Elderly patients have the highest rate of ED usage amongst all adult populations as well as the highest return rate. Despite this increased burden on the healthcare system, it is difficult to predict poor outcomes after discharge. We all want to treat each patient “as if they were my grandfather/grandmother” yet we still cannot prevent many catastrophic outcomes. Of course we know that many chronic diseases increase the risk of readmission, and the 1-year mortality of many injuries are very well studied—but translating these risks into improvement of patient care is difficult, and many patients don’t fall so neatly into these boxes. There is still a need to identify risk factors to help providers identify patients at high risk of poor or catastrophic outcomes.
A new article by Dr. Gelareh Gabayan et. Al takes a new perspective on this problem. Instead of identifying historical information, type of injury, or other clinical data that is classically used to highlight at-risk patients, the team instead looked at process-of-care factors which occurred during the ER visit. What are we doing during a visit that can raise a red flag? Their study generated 300 case-control visit pairs of patients >65 years old who were treated in their ED system, and either died or was admitted to the ICU within 7 days of discharge. The chart review matched 300 patients who experienced such an outcome with 300 case control patients who did not, then compared the charts to identify predictors for ICU admission and/or death. Read more about their methods of exclusion, randomization, and measurement in their article, here. The article identifies many characteristics as having an increased adjusted odds ratio for death or ICU admission, including Asian/Pacific islander, Hispanic, or black ethnicity, hypotension, tachycardia, and mental status changes.
Most interesting, however is that changing the disposition of a patient (or noting the consideration of admission) was found to be associated with a greater likelihood of death or an ICU admission. Change in disposition was the only association that was not a hard number. In fact, it’s the only association that we actively play a role in as physicians. Interestingly, Dr. Gabayan’s paper finds that when a change in disposition was related to specialty consultation, there was no longer an increase in risk. It appears these consults were able to provide services or follow-up care outside of an emergency physician’s scope of practice. Per the article; “Our findings, coupled with that of other studies, suggest that regardless of the initiating event causing the change in disposition status, the emergency providers’ clinical judgment about the disposition (admit versus discharge) of the patient should be given special attention by both the care team and the patient.” Next time you consider your disposition of an elderly patient, take a moment and consider their next 7 days.
Interested in more? This month’s Annals of Emergency Medicine included several articles regarding the care of our elderly patients, including two other very interesting articles: Dr. Fassier’s article explores the attitudes of EM physicians regarding critically ill elderly patients, while Drs. LeFebvre and Platts-Mills provide an editorial to the article, including discussing the frustrations many EM physicians have when it comes to both the patient and family.
Evan Kuhl, MD is an Emergency Medicine Resident at The George Washington University Hospital
