Changing your mind kills old people

Short Attention Span Summary

Old people are nice but scary.
If you're on the fence about discharging an elderly (>65 years) patient, this study says don't.  More specifically, this case-control found that patients with a change in dispo plan from admission 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."

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If you think an older patient needs admission but later change your mind and discharge them, that has a strong association with ED bounceback, with increased mortality and need for ICU level care upon return.  Or if they have other high-risk features above, plan to admit.

ACEP did an author interview.


Abstract

Ann Emerg Med. 2016 Jul;68(1):43-51.e2. doi: 10.1016/j.annemergmed.2016.01.007. Epub 2016 Mar 2.

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

Gabayan GZ1, Gould MK2, Weiss RE3, Patel N4, Donkor KA4, Chiu VY2, Yiu SC2, Jones JP5, Hoffman JR6, Sarkisian CA4.

Author information:

1Department of Medicine, University of California, Los Angeles, CA; Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA. Electronic address: gelareh@gabayan.com.

2Department of Research and Evaluation, Kasier Permanente Southern California, Pasadena, CA.

3Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, CA.

4Department of Medicine, University of California, Los Angeles, CA; Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA.

5Kaiser Foundation Hospital and Health Plan, Pasadena, CA.

6Emergency Medicine Center, University of California, Los Angeles, CA.

Abstract

STUDY OBJECTIVE:

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.

METHODS:

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.

RESULTS:

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).

CONCLUSION:

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.

Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 26947799 [PubMed - in process]