The Emergency Department is a high-risk setting. The elderly are a high-risk population – if only by actuarial measures alone. Despite the inherit natural risks – might there be a clue on top of physician gestalt predicting poor outcomes of the elderly discharged from the Emergency Department?
This is a retrospective, chart review, case-control study looking at discharges matched from the Kaiser Permanente Southern California cohort. Non-hospice patients aged greater than 65 were eligible for inclusion if they were discharged from the Emergency Department, and were subsequently dead or hospitalized in the intensive care unit within 7 days.
There’s good news and bad news here. The good news is there were a few items that seemed to leap out on their structured chart review as clues to poor outcomes. These items could, potentially, stick in your mind as portending ill. The bad news is, despite the presence of these features, the reasonable clinician judgement for these patients in the acute setting still felt as though they were safer discharged than in the hospital. This implies it is challenging to incorporate these few high-risk items into clinical decision-making, and potentially the incompleteness of their retrospective abstraction. And, more bad news – even though there were some significant odds ratios between groups, the absolute differences between groups were minor. Therefore, overall, these groups were really quite similar.
Without much further ado, the items with the most relevant adjusted odds ratios for their combined outcome:
- Systolic blood pressure <120 bpm.
- Pulse greater than 90 mmHg.
- Mental status change.
- Initial documentation of intention to admit, subsequently changed to discharge.
Interestingly, the Methods section extolls the virtues of data-mining the electronic health record of a large health system for rare outcomes. Just how rare was death or ICU admission within 7 days of ED discharge for patients over 65? Approximately 0.58% met this combined outcome. Although, it is difficult to fully generalize the Kaiser membership base to the rest of ED patients, this is a reasonable baseline to reflect upon.
“Poor Outcomes After Emergency Department Discharge of the Elderly: A Case-Control Study”
http://www.annemergmed.com/article/S0196-0644(16)00008-1/abstract