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

Gabayan, Gelareh Z.; Gould, Michael K.; Weiss, Robert E.; Patel, Neil; Donkor, Kwame; Chiu, Vicki; Yiu, Sau C.; Jones, Jason P.; Hoffman, Jerome R.; Sarkisian, Catherine A.

doi:10.1016/j.annemergmed.2016.01.007

Cited by 11 publications

(10 citation statements)

References 38 publications

(45 reference statements)

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“…A diagnosis of mental illness includes dementia, mood disorders, depression, and substance-related disorders. Although this is a different study with a different population, our finding in this study are similar to our prior work in that we found cognitive impairment 43 and chronic medical conditions 44 to be associated with a poor outcome after ED discharge in older adults. Patients with mental illness possibly have a diagnosis masked by the mental illness or are suffering an impairment in mental judgment and are unable to follow ED after care instructions.…”

Section: Discussionsupporting

confidence: 88%

“…Second, as there have been several analyses in the past evaluating death after ED discharge, this analysis did not evaluate outcomes of death. 16,43 Also, the EDs at Kaiser Permanente Southern California do not represent the most overcrowded conditions (such as those seen at safety net hospitals) 45 and the uninsured and underinsured are not represented in this study. In addition, the data used for this analysis are from 2009–2010 and practices in admission after discharge may have changed since that time frame.…”

Section: Discussionmentioning

confidence: 95%

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Emergency Department Vital Signs and Outcomes After Discharge

Gabayan

Gould

Weiss

et al. 2017

Academic Emergency Medicine

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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 2009–2010. We used univariate contingency tables to assess the relationship between hospital admission within 7 days of discharge and vital sign (including systolic blood pressure, heart rate, body temperature, and pulse oximetry (Sp02) 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 cut-off. The vital signs with at least twice the odds of admission were systolic blood pressure ≤ 97 mmHg (OR 2.02, 95% CI 1.57–2.60), heart rate ≥ 101 bpm (OR 2.00 95% CI 1.75–2.29), body temperature ≥99.2 degrees Fahrenheit (OR 2.14, 95% CI 1.90–2.41), and pulse oximetry ≤ 92 Sp02 (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.

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Section: Discussionsupporting

confidence: 88%

Section: Discussionmentioning

confidence: 95%

Emergency Department Vital Signs and Outcomes After Discharge

Gabayan

Gould

Weiss

et al. 2017

Academic Emergency Medicine

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“…Our primary outcome was death within seven days after discharge from emergency departments, as in prior studies. 14 15 16 24 25 People admitted as inpatients, transferred out of the department, or discharged to palliative care or a hospice were ineligible for the outcome. In many US emergency departments, patients who require a period of observation for diagnostic testing or monitoring are billed under a specific “observation status.” These patients are subsequently discharged or formally admitted as inpatients, and, for the purposes of this study, we classified patients by this ultimate disposition (that is, admitted or discharged).…”

Section: Methodsmentioning

confidence: 99%

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

Obermeyer

Cohn

Wilson

et al. 2017

BMJ

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ObjectiveTo 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.DesignRetrospective cohort study.SettingClaims data from the US Medicare program, covering visits to an emergency department, 2007-12.ParticipantsNationally 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 measureDeath within seven days after discharge from the emergency department, excluding patients transferred or admitted as inpatients.ResultsAmong 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).ConclusionsEvery 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.

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“…What could have been confounders in this population of the primary outcomes: "combined poor outcome of either death or an ICU admission shortly after ED discharge"? 1 C. This study was a case-control design. Why might investigators choose a case-control study design instead of a cohort study?…”

Section: Discussion Pointsmentioning

confidence: 99%