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Failing to Appropriately Admit Elderly Patients Can Have Dire Repercussions

LOS ANGELES – Deciding whether to admit or discharge an older patient can be a difficult decision for emergency physicians. A new study provides some information to help make the choice.

A matched case-control study of patients age 65 or older who died or were admitted to the intensive care unit (ICU) within seven days of being evaluated in the emergency department, published recently in Annals of Emergency Medicine, finds that older adults at the ED with cognitive impairment, a change in disposition plan from admit to discharge, low blood pressure, and elevated heart rate were more likely to be admitted to the ICU or to die within seven days.

"Emergency physicians must exercise extra caution when making the decision to admit or discharge a geriatric patient," warned Gelareh Gabayan, MD, MSHS, of the Department of Medicine at the University of California at Los Angeles. "These patients tend to be more delicate than their younger counterparts. Even abnormal vital signs, like blood pressure and heart rate, are associated with potentially catastrophic events for patients who are discharged from the ER rather than admitted."

Here are the factors identified by the study in patients 65 or older:

  • A change in disposition plan from admit to discharge;
  • Acute or chronic cognitive impairment or mental status changes, and
  • Abnormal vital signs -- a systolic blood pressure below 120 and heart rate above 90.

Study authors explain that a change in disposition could be directed by a physician or by the patient leaving the hospital against medical advice.

"Both patient families and hospital administrators can pressure emergency physicians to discharge seniors from the emergency department, but our study supports caution in these decisions," Gabayan added in an American College of Emergency Physicians press release. "Our study identifies the patients at risk and the findings show that even seemingly small indicators can add up to something dangerous in these vulnerable patients. It is important to note, however, that this study does not encourage that all older adults be admitted. The findings should act as a tool for emergency department providers."

For the study, researchers reviewed charts of 600 ED visit records among adults older than 65 years that resulted in discharge from any of 13 hospitals within Kaiser Permanente Southern California’s integrated health system in 2009 to 2010. Randomly choosing 300 patients who experienced the combined outcome -- either death or an ICU admission shortly after ED discharge – from 1.4 million visits, the study team matched them to controls who did not experience those outcomes. Two emergency physicians blinded to the outcome reviewed the records and identified whether a number of characteristics were present.

Results indicate that characteristics associated with the combined poor outcome included cognitive impairment with an adjusted odds ratio (AOR) of 2.10; disposition plan change with an AOR of 2.71; systolic blood pressure less than 120 mm Hg with an AOR of 1.48; and pulse rate greater than 90 beats/min with an AOR of 1.66.

“Increased awareness of these high-risk characteristics may improve ED disposition decision-making,” study authors conclude.