Emergency department admissions, older people, functional decline, and length of stay in hospital

Abstract Background 53% of hospital inpatient beds are occupied by patients >/= 65 years. These patients often experience functional decline. In those transferred to our post-acute rehabilitation unit the average length of stay prior to transfer is 16 days and 38 days post transfer. Our hospital has a Community Response Unit (CRU) which provides an alternative to this care pathway, offering direct admission to a 15 bed unit with 24-hour medical cover and full multidisciplinary input. This study reviews the use of this unit over a one year period. Methods We retrospectively reviewed the discharge letter or medical notes of patients admitted to the CRU during 2018. The referral source, indication for admission, length of stay and discharge destination were recorded. Results One-hundred and fourteen patients were admitted over the one year period. Source of referral was identified for 81 patients and included day hospitals (53.1%), acute hospitals (14.8%), respite/ transitional care wards (12.3%), nursing homes (8.7%), home visits (6.2%), community sources (3.7%) and other speciality clinics (1.2%). The most common indications for admission were-mobility/functional decline (26.3%), falls (17.5%), requirement for medical investigations (14.9%), cognitive decline with behavioural issues (11.4%), blood transfusion (10.5%), pain management (7%), general deterioration (7%), requirement for increased home supports (7%), treatment of infection (6.1%), rehab post fracture (5.3%), wound management (4.4%), alcohol detoxification (1.8%) and self-neglect (1.8%). Multifactorial reasons for admission frequently occurred. The median length of stay was 24 days (1-176 days), 67% of patients were discharged to their original residence, 17.4% were newly admitted to residential care, 9.2% required transfer to an acute hospital and 6.4% died during their admission. Conclusion The CRU provides comprehensive Geriatrician led care for a wide variety of indications. This model of care offers a valid alternative to Emergency Department presentation and acute hospital admission.

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Impact of emergency department length of stay on anxiety and comfort in older people

International Emergency Nursing ◽

10.1016/j.ienj.2021.100974 ◽

2021 ◽

Vol 56 ◽

pp. 100974

Author(s):

Julie Considine ◽

Debra Berry ◽

Bodil Rasmussen ◽

Alison M Hutchinson ◽

Helen Rawson ◽

...

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Older People

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Prevalence of Hospital Admissions for Low Back Pain: Protocol for a Systematic Review and Meta-Analysis

10.31219/osf.io/ym9ka ◽

2020 ◽

Author(s):

Harrison J Lord ◽

Danielle Coombs ◽

Christopher Maher ◽

Gustavo C Machado

Keyword(s):

Emergency Department ◽

Low Back Pain ◽

Back Pain ◽

Length Of Stay ◽

Hospital Admission ◽

Hospital Admissions ◽

Functional Decline ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Low Back

Low back pain is the leading cause of years lived with disability in most countries and creates a huge burden for healthcare systems globally. Around the globe, 4.4% of all emergency department attendances are attributed to low back pain, and subsequent admissions to hospital seem to be common. These hospitalisations can result in unnecessary medical care, functional decline and high costs. There are no systematic reviews summarising the global prevalence of hospital admission for low back pain, identifying the sources of admissions or estimating hospital length of stay. This information would be valuable for health and medical researchers, front-line clinicians, and health planners aiming to improve and increase the value of their health services. The objectives of this study are to estimate the prevalence of hospital admission for low back pain from different healthcare facilities across the globe, including the emergency department, as well as investigate hospital length of stay and explore sources of heterogeneity when categorising studies according to low back pain definitions, sources of admission, study period, study setting and country’s region and income level.

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Estimating the risk of functional decline in the elderly after discharge from an Australian public tertiary hospital emergency department

Australian Health Review ◽

10.1071/ah12034 ◽

2013 ◽

Vol 37 (3) ◽

pp. 341 ◽

Cited By ~ 9

Author(s):

Karen Grimmer ◽

Kate Beaton ◽

Saravana Kumar ◽

Kevan Hendry ◽

John Moss ◽

...

Keyword(s):

At Risk ◽

Emergency Department ◽

Older People ◽

Hospital Admission ◽

Functional Decline ◽

Tertiary Hospital ◽

Older Individuals ◽

Large Hospital ◽

General Medical Practitioner ◽

Males And Females

Objective. To estimate the risk of functional decline after discharge for older people presenting to, and discharged from, a large emergency department (ED) of a tertiary hospital. Methods. The cohort was generated by consecutive sampling of non-Indigenous males and females aged 65 years or over or Aboriginal and Torres Strait Islander males and females aged 45 years or more, without diagnosed dementia, who were living independently in the community before presenting at ED and who were not admitted to hospital as an inpatient after presenting to ED. The hospital assessment risk profile (HARP) was administered to all eligible participants. Sociodemographic information was collected. Results. Approximately 40 patients per day over two 14-week data collection periods were potentially eligible for inclusion in the study. In total, 597 (17.6% of individuals who presented to ED) were eligible, agreed to participate and continued to be eligible on discharge from ED. Their HARP scores suggested that ~52% were at-risk of functional decline (14.1% high risk, 38.5% intermediate risk). Conclusions. Elderly patients present to and are discharged from ED every day. The routinely administered HARP instrument scores suggested that approximately half these individuals were at-risk of functional decline in one large hospital ED. Given this instrument’s moderate diagnostic accuracy, the true figure may be higher. We suggest that all over-65 year olds presenting at ED without being admitted as an inpatient should be considered for routine screening for potential downstream functional decline, and for intervention if indicated. What is known about the topic? Older individuals often present to ED in lieu of consulting a general medical practitioner, and are not admitted to a hospital bed. Patient demographics, functional and mental capacity and reasons for presentation may be flags for functional decline in the coming months. These could be used by ED staff to implement targeted assessment and intervention. What does this paper add? This paper highlights the high percentage of older individuals who, at time of ED presentation, are at-risk of downstream functional decline. What are the implications for practitioners? Older people who are discharged from ED without a hospital admission may ‘slip through the net’, as an ED presentation presents a limited window of opportunity for ED staff to undertake targeted assessment, and intervention, to address the potential for downstream functional decline. The busy nature of ED, resource implications and the range of presenting conditions of older people may preclude this. This research suggests a reality that a large percentage of older people who present at ED but do not require a subsequent hospital admission have the potential for functional decline after discharge. Addressing this, in terms of specific screening processes and interventions, requires a rethink of hospital and community resources, and relationships.

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103 A Review of Reviews of Emergency Department Interventions for Older People: Outcomes, Costs and Implementation Factors

Age and Ageing ◽

10.1093/ageing/afz196.05 ◽

2020 ◽

Vol 49 (Supplement_1) ◽

pp. i34-i36

Author(s):

J van Oppen ◽

L Preston ◽

S Ablard ◽

H Buckley Woods ◽

S Mason ◽

...

Keyword(s):

Emergency Department ◽

Older People ◽

Emergency Care ◽

Assessment Tool ◽

Discharge Planning ◽

Meta Analysis ◽

Functional Decline ◽

Reporting Standards ◽

Inclusion Criteria ◽

Review Of Reviews

Abstract Introduction Older people’s emergency care is an international public health priority and remains sub-optimal in the UK. Strategies are needed to manage older patients sensitively and effectively. We reviewed emergency care interventions, evaluating evidence for outcomes, costs, and implementation. Methods We developed and registered (with PROSPERO, CRD42018111461) a review of reviews protocol. Screening was according to inclusion criteria for subject and reporting standards. Data were extracted and summarised in tabular and narrative form. Quality was assessed using AMSTAR2 and Joanna Briggs Institute tools. Due to intervention and outcome heterogeneity, findings were synthesised narratively. McCusker’s Elder-Friendly Emergency Department assessment tool was used as a classification framework. Results Eighteen review articles and three conference abstracts fulfilled inclusion criteria. The majority were systematic reviews, with four using meta-analysis. Fourteen reviews reported interventions initiated or wholly delivered within the ED, and four focussed on quality indicators or patient preferences. Confidence was limited to each review’s interpretation of primary studies. Descriptions of interventions were inconsistent, and there was high variability in reporting standards. Interventions mostly focussed on screening and assessment, discharge planning, referrals and follow-up, and multi-disciplinary team composition and professional activities. 26 patient and health service outcomes were reported, including admissions and readmissions, length of stay, mortality, functional decline, and quality of life. Conclusions Our review of reviews demonstrated that the current, extensive evidence base of review studies lacks complexity, with limited or no evidence for the effectiveness of interventions; reviews commonly called for more primary research using rigorous methods. There is little review evidence for factors influencing implementation. There was evidence that among interventions initiated in ED, those continued into the community yielded better outcomes. Service metrics (as valued by care commissioners) were evaluated as intervention outcomes more frequently than person-centred attributes (as valued by older people). Interventions were broadly holistic in nature.

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Can we predict functional decline in hospitalized older people admitted through the emergency department? Reanalysis of a predictive tool ten years after its conception

BMC Geriatrics ◽

10.1186/s12877-017-0498-0 ◽

2017 ◽

Vol 17 (1) ◽

Cited By ~ 5

Author(s):

Isabelle De Brauwer ◽

Pascale Cornette ◽

Benoît Boland ◽

Franck Verschuren ◽

William D’Hoore

Keyword(s):

Emergency Department ◽

Older People ◽

Functional Decline ◽

Predictive Tool

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298 Falls and Syncope in Older People in the Emergency Department: Prevalence, Clinical Characteristics and Outcomes

Age and Ageing ◽

10.1093/ageing/afz103.190 ◽

2019 ◽

Vol 48 (Supplement_3) ◽

pp. iii17-iii65

Author(s):

Robbie Bourke ◽

Ciara Rice ◽

Geraldine McMahon ◽

Conal Cunningham ◽

Rose Anne Kenny ◽

...

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Older People ◽

Clinical Characteristics ◽

Working Hours ◽

University Teaching ◽

Urgent Care ◽

Hard Copy ◽

Admission Rates ◽

Urban University

Abstract Background Falls, syncope and presyncope comprise a large proportion of emergency department (ED) presentations among older people, however accurate data detailing this is limited. The aim of this study therefore was to ascertain the percentage of ED presentations in older people due to falls/syncope/presyncope, and examine admission rates, length of stay and likely underlying diagnosis. Methods Over 1,300 consecutive presentations of older people (aged ≥60 years) to the ED of a large urban university teaching hospital in March 2018 were examined (electronic and hard-copy notes) to ascertain the prevalence of falls/syncope/presyncope presentations. Data was collected for each presentation with fall/syncope/presyncope on demographics, and relevant clinical characteristics, including admission outcome and length of stay (LOS). Results Falls/syncope/presyncope comprised 19% (250/1,324) of presentations of older people to the ED, with a mean age of 75.3 +/-0.64 years. Almost 60% (158/250) presented during ‘normal’ working hours, i.e. Monday to Friday, 0800-1800. Almost half (121/250) had a Manchester Triage Score (MTS) of 3, indicating a need for urgent care, while one third (93/250) were categorized as requiring very urgent or immediate assessment (MTS 2 or 1 respectively). Over one third (97/250) presented with explained/accidental falls, while 26% (66/250) and 35% (87/250) presented with syncope and unexplained falls respectively. One in two (118/250) older people presenting with falls/syncope/presyncope were admitted to the acute hospital, and this rises to almost two thirds (82/135) of those aged ≥75 years. The median LOS was 15 (9.9 -22.0) days. Conclusion Older people frequently present to the ED with falls/syncope/presyncope. The majority present during working hours and admission rates and LOS are relatively high. Falls/syncope/presyncope therefore represent an appropriate target for structured, multidisciplinary assessment at the ‘front door’ to provide early specialist assessment and management, and reduce complications associated with unnecessary admission to hospital.

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