Differences in triage category, priority level and hospitalization rate between young-old and old-old patients visiting the emergency department

Clinical Acuity in the Emergency Department and Injury Severity Determine Hospital Admission of Older Patients with Low Energy Falls: Outcomes from a Prospective Feasibility Study

BACKGROUND

Low energy falls (LEF) in older adults constitute a relevant cause for emergency department (ED) visits, hospital admission and in-hospital mortality. Patient-reported outcome measures containing information about patients' medical, mental and social health problems might support disposition and therapy decisions. We investigated the value of a tablet-based (self-)assessment in predicting hospital admission and in-hospital mortality.

METHODS

Patients 65 years or older, consecutively presenting with LEF to our level I trauma center ED (from November 2020 to March 2021), were eligible for inclusion in this prospective observational study. The primary endpoint was hospital admission; secondary endpoints were in-hospital mortality and the use of the tablet for self-reported assessment. Multivariate logistic regression models were calculated to measure the association between clinical findings and endpoints.

RESULTS

Of 618 eligible patients, 201 patients were included. The median age was 82 years (62.7% women). The hospital admission rate was 45.3% (110/201), with an in-hospital mortality rate of 3.6% (4/110). Polypharmacy (odds ratio (OR): 8.48; 95% confidence interval (95%CI) 1.21-59.37, p = 0.03), lower emergency severity index (ESI) scores (OR: 0.33; 95%CI 0.17-0.64, p = 0.001) and increasing injury severity score (ISS) (OR: 1.54; 95%CI 1.32-1.79, p < 0.001) were associated with hospital admission. The Charlson comorbidity index (CCI) was significantly associated with in-hospital mortality (OR: 2.60; 95%CI: 1.17-5.81, p = 0.03). Increasing age (OR: 0.94; 95%CI: 0.89-0.99, p = 0.03) and frailty (OR: 0.71; 95%CI: 0.51-0.99, p = 0.04) were associated with the incapability of tablet use.

CONCLUSIONS

The severity of fall-related injuries and the clinical acuity are easily accessible, relevant predictors for hospital admission. Tablet-based (self-)assessment may be feasible and acceptable during ED visits and might help facilitate comprehensive geriatric assessments during ED stay.

To Admit or Not to Admit to the Emergency Department: The Disposition Question at a Tertiary Teaching and Referral Hospital

BACKGROUND

Disposition decision-making in the emergency department (ED) is crucial to patient safety and quality of care. It can inform better care, lower chance of infections, appropriate follow-up care, and reduced healthcare costs. The aim of this study was to examine correlates of ED disposition among adult patients at a teaching and referral hospital based on patients' demographic, socioeconomic, and clinical characteristics.

METHOD

A cross-sectional study conducted at the ED of the King Abdulaziz Medical City hospital in Riyadh. A two-level validated questionnaire was used-a patient questionnaire and healthcare staff/facility survey. The survey employed a systematic random sampling technique to recruit subjects at a pre-specified interval as patients arrived at the registration desk. We analyzed 303 adult patients visiting the ED, who were triaged, consented to participate in the study, completed the survey, and admitted to a hospital bed or discharged home. We used descriptive and inferential statistics to summarize and determine the interdependence and relationships of variables. We used logistic multivariate regression analysis to establish relationships and the odds of admission to a hospital bed.

RESULTS

The mean age of the patients was 50.9 (SD = 21.4, Range 18 to 101). A total of 201 (66%) were discharged home while the rest were admitted to a hospital bed. Results of the unadjusted analysis suggest that older patients, males, patients with low level of education, and those with comorbidities and middle-income were more likely to be admitted to the hospital. The results of the multivariate analysis suggest that patients with comorbidities, urgent conditions, prior history of hospitalization, and higher triage levels were more likely to be admitted to a hospital bed.

CONCLUSIONS

Having proper triage and timely stopgap review measures in the admission process can help new patients to locations that best support their needs and improve the quality and efficiency of the facility. The findings may be a sentinel indicator that informs overuse or inappropriate use of EDs for non-emergency care, which is a concern in the Saudi Arabian publicly funded health system.

Emergency department use and length of stay by younger and older adults: Nottingham cohort study in the emergency department (NOCED)

BACKGROUND

Younger and older adults attending the Emergency Department (ED) are a heterogeneous population. Longer length of ED stay is associated with adverse outcomes and may vary by age.

AIMS

To evaluate the associations between age and (1) clinical characteristics and (2) length of ED stay among adults attending ED.

METHODS

The NOttingham Cohort study in the Emergency Department (NOCED)-a retrospective cohort study-comprises new consecutive ED attendances by adults ≥ 18 years, at a secondary/tertiary care hospital, in 2019. Length of ED stay was dichotomised as < 4 and ≥ 4 h. The associations between age and length of ED stay were analysed by binary logistic regression and adjusted for socio-demographic and clinical factors including triage acuity.

RESULTS

146,636 attendances were analysed; 75,636 (51.6%) resulted in a length of ED stay ≥ 4 h. Attendances of adults aged 65 to 74 years, 75 to 84 years and ≥ 85 years, respectively, had an increased risk (odds ratio (95% confidence interval) of length of ED stay ≥ 4 h of 1.52 (1.45-1.58), 1.65 (1.58-1.72), and 1.84 (1.75-1.93), compared to those of adults 18 to 64 years (all p < 0.001). These findings remained consistent in the subsets of attendances leading to hospital admission and those leading to discharge from ED.

DISCUSSION AND CONCLUSION

In this real-world cohort study, older adults were more likely to have a length of ED stay ≥ 4 h, with the oldest old having the highest risk. ED target times should take into account age of attendees.

Development and Assessment of an Interpretable Machine Learning Triage Tool for Estimating Mortality After Emergency Admissions

IMPORTANCE

Triage in the emergency department (ED) is a complex clinical judgment based on the tacit understanding of the patient's likelihood of survival, availability of medical resources, and local practices. Although a scoring tool could be valuable in risk stratification, currently available scores have demonstrated limitations.

OBJECTIVES

To develop an interpretable machine learning tool based on a parsimonious list of variables available at ED triage; provide a simple, early, and accurate estimate of patients' risk of death; and evaluate the tool's predictive accuracy compared with several established clinical scores.

DESIGN, SETTING, AND PARTICIPANTS

This single-site, retrospective cohort study assessed all ED patients between January 1, 2009, and December 31, 2016, who were subsequently admitted to a tertiary hospital in Singapore. The Score for Emergency Risk Prediction (SERP) tool was derived using a machine learning framework. To estimate mortality outcomes after emergency admissions, SERP was compared with several triage systems, including Patient Acuity Category Scale, Modified Early Warning Score, National Early Warning Score, Cardiac Arrest Risk Triage, Rapid Acute Physiology Score, and Rapid Emergency Medicine Score. The initial analyses were completed in October 2020, and additional analyses were conducted in May 2021.

MAIN OUTCOMES AND MEASURES

Three SERP scores, namely SERP-2d, SERP-7d, and SERP-30d, were developed using the primary outcomes of interest of 2-, 7-, and 30-day mortality, respectively. Secondary outcomes included 3-day mortality and inpatient mortality. The SERP's predictive power was measured using the area under the curve in the receiver operating characteristic analysis.

RESULTS

The study included 224 666 ED episodes in the model training cohort (mean [SD] patient age, 63.60 [16.90] years; 113 426 [50.5%] female), 56 167 episodes in the validation cohort (mean [SD] patient age, 63.58 [16.87] years; 28 427 [50.6%] female), and 42 676 episodes in the testing cohort (mean [SD] patient age, 64.85 [16.80] years; 21 556 [50.5%] female). The mortality rates in the training cohort were 0.8% at 2 days, 2.2% at 7 days, and 5.9% at 30 days. In the testing cohort, the areas under the curve of SERP-30d were 0.821 (95% CI, 0.796-0.847) for 2-day mortality, 0.826 (95% CI, 0.811-0.841) for 7-day mortality, and 0.823 (95% CI, 0.814-0.832) for 30-day mortality and outperformed several benchmark scores.

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study, SERP had better prediction performance than existing triage scores while maintaining easy implementation and ease of ascertainment in the ED. It has the potential to be widely applied and validated in different circumstances and health care settings.

Assessing Older Patients' Vulnerability in the Emergency Department: A Study of InterRAI ED Screener Accuracy

BACKGROUND

Identifying vulnerable older patients admitted to an emergency department (ED) who are at increased risk for adverse events and require a comprehensive geriatric assessment remains a major challenge. The interRAI Emergency Department Screener (EDS) was developed for this specific purpose, but data regarding its validity are scarce.

OBJECTIVES

To determine (1) convergent validity of the EDS with results of a geriatrician's assessment in defining the need for prompt versus delayed/no further geriatric assessment and (2) predictive validity of the EDS for hospital admission, prolonged hospital length of stay (LOS), and 30-day readmission.

DESIGN

Prospective observational study.

SETTING

ED of an academic hospital in Switzerland.

PARTICIPANTS

Older patients, aged 75 years or older (N = 202), who visited the ED over a 4-month period. Patients with life-threatening conditions were excluded.

MEASUREMENTS

Data for EDS were collected by two clinical nurses. A brief geriatric assessment was performed separately and interpreted by a geriatrician blinded to the EDS results. Orientation after ED discharge, hospital LOS, and 30-day readmission were retrieved from the administrative database.

RESULTS

Participants were aged 83.2 ± 5.4 years, 56.9% were female, and 43.6% lived alone. Frequent findings at geriatric assessment were impairment in gait/balance (69.3%), polypharmacy (64.9%), cognitive impairment/delirium (48.2%), risk of malnutrition (46.0%), and mood impairment (38.1%). The proportions of participants who required prompt, delayed, and no further geriatric assessment, according to the EDS, were 27.2%, 29.2%, and 43.6%, respectively. The EDS had low sensitivity in predicting hospital admission (28.8%), prolonged LOS (26.3%), and 30-day readmission (26.1%), with the Area Under the Receiver Operating Characteristics (AUROC) being 51.8%, 48.1%, and 49.4%, respectively.

CONCLUSION

The EDS performed poorly in both convergent and predictive validity analyses, precluding its use as a screening tool in this ED environment. Further efforts should be undertaken to better target interventions to reduce adverse health trajectories in the older ED population.

Emergency care access to primary care records: an observational study

OBJECTIVE

To measure lookup rates of externally held primary care records accessed in emergency care and identify patient characteristics, conditions and potential consequences associated with access.

MEASURES

Rates of primary care record access and re-presentation to the emergency department (ED) within 30 days and hospital admission.

DESIGN

A retrospective observational study of 77 181 ED presentations over 4 years and 9 months, analysing 8184 index presentations in which patients' primary care records were accessed from the ED. Data were compared with 17 449 randomly selected index control presentations. Analysis included propensity score matching for age and triage categories.

RESULTS

6.3% of overall ED presentations triggered a lookup (rising to 8.3% in year 5); 83.1% of patients were only looked up once and 16.9% of patients looked up on multiple occasions. Lookup patients were on average 25 years older (z=-9.180, p<0.001, r=0.43). Patients with more urgent triage classifications had their records accessed more frequently (z=-36.47, p<0.001, r=0.23). Record access was associated with a significant but negligible increase in hospital admission (χ² (1, n=13 120)=98.385, p<0.001, phi=0.087) and readmission within 30 days (χ² (1, n=13 120)=86.288, p<0.001, phi=0.081).

DISCUSSION

Emergency care clinicians access primary care records more frequently for older patients or those in higher triage categories. Increased levels of inpatient admission and re-presentation within 30 days are likely linked to age and triage categories.

CONCLUSION

Further studies should focus on the impact of record access on clinical and process outcomes and which record elements have the most utility to shape clinical decisions.

Resuscitation status and characteristics and outcomes of patients transferred from subacute care to acute care hospitals: A multi-site prospective cohort study

AIMS AND OBJECTIVES

To examine the relationship between resuscitation status and (i) patient characteristics; (ii) transfer characteristics; and (iii) patient outcomes following an emergency inter-hospital transfer from a subacute to an acute care hospital.

BACKGROUND

Patients who experience emergency inter-hospital transfers from subacute to acute care hospitals have high rates of acute care readmission (81%) and in-hospital mortality (15%).

DESIGN

This prospective, exploratory cohort study was a subanalysis of data from a larger case-time-control study in five Health Services in Victoria, Australia. There were 603 transfers in 557 patients between August 2015 and October 2016. The study was conducted in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology guidelines.

METHODS

Data were extracted by medical record audit. Three resuscitation categories (full resuscitation; limitation of medical treatment (LOMT) orders; or not-for-cardiopulmonary resuscitation (CPR) orders) were compared using chi-square or Kruskal-Wallis tests. Stratified multivariable proportional hazard Cox regression models were used to account for health service clustering effect.

FINDINGS

Resuscitation status was 63.5% full resuscitation; 23.1% LOMT order; and 13.4% not-for-CPR. Compared to patients for full resuscitation, patients with not-for-CPR or LOMT orders were more likely to have rapid response team calls during acute care readmission or to die during hospitalisation. Patients who were not-for-CPR were less likely to be readmitted to acute care and more likely to return to subacute care.

CONCLUSIONS

Two-thirds of patients in subacute care who experienced an emergency inter-hospital transfer were for full resuscitation. Although the proportion of patients with LOMT and not-for-CPR orders increased after transfer, there were deficiencies in the documentation of resuscitation status and planning for clinical deterioration for subacute care patients.

RELEVANCE TO CLINICAL PRACTICE

As many subacute care patients experience clinical deterioration, patient preferences for care need to be discussed and documented early in the subacute care admission.

Nonspecific complaints in the emergency department - a systematic review

BACKGROUND

Nonspecific complaint (NSC) is a common presenting complaint in the emergency setting, especially in the elderly population. Individual studies have shown that it is associated with significant morbidity and mortality. This prognostic systematic review draws a synthesis of reported outcomes for patients presenting with NSC and compares them with outcomes for patients presenting with a specific complaint.

METHODS

We conducted a literature search for publications, abstracts and conference presentations from Ovid, Scopus and Web of Science for the past 20 years. Studies were included which treated adult patients presenting to the Emergency Medical Services or Emergency Department with NSC. 2599 studies were screened for eligibility and quality was assessed using the SIGN assessment for bias tool. We excluded any low-quality studies, resulting in nine studies for quantitative analysis. We analysed the included studies for in-hospital mortality, triage category, emergency department length of stay, admission rate, hospital length of stay, intensive care admissions and re-visitation rate and compared outcomes to patients presenting with specific complaints (SC), where data were available. We grouped discharge diagnoses by ICD-10 category.

RESULTS

We found that patients presenting with NSC were mostly older adults. Mortality for patients with NSC was significantly increased compared to patients presenting with SC [OR 2.50 (95% CI 1.40-4.47)]. They were triaged as urgent less often than SC patients [OR 2.12 (95% CI 1.08-4.16)]. Emergency department length of stay was increased in two out of three studies. Hospital length of stay was increased by 1-3 days. Admission rates were high in most studies, 55 to 84%, and increased in comparison to patients with SC [OR 3.86 (95% CI 1.76-8.47)]. These patients seemed to require more resources than patients with SC. The number for intensive care admissions did not seem to be increased. Data were insufficient to make conclusions regarding re-visitation rates. Discharge diagnoses were spread throughout the ICD-10 main chapters, infections being the most prevalent.

CONCLUSIONS

Patients with NSC have a high risk of mortality and their care in the Emergency Department requires more time and resources than for patients with SC. We suggest that NSC should be considered a major emergency presentation.