A Framework to Triage Older Adults with Covid-19 to Provide Patient-Centered Care

[..] Our institution developed and implemented a triage framework in the Emergency Department utilizing the Clinical Frailty Scale (CFS) to promote patient-centered care during our Covid-19 surge. A triage clinician assessed 40 patients aged 70 and older from April 7 to May 22, 2020. In addition to recommendations for medication management, fall risk reduction, delirium prevention and advance care planning, the triage clinician directed patients with a CFS of 1-3 to usual care (n=8, 20.0%), a CFS of 4-6 to geriatric co-management (n=6, 15.0%), a CFS of 7-9 to palliative care triage (n=23, 57.5%) and 7.5% (n=3) to both palliative and geriatric care. This novel triage framework was integrated into a busy practice environment and rapidly directed limited geriatric and palliative care resources to where they were most needed.

[..] the Clinical Frailty Scale (CFS), is a simple 9-point scale for classifying patients on a spectrum from “very fit” to “terminally ill” that is feasible for clinicians to implement in busy practice environments.

[Program Development and Implementation]
[..] The largest proportion of patients were triaged to palliative care (23 patients; 57.5%), followed by usual care (8 patients; 20.0%) and geriatric co-management (6 patients; 15.0%); the remaining 3 patients (7.5%) were triaged to both palliative care and geriatric co-management. Of the patients who were triaged to palliative care, 9 were clinically unstable in the ED and received an urgent palliative care consultation. In addition to targeting consultant resources to where they were most needed, the triage clinician also made recommendations for medication management, fall risk reduction, delirium prevention, and advance care planning. The most common recommendations were for formal documentation of HCP/Massachusetts Medical Order for Life-Sustaining Treatments (MOLSTs) (11 patients), non-pharmacological delirium-prevention measures such as preserving the sleep-wake cycle and ensuring the availability of personal sensory equipment (8 patients), and withholding potentially inappropriate medications (8 patients).

[..] The majority of surviving patients were discharged to a rehabilitation or skilled nursing facility (13 patients; 50.0%), followed by home with services (8 patients; 30.8%), home without services (3 patients; 11.5%), assisted living (1 patient; 3.8%), and home with palliative care (1 patient; 3.8%). For the 14 patients who died in the hospital, the mean time to death was 5.4 ± 3.5 days. For the 11 patients who died in the hospital and for whom the CFS score could be calculated, the mean score was 7.1 ± 0.7; the score could not be calculated for the remaining 3 patients because of the need for urgent care. The mortality rate was 35.0% (14 of 40 patients) at 30 days and 45.0% (18 of 40 patients) at 90 days.

[..] We believe that this triage framework was successful largely because it could be quickly integrated into existing workflows, it could be utilized in a busy practice setting, and it provided structured, personalized care to a heterogenous population of older adults. Because this framework is independent from and parallel to ED workflows, it did not burden busy ED clinicians, which is a critical consideration when planning for other demanding clinical scenarios such as Covid-19 resurgences or influenza outbreaks.”

Full article, O’Mara L, Streiter S, Orkaby AR et al. NEJM Catalyst: Innovations in Care Delivery 2020.11.5