According to published research, the elderly have the highest rate of ED use among all adult patient groups. Poor outcomes, such as death or an ICU admission shortly after discharge from the ED, can be catastrophic events. Data on outcomes after elderly patients are discharged from the ED are important patient safety and quality of care issues, but few analyses have investigated the specific risk factors that lead to these events.
Previous studies have used clinical data to identify predictors of poor outcomes after discharge from the ED. While this is an important first step in understanding the problem, previous research has been limited. “Most studies on this issue do not have follow-up information because the elderly may go to other hospitals or EDs to receive care after they are discharged,” explains Gelareh Z. Gabayan, MD, MSHS, FACEP. Much of the available research lacks direct access to patient records and cannot identify patient and process-of-care characteristics that were inherent to ED encounters.
For a study published in Annals of Emergency Medicine, Dr. Gabayan and colleagues extracted data from patient records by using a matched case-control review analysis among elderly ED patient visits. The authors randomly chose 300 patients who experienced the combined outcome of either death or an ICU admission within 7 days of discharge and matched case patients to controls who did not experience these outcomes. They then identified patient and process-of-care factors that may be associated with early death or ICU admission within 7 days of discharge from the ED visit. The study team evaluated charts of 600 ED visit records among adults older than age 65 that resulted in an ED discharge from any of 13 hospitals within an integrated health system in 2009 to 2010. The original sample included 1.4 million ED visits in the investigation.
Key Factors Identified
“Results of our study showed that the presence of cognitive impairment or mental status changes and changes in disposition plans from admission to discharge were associated with a poor outcome of either death or ICU admission,” says Dr. Gabayan (Table). Other factors that somewhat impacted either outcome included a fall in the 30 days prior to an ED visit, use of specialty consultants, having a systolic blood pressure of less than 120 mm Hg, and having a pulse rate higher than 90 beats per minute.
The study also examined the role of race and ethnicity with regard to the risk of death or an ICU admission within 7 days of ED discharge among elderly patients. When compared with non-Hispanic whites, the investigators found that Asian/Pacific Islanders were more likely to experience either poor outcome. These data suggest that older adults of different ethnicities may have differing social support services and a different threshold for visiting the ED.
“Identifying factors that may be associated with early death or ICU admission after an ED discharge is important to improving both ED care as well as follow-up care,” Dr. Gabayan says. “Our study identifies clinical characteristics and management decisions that are associated with poor outcomes after ED discharge.” She adds that the findings also reaffirm the importance of vital signs when evaluating records of ED visits of patients aged 65 or older.
“When coupling data from this study with that of others, it’s apparent that the clinical judgment of emergency providers about admitting versus discharging patients should be given special attention,” says Dr. Gabayan. This should occur regardless of the event that initially causes changes in disposition status. In light of the results, ED provider decisions should not be based solely on consultant recommendations and should also include their intuition.
In many cases, ED providers and ancillary staff may not have a predetermined plan about how to manage these patients, according to Dr. Gabayan. “As such, it’s important that EDs, managers, and follow-up services consider creating preset disposition plans to optimize the care of these patients,” she says. “Emergency physicians should also take extra steps to ensure that the elderly have good cognition and understand what they should be doing after they’re discharged. We should write down and print out any specific discharge instructions before they leave the ED.”
Ultimately, results of the study suggest that emergency physicians should use higher scrutiny when managing the elderly who are cared for in the ED. “Based on our results, emergency providers should address cognition and specific abnormal vital signs before patients are discharged,” Dr. Gabayan adds. “At the same time, we need to be especially cautious when we change disposition plans. By making concerted efforts to address these issues, we may be able to reduce the risk of catastrophic events like death or ICU admissions shortly after the elderly are discharged from the ED.”
Readings & Resources (click to view)
Gabayan GZ, Gould MK, Weiss RE, et al. Poor outcomes after emergency department discharge of the elderly: a case-control study. Ann Emerg Med. 2016 Feb 29 [Epub ahead of print]. Available at: http://www.annemergmed.com/article/S0196-0644(16)00008-1/fulltext.
Gabayan GZ, Sun BC, Asch SM, et al. Qualitative factors in patients who die shortly after emergency department discharge. Acad Emerg Med. 2013;20:778-785.
Gabayan GZ, Derose SF, Asch SM, et al. Patterns and predictors of short-term death after emergency department discharge. Ann Emerg Med. 2011;58:551-558.e552.
Gabayan GZ, Sarkisian CA, Liang LJ, et al. Predictors of admission after emergency department discharge in older adults. J Am Geriatr Soc. 2015;63:39-45.
Gabayan GZ, Asch SM, Hsia RY, et al. Factors associated with shortterm bounce-back admissions after emergency department discharge. Ann Emerg Med. 2013;62:136-144.