Epidemiological profile of geriatric patients admitted to the emergency department of a university hospital localized in a rural area

Elderly patients with non-specific complaints at the emergency department have a high risk for admission and 30-days mortality

BACKGROUND

Older adults have complex medical needs that causes increased use of resources at the emergency department (ED). The prevalence of non-specific complaint (NSC) as a chief-complaint in the ED is common among older adults and is not prioritized even though possibly having worse clinical outcome. The objective was to study hospital admission and mortality for older adults visiting the ED with NSC compared to specific complaints such as dyspnea, chest pain and abdominal pain.

METHODS

A retrospective observational study of older adults visiting the ED with NSC and specific complaints; dyspnea, chest pain and abdominal pain was performed. Chief-complaint were collected from electronic medical records. Fatigue, confusion, non-specific complaints, generalized weakness and risk of falling were defined as non-specific complaint (NSC) when registered as chief-complaint at the ED. Admission rate and 30-days mortality were the primary outcomes.

RESULTS

A total of 4927 patients were included in the study based on chief-complaint; patients with chest pain 1599 (32%), dyspnea 1343 (27%), abdominal pain 1460 (30%) and NSC 525 (11%). Patients with dyspnea and NSC had the highest hospital admission rate 79% vs 70% compared to patients with chest pain (63%) and abdominal pain (61%) (p =  < 0.001). Patients with NSC had a mean LOS 4.7 h at the ED which was significantly higher compared to chest pain, dyspnea and abdominal pain. Mean bed-days for the whole population was 4.2 days compared to patients with NSC who had a mean LOS of 5.6 days. NSC and dyspnea were both associated with the highest 30-day mortality.

CONCLUSION

Older patients who present with NSC at the ED are associated with a high risk for admission and 30-days mortality. In addition, patients with NSC have a longer LOS at the ED, a high admission rate and the highest number of bed-days once admitted. This study indicates that ED staff should be more vigilant when an elderly patient presents with NSC at the ED. Further studies and guidelines are needed to improve the management of these individuals.

Soluble urokinase plasminogen activator receptor and lactate as prognostic biomarkers in patients presenting with non-specific chief complaints in the pre-hospital setting - the PRIUS-study

BACKGROUND

Emergency Medical Services (EMS) are faced daily with patients presenting with non-specific chief complaints (NSC). Patients presenting with NSCs often have normal vital signs. It has previously been established that NSCs may have a serious underlying condition that has yet to be identified. The aim of the current study was to determine if soluble urokinase plasminogen activator receptor (suPAR) and lactate could be used to identify serious conditions among patients presenting with NSCs to the EMS. The secondary aim was to describe the prognostic value for mortality in the group.

METHOD

A blinded prospective observational cohort study was conducted of patients brought to the ED by ambulance after calling the national emergency number 112 and who were assessed as having NSC by the EMS. Biomarkers were measured during index EMS assessment before transportation to the ED. Patients were followed via EMS and hospital electronic health records. Descriptive and logistic regression analyses were used.

RESULTS

A total of 414 patients were included, with a median age of 82 years. A serious condition was present in 15.2% of the patients. Elevated suPAR above 3 ng/ml had a positive likelihood ratio (LR+) of 1.17 and a positive predictive value (PPV) of 17.3% as being predictive of a prevalent serious condition. Elevated suPAR above 9 ng/ml had LR+ 4.67 and a PPV of 16.7% as being predictive of 30-day mortality. Lactate was not significantly predictive.

CONCLUSION

Pre-hospital suPAR and lactate cannot differentiate serious conditions in need of urgent treatment and assessment in the ED among patients presenting with non-specific chief complaints. suPAR has shown to be predictive of 30-day mortality, which could add some value to the clinical assessment.

TRIAL REGISTRATION

NCT03089359. Registered 20 March 2017, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03089359 .

Elderly patients presenting to a rural hospital emergency department in inland Croatia - A retrospective study

BACKGROUND

Emergency departments are faced with a high influx of patients presenting for various complaints. The aim of the present study was to assess the basic characteristics of elderly patients presenting to a rural hospital emergency department in inland Croatia in 2017.

METHODS

Retrospective data collected from the Hospital Information System and by analysis of medical records on patients presenting to emergency department in 2017 were used in the study.

RESULTS

Study results indicated that a lower proportion of elderly individuals aged 65-74 were hospitalized following emergency department workup. A statistically significantly higher proportion of patients older than 74 years was presented to ED due to various discomforts and diseases (ICD-10 group I; χ2 = 324.85; p < 0.01) than due to cardiorespiratory diseases and acute abdomen (χ2 = 285.04; p < 0.01).

CONCLUSION

Our findings highlight the need for a complex approach in care for elderly people, given that they are a fragile population with multiple comorbidities, chronic diseases, atypical symptoms, and often with cognitive and functional impairments.

The presentational flow chart "unwell adult" of the Manchester Triage System-Curse or blessing?

Background

The presentational flow chart “unwell adult” of the Manchester Triage System (MTS) occupies a special role in this triage system, defined as the nonspecific presentation of an emergency patient. Current scientific studies show that a considerable proportion of emergency room patients present with so-called "nonspecific complaints". The aim of the present study is to investigate in detail the initial assessment of emergency patients triaged according to the presentational flow chart "unwell adult".

Methods

Monocentric, retrospective observational study.

Results

Data on 14,636 emergency department visits between March 12^th and August 12^th, 2019 were included. During the observation period, the presentational flow chart "unwell adult" was used 1,143 times and it was the third most frequently used presentational flow chart. Patients triaged with this flow chart often had unspecific complaints upon admission to the emergency department. Patients triaged with the “unwell adult” chart were often classified with a lower triage level. Notably, patients who died in hospital during the observation period frequently received low triage levels. The AUC for the MTS flow chart “unwell adult” and hospitalization in general for older patients (age ≥ 65 years) was 0.639 (95% CI 0.578–0.701), and 0.730 (95% CI 0.714–0.746) in patients triaged with more specific charts. The AUC for the MTS flow chart “unwell adult” and admission to ICU for older patients (age ≥65 years) was 0.631 (95% CI 0.547–0.715) and 0.807 (95% CI 0.790–0.824) for patients triaged with more specific flow charts. Comparison of the predictive ability of the MTS for in-hospital mortality in the group triaged with the presentational flow chart “unwell adult” revealed an AUC of 0.682 (95% CI 0.595–0.769) vs. 0.834 (95% CI 0.799–0.869) in the other presentational flow charts.

Conclusion

The presentational flow chart "unwell adult" is frequently used by triage nurses for initial assessment of patients. Patient characteristics assessed with the presentational flow chart "unwell adult" differ significantly from those assessed with MTS presentational flow charts for more specific symptoms. The quality of the initial assessment in terms of a well-functioning triage priority assessment tool is less accurate than the performance of the MTS described in the literature.

Emergency department management of older people living with frailty: a guide for emergency practitioners

Emergency Departments (EDs) are increasingly seeing more seriously unwell older people living with frailty. In the context of limited resources and increasing demand it's the ED practitioner's challenge to unpick this constellation of physical, psychological, functional and social issues.To properly assess older people living with frailty at the ED it is crucial to use an holistic approach. This consists of triage with algorithms sensitive to the higher risk of older people living with frailty, a frailty assessment, and an assessment with the help of the principles of Comprehensive Geriatric Assessment. Multi-disciplinary care, a tailor-made treatment plan, based on what the person values most, will help the ED practitioner to deliver appropriate and valuable care during the ED stay, but also in transition from hospital to home.

Emergency department patients with weakness or fatigue: Can physicians predict their outcomes at the front door? A prospective observational study

BACKGROUND

Generalized weakness and fatigue are underexplored symptoms in emergency medicine. Triage tools often underestimate patients presenting to the emergency department (ED) with these nonspecific symptoms (Nemec et al., 2010). At the same time, physicians' disease severity rating (DSR) on a scale from 0 (not sick at all) to 10 (extremely sick) predicts key outcomes in ED patients (Beglinger et al., 2015; Rohacek et al., 2015). Our goals were (1) to characterize ED patients with weakness and/or fatigue (W|F); to explore (2) to what extent physicians' DSR at triage can predict five key outcomes in ED patients with W|F; (3) how well DSR performs relative to two commonly used benchmark methods, the Emergency Severity Index (ESI) and the Charlson Comorbidity Index (CCI); (4) to what extent DSR provides predictive information beyond ESI, CCI, or their linear combination, i.e., whether ESI and CCI should be used alone or in combination with DSR; and (5) to what extent ESI, CCI, or their linear combination provide predictive information beyond DSR alone, i.e., whether DSR should be used alone or in combination with ESI and / or CCI.

METHODS

Prospective observational study between 2013-2015 (analysis in 2018-2020, study team blinded to hypothesis) conducted at a single center. We study an all-comer cohort of 3,960 patients (48% female patients, median age = 51 years, 94% completed 1-year follow-up). We looked at two primary outcomes (acute morbidity (Bingisser et al., 2017; Weigel et al., 2017) and all-cause 1- year mortality) and three secondary outcomes (in-hospital mortality, hospitalization and transfer to ICU). We assessed the predictive power (i.e., resolution, measured as the Area under the ROC Curve, AUC) of the scores and, using logistic regression, their linear combinations.

FINDINGS

Compared to patients without W|F (n = 3,227), patients with W|F (n = 733) showed higher prevalences for all five outcomes, reported more symptoms across both genders, and received higher DSRs (median = 4; interquartile range (IQR) = 3-6 vs. median = 3; IQR = 2-5). DSR predicted all five outcomes well above chance (i.e., AUCs > ~0.70), similarly well for both patients with and without W|F, and as good as or better than ESI and CCI in patients with and without W|F (except for 1-year mortality where CCI performs better). For acute morbidity, hospitalization, and transfer to ICU there is clear evidence that adding DSR to ESI and/or CCI improves predictions for both patient groups; for 1-year mortality and in-hospital mortality this holds for most, but not all comparisons. Adding ESI and/or CCI to DSR generally did not improve performance or even decreased it.

CONCLUSIONS

The use of physicians' disease severity rating has never been investigated in patients with generalized weakness and fatigue. We show that physicians' prediction of acute morbidity, mortality, hospitalization, and transfer to ICU through their DSR is also accurate in these patients. Across all patients, DSR is less predictive of acute morbidity for female than male patients, however. Future research should investigate how emergency physicians judge their patients' clinical state at triage and how this can be improved and used in simple decision aids.

Serious conditions among patients with non-specific chief complaints in the pre-hospital setting: a retrospective cohort study

Background

Emergency Medical Services (EMS) are faced daily with patients presenting with a non-specific chief complaints (NSC); i.e. decreased general condition, general malaise, sense of illness, or just being unable to cope with usual daily activities. Patients presenting with NSCs often have normal vital signs. It has previously been established that however, NSCs may have a serious underlying condition that has yet to be identified. The primary outcome of this study was to determine the prevalence of serious conditions in patients presenting with NSCs to the EMS.

Method

A retrospective cohort study of patients ≥18 years of age who were reported as presenting with chief complaints compatible with NSCs to the EMS in Stockholm Region and transported to an emergency department between January 1st, 2013 and December 31st, 2013. Patients were identified via the EMS electronic health care record and followed via records from the National Patient Registry and Causes of Death Registry at Sweden’s National Board for Health and Welfare. The definition of serious condition was defined by expert consensus. Descriptive statistics as well as regression analyses were used.

Results

A total of 3780 patients were included, with a median age of 77 years. A serious condition was present in 35.3% of the patients. The in-hospital mortality rate for the group with serious conditions was 10.1% (OR 6.8, CI 95%, 4.1–11.3), and the 30-day mortality rate was 20.2% (OR 3.1, CI 95%, 2.3–4.0). In the group with no serious conditions the rates were 1.0 and 4.2%, respectively. The total hospitalization rate was 67.6%. The presence of serious conditions as well as increased mortality rates were associated with Rapid Emergency Triage and Treatment system (RETTS) as well as National Early Warning Score (NEWS) irrespective of triage score.

Conclusion

More than one-third of the patients presenting with NSCs to EMS had a serious underlying condition which was associated with increased mortality and hospitalization rates.

Trial registration

Not applicable.

Contact characteristics and factors associated with the degree of urgency among older people in emergency primary health care: a cross-sectional study

Background

As the proportion of older people increases, so will the consumption of health services. The aim of this study was to describe the contact characteristics among older people and to identify factors associated with the degree of urgency at the Norwegian out-of-hours (OOH) emergency primary health care services.

Methods

Inhabitants aged ≥70 years who contacted the OOH service during 2014–2017 in seven OOH districts in Norway were included. We investigated the variables sex, age, time of contact, mode of contact, ICPC-2 based reason for encounter (RFE), priority degree and initial response. We also performed frequency analyses, rate calculations and a log-binomial regression.

Results

A total of 38,293 contacts were registered. The contact rate/1000 inhabitants/year was three times higher in the oldest age group (≥90 years) compared to the youngest age group (70–74 years). Direct attendance accounted for 8.4% of the contacts and 32.8% were telephone contacts from health professionals. The most frequent RFE chapter used was “A General and unspecified” (21.0%) which also showed an increasing rate with higher age. 6.0% of the contacts resulted in a home visit from a doctor. Variables significantly associated with urgent priority degree were RFEs regarding cardiovascular (Relative risk (RR) 1.85; CI 1.74–1.96), neurological (RR 1.55; CI 1.36–1.77), respiratory (RR 1.40; CI 1.30–1.51) and digestive (RR 1.22; CI 1.10–1.34) issues. In addition, telephone calls from health professionals (RR 1.21; CI 1.12–1.31), direct attendance (RR 1.13; CI 1.04–1.22), contacts on weekdays (RR 1.13; CI 1.06–1.20) and contacts from men (RR 1.13; CI 1.09–1.17) were significantly associated with urgent priority degree.

Conclusions

This study provides important information about the Norwegian older inhabitants’ contact with the OOH emergency primary health care services. There are a wide variety of RFEs, and the contact rate is high and increases with higher age. Telephone contact is most common. The OOH staff frequently identify older people as having “general and unspecified” reasons for encounters. OOH nursing staff would benefit from having screening tools and enhanced geriatric training to best support this vulnerable group when these individuals call the OOH service.

Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting?

BACKGROUND

Elderly patients presenting to the emergency department (ED) with nonspecific complaints (NSCs) often undergo troponin testing to assess for atypical acute coronary syndrome (ACS). However, the rate of ACS and utility of troponin testing in this population is unknown. We sought to determine the rate of ACS and diagnostic yield of troponin testing in elderly patients with NSCs.

METHODS

We retrospectively identified all patients aged ≥ 65 years triaged in the ED with NSCs from January 1, 2017, to June 30, 2017. NSCs were defined a priori and included complaints such as weakness, dizziness, or fatigue. NSCs were verified in ED provider notes by trained abstractors blind to testing results. Exclusions were focal chief complaint in provider notes, fever, and no troponin ordered. ACS was strictly defined and independently adjudicated by two trained physician researchers blind to the study hypothesis. We calculated the proportion of patients with ACS within 30 days and the test characteristics of troponin to diagnose ACS.

RESULTS

Screening identified 1,146 encounters, and 552 were excluded for fever or focal chief complaints in the provider notes. Of the remaining 594 patients, troponin was ordered in 412 (69%), comprising the study cohort. The mean (±SD) age was 78.7 (±8.3) years, with 58% female and 75% admitted. Troponin elevation occurred in 81 patients (20%). ACS occurred in 5 of 412 (1.2%). Troponin was 100% sensitive (95% confidence interval [CI] = 48% to 100%) and 81% specific (95% CI = 77% to 85%) for ACS. Of patients with elevated troponin, 93.8% were false positives (no ACS). All patients with troponin elevation were admitted, but only one underwent angiography and no patients received reperfusion therapy.

CONCLUSIONS

While consideration for ACS is prudent in selected elderly patients with NSCs, ACS was rare and no patients received reperfusion therapy. Given the false-positive rate in our study, our results may not support routine troponin testing for ACS in this population.

[Triage, screening, and assessment of geriatric patients in the emergency department]

BACKGROUND

Geriatric patients are increasingly dominating the daily routine in German emergency departments (ED). With their typical characteristics multimorbidity, polypharmacy, vulnerability, frailty and cognitive impairment, especially delirium, they are a special challenge for the processes in the ED. Though some emergency physician might consider "the old patient" as not exciting, there is a broad consensus that pragmatic geriatric screening tools are required. This consensus exists not only among the medical societies but also within the German Society for Emergency Medicine itself. In this article the characteristics of the geriatric patient, the pitfalls of triage systems and the difficulties to screen geriatric patients in a sensible manner are described.

DISCUSSION

The common triage systems and the screening tools that have been developed for geriatric emergency patients have disadvantages. In Manchester Triage System (MTS) and Emergency Severity Index (ESI) geriatric patients are at risk of incorrect triage, though both systems, e.g., name acute cognitive impairment as a high-risk factor. The ESI has been validated for geriatric patients. The correct use of the triage algorithms is crucial, but for a triage nurse, acute cognitive impairment, e.g., might be difficult to identify. One reason for that is that many of the existing screening tools are not applicable in the ED or are without immediate benefit for the patient. More practical tools will have to be developed in the future.

Which near-patient tests might improve the diagnosis of UTI in older people in urgent care settings? A mapping review and consensus process

PURPOSE

The aim of this study was to map out the existing knowledge on near-patient tests for urinary tract infections, and use a consensus building approach to identify those which might be worthy of further evaluation in the urgent care context, defined as clinically useful and feasible results available within 4-24 h.

METHODS

A systematic search for reviews describing diagnostic tests for UTI was undertaken in Medline, EMBASE, Cochrane database of systematic reviews and CINAHL selected reviews were retained according to a priori inclusion and exclusion criteria, and then graded for quality using the CASP tool for reviews. A consensus process involving microbiologists and chemical pathologists helped identify which test might conceivably be applied in the urgent care context (e.g. Emergency Department, giving results within 24 h).

RESULTS

The initial search identified 1079 papers, from which 26 papers describing 35 diagnostic tests were retained for review. The overall quality was limited, with only 7/26 retained papers scoring more than 50% on the CASP criteria. Reviews on urine dipstick testing reported wide confidence intervals for sensitivity and specificity; several raised concerns about urine dip testing in older people. A number of novel biomarkers were reported upon but appeared not to be helpful in differentiating infection from asymptomatic bacteriuria. Blood markers such as CRP and procalcitonin were reported to be helpful in monitoring rather than diagnosing UTI. The consensus process helped to refine the 35 test down to 17 that might be useful in the urgent care context: urinalysis (nitrites and leucocytes), uriscreen catalase test, lactoferrin, secretory immunoglobulin A, xanthine oxidase, soluble triggering receptor expressed on myeloid cells, A-1 microglobulin (a1 Mg) and a1 Mg/creatinine ratio, cytokine IL-6, RapidBac, MALDI-TOF, electronic noses, colorimetric sensor arrays, electro chemical biosensor, WBC count (blood), C-reactive peptide, erythrocyte sedimentation rate.

CONCLUSIONS

A wide range of diagnostic tests have been explored to diagnose UTI, but, in general, have been poorly evaluated or have wide variation in predictive properties. This study identified 17 tests for UTI that seemed to offer some primes and merit further evaluation for diagnosing UTI in older people in urgent care settings.

[Older emergency patients in the emergency department : A key performance indicator analysis based on the DIVI emergency department protocol]

BACKGROUND

Overall, there is only little data in health care research on the subject of emergency care in older patients in Germany. The aim of the present study is to assess the older emergency patient in regard to the core data set "Emergency Department" of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI).

MATERIALS AND METHODS

Monocentric, retrospective observational study.

RESULTS

In the observation period, a total of 29,391 emergency patients were treated at the interdisciplinary emergency center. Of these, 8072 emergency patients were ≥65 years old (27.4%). With increasing age, paramedic ambulances (RTW) or physician-led ambulances (NEF) are increasingly used (p < 0.001). Older emergency patients arriving by a physician-led emergency service show a 38.9-fold increase in mortality compared to ambulatory patients (odds ratio = 38.98 [29.22-51.87]). The initial assessment, using the Manchester Triage System (MTS), shows a steady rise towards higher urgency levels with increasing age (p < 0.001). In the multivariate analysis within the individual age clusters, there is a correlation between the triage level and hospital mortality, unrelated to gender (p < 0.001). Likewise the use of consulting physicians can be linked to advanced age (p < 0.001). Also the length of stay in the interdisciplinary emergency center correlates highly with age (p < 0.001).

CONCLUSION

The older emergency patient clearly differs from younger emergency patients in all key performance indicators considered and already poses a special challenge to emergency departments.

Modification of the Emergency Severity Index Improves Mortality Prediction in Older Patients

Introduction

Older patients frequently present to the emergency department (ED) with nonspecific complaints (NSC), such as generalized weakness. They are at risk of adverse outcomes, and early risk stratification is crucial. Triage using Emergency Severity Index (ESI) is reliable and valid, but older patients are prone to undertriage, most often at decision point D. The aim of this study was to assess the predictive power of additional clinical parameters in NSC patients.

Methods

Baseline demographics, vital signs, and deterioration of activity of daily living (ADL) in patients with NSC were prospectively assessed at four EDs. Physicians scored the coherence of history and their first impression. For prediction of 30-day mortality, we combined vital signs at decision point D (heart rate, respiratory rate, oxygen saturation) as “ESI vital,” and added “ADL deterioration,” “incoherence of history,” or “first impression,” using logistic regression models.

Results

We included 948 patients with a median age of 81 years, 62% of whom were female. The baseline parameters at decision point D (ESI vital) showed an area under the curve (AUC) of 0.64 for predicting 30-day mortality in NSC patients. AUCs increased to 0.67 by adding ADL deterioration to 0.66 by adding incoherence of history, and to 0.71 by adding first impression. Maximal AUC was 0.73, combining all parameters.

Conclusion

Adding the physicians’ first impressions to vital signs at decision point D increases predictive power of 30-day mortality significantly. Therefore, a modified ESI could improve predictive power of triage in older patients presenting with NSCs.

Analysis of the citation of articles published in the European Journal of Emergency Medicine since its foundation

OBJECTIVES

The aim of this study was to evaluate the evolution of the citation of articles from the European Journal of Emergency Medicine (EJEM) from 1994 (EJEM foundation) to 2015 and identify highly cited articles and their principal characteristics and determine a possible correlation between the citations counted in different databases.

MATERIALS AND METHODS

We obtained the articles published in EJEM from 1994 to 2015 in ISI-WoS (main source) and Scopus, Google Scholar, and Medline databases (accessory sources). The citations were quantified and their annual evolution and the bibliometric indices derived (impact factor and SCImago Journal Rank) were evaluated. We identified and analyzed the highly cited EJEM articles and evaluated the possible correlation between the citations counted for these articles in the databases.

RESULTS

Overall, 1705 EJEM articles were cited 9422 times in 8122 different articles. The evolution of the global citation, impact factor, and SCImago Journal Rank from 1994 to 2015 increased significantly. The h-index of EJEM was 30, and 31 articles were considered highly cited (≥30 citations), 16.1% of them being clinical trials. By subjects, 22.5% corresponded to cardiology, 19.3% to emergency department management, and 12.9% to pediatrics; by countries, 81% were from Europe, with Belgian authors publishing four (12.9%) highly cited articles, and French, Spanish, British, and Swedish authors having three (9.7%) each. Two studies in the EJEM achieved the definition of 'citation classics' (more than 100 citations). The number of citations in all the databases, except Medline, showed statistically significant correlations.

CONCLUSION

Citation of EJEM articles has progressively increased and EJEM bibliometric indicators have improved; most highly cited articles are mainly by European authors.

Disability and morbidity among older patients in the emergency department: a Danish population-based cohort study

OBJECTIVES

The objective was to describe the prevalence of geriatric conditions among older medical patients in the emergency department (ED) and the association with admission, mortality, reattendance and loss of independency.

DESIGN

Population-based prospective cohort study.

SETTING

ED of a large university hospital.

PARTICIPANTS

All medical patients ≥65 years of age from a single municipality with a first attendance to the ED during a 1-year period (November 2013 to November 2014).

PRIMARY AND SECONDARY OUTCOME MEASURES

Based on information from healthcare registers, we defined geriatric conditions as disability, recently increased disability, polypharmacy and comorbidity. Outcomes were admission, length of admission, 30 days postdischarge mortality, 30 days hospital reattendance and home care dependency 0-360 days following ED contact.

RESULTS

Totally, 3775 patients (55% women) were included, age 78 (71-85) years (median (IQR)). No patients were lost to follow-up. The prevalence of 0-4 geriatric conditions was 14.9%, 27.3%, 25.2%, 22.3% and 10.3%, respectively. The number of conditions was significantly associated with hospital admission, length of admission, 30 days postdischarge mortality and 30 days hospital reattendance. Among patients with no geriatric conditions, 70% lived independent all 360 days after discharge, whereas all patients with ≥3 conditions had some dependency or were dead within 360 days following discharge.

CONCLUSION

Among older medical patients in the ED, 50% had two or more geriatric conditions which were associated with poor health outcomes. This highlights the need for studies of the effect of geriatric awareness and competences in the ED.

Feasibility of predictive model by clinical and laboratory parameters for risk stratification of geriatric abdominal pain

Background:

Assessment of geriatric patients presented with abdominal pain had been challenge for emergency physicians with the ageing population. A rapid, reproducible risk stratification model for the assessment of the need for admission for geriatric abdominal pain would be required to identify low-risk patients to be managed as out-patient basis.

Objective:

Assess the feasibility of risk stratification model to predict the need of hospital admission based on readily available bedside parameters in emergency departments.

Methods:

This is a multicenter retrospective cohort study in four emergency departments. Patients aged at least 65 who presented with chief complaint of abdominal pain within the previous 7 days of attendance as the chief complaint were included. Chart review was performed for the included patients. The primary outcome was defined as a composite of mortality, abdominal surgery or endoscopic treatment, and other inpatient treatments for abdominal diseases within 14 days, surrogating the need of hospital admission. Logistic regression was modeled to identify independent predictors. The diagnostic accuracy of the risk model was evaluated with the receiver operating characteristic curve and compared with the clinical gestalt of decision for hospital admission by the attending physician.

Results:

In total, 553 patients were included. Symptoms of upper gastrointestinal bleeding, non-ambulatory presenting status, pain duration, focal abdominal tenderness, hyperglycemia, leukocytosis, and elevated creatinine were independent predictors of the outcome. The area under the receiver operating characteristic curve of the predicted probabilities of the logistic model was 0.741. In keeping for a low-risk criterion to achieve more than 90% sensitivity, the predictive model would only achieve 18.2% specificity which was inferior to clinical gestalt for hospital admission (sensitivity 99.3%, specificity 44.3%).

Conclusion:

Risk stratification model by clinical assessment and laboratory markers alone were inadequate and inferior to clinical gestalt for identification of the group of patients requiring inpatient treatment.

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

Background

Emergency Department (ED) are challenged by the increasing number of visits made by the heterogeneous population of elderly persons. This study aims to 1) compare chief complaints (triage categories) and level of priority; 2) to investigate their association with hospitalization after an ED visit; 3) to explore factors explaining the difference in hospitalization rates among community-dwelling older adults aged 65–84 vs 85+ years.

Methods

All ED visits of patients age 65 and over that occurred between 2005 and 2010 to the University of Lausanne Medical Center were analyzed. Associations of hospitalization with triage categories and level of priority using regressions were compared between the two age groups. Blinder-Oaxaca decomposition was performed to explore how much age-related differences in prevalence of priority level and triage categories contributed to predicted difference in hospitalization rates across the two age groups.

Results

Among 39′178 ED visits, 8′812 (22.5%) occurred in 85+ patients. This group had fewer high priority and more low priority conditions than the younger group. Older patients were more frequently triaged in “Trauma” (20.9 vs 15.0%) and “Home care impossible” (10.1% vs 4.2%) categories, and were more frequently hospitalized after their ED visit (69.1% vs 58.5%). Differences in prevalence of triage categories between the two age groups explained a quarter (26%) of the total age-related difference in hospitalization rates, whereas priority level did not play a role.

Conclusions

Prevalence of priority level and in triage categories differed across the two age groups but only triage categories contributed moderately to explaining the age-related difference in hospitalization rates after the ED visit. Indeed, most of this difference remained unexplained, suggesting that age itself, besides other unmeasured factors, may play a role in explaining the higher hospitalization rate in patients aged 85+ years.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3257-9) contains supplementary material, which is available to authorized users.

Elderly emergency patients presenting with non-specific complaints: Characteristics and outcomes

Background

Non-specific complaints (NSC) are common at the emergency department, but only a few studies have shown evidence that these complaints are associated with a poor prognosis in elderly emergency patients.

Objective

To describe patient characteristics and outcomes in a cohort of elderly emergency patients presenting with NSC. Outcomes were: patient characteristics, hospitalization, 90-day ED-return visits, and 30-day mortality.

Method

A retrospective cohort study was conducted amongst elderly patients present to the Internal Medicine Emergency Department (ED) between 01-09-2010 and 31-08-2011. NSC were defined as indefinable complaints that lack a pre-differential diagnosis needed to initiate of a standardized patient evaluation. Cox regression was performed to calculate Hazard Ratios (HR) and corrected for confounders such as comorbidity.

Results

In total, 1784 patients were enrolled; 244 (13.7%) presented with NSC. Compared to those with SC, comorbidity was higher in the NSC-group (Charlson comorbidity index 3.0 vs. 2.4, p<0.001). The triage level did not differ, but ED-length of stay was longer in the NSC-group (188 vs. 178 minutes, p = 0.004). Hospitalization was more frequent (84.0 vs. 71.1%, p<0.001) and the length of hospital stay (9 vs. 6 days, p<0.001 was longer in the NSC- than in the SC-group. The number of ED-return visits were comparable between both groups (HR 0.8, 95%CI 0.6–1.1). Mortality within 30-days was higher in the NSC- (20.1%) than in the SC-group (11.0%, HR 1.7 95%CI 1.2–2.4).

Conclusion

Elderly patients present with NSC at the ED regularly. These patients are more often hospitalized and have a substantially higher 30-day mortality than patients with SC.

A secondary analysis of atypical presentations of older patients with infection in the emergency department of a tertiary care hospital in Thailand

Background

Classic symptoms of illness are often absent in older adults, delaying diagnosis and management, and resulting in unfavorable outcomes.

Objectives

To determine the prevalence of atypical presentations by older Thai adults with infections in the emergency department (ED) of a tertiary care hospital, and to identify factors associated with atypical presentations in such patients.

Methods

We performed a secondary analysis of a retrospective cohort observational study of atypical presentations of patients aged ≥65 years in the ED using a subset of data first reported in the Archives of Gerontology and Geriatrics in 2015; 62:97-102.

Results

The prevalence of atypical presentations was 35% of those with infectious diseases (64 of 183 cases). Pneumonia was the most common (30%). We identified 4 associated risk factors: complicated urinary tract infection (UTI) (odds ratio (OR) 4.54; 95% confidence interval (CI) 1.75,11. 78; P = 0.002), cancer (OR 2.64; 95% CI 1.07, 6.53; P = 0.04), dementia (OR 6.66; 95% CI 1.47, 30.11; P = 0.01), and pulse rate >90 beats/min (OR 2.06; 95% CI 1.01, 4.22; P = 0.04). Infective diarrhea was protective (OR 0.27; 95% CI 0.09, 0.8; P = 0.02).

Conclusions

Atypical presentations of infectious diseases by older Thai patients in the ED accounted for about one third of those with infectious disease. Associated risk factors were complicated UTI, cancer, dementia, and increased pulse rate. Older patients with these factors who have uncertain diagnoses should be considered for hospitalization because the absence of classic symptoms does not exclude life-threatening infections.

The ED use and non-urgent visits of elderly patients

Objective

To evaluate the use of the emergency department (ED) by elderly patients, their non-urgent visits and the prevalence of main disease for ED visits.

Methods

This cross-sectional study was conducted on patients aged 65 years and over who visited the ED of a tertiary care university hospital in Turkey between January 2015 and January 2016 retrospectively.

Results

A total of 36,369 elderly patients who visited the ED were included in the study. The rate of ED visits by elderly patients was higher than their representation within the general population (p < 0.001). While the rate of elderly patients visiting polyclinics was 15.8%, the rate of elderly patients visiting the ED was 24.3% (p < 0.001). For both genders, the rates of ED visits for patients between 65 and 74 years old was higher than for other elderly age groups (p < 0.001). The prevalence of upper respiratory tract infection (URTI) was the highest within the elderly population (17.5%, CI: 17.1–17.9). The proportion of ED visits for non-urgent conditions was 23.4%. Most of the ED visits were during the non-business hours (51.1%), and they were highest in the winter season (25.9%) and in January (10.2%). The hospitalization rate was 9.4%, and 37.9% of hospitalized patients were admitted to intensive care units.

Conclusion

The proportion of ED visits by elderly patients was higher than their representation within the general population. Elderly patients often visited the ED instead of a polyclinic. The rate of inappropriate ED use by elderly patients in this hospital was higher than in other countries.

Risk stratification using D-dimers in patients presenting to the emergency department with nonspecific complaints

BACKGROUND

Patients with nonspecific complaints (NSC) such as generalized weakness present frequently to acute care settings. These patients are at risk of adverse health outcomes. The aim of our study was to test the hypothesis whether D-dimers are predictive for 30-day mortality in patients with NSCs.

METHODS

Delayed type cross-sectional diagnostic study with a 30-day follow-up period, registered with ClinicalTrials.gov (NCT00920491). This study took place in 2 EDs in Northwestern Switzerland. Patients were enrolled in the study if they were over 18years of age, gave informed consent, and if they presented with NSCs such as generalized weakness. D-dimer levels were determined at ED presentation.

RESULTS

The final study population consisted of 524 patients. Median age was 82years (IQR=75 to 87years); 40.5% were men. There were 489 survivors and 35 non-survivors at 30-day follow-up. Twenty-one (60%) of the non-survivors were males. D-dimer levels were significantly higher in non-survivors than in survivors (p<0.001). Univariate Cox regression models for D-dimer resulted in a C-index of 0.77 for prediction of mortality. A model including sex, age, Katz ADL and D-dimer in a multivariate Cox regression lead to a C-Index of 0.80.

CONCLUSION

D-dimer testing might be an effective risk stratification tool in patients with NSC by helping to identify patients at low risk of short-term mortality with a sensitivity of 0.97 and a negative likelihood ratio of 0.121. The use of D-dimers for risk stratification in patients with NSC should be confirmed with prospective studies.

Impact of CT in elderly patients presenting to the emergency department with acute abdominal pain

PURPOSE

The purpose of the study was to document the clinical impact of CT in elderly patients presenting to the emergency department (ED) with abdominal pain.

METHODS

This retrospective IRB-approved study from 2006 to 2013 evaluated 464 patients ≥80 years (mean 89 years, range 80-100: M150, W314), who presented to the ED with acute abdominal symptoms and underwent CT. CTs were divided into those negative and positive for actionable findings, defined as potentially requiring a change in surgical or medical management. Physician diagnosis, treatment plan, and disposition before and after CT were reviewed in the electronic medical record to assess CT influence on management and disposition. CT diagnosis was confirmed with final clinical diagnosis, surgical intervention, pathology, and follow-up. Descriptive statistics were used.

RESULTS

CTs were positive in 55%. The most common diagnoses were SBO (18%), diverticulitis (9%), non-ischemic vascular-related emergency (6%), bowel ischemia (4%), appendicitis (3%), and colonic obstruction (2%). These diagnoses were clinically unsuspected prior to CT in 43% (p < 0.05), with significant difficultly in diagnosing SBO (p < 0.05), diverticulitis (p < 0.01), and colonic obstruction (p < 0.01). Positive CT results influenced treatment plans in 65%, surgical in 48%, and medical in 52%. Disposition from the ED was significantly affected by CT (p < 0.001), 65% of admissions with positive CT (p < 0.001) and 63% of discharges with negative CT (p < 0.001).

CONCLUSION

Utilization of abdominopelvic CT in geriatric patients presenting to the ED with acute abdominal symptoms strongly influences clinical management and significantly affects disposition. As the US population ages, the clinical impact of emergent CT in the elderly will intensify.

Infectious Disease-Related Emergency Department Visits of Elderly Adults in the United States, 2011-2012

OBJECTIVES

To investigate the frequency of infectious disease (ID)-related emergency department (ED) visits of elderly adults in the United States.

DESIGN

Cross-sectional analysis.

SETTING

Nationwide emergency department sample in 2011-12.

PARTICIPANTS

Individuals in the ED aged 65 and older with a primary diagnosis of an ID.

MEASUREMENTS

ID-related ED visits, hospitalizations, hospital-based mortality.

RESULTS

During 2012, a weighted estimate of 3,123,909 ED visits for IDs was calculated in elderly U.S. adults. This accounted for 13.5% (3.1 million visits) of all ED visits of elderly adults; this burden was higher than that for myocardial infarction and congestive heart failure combined. The rate of ID-related ED visits was 7,231 per 100,000 elderly adults. The most-common diagnoses were lower respiratory infections (26.2%; 95% confidence interval (CI)=25.7-26.6%), urinary tract infections (25.3%, 95% CI=25.0-25.7%), and septicemia (18.9%, 95% CI=18.3-19.6%). Of all ID-related ED visits, 1,786,657 (57.2%, 95% CI=56.6-57.7%) resulted in hospitalization. The leading cause of hospitalization was septicemia, accounting for 32.2% (95% CI=31.1-33.3%) of all ID-related hospitalizations through EDs, followed by lower respiratory infections (27.8%, 95% CI=27.2-28.4%). Overall, 123,894 individuals (4.0%, 95% CI=3.8-4.1%) died during their ED visit or hospitalization. Of these, septicemia was the leading cause of mortality (74.7%, 95% CI=73.8-75.6%), followed by lower respiratory infections (15.2%, 95% CI=14.6-15.9%). Analysis of the 2011 data gave similar results for the burden of ID-related ED visits, hospitalizations, and mortality.

CONCLUSION

Using a nationally representative sample, it was found that the public health burden of IDs in elderly U.S. adults was substantial, as measured by ED visits, subsequent hospitalizations, and hospital-based mortality.

Are Mortality and Acute Morbidity in Patients Presenting With Nonspecific Complaints Predictable Using Routine Variables?

OBJECTIVES

Patients presenting to the emergency department (ED) with nonspecific complaints are difficult to accurately triage, risk stratify, and diagnose. This can delay appropriate treatment. The extent to which key medical outcomes are at all predictable in these patients, and which (if any) predictors are useful, has previously been unclear. To investigate these questions, we tested an array of statistical and machine learning models in a large group of patients and estimated the predictability of mortality (which occurred in 6.6% of our sample of patients), acute morbidity (58%), and presence of acute infectious disease (28.2%).

METHODS

To investigate whether the best available tools can predict the three key outcomes, we fed data from a sample of 1,278 ED patients with nonspecific complaints into 17 state-of-the-art statistical and machine learning models. The patient sample stems from a diagnostic multicenter study with prospective 30-day follow-up conducted in Switzerland. Predictability of the three key medical outcomes was quantified by computing the area under the receiver operating characteristic curve (AUC) for each model.

RESULTS

The models performed at different levels but, on average, the predictability of the target outcomes ranged between 0.71 and 0.82. The better models clearly outperformed physicians' intuitive judgments of how ill patients looked (AUC = 0.67 for mortality, 0.65 for morbidity, and 0.60 for infectious disease).

CONCLUSIONS

Modeling techniques can be used to derive formalized models that, on average, predict the outcomes of mortality, acute morbidity, and acute infectious disease in patients with nonspecific complaints with a level of accuracy far beyond chance. The models also predicted these outcomes more accurately than did physicians' intuitive judgments of how ill the patients look; however, the latter was among the small set of best predictors for mortality and acute morbidity. These results lay the groundwork for further refining triage and risk stratification tools for patients with nonspecific complaints. More research, informed by whether the goal of a model is high sensitivity or high specificity, is needed to develop readily applicable clinical decision support tools (e.g., decision trees) that could be supported by electronic health records.

Emergency Presentations With Nonspecific Complaints-the Burden of Morbidity and the Spectrum of Underlying Disease: Nonspecific Complaints and Underlying Disease

The prevalence of diagnoses, morbidity, and mortality of patients with nonspecific complaints (NSC) presenting to the emergency department (ED) is unknown.To determine the prevalence of diagnoses, acute morbidity, and mortality of patients with NSC.Prospective observational study with a 30-day follow-up. Patients presenting to 2 EDs were enrolled by a study team and diagnosed according to the World Health Organization ICD-10 System.Of 217,699 presentations to the ED from May 2007 through to February 2011, a total of 1300 patients were enrolled. After exclusion of 90 patients who fulfilled exclusion criteria, 1210 patients were analyzed. No patient was lost to follow-up. In patients with NSC, the underlying diseases were spread throughout 18 chapters of the ICD-10. A total of 58.7% of the patients were diagnosed with acute morbidity. Thirty-day mortality was 6.4% overall. Patients with acute morbidity and suffering from heart failure and pneumonia had mortalities >15%; patients lacking acute morbidity, but suffering from functional impairment or depression/anxiety had mortalities of 0%. Although the history did not allow any prediction, age and sex were predictive of morbidity and mortality.The differential diagnoses in patients presenting with NSC is broad. Acute morbidity and mortality were high in the presented cohort, the predictors of morbidity and mortality being age and sex rather than the nature of the complaints. Urgently needed management strategies could be based on these results.ClinicalTrials.gov (#NCT00920491).

Common Diagnoses and Outcomes in Elderly Patients Who Present to the Emergency Department with Non-Specific Complaints

OBJECTIVE

Elderly patients often present to the emergency department (ED) with non-specific complaints. Previous studies indicate that such patients are at greater risk for life-threatening illnesses than similarly aged patients with specific complaints. We evaluated the diagnoses and outcomes of elderly patients presenting with non-specific complaints.

METHODS

Two trained data abstractors independently reviewed all records of patients over 70 years old presenting (to two academic EDs) with non-specific complaints, as defined by the Canadian Emergency Department Information System (CEDIS). Outcomes of interest were ED discharge diagnosis, hospital admission, length of stay, and ED revisit within 30 days.

RESULTS

Of the 743 patients screened for the study, 265 were excluded because they had dizziness, vertigo, or a specific complaint recorded in the triage notes. 419 patients (87.7%) presented with weakness and 59 patients (12.3%) presented with general fatigue or unwellness. The most common diagnoses were urinary tract infection (UTI) (11.3%), transient ischemic attack (TIA) (10.0%), and dehydration (5.6%). There were 11 hospital admissions with median length of stay of five days. Eighty-one (16.9%) patients revisited the ED within 30 days of discharge. Regression analysis indicated that arrival to the ED by ambulance was independently associated with hospital admission.

CONCLUSIONS

Our results suggest that elderly patients presenting to the ED with non-specific complaints are not at high risk for life-threatening illnesses. The most common diagnoses are UTI, TIA, and dehydration. Most patients can be discharged safely, although a relatively high proportion revisit the ED within 30 days.

Non-specific complaints in the ambulance; predisposing structural factors

BACKGROUND

The pre-hospital assessment non-specific complaint (NSC) often applies to patients whose diagnosis does not match any other specific assessment correlating to particular symptoms or diseases, though some previous studies have found them to be related to serious underlying conditions. The aim was to identify whether the structural factors such as urgency according to the dispatch priority of the Emergency Medical Communication Centre (EMCC) or work load in the Emergency Medical Services (EMS) are predisposing factors for the assessment of NSC instead of a specific assessment.

METHODS

All patients with assessed condition NSCs by the EMS to Södersjukhuset during 2011 (n = 493) were compared with gender- and age-matched controls (n = 493), which were randomly drawn from all patients with specific conditions in the EMS, regarding day of week, time of day and priority set by EMCC with chi-squared tests and multivariate logistic regression models.

RESULTS

Among patients with NSCs, more were females (58 %) and the median age was 82. Almost all patients were categorized with NSCs during the daytime (8 a.m. to 9 p.m.), i.e. 450 (91 %) as compared to 373 (75 %) of those with specific conditions (p < 0.01). The risk of having an EMS dispatched as low priority by the EMCC was almost doubled among patients with NSCs compared to controls (OR 1.97, 95 % CI 1.38-2.79).

CONCLUSIONS

Since patients with NSCs appear most frequently during the hours with most transportations for the EMS, i.e. 10 a.m. to 2 p.m., and the risk of having the assessment NSC was doubled if the EMCC dispatched EMS as low priority, structural factors might be predisposing factors for the assessment.

Physician's first clinical impression of emergency department patients with nonspecific complaints is associated with morbidity and mortality

The association between the physician's first clinical impression of a patient with nonspecific complaints and morbidity and mortality is unknown. The aim was to evaluate the association of the physician's first clinical impression with acute morbidity and mortality. We conducted a prospective observational study with a 30-day follow-up. This study was performed at the emergency departments (EDs) of 1 secondary and 1 tertiary care hospital, from May 2007 to February 2011. The first clinical impression ("looking ill"), expressed on a numerical rating scale from 0 to 100, age, sex, and the Charlson Comorbidity Index (CCI) were evaluated. The association was determined between these variables and acute morbidity and mortality, together with receiver operating characteristics, and validity. Of 217,699 presentations to the ED, a total of 1278 adult nontrauma patients with nonspecific complaints were enrolled by a study team. No patient was lost to follow-up. A total of 84 (6.6%) patients died during follow-up, and 742 (58.0%) patients were classified as suffering from acute morbidity. The variable "looking ill" was significantly associated with mortality and morbidity (per 10 point increase, odds ratio 1.23, 95% confidence interval [CI] 1.12-1.34, P < 0.001, and odds ratio 1.19, 95% CI 1.14-1.24, P < 0.001, respectively). The combination of the variables "looking ill," "age," "male sex," and "CCI" resulted in the best prediction of these outcomes (mortality: area under the curve [AUC] 0.77, 95% CI 0.72-0.82; morbidity: AUC 0.68, 95% CI 0.65-0.71). The physician's first impression, with or without additional variables such as age, male sex, and CCI, was associated with morbidity and mortality. This might help in the decision to perform further diagnostic tests and to hospitalize ED patients.

Comprehensive geriatric assessment in the emergency department

Changing global demography is resulting in older people presenting to emergency departments (EDs) in greater numbers than ever before. They present with greater urgency and are more likely to be admitted to hospital or re-attend and utilize greater resources. They experience longer waits for care and are less likely to be satisfied with their experiences. Not only that, but older people suffer poorer health outcomes after ED attendance, with higher mortality rates and greater dependence in activities of daily living or rates of admission to nursing homes. Older people's assessment and management in the ED can be complex, time consuming, and require specialist skills. The interplay of multiple comorbidities and functional decline result in the complex state of frailty that can predispose to poor health outcomes and greater care needs. Older people with frailty may present to services in an atypical fashion requiring detailed, multidimensional, and increasingly multidisciplinary care to provide the correct diagnosis and management as well as appropriate placement for ongoing care or admission avoidance. Specific challenges such as delirium, functional decline, or carer strain need to be screened for and managed appropriately. Identifying patients with specific frailty syndromes can be critical to identifying those at highest risk of poor outcomes and most likely to benefit from further specialist interventions. Models of care are evolving that aim to deliver multidimensional assessment and management by multidisciplinary specialist care teams (comprehensive geriatric assessment). Increasingly, these models are demonstrating improved outcomes, including admission avoidance or reduced death and dependence. Delivering this in the ED is an evolving area of practice that adapts the principles of geriatric medicine for the urgent-care environment.

Minor injuries in older adults have different characteristics, injury patterns, and outcomes when compared with younger adults: an emergency department correlation study

AIM

To examine the injury patterns, characteristics, and outcomes of older adults presenting with minor injuries compared with younger adults.

BACKGROUND

Sustaining a minor injury is one of the most common reasons people present to an Emergency Department. Many presentations involve older Australians and greater than 50% of older adults are discharged from the Emergency Department. However, little is known about the characteristics, injury patterns, and outcomes of minor injuries in older adults compared to younger adults.

METHODS

A 12-month exploratory correlational study was conducted using Emergency Department electronic medical record data from a single metropolitan hospital located in Sydney, Australia. Older adults were defined as ≥65 years with younger adults defined as 18-64 years. Minor injuries were classified by diagnoses as fractures/dislocations, sprains/strains, wounds/burns/infections, minor head injuries, eye/ear/nose/oral injuries. Exclusion criteria included: triage category 1 or 2, major trauma, critical care admission, or injuries and fractures to the hip or neck of femur.

RESULTS

There were 36,671 Emergency Department presentations of which 7582 (21%) were for older adults and 19,234 (52%) were younger adults (aged 18-64). Injuries represented 21% (n = 7754) of all Emergency Department presentations with 1294 (17%) occurring in those aged 65 years and older and 3937 (20%) in younger adults. Of the minor injuries (n = 3594; 10%), the most common presentation in younger adults was sprains/strains (n = 1045; 36%) but in older adults it was fractures (n = 229; 32%). There was a statistical (Pearson's χ(2) test 63.4, df = 4, P < 0.001) difference with injury pattern when comparing age groups. Older adults were allocated proportionately higher triage categories when compared with younger adults (Pearson's χ(2) test 26.3, df = 2, P < 0.001). Older adults with minor injuries had a longer mean stay (315 min; SD 238.9 min; younger adults 198 min, SD 132.3 min) and this difference was statistically (P ≤ 0.001) and clinically significant. Fewer older adults were discharged home (n = 531, 73%; n = 2648, 92%; P < 0.001) and more were admitted for minor injuries (n = 179, 25%; n = 156, 5%; P < 0.001) when compared with younger adults.

CONCLUSION

Older adults with minor injuries have different injury patterns, higher acuity, longer length of stay, and lower discharge rates compared with younger adults. Clinicians may need to modify their approach and differential diagnoses when treating older adults with minor injuries. Further research is needed to explore the reasons for these differences and whether older adults have different service needs compared with younger adults with minor injuries.

Determining emergency physicians' and nurses' views concerning older patients: a mixed-method study

The number of elderly patients presenting to emergency services is gradually increasing. Given that the needs of older patients differ from those of other patients, the quality of emergency care for this patient group also varies. This mixed-method study aimed to reveal the views of emergency service staff concerning ageing and elderly patients. Participants were 19 physicians and 17 nurses employed by the adult emergency service of a university hospital. Data were gathered using questionnaires and focus group interviews. Frequency and percentages were used to evaluate quantitative data. Open-ended questions used to gather quantitative data were analysed using thematic analysis and four themes (including understanding older patients' situations, good nursing care and medical treatment, affecting good nursing care and medical treatment, emotions experienced) were determined. Emergency department staff identified older patients as dependent individuals requiring health care. Nurses indicated that good care for older patients included ensuring that their physical, social, and psychological needs were met; whereas, physicians identified good treatment as improving the quality of life. Impediments to the care and treatment of older patients were identified as staff shortages, emergency service crowding, and lack of proper training for emergency department staff. Emergency department staff also indicated that they experienced weariness and exhaustion while providing health care for older patients. Emergency nurses and physicians were aware of older patients and their needs but experienced difficulties regarding patient density, physical settings, staff shortages, and a lack of training.

Functional Decline Predicts Emergency Department Use in Veterans With Dementia

BACKGROUND

We examined emergency room (ER) utilization by persons with dementia (PWDs) using caregiver and patient characteristics as predictors.

METHODS

A secondary analysis of 296 veteran-caregiver dyads. Caregivers recorded PWD baseline characteristics and noted ER visits over the next year. Two sets of regression models analyzed categorical ER use and repeat ER use.

RESULTS

In the univariate analysis, categorical use of the ER was predicted by patients' functional status (P ≤ .008) and Veterans Affairs priority grouping (P ≤ .02). Repeat ER admissions were predicted by functional status (P ≤ .04), number of chronic conditions (P ≤ .01), and caregiver-reported relationship strain (P ≤ .04). In multivariate analysis, categorical ER use was predicted by functional status (P ≤ .02), priority grouping (P ≤ .03), and number of chronic conditions (P ≤ .06).

CONCLUSIONS

Functional status most strongly predicted ER use, highlighting the promise of home-based interventions to improve activities of daily living. Number of chronic conditions and caregiver-reported relationship strain are potential targets of intervention during discharge process.

Pattern of emergency department visits by elderly patients: study from a tertiary care hospital, Karachi

Background

Worldwide the proportion of elderly people in the population is increasing. Currently in Pakistan 7.3 million people (5.6% of total population) are more than 60 years old. This age shift has emerged as an important health issue and is associated with an increased utilization of emergency services by the elderly. We carried out this study to assess the pattern of elderly patients (>60 years) who visit emergency departments in comparison to young adults (18–60 years).

Methods

Data was collected retrospectively of patients aged 18 years or more who visited the Emergency Department (ED) of Aga Khan University Hospital, Karachi (AKUH) during September, 2009 to September, 2011. The data collection sheet included patient’s demographic information, triage category, reason for visit, clinical presentation, ED length of stay, day and time of presentation and their disposition. Data was entered and analyzed using SPSS version 19.0. Descriptive statistics were used to describe patient’s demographics. Chi-square (χ²) test was used as a test of significance to compare differences between groups for categorical data and t-test for continuous data. Multiple logistic regression analysis was done to find out the association between the patient characteristics and outcomes (admission and expiry).

Results

Almost 24% (n = 13014) of all adults (n = 54588) presenting to the ED were over the age of 60 years. More than 57% of elderly patients belonged to the high priority triage category compared to 35% in younger patients. Most of the elderly patients ( 27%) presented with nonspecific complaints followed by shortness of breath (13%) and fever (9%). The median length of stay (LOS) in the ED for elderly was 379 minutes (252 min in under-60 yrs patients) and they were more likely to get admitted to in-patient departments compared to younger patients (OR 1.7 95% CI 1.6-1.8). A high proportion of those admitted (20%) required intensive or special care. Mortality in elderly patients was 2.3% as compared to 0.7% in young adults. This was accompanied by a higher mortality risk in the elderly with an odds ratio of 2.3 (CI 2–2.5).

Conclusion

Elderly ED users differ significantly from younger adults in terms of criticality on presentation, ED LOS and final disposition.

Drug-related emergency department visits by elderly patients presenting with non-specific complaints

Background

Since drug-related emergency department (ED) visits are common among older adults, the objectives of our study were to identify the frequency of drug-related problems (DRPs) among patients presenting to the ED with non-specific complaints (NSC), such as generalized weakness and to evaluate responsible drug classes.

Methods

Delayed type cross-sectional diagnostic study with a prospective 30 day follow-up in the ED of the University Hospital Basel, Switzerland. From May 2007 until April 2009, all non-trauma patients presenting to the ED with an Emergency Severity Index (ESI) of 2 or 3 were screened and included, if they presented with non-specific complaints. After having obtained complete 30-day follow-up, two outcome assessors reviewed all available information, judged whether the initial presentation was a DRP and compared their judgment with the initial ED diagnosis. Acute morbidity (“serious condition”) was allocated to individual cases according to predefined criteria.

Results

The study population consisted of 633 patients with NSC. Median age was 81 years (IQR 72/87), and the mean Charlson comorbidity index was 2.5 (IQR 1/4). DRPs were identified in 77 of the 633 cases (12.2%). At the initial assessment, only 40% of the DRPs were correctly identified. 64 of the 77 identified DRPs (83%) fulfilled the criteria “serious condition”. Polypharmacy and certain drug classes (thiazides, antidepressants, benzodiazepines, anticonvulsants) were associated with DRPs.

Conclusion

Elderly patients with non-specific complaints need to be screened systematically for drug-related problems.

Trial Registration

ClinicalTrials.gov: NCT00920491

Association between acute geriatric syndromes and medication-related hospital admissions

BACKGROUND

Elderly patients are at a 4-fold higher risk of adverse drug events (ADEs) and drug-related hospitalization. Hospitalization of an elderly patient is often preceded by geriatric syndromes, like falls or delirium.

OBJECTIVES

The primary aim of this study was to investigate whether geriatric syndromes were associated with ADEs in acutely admitted elderly patients.

METHODS

Consecutive medical patients, aged 65 years or more, who were acutely admitted, were enrolled. An initial multidisciplinary evaluation was completed and baseline characteristics were collected. A fall before admission was retrieved from medical charts. Delirium was determined by the Confusion Assessment Method.

RESULTS

A total of 641 patients were included. Over 25% had an ADE present at admission, 26% presented with delirium and 12% with a fall. Delirium was associated with the use of antidepressants, antipsychotics and antiepileptics. In all ADEs (n = 167), ADEs were associated with a fall, with non-steroidal anti-inflammatory drugs or diuretics, but not with pre-existing functioning, delirium or older age. For ADEs involving psychoactive medication (n = 35), an association was found between delirium, falls, opioids and antipsychotics in bivariate analyses. A fall just before hospitalization (odds ratio [OR] 3.69 [95% CI 1.41, 9.67]), antipsychotics (OR 3.70 [95% CI 1.19, 11.60]) and opioids (OR 14.57 [95% CI 2.02, 105.30]) remained independently associated with an ADE involving psychoactive medication.

CONCLUSION

This prospective study demonstrated that, in a cohort of elderly hospital patients, a fall before admission and prevalent delirium are associated with several pharmacological groups and/or with ADE-related hospital admission.

Correlates of diagnostic accuracy in patients with nonspecific complaints

OBJECTIVE

To investigate diagnostic accuracy in patient histories involving nonspecific complaints and the extent to which characteristics of physicians and structural properties of patient histories are associated with accuracy.

METHODS

Six histories of patients presenting to the emergency department (ED) with nonspecific complaints were provided to 112 physicians: 36 ED physicians, 50 internists, and 26 family practitioners. Physicians listed the 3 most likely diagnoses for each history and indicated which cue(s) they considered crucial. Four weeks later, a subset of 20 physicians diagnosed the same 6 histories again. For each history, experts had previously determined the correct diagnoses and the diagnostic cues.

RESULTS

Accuracy ranged from 14% to 64% correct diagnoses (correct diagnosis listed as the most likely) and from 29% to 87% correct differential diagnoses (correct diagnosis listed in the differential). Acute care physicians (ED physicians and internists) included the correct diagnosis in the differential in, on average, 3.4 histories, relative to 2.6 for the family practitioners (P = 0.001, d = .75). Diagnostic performance was fairly reliable (r = .61, P < 0.001). Clinical experience was negatively correlated with diagnostic accuracy (r = -.25, P = 0.008). Two structural properties of patient histories-cue consensus and cue substitutability-were significantly associated with diagnostic accuracy, whereas case difficulty was not. Finally, prevalence of diagnosis also proved significantly correlated with accuracy.

CONCLUSIONS

Average diagnostic accuracy in cases with nonspecific complaints far exceeds chance performance, and accuracy varies with medical specialty. Analyzing cue properties in patient histories can help shed light on determinants of diagnostic performance and thus suggest ways to enhance physicians' ability to accurately diagnose cases with nonspecific complaints.

Six-month outcome of elderly people hospitalized via the emergency department: the SAFES cohort

BACKGROUND

The objective of the study was to identify factors predictive of 6-month institutionalization or mortality in frail elderly patients after acute hospitalization.

METHODS

A prospective cohort of elderly subjects 75 years and older was set up in nine French teaching hospitals. Data obtained from a comprehensive geriatric assessment were used in a Cox model to predict 6-month institutionalization or mortality. Institutionalization was defined as incident admission either to a nursing home or other long-term care facility during the follow-up period.

RESULTS

Crude institutionalization and death rates after 6 months of follow-up were 18% and 24%, respectively. Independent predictors of institutionalization were: living alone (HR=1.83; 95% CI=1.27-2.62) or a higher number of children (HR=0.86; 95% CI=0.78-0.96), balance problems (HR=1.72; 95% CI=1.19-2.47), malnutrition or risk thereof (HR=1.93; 95% CI=1.24-3.01), and dementia syndrome (HR=1.88; 95% CI=1.32-2.67). Factors found to be independently related to 6-month mortality were exclusively medical factors: malnutrition or risk thereof (HR=1.92; 95% CI=1.17-3.16), delirium (HR=1.80; 95% CI=1.24-2.62), and a high level of comorbidity (HR=1.62; 95% CI=1.09-2.40). Institutionalization (HR=1.92; 95% CI=1.37-2.71) and unplanned readmission (HR=4.47; 95% CI=3.16-2.71) within the follow-up period were also found as independent predictors.

CONCLUSION

The main factors predictive of 6-month outcome identified in this study are modifiable by global and multidisciplinary interventions. Their early identification and management would make it possible to modify frail elderly subjects' prognosis favorably.

[Geriatric patients in emergency and intensive care medicine]

The democratic shift poses new challenges in emergency medicine and intensive care. Old patients call for special needs that have to be taken into consideration during treatment. Due to the heterogeneity in this patient group biological age plays an important role. Mortality among old patients is high, but functionality and comorbidity have a great effect on patient outcome. Structural and functional organ changes have an additional impact on the treatment of geriatric patients in emergency medicine and intensive care. Therefore, basic geriatric knowledge should be part of the curricula of both, intensive care and emergency medicine.