Dataset Information

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

ABSTRACT: The emergency department (ED) is an inherently high-risk setting. Our objective is to identify the factors associated with the combined poor outcome of either death or an ICU admission shortly after ED discharge in older adults.We conducted chart review of 600 ED visit records among adults older than 65 years that resulted in discharge from any of 13 hospitals within an integrated health system in 2009 to 2010. We randomly chose 300 patients who experienced the combined outcome within 7 days of discharge and matched case patients to controls who did not experience the outcome. Two emergency physicians blinded to the outcome reviewed the records and identified whether a number of characteristics were present. Predictors of the outcome were identified with conditional logistic regression.Of 1,442,594 ED visits to Kaiser Permanente Southern California in 2009 to 2010, 300 unique cases and 300 unique control records were randomly abstracted. Characteristics associated with the combined poor outcome included cognitive impairment (adjusted odds ratio [AOR] 2.10; 95% confidence interval [CI] 1.19 to 3.56), disposition plan change (AOR 2.71; 95% CI 1.50 to 4.89), systolic blood pressure less than 120 mm Hg (AOR 1.48; 95% CI 1.00 to 2.20), and pulse rate greater than 90 beats/min (AOR 1.66; 95% CI 1.02 to 2.71).We found that older patients discharged from the ED with a change in disposition from "admit" to "discharge," cognitive impairment, systolic blood pressure less than 120 mm Hg, and pulse rate greater than 90 beats/min were at increased risk of death or ICU admission shortly after discharge. Increased awareness of these high-risk characteristics may improve ED disposition decisionmaking.

SUBMITTER: Gabayan GZ

PROVIDER: S-EPMC5310269 | biostudies-literature | 2016 Jul

REPOSITORIES: biostudies-literature

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

Gabayan Gelareh Z GZ Gould Michael K MK Weiss Robert E RE Patel Neil N Donkor Kwame A KA Chiu Vicki Y VY Yiu Sau C SC Jones Jason P JP Hoffman Jerome R JR Sarkisian Catherine A CA

Annals of emergency medicine 20160302 1

<h4>Study objective</h4>The emergency department (ED) is an inherently high-risk setting. Our objective is to identify the factors associated with the combined poor outcome of either death or an ICU admission shortly after ED discharge in older adults.<h4>Methods</h4>We conducted chart review of 600 ED visit records among adults older than 65 years that resulted in discharge from any of 13 hospitals within an integrated health system in 2009 to 2010. We randomly chose 300 patients who experience ...[more]

PMID: 26947799

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Project description:BACKGROUND:Intra-abdominal emergency surgery is associated with high mortality risk and long length of hospital stay. The objective of this study was to explore variations in surgery rates, the relationship between admission source and discharge destination, and whether the postoperative length of stay was related to nursing home capacity in Irish counties. METHODS:Data on emergency hospital episodes for 2014-18 for patients aged over 65?years with a primary abdominal procedure code were obtained from the National Quality Assurance Improvement System. Data on population and nursing home capacity were obtained from the Central Statistics Office and the Health Information and Quality Authority. Episode rates per 100,000 were estimated for sex and age groups and compared between 26 Irish counties. The association between admission source and discharge destination was explored in terms episode numbers, length of stay and mortality. A negative binomial regression model estimated casemix adjusted excess post-operative length of stay. The correlation between excess post-operative length of stay and nursing home capacity was explored by linear regression. RESULTS:Overall, 4951 hospital episodes were included. The annual surgery rate ranged from 100 episodes per 100,000 65-69?years old to 250 per 100,000 85-89?year old men. 90% of the episodes were admitted from patients' home. Four in five of these patients returned to their home while 12.7% died at hospital. The proportion of episodes where patients returned to their home reduced to two in five for those aged 85-89?years. The post-operative length of stay was 13.6?days longer (p <?0.01) for episodes admitted from home and discharged to nursing home in comparison with episodes discharged home. A negative association (p =?0.08) was found between excess post-operative length of stay and county-level nursing home capacity. CONCLUSIONS:This study provides relevant information to support informed consent to surgery for patients and clinicians and to improve the provision of care to older patients presenting with intra-abdominal emergencies.

Project description:BACKGROUND: While Canadian ED physicians discharge most syncope patients with no specific further follow-up, approximately 5% will suffer serious outcomes after ED discharge. The goal of this study is to prospectively identify risk factors and to derive a clinical decision tool to accurately predict those at risk for serious outcomes after ED discharge within 30 days. METHODS/DESIGN: We will conduct a prospective cohort study at 6 Canadian EDs to include adults with syncope and exclude patients with loss of consciousness>5 minutes, mental status changes from baseline, obvious witnessed seizure, or head trauma prior to syncope. Emergency physicians will collect standardized clinical variables including historical features, physical findings, and results of immediately available tests (blood, ECG, and ED cardiac monitoring) prior to ED discharge/hospital admission. A second emergency physician will evaluate approximately 10% of study patients for interobserver agreement calculation of predictor variables. The primary outcome will be a composite serious outcome occurring within 30 days of ED discharge and includes three distinct categories: serious adverse events (death, arrhythmia); identification of serious underlying disease (structural heart disease, aortic dissection, pulmonary embolism, severe pulmonary hypertension, subarachnoid hemorrhage, significant hemorrhage, myocardial infarction); or procedures to treat the cause of syncope. The secondary outcome will be any of the above serious outcomes either suspected or those occurring in the ED. A blinded Adjudication Committee will confirm all serious outcomes. Univariate analysis will be performed to compare the predictor variables in patients with and without primary outcome. Variables with p-values <0.2 and kappa values ? 0.60 will be selected for stepwise logistic regression to identify the risk factors and to develop the clinical decision tool. We will enroll 5,000 patients (with 125 positive for primary outcome) for robust identification of risk factors and clinical decision tool development. DISCUSSION: Once successfully developed, this tool will accurately risk-stratify adult syncope patients; however, validation and implementation will still be required. This program of research should lead to standardized care of syncope patients, and improve patient safety.

Project description:ImportanceSepsis guidelines and research have focused on patients with sepsis who are admitted to the hospital, but the scope and implications of sepsis that is managed in an outpatient setting are largely unknown.ObjectiveTo identify the prevalence, risk factors, practice variation, and outcomes for discharge to outpatient management of sepsis among patients presenting to the emergency department (ED).Design, setting, and participantsThis cohort study was conducted at the EDs of 4 Utah hospitals, and data extraction and analysis were performed from 2017 to 2021. Participants were adult ED patients who presented to a participating ED from July 1, 2013, to December 31, 2016, and met sepsis criteria before departing the ED alive and not receiving hospice care.ExposuresPatient demographic and clinical characteristics, health system parameters, and ED attending physician.Main outcomes and measuresInformation on ED disposition was obtained from electronic medical records, and 30-day mortality data were acquired from Utah state death records and the US Social Security Death Index. Factors associated with ED discharge rather than hospital admission were identified using penalized logistic regression. Variation in ED discharge rates between physicians was estimated after adjustment for potential confounders using generalized linear mixed models. Inverse probability of treatment weighting was used in the primary analysis to assess the noninferiority of outpatient management for 30-day mortality (noninferiority margin of 1.5%) while adjusting for multiple potential confounders.ResultsAmong 12 333 ED patients with sepsis (median [IQR] age, 62 [47-76] years; 7017 women [56.9%]) who were analyzed in the study, 1985 (16.1%) were discharged from the ED. After penalized regression, factors associated with ED discharge included age (adjusted odds ratio [aOR], 0.90 per 10-y increase; 95% CI, 0.87-0.93), arrival to ED by ambulance (aOR, 0.61; 95% CI, 0.52-0.71), organ failure severity (aOR, 0.58 per 1-point increase in the Sequential Organ Failure Assessment score; 95% CI, 0.54-0.60), and urinary tract (aOR, 4.56 [95% CI, 3.91-5.31] vs pneumonia), intra-abdominal (aOR, 0.51 [95% CI, 0.39-0.65] vs pneumonia), skin (aOR, 1.40 [95% CI, 1.14-1.72] vs pneumonia) or other source of infection (aOR, 1.67 [95% CI, 1.40-1.97] vs pneumonia). Among 89 ED attending physicians, adjusted ED discharge probability varied significantly (likelihood ratio test, P < .001), ranging from 8% to 40% for an average patient. The unadjusted 30-day mortality was lower in discharged patients than admitted patients (0.9% vs 8.3%; P < .001), and their adjusted 30-day mortality was noninferior (propensity-adjusted odds ratio, 0.21 [95% CI, 0.09-0.48]; adjusted risk difference, 5.8% [95% CI, 5.1%-6.5%]; P < .001). Alternative confounder adjustment strategies yielded odds ratios that ranged from 0.21 to 0.42.Conclusions and relevanceIn this cohort study, discharge to outpatient treatment of patients who met sepsis criteria in the ED was more common than previously recognized and varied substantially between ED physicians, but it was not associated with higher mortality compared with hospital admission. Systematic, evidence-based strategies to optimize the triage of ED patients with sepsis are needed.

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Dataset Information

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

Publications

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

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