Poor Outcomes After Emergency Department Discharge of the Elderly: A Case-Control Study

Modified Shock Index as a Predictor for Mortality and Hospitalization Among Patients With Dementia

BACKGROUND

One in four older adults in the Emergency Department (ED) suffers from severe cognitive impairment, creating great difficulty for the emergency physicians who determine the urgency of their patients' condition, which informs decisions regarding discharge or hospitalization.

OBJECTIVE

Our objective was to determine whether modified shock index (MSI) can be a clinical mortality and hospitalization predictor when applied to older patients with dementia in the ED.

METHODS

Included in the research were all patients with dementia, > 65 years old, who arrived at the Soroka University Medical Center ED during 2014-2017. The population was divided into three groups according to their MSI score, calculated as heart rate/mean arterial pressure: MSI < 0.7; 0.7 > MSI < 1.3; and MSI > 1.3. We performed multivariable logistic regression as a predictor of death within 30 days, Cox analysis for number of days to death, and a negative binominal regression for predicting the number of admission days.

RESULTS

Included were 1437 patients diagnosed with dementia. Patients with an MSI > 1.3 vs. those with MSI < 0.7 had an odds ratio of 8.23 (95% confidence interval [CI] 4.64-4.54) for mortality within 30 days, increased mortality risk within 180 days (hazard ratio 4.42; 95% CI 2.64-7.41), and longer hospitalization duration (incidence rate ratio 1.8; 95% CI 1.32-2.45).

CONCLUSIONS

High MSI scores were associated with high mortality rates and longer hospitalization duration for patients diagnosed with dementia who were > 65 years old. We suggest performing prospective studies utilizing the MSI score as an indicator in ED triage settings to classify patients with dementia by their severity of risk, to determine if this benefits health, minimizes expenses, and prevents unnecessary hospitalizations.

A Scoping Review of Emergency Department Discharge Risk Stratification

INTRODUCTION

Although emergency department (ED) discharge presents patient-safety challenges and opportunities, the ways in which EDs address discharge risk in the general ED population remains disparate and largely uncharacterized. In this study our goal was to conduct a review of how EDs identify and target patients at increased risk at time of discharge.

METHODS

We conducted a literature search to explore how EDs assess patient risk upon discharge, including a review of PubMed and gray literature. After independently screening articles for inclusion, we recorded study characteristics including outcome measures, patient risk factors, and tool descriptions. Based on this review and discussion among collaborators, major themes were identified.

RESULTS

PubMed search yielded 384 potentially eligible articles. After title and abstract review, we screened 235 for potential inclusion. After full text and reference review, supplemented by Google Scholar and gray literature reviews, we included 30 articles for full review. Three major themes were elucidated: 1) Multiple studies include retrospective risk assessment, whereas the use of point-of-care risk assessment tools appears limited; 2) of the point-of-care tools that exist, inputs and outcome measures varied, and few were applicable to the general ED population; and 3) while many studies describe initiatives to improve the discharge process, few describe assessment of post-discharge resource needs.

CONCLUSION

Numerous studies describe factors associated with an increased risk of readmission and adverse events after ED discharge, but few describe point-of-care tools used by physicians for the general ED population. Future work is needed to investigate standardized tools that assess ED discharge risk and patients' needs upon ED discharge.

Predicting Emergency Department "Bouncebacks": A Retrospective Cohort Analysis

INTRODUCTION

The short-term return visit rate among patients discharged from emergency departments (ED) is a quality metric and target for interventions. The ability to accurately identify which patients are more likely to revisit the ED could allow EDs and health systems to develop more focused interventions, but efforts to reduce revisits have not yet found success. Whether patients with a high number of ED visits are at increased risk of a return visit remains underexplored.

METHODS

This was a population-based, retrospective, cohort study using administrative data from a large physician partnership. We included patients discharged from EDs from 80 hospitals in seven states from July 2014 - June 2016. We performed multivariable logistic regression of short-term return visits on patient, visit, hospital, and community characteristics. The primary outcome was the proportion of patients who had a return visit within 14 days of an index ED visit.

RESULTS

Among 6,699,717 index visits, the overall risk of 14-day revisit was 12.6%. Frequent visitors accounted for 18.7% of all visits and 40.2% of all 14-day revisits. Frequent visitor status was associated with the highest odds of a revisit (odds ratio [OR] 3.06; 95% confidence interval [CI], 3.041 - 3.073). Other predictors of revisits were cellulitis (OR 2.131; 95% CI, 2.106 - 2.156), alcohol-related disorders (OR 1.579; 95%CI, 1.548 - 1.610), congestive heart failure (OR 1.175; 95% CI, 1.126 - 1.226), and public insurance (Medicaid OR 1.514; 95% CI, 1.501 - 1.528; Medicare OR 1.601; 95% CI, 1.583 - 1.620).

CONCLUSION

Previous ED use - even a single previous visit - was a stronger predictor of a return visit than any other patient, hospital, or community characteristic. Clinicians should consider previous ED use when considering treatment decisions and risk of return visit, as should stakeholders targeting patients at risk of a return visit.

Risk of death within 7 days of discharge from emergency departments with different organizational models

OBJECTIVE

The aim of this study is to investigate the association between emergency department (ED) organizational models and the risk of death within 7 days of ED discharge.

PATIENTS AND METHODS

We included Danish ED discharges between 1 January 2011 and 24 December 2014 that led to death within 7 days of discharge. The inclusion criterion was age older than 18 years. The exclusion criterion was further in-hospital admission. First model (Virtual): other departments employ interns who perform ED tasks. They are responsible for ED patient care and prioritize their task order between their own department and the ED. Second model (Hybrid): the ED/other departments perform tasks; interns/consultants are employed by the ED/other departments. The ED/other departments have patient care responsibility. Third model (Independent): the ED performs all tasks; employs interns/consultants; and have patient care responsibility. Sex, age, Charlson Comorbidity Index score, and primary diagnosis were used to describe patient characteristics. We calculated the risk of death within 7 days of discharge using multiple logistic regression analysis.

RESULTS

In 805 out of 201 299 discharges included in the study, the patient died within 7 days. Compared with the Virtual model, the odds ratio for death within 7 days of discharge was 0.72 (95% confidence interval: 0.59-0.92) for the Independent model and 0.75 (95% confidence interval: 0.61-0.92) for the Hybrid+Virtual model. Increased risk was associated with male sex, older age, and a medium or a high Charlson Comorbidity Index score.

CONCLUSION

Compared with discharges from a Virtual model, the risk of death within 7 days of discharge was lower if the ED had an Independent or a Hybrid+Virtual model.

A Risk Score to Predict Short-term Outcomes Following Emergency Department Discharge

Introduction

The emergency department (ED) is an inherently high-risk setting. Risk scores can help practitioners understand the risk of ED patients for developing poor outcomes after discharge. Our objective was to develop two risk scores that predict either general inpatient admission or death/intensive care unit (ICU) admission within seven days of ED discharge.

Methods

We conducted a retrospective cohort study of patients age > 65 years using clinical data from a regional, integrated health system for years 2009–2010 to create risk scores to predict two outcomes, a general inpatient admission or death/ICU admission. We used logistic regression to predict the two outcomes based on age, body mass index, vital signs, Charlson comorbidity index (CCI), ED length of stay (LOS), and prior inpatient admission.

Results

Of 104,025 ED visit discharges, 4,638 (4.5%) experienced a general inpatient admission and 531 (0.5%) death or ICU admission within seven days of discharge. Risk factors with the greatest point value for either outcome were high CCI score and a prolonged ED LOS. The C-statistic was 0.68 and 0.76 for the two models.

Conclusion

Risk scores were successfully created for both outcomes from an integrated health system, inpatient admission or death/ICU admission. Patients who accrued the highest number of points and greatest risk present to the ED with a high number of comorbidities and require prolonged ED evaluations.

Emergency Department Vital Signs and Outcomes After Discharge

OBJECTIVE

Vital signs are critical markers of illness severity in the emergency department (ED). Providers need to understand the abnormal vital signs in older adults that are problematic. We hypothesized that in patients age > 65 years discharged from the ED, there are abnormal vital signs that are associated with an admission to an inpatient bed within 7 days of discharge.

METHODS

We conducted a retrospective cohort study using data from a regional integrated health system of members age > 65 years during the years 2009 to 2010. We used univariate contingency tables to assess the relationship between hospital admission within 7 days of discharge and vital sign (including systolic blood pressure [sBP], heart rate [HR], body temperature, and pulse oximetry [SpO₂ ] values measured closest to discharge) using standard thresholds for abnormal and thresholds derived from the study data.

RESULTS

Of 104,025 ED discharges, 4,638 (4.5%) were followed by inpatient admission within 7 days. Vital signs had a greater odds of admission beyond a single cutoff. The vital signs with at least twice the odds of admission were sBP < 97 mm Hg (odds ratio [OR] = 2.02, 95% CI = 1.57-2.60), HR > 101 beats/min (OR = 2.00 95% CI = 1.75-2.29), body temperature > 37.3°C (OR = 2.14, 95% CI = 1.90-2.41), and pulse oximetry < 92 SpO₂ (OR = 2.04, 95% CI = 1.55-2.68). Patients with two vital sign abnormalities per the analysis had the highest odds of admission. A majority of patients discharged with abnormal vital signs per the analysis were not admitted within 7 days of ED discharge.

CONCLUSION

While we found a majority of patients discharged with abnormal vital signs as defined by the analysis, not to be admitted after discharge, we identified vital signs associated with at least twice the odds of admission.

Early death after discharge from emergency departments: analysis of national US insurance claims data

OBJECTIVE

 To measure incidence of early death after discharge from emergency departments, and explore potential sources of variation in risk by measurable aspects of hospitals and patients.

DESIGN

 Retrospective cohort study.

SETTING

 Claims data from the US Medicare program, covering visits to an emergency department, 2007-12.

PARTICIPANTS

 Nationally representative 20% sample of Medicare fee for service beneficiaries. As the focus was on generally healthy people living in the community, patients in nursing facilities, aged ≥90, receiving palliative or hospice care, or with a diagnosis of a life limiting illnesses, either during emergency department visits (for example, myocardial infarction) or in the year before (for example, malignancy) were excluded.

MAIN OUTCOME MEASURE

 Death within seven days after discharge from the emergency department, excluding patients transferred or admitted as inpatients.

RESULTS

 Among discharged patients, 0.12% (12 375/10 093 678, in the 20% sample over 2007-12) died within seven days, or 10 093 per year nationally. Mean age at death was 69. Leading causes of death on death certificates were atherosclerotic heart disease (13.6%), myocardial infarction (10.3%), and chronic obstructive pulmonary disease (9.6%). Some 2.3% died of narcotic overdose, largely after visits for musculoskeletal problems. Hospitals in the lowest fifth of rates of inpatient admission from the emergency department had the highest rates of early death (0.27%)-3.4 times higher than hospitals in the highest fifth (0.08%)-despite the fact that hospitals with low admission rates served healthier populations, as measured by overall seven day mortality among all comers to the emergency department. Small increases in admission rate were linked to large decreases in risk. In multivariate analysis, emergency departments that saw higher volumes of patients (odds ratio 0.84, 95% confidence interval 0.81 to 0.86) and those with higher charges for visits (0.75, 0.74 to 0.77) had significantly fewer deaths. Certain diagnoses were more common among early deaths compared with other emergency department visits: altered mental status (risk ratio 4.4, 95% confidence interval 3.8 to 5.1), dyspnea (3.1, 2.9 to 3.4), and malaise/fatigue (3.0, 2.9 to 3.7).

CONCLUSIONS

 Every year, a substantial number of Medicare beneficiaries die soon after discharge from emergency departments, despite no diagnosis of a life limiting illnesses recorded in their claims. Further research is needed to explore whether these deaths were preventable.