Qualitative analysis of disposition decision making for patients referred for admission from the emergency department without definite medical acuity

A Retrospective Study on the Outcomes of Injuries From Border Wall Falls

Objective Our retrospective cohort study focuses on the outcomes of injuries sustained from falls from the USA-Mexico border wall. The purpose of this study is to understand and predict the types of injuries that will be present in patients who fall from the border wall. This can further help trauma response teams to better predict and prepare for the care of these patients.  Methods  This retrospective cohort study included all patients that were admitted to Desert Regional Medical Center, a trauma I center, after a fall from the border wall that ranged from heights of 15 to 30 feet. The admissions occurred between March 2016 to December 2021.  Results  Of the 108 patients included, 38.2% (78) sustained at least one lower extremity injury, of which the most common was injury to the calcaneus bone. Additionally, there were several concomitant injuries, of which the combination of lower extremity and lumbar injury was found to be the most common (11.2%). The injury severity score (ISS) was found to not be statistically significant (ɑ=0.05) between groups of patients whose length of stay (LOS) in the hospital was greater than 10 days and less than 10 days. There was 1% fatality (1 of 108) and 92.5% required surgical intervention (100 of 108).  Conclusions Patients injured from border wall falls are more likely to sustain lower extremity injuries than injuries to other parts of the body. Additionally, patients with lower extremity injuries sustained lumbar spinal injuries concomitantly, which can be most likely attributed to the axial compression of the spine during these falls. Most of these injuries required surgery and hospital admissions to treat. Understanding the patterns of injury from border wall falls can further help trauma response teams treat patients with efficient management.

Association of Functional Status, Cognition, Social Support, and Geriatric Syndrome With Admission From the Emergency Department

Importance

The role of patient-level factors that are unrelated to the specific clinical condition leading to an emergency department (ED) visit, such as functional status, cognitive status, social supports, and geriatric syndromes, in admission decisions is not well understood, partly because these data are not available in administrative databases.

Objective

To determine the extent to which patient-level factors are associated with rates of hospital admission from the ED.

Design, Setting, and Participants

This cohort study analyzed survey data collected from participants (or their proxies, such as family members) enrolled in the Health and Retirement Study (HRS) from January 1, 2000, to December 31, 2018. These HRS data were linked to Medicare fee-for-service claims data from January 1, 1999, to December 31, 2018. Information on functional status, cognitive status, social supports, and geriatric syndromes was obtained from the HRS data, whereas ED visits, subsequent hospital admission or ED discharge, and other claims-derived comorbidities and sociodemographic characteristics were obtained from Medicare data. Data were analyzed from September 2021 to April 2023.

Main Outcomes and Measures

The primary outcome measure was hospital admission after an ED visit. A baseline logistic regression model was estimated, with a binary indicator of admission as the dependent variable of interest. For each primary variable of interest derived from the HRS data, the model was reestimated, including the HRS variable of interest as an independent variable. For each of these models, the odds ratio (OR) and average marginal effect (AME) of changing the value of the variable of interest were calculated.

Results

A total of 42 392 ED visits by 11 783 unique patients were included. At the time of the ED visit, patients had a mean (SD) age of 77.4 (9.6) years, and visits were predominantly for female (25 719 visits [60.7%]) and White (32 148 visits [75.8%]) individuals. The overall percentage of patients admitted was 42.5%. After controlling for ED diagnosis and demographic characteristics, functional status, cognition status, and social supports all were associated with the likelihood of admission. For instance, difficulty performing 5 activities of daily living was associated with an 8.5-percentage point (OR, 1.47; 95% CI, 1.29-1.66) AME increase in the likelihood of admission. Having dementia was associated with an AME increase in the likelihood of admission of 4.6 percentage points (OR, 1.23; 95% CI, 1.14-1.33). Living with a spouse was associated with an AME decrease in the likelihood of admission of 3.9 percentage points (OR, 0.84; 95% CI, 0.79-0.89), and having children living within 10 miles was associated with an AME decrease in the likelihood of admission of 5.0 percentage points (OR, 0.80; 95% CI, 0.71-0.89). Other common geriatric syndromes, including trouble falling asleep, waking early, trouble with vision, glaucoma or cataract, use of hearing aids or trouble with hearing, falls in past 2 years, incontinence, depression, and polypharmacy, were not meaningfully associated with the likelihood of admission.

Conclusion and Relevance

Results of this cohort study suggest that the key patient-level characteristics, including social supports, cognitive status, and functional status, were associated with the decision to admit older patients to the hospital from the ED. These factors are critical to consider when devising strategies to reduce low-value admissions among older adult patients from the ED.

Injury Patterns and Hospital Admission After Trauma Among People Experiencing Homelessness

Importance

Traumatic injury is a major cause of morbidity for people experiencing homelessness (PEH). However, injury patterns and subsequent hospitalization among PEH have not been studied on a national scale.

Objective

To evaluate whether differences in mechanisms of injury exist between PEH and housed trauma patients in North America and whether the lack of housing is associated with increased adjusted odds of hospital admission.

Design, Setting, and Participants

This was a retrospective observational cohort study of participants in the 2017 to 2018 American College of Surgeons' Trauma Quality Improvement Program. Hospitals across the US and Canada were queried. Participants were patients aged 18 years or older presenting to an emergency department after injury. Data were analyzed from December 2021 to November 2022.

Exposures

PEH were identified using the Trauma Quality Improvement Program's alternate home residence variable.

Main Outcomes and Measures

The primary outcome was hospital admission. Subgroup analysis was used to compared PEH with low-income housed patients (defined by Medicaid enrollment).

Results

A total of 1 738 992 patients (mean [SD] age, 53.6 [21.2] years; 712 120 [41.0%] female; 97 910 [5.9%] Hispanic, 227 638 [13.7%] non-Hispanic Black, and 1 157 950 [69.6%] non-Hispanic White) presented to 790 hospitals with trauma, including 12 266 PEH (0.7%) and 1 726 726 housed patients (99.3%). Compared with housed patients, PEH were younger (mean [SD] age, 45.2 [13.6] years vs 53.7 [21.3] years), more often male (10 343 patients [84.3%] vs 1 016 310 patients [58.9%]), and had higher rates of behavioral comorbidity (2884 patients [23.5%] vs 191 425 patients [11.1%]). PEH sustained different injury patterns, including higher proportions of injuries due to assault (4417 patients [36.0%] vs 165 666 patients [9.6%]), pedestrian-strike (1891 patients [15.4%] vs 55 533 patients [3.2%]), and head injury (8041 patients [65.6%] vs 851 823 patients [49.3%]), compared with housed patients. On multivariable analysis, PEH experienced increased adjusted odds of hospitalization (adjusted odds ratio [aOR], 1.33; 95% CI, 1.24-1.43) compared with housed patients. The association of lacking housing with hospital admission persisted on subgroup comparison of PEH with low-income housed patients (aOR, 1.10; 95% CI, 1.03-1.19).

Conclusions and Relevance

Injured PEH had significantly greater adjusted odds of hospital admission. These findings suggest that tailored programs for PEH are needed to prevent their injury patterns and facilitate safe discharge after injury.

Clinical risk calculators informing the decision to admit: A methodologic evaluation and assessment of applicability

INTRODUCTION

Clinical prediction and decision tools that generate outcome-based risk stratification and/or intervention recommendations are prevalent. Appropriate use and validity of these tools, especially those that inform complex clinical decisions, remains unclear. The objective of this study was to assess the methodologic quality and applicability of clinical risk scoring tools used to guide hospitalization decision-making.

METHODS

In February 2021, a comprehensive search was performed of a clinical calculator online database (mdcalc.com) that is publicly available and well-known to clinicians. The primary reference for any calculator tool informing outpatient versus inpatient disposition was considered for inclusion. Studies were restricted to the adult, acute care population. Those focused on obstetrics/gynecology or critical care admission were excluded. The Wasson-Laupacis framework of methodologic standards for clinical prediction rules was applied to each study.

RESULTS

A total of 22 calculators provided hospital admission recommendations for 9 discrete medical conditions using adverse events (14/22), mortality (6/22), or confirmatory diagnosis (2/22) as outcomes of interest. The most commonly met methodologic standards included mathematical technique description (22/22) and clinical sensibility (22/22) and least commonly met included reproducibility of the rule (1/22) and measurement of effect on clinical use (1/22). Description of the studied population was often lacking, especially patient race/ethnicity (2/22) and mental or behavioral health (0/22). Only one study reported any item related to social determinants of health.

CONCLUSION

Studies commonly do not meet rigorous methodologic standards and often fail to report pertinent details that would guide applicability. These clinical tools focus primarily on specific disease entities and clinical variables, missing the breadth of information necessary to make a disposition determination and raise significant validation and generalizability concerns.