environment where time and resources are limited.