A brief risk stratification tool to predict functional decline in older adults discharged from emergency departments

Objectives: To determine the effectiveness of the six-item Triage Risk Screening Tool (TRST) to assess baseline functional status and predict subsequent functional decline in older community-dwelling adults discharged home from the emergency department (ED). Design: Secondary data analysis of a randomized, controlled trial. Setting: EDs of two urban academic hospitals. Participants: Six hundred fifty community-dwelling adults aged 65 and older presenting to the ED and discharged home. Patients were categorized a priori as "high risk" if they had cognitive impairment or two or more risk factors on the TRST. Measurements: Functional status: summed activity of daily living (ADL) and instrumental activity of daily living (IADL) scores at baseline, 30 days, and 120 days. Self-perceived physical health: standardized physical health component of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Functional decline: loss of one or more ADLs and one or more IADLs from ED baseline at 30 and 120 days. Decline in self-perceived physical health: follow-up SF-36 standardized physical health component scores four or more points lower than baseline. Results: TRST scores correlated with baseline ADL Impairments, IADL impairments, and self-perceived physical health at all endpoints (P<.001). A TRST score of two or more was moderately predictive of decline in ADLs or IADLs (30-day ADL area under the receiver operating characteristic curve (AUC) = 0.64; 95% confidence interval (CI) = 0.56-0.72; 120-day ADL AUC = 0.66; 95% CI = 0.58-0.74) but not perceived physical health. Conclusion: The TRST identifies baseline functional impairment in older ED patients and is moderately predictive of subsequent functional decline after an initial ED visit. The TRST provides a valid proxy measure for assessing functional status in the ED and may be useful in identifying high-risk patients who would benefit from referrals for further evaluation or surveillance upon ED discharge.