Podcast: Play in new window | Download

Subscribe: RSS

Reference: Roussel et al. Overnight stay in the emergency department and mortality in older patients, JAMA Intern Med 2023

Date: December 18, 2023

Guest Skeptic: Dr. Chris Carpenter, Vice Chair of Emergency Medicine at Mayo Clinic.

Case: An 85-year-old patient (Ms. McG) presents to your emergency department (ED) after being found by family on the ground at her independent living facility. Her family was concerned because she has had multiple recent falls, and she wasn’t answering the telephone that morning.  They found her in a pool of blood with a scalp laceration and complaining of left hip pain. Although she had exhibited occasional disorientation and gradually diminishing physical activity over the last 5-years, she was still functionally independent.  While your ED evaluation, computed tomography (CT) imaging of her head and spine demonstrated no traumatic injury and an x-ray of her pelvis showed no fracture or dislocation, she was unable to bear weight due to her hip pain, so you ordered a CT to further evaluate for occult fracture. Advanced imaging was unavailable until morning by the time that test was ordered.  Suspecting an occult fracture, you consult Orthopedic surgery for admission, but they wanted to wait for the CT the next day.  You then consult Internal Medicine/Hospitalist who also want to wait for CT imaging in case the admission is more appropriate on the Orthopedic surgery service.  After all these consultant calls it is now after midnight and you are concerned that the patient will be in the ED all night and what the consequences of a preventable episode of overnight ED boarding might have on the patient and the rest of the department since the waiting room still has 20 patients awaiting evaluation.

Background: Falling is the most common cause of traumatic injury resulting in older adults presenting to the ED [1]. Approximately 20% of falls result in injuries, and falls are the leading cause of traumatic mortality in this age group [2-4].

Older adults who are admitted to the hospital after a fall will be readmitted to the hospital within one-year in 44% of cases and 33% will die within one-year. Because it is such a serious topic, we have covered it several times on the SGEM:

EDs are becoming more and more crowded. The Canadian Association of Emergency Physicians (CAEP) flagged this issue 10 years ago in 2013. They published a position statement with several suggested solutions. Unfortunately, things have only gotten worse, and it does not seem to be an isolated problem in Canada.

The American College of Emergency Physicians (ACEP) held a summit of stakeholders across health care in September of 2023. They got together a wide range of leaders in various organizations to discuss potential solutions to what is called “boarding” of patients.

Perhaps we should define the term boarding as we are using it in the context of emergency medicine. It is when patients have been assessed and deemed to need admission to hospital. However, there are no beds available in the hospital and the patient remains in the ED. They can end up waiting for hours, days or even have their entire in-patient hospital care delivered in the ED.

The Joint Commission is an organization in the US that sets standards to improve safety in healthcare. They have identified the boarding of patients in the ED as a significant safety risk. In 2012, they said patients should not remain in the ED after the decision to admit to hospital of more than four hours [5]. It has been reported that waiting longer than four hours can result in downstream harms which include but are likely not limited to increased medical errors, compromises to patient privacy, and increased mortality [6]. Kelen et al said boarding is like a canary in a coal mine for the healthcare system and is more likely to happen when hospital occupancy rates exceed 85% to 90% [7].

That comment about the canary reminds me of a tweet by one of my mentors, Dr. Alan Drummond. He has been warning about this problem of overcrowding for years and emphasizes that it is a system problem not just a problem in the ED. Al Drummond posted some sad news on the site formerly known as Twitter saying that “The F-ing canary was dead.”

There was a study published in the EMJ last year talking about an increased mortality associated with longer wait times in the Nasional Health Service in the UK [8]. They observed an increase in all-cause mortality in the next month for patients who waited more than 5 hours to be admitted. This was not a unique observation and other researchers have published similar findings including our friends Jesse Pines and Peter Viccellio [9-10].

Clinical Question: What is the association between older adults who are boarded in the ED overnight and in-hospital mortality?

Reference: Roussel et al. Overnight stay in the emergency department and mortality in older patients, JAMA Intern Med 2023

  • Population: Patients 75 years or older from 97 EDs across France who were admitted to the hospital after the emergency medicine evaluation.
    • Excluded: Patients discharged home from the ED (including transfer to a long-term care facility or nursing home), admitted to Intensive Care Unit (ICU), or admitted to a ward between midnight and 8:00 AM.
  • Intervention: ED group spent night in ED on a trolley awaiting ward bed (between midnight and 8AM).
  • Comparison: Ward group admitted to an inpatient ward before midnight.
  • Outcome:
    • Primary Outcome: In-hospital mortality truncated at 30 days.
    • Secondary Outcomes: In-hospital length-of-stay (LOS) and in-patient adverse events (fall, nosocomial infection, bleeding, myocardial infarction, stroke, venous thromboembolism, pressure ulcer, dysnatremia).
  • Type of Study: Retrospective cohort adherent to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) standards of the EQUATOR Network.

Authors’ Conclusions: “For older patients, waiting overnight in the ED for admission to a ward was associated with increased in-hospital mortality and morbidity, particularly in patients with limited autonomy.  Older adults should be prioritized for admission to a ward.”

Quality Checklist for Observational Study:

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question? Yes
  3. Was the cohort recruited in an acceptable way? Yes
  4. Was the exposure accurately measured to minimize bias? Yes
  5. Was the outcome accurately measured to minimize bias? Yes/Unsure
  6. Have the authors identified all-important confounding factors? The authors adjusted for age, sex, high-level of co-morbidity (Charlson Co-morbidity Index >6), high-level of dependency, blood pressure, oxygenation, and trauma-related ED visit. Other factors that could possibly be associated with increased in-hospital mortality could be related to patient-level or hospital-level issues. Patient-level factors could include frailty, cognitive dysfunction, end-of-life scenarios, and what matters most to the patient.  Hospital-level issues could include individual unit crowding delaying access to time-dependent interventions (endoscopy, operating room, catheterization lab, etc.).
  7. Was the follow up of subjects complete enough? Yes
  8. How precise are the results? The median ED LOS was 23 hours (IQR 18-28) in the ED group and 7 hours 35 minutes (IQR 5.5-10 hours) in the ward group. A substantial number (11%) stayed in the ED for two nights!  In-hospital mortality was higher in the ED group than the ward group (15.7% vs. 11.1%, aRR 1.39 with 95% CI 1.07-1.81).  The risk of adverse events was also higher in the ED group (15.8% vs. 10.8%, aRR 1.24, 95% CI 1.04-1.49), particularly for nosocomial infection and falls.  The median hospital length-of-stay was 9 days in the ED group and 8 days in the ward group.
  9. Do you believe the results? Yes
  10. Can the results be applied to the local population? Yes
  11. Do the results of this study fit with other available evidence? Yes
  12. Funding of the Study. No direct funding of this research is reported. The Paris Public Hospital Association sponsored the work but did not fund it. Two authors report work with multiple biomedical device and pharmaceutical companies, but the personal fees associated with that corporate work were “outside the submitted work”.

Results: The cohort consisted of 1,598 patients with a median [IQR] age of 86 [80-90] years. Female patients comprised 55% of the total sample size. ; 880 [55%] female and 718 [45%] male), with 707 (44%) in the ED. Top five reasons for the ED visit were Respiratory (35%), Asthenia (34%), infection (27%), falls (25%) and cardiovascular (16%).

Key Result: Among admitted adults older than age 75, overnight stays in the emergency department are associated with significantly increased in-hospital mortality and adverse events over the subsequent 30-days.

  • Primary Outcome: Patients who spent the night in the ED had a higher in-hospital mortality rate of 15.7% vs 11.1% (adjusted risk ratio [aRR], 1.39; 95% CI, 1.07-1.81).
  • Secondary Outcomes: Older patients who spent the night also had several worse secondary outcomes:
    • Risk of adverse events was also higher in the ED group (15.8% vs. 10.8%, aRR 1.24, 95% CI 1.04-1.49), particularly for nosocomial infection and falls.
    • The median ED LOS was 23 hours (IQR 18-28) in the ED group and 7 hours 35 minutes (IQR 5.5-10 hours) in the ward group.
    • A substantial number (11%) stayed in the ED for two nights!
    • Increased median hospital LOS (9 vs 8 days; rate ratio, 1.20; 95% CI, 1.11-1.31).

1. Race and Ethnicity: This data was collected in accordance with French law. Substantial health inequities associated with race, religious affiliation, or socioeconomic status may be linked with in-hospital mortality or ED boarding delays.

2. Confounders: Unmeasured patient-level and hospital-level confounding variables (frailty, cognitive dysfunction, palliative care aligned with patient goals of care) may have been associated with the primary outcome.

3. Geriatricized: The extent to which the 97 French EDs were “geriatricized” was not reported or contemplated [11]. Measures of geriatric appropriateness exist [12], along with clinical practice guidelines [13], accreditation processes [14], implementation strategies [15], and learning collaboratives [16].

4. STROBE: We mentioned they followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) standards of the EQUATOR Network. However, the limitations to applying STROBE to geriatric observational data research is not contemplated (see JAGS new “Around the EQUATOR” series [17].

5. So What? The implications of this research are not sufficiently contemplated within the context of contemporary financial pressures confronting emergency medicine compounding burnout rates and a delicate balance between pragmaticism and meaningful action [18-23]. What would be the unintended consequences of moving these older adults to the front of the admission line (delayed access to care for other time-dependent emergencies, increased mortality in a different subset of patients who now await admission)?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We accept the validity of these results although future researchers should dig more deeply into the potential patient-level and hospital-level confounders.

SGEM Bottom Line: Without further research to understand the unintended consequences and associated costs, I would tread cautiously with the recommendation that “Older adults should be prioritized for admission to a ward”.

Case Resolution: Due to exceptional care of an ED nurse with an interest in Geriatrics who ensures prompt attention to toileting, nutrition, and analgesic requests, Ms. McG has an uneventful evening on a gurney in the ED and has MRI imaging at 8AM the next morning.  No fracture is identified, so the Hospitalist service admits her, and rehabilitation begins the following day with discharge home a day later.  Intrigued by the potential to standardize geriatric emergency care, you set up a meeting with your ED and hospital leadership the next week to begin discussing ACEP GEDA accreditation and American College of Surgery Geriatric Surgery Verification, and during that meeting you distribute a copy of “Creating a Geriatric Emergency Department: A Practical Guide” to all attendees while encouraging them to join GEDC’s upcoming webinars.

Dr. Chris Carpenter

Clinical Application: I would encourage every ED to consider becoming an ACEP GEDA accredited and “geriatricize” care for all older adults whether admitted or discharged.  In addition, hospital leaders could join the Geriatric Emergency Department Collaborative and learn how ED nurses, physicians, pharmacists, physiotherapists, social workers, and hospital leaders are creating age-friendly emergency departments across a range of settings (rural/urban, academic/community).

What Do I Tell My Patient? Hospital crowding and ED boarding are a frequent problem in many (if not most) healthcare systems these days.  Our ED staff will continue to provide your care overnight while awaiting imaging to exclude a fracture (which may be missed in up to 9% of patients after a hip x-ray, see Chapter 14 of Evidence‐Based Emergency Care: Diagnostic Testing and Clinical Decision Rules and [24].  Once that imaging is available, we will plan to admit you to the appropriate hospital service if your pain persists and you are still unable to ambulate.  While awaiting that imaging, please notify your nurse if you need to use the restroom, eat, or receive additional pain medications.

Keener Kontest: Listen to the SGEM podcast to hear this weeks keener question. The first correct answer will receive a cool skeptical prize.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References:

  1. Albert A, McCaig LF, Ashman JJ. Emergency department visits by persons aged 65 and over: United States, 2009–2010. NCHS Data Brief2013;130:1–8.
  2. Carpenter CR, Cameron A, Ganz DA, Liu S. Older adult falls in emergency medicine – 2019 update, Clin Geriatr Med 2019; 35: 205-219.
  3. Yildiz M, Bozdemir MN, Kilicaslan I, et al. Elderly trauma: the two years experience of a university-affiliated emergency department. Eur Rev Med Pharmacol Sci2012;16(Suppl 1):62–7.
  4. Burns E, Kakara R. Deaths from falls among persons aged ≥65 years – United States, 2007-2016. MMWR Morb Wkly Rep 2018; 67: 509-514.
  5. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_report_issue_4.pdf
  6. Boudi Z, Lauque D, Alsabri M, Östlundh L, Oneyji C, Khalemsky A, Lojo Rial C, W Liu S, A Camargo C Jr, Aburawi E, Moeckel M, Slagman A, Christ M, Singer A, Tazarourte K, Rathlev NK, A Grossman S, Bellou A. Association between boarding in the emergency department and in-hospital mortality: A systematic review. PLoS One. 2020 Apr 15;15(4):e0231253. doi: 10.1371/journal.pone.0231253. PMID: 32294111; PMCID: PMC7159217.
  7. Kelen GD, Richard W, D’Onofrio G, et al.. Emergency department crowding: the canary in the health care system. NEJM Catal. Published online September 28, 2021. doi: 10.1056/CAT.21.0217
  8. Jones S, Moulton C, Swift S, et al. Association between delays to patient admission from the emergency department and all-cause 30-day mortality Emergency Medicine Journal 2022;39:168-173.
  9. LauqueD, KhalemskyA, BoudiZ, et al. Length-of-stay in the emergency department and in-hospital mortality: a systematic review and meta-analysis. J Clin Med. 2022;12(1):32. doi:10. 3390/jcm12010032
  10. Singer AJ, Thode HC Jr, Viccellio P, PinesJM. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18(12):1324-1329. doi:10.1111/j.1553-2712.2011. 01236.x
  11. Southerland LT, Lo AX, Biese K, Arendts G, Banerjee J, Hwang U, Dresden S, Argento V, Kennedy M, Shenvi CL, Carpenter CR. Concepts in Practice: Geriatric Emergency Departments. Ann Emerg Med. 2020 Feb;75(2):162-170. doi: 10.1016/j.annemergmed.2019.08.430. Epub 2019 Nov 13. PMID: 31732374; PMCID: PMC6980991.
  12. McCusker J, Minh Vu TT, Veillette N, Cossette S, Vadeboncoeur A, Ciampi A, Cetin-Sahin D, Belzile E. Elder-Friendly Emergency Department: Development and Validation of a Quality Assessment Tool. J Am Geriatr Soc. 2018 Feb;66(2):394-400. doi: 10.1111/jgs.15137. Epub 2017 Sep 27. PMID: 28960240.
  13. American College of Emergency Physicians; American Geriatrics Society; Emergency Nurses Association; Society for Academic Emergency Medicine; Geriatric Emergency Department Guidelines Task Force. Geriatric emergency department guidelines. Ann Emerg Med. 2014 May;63(5):e7-25. doi: 10.1016/j.annemergmed.2014.02.008. PMID: 24746437.
  14. ACEP Geriatric Emergency Department Accreditation https://www.acep.org/geda
  15. Southerland LT, Gulker P, Van Fossen J, Rine-Haghiri L, Caterino JM, Mion LC, Carpenter CR, Cardone MS, Hill M, Hunold KM. Implementation of geriatric screening in the emergency department using the Consolidated Framework for Implementation Research. Acad Emerg Med. 2023 Nov;30(11):1117-1128. doi: 10.1111/acem.14776. Epub 2023 Jul 25. PMID: 37449967.
  16. Geriatric Emergency Department Collaborative https://gedcollaborative.com
  17. Carpenter CR, Gill TM. Transparent transdisciplinary reporting in geriatric research using the EQUATOR Network. J Am Geriatr Soc. 2022 Dec;70(12):3352-3355. doi: 10.1111/jgs.18097. Epub 2022 Oct 26. PMID: 36289574; PMCID: PMC9772164.
  18. Lo AX, Carpenter CR. Balancing Evidence and Economics While Adapting Emergency Medicine to the 21st Century’s Geriatric Demographic Imperative. Acad Emerg Med. 2020 Oct;27(10):1070-1073. doi: 10.1111/acem.13997. Epub 2020 Jun 5. PMID: 32335974.
  19. Pines JM, Edginton S, Aldeen AZ. What We Can Do To Justify Hospital Investment in Geriatric Emergency Departments. Acad Emerg Med. 2020 Oct;27(10):1074-1076. doi: 10.1111/acem.13999. Epub 2020 May 18. PMID: 32338413.
  20. Southerland LT, Biese K, Hwang U. Geriatric assessment in the emergency department reduces healthcare costs-So when will CMS pay for it? J Am Geriatr Soc. 2023 Sep;71(9):2698-2700. doi: 10.1111/jgs.18473. Epub 2023 Jul 12. PMID: 37435831.
  21. Gettel CJ, Courtney DM, Janke AT, Rothenberg C, Mills AM, Sun W, Venkatesh AK. The 2013 to 2019 Emergency Medicine Workforce: Clinician Entry and Attrition Across the US Geography. Ann Emerg Med. 2022 Sep;80(3):260-271. doi: 10.1016/j.annemergmed.2022.04.031. Epub 2022 Jun 16. PMID: 35717274; PMCID: PMC9398978.
  22. Gettel CJ, Courtney DM, Agrawal P, Madsen TE, Rothenberg C, Mills AM, Lall MD, Keim SM, Kraus CK, Ranney ML, Venkatesh AK. Emergency medicine physician workforce attrition differences by age and gender. Acad Emerg Med. 2023 Nov;30(11):1092-1100. doi: 10.1111/acem.14764. Epub 2023 Jun 23. PMID: 37313983.
  23. Shih RD, Carpenter CR, Tolia V, Binder EF, Ouslander JG. Balancing vision with pragmatism: The geriatric emergency department guidelines-realistic expectations from emergency medicine and geriatric medicine. J Am Geriatr Soc. 2022 May;70(5):1368-1373. doi: 10.1111/jgs.17745. Epub 2022 Mar 12. PMID: 35277967.
  24. Dominguez S, Liu P, Roberts C, Mandell M, Richman PB. Prevalence of traumatic hip and pelvic fractures in patients with suspected hip fracture and negative initial standard radiographs–a study of emergency department patients. Acad Emerg Med. 2005 Apr;12(4):366-9. doi: 10.1197/j.aem.2004.10.024. PMID: 15805330.