The Elderly Risk Assessment (ERA) score is a validated index that predicts hospitalizations, mortality, and emergency department (ED) visits in adults older than age 60 presenting to primary care. The index is composed of age, sex, number of hospital days in the prior 2 years, marital status, and selected medical conditions (diabetes, coronary artery disease, congestive heart failure, stroke, chronic obstructive pulmonary disease and dementia). The aim of this study was to validate the ERA score in a cohort of ED patients, including need for hospitalization, mortality and return ED visits. This was an observational cohort study of consecutive patients age 60 years and older who presented to the ED from Jan-Dec 2017. This study was approved by the Institutional Review Board. The ERA score uses demographic and clinical data and is automatically calculated and displayed in the electronic medical record. It ranges from -1 to 34 points. Medians with interquartile range (IQR), and odds ratios (OR) with 95% confidence intervals (CI) were calculated. Chi-square and Wilcoxon test were used for statistical analysis. There were 29,991 ED visits in 2017 by patients age 60 and older; this represents 39% of all ED visits at our hospital. Of these, 9% did not consent for medical record review and were excluded. The final cohort included 27,397 visits among 18,607 patients. The median age was 74 years (IQR 66 to 82), 48% were female and 59% were married. The median ERA score was 7 (IQR 2 to 14). A total of 53.7% patients were admitted to the hospital; those with higher ERA scores were more likely to be admitted with a median of 10 (4 to 16) versus 5 (1 to 11). A total of 15.1% of the patients returned to the ED within 30 days; those with a higher ERA score were more likely to return to the ED, with a median of 11 (5 to 17) versus 7 (2 to 13), p<0.0001. Despite being younger, male patients were more likely to return to the ED within 30 days (OR 1.16, CI 1.1-1.2), p<0.001. A total of 15.1% of the patients died within a year; those with a higher ERA score were more likely to die, with a median score of 14 (8 to 19) versus 6 (2 to 13), p<0.0001. When using a cutoff of ERA>=16, those with >=16 were more likely to be admitted to the hospital OR 2.19 (CI 2.06-2.33), more likely to return within 30 days OR 2.05 (CI 1.91-2.21), and to die within the year follow-up, OR 3.45 (CI 3.21-3.70). The ERA score can be automatically calculated into the medical record and can help identify ED patients at higher risk of death, hospitalization and return ED visits. This score could help clinicians identify patients who may benefit from additional resources like advanced care planning, multi-disciplinary team coordination in the ED and even palliative care. Identifying this high risk population has to target patients who could benefit from geriatric referral, social work evaluation for home resources amongst others. Ultimately, this score may be used to identify patients who can be targeted for goals of care discussion while in the ED.