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Death trajectories of emergency department patients and palliative care service utilization
RESEARCH FORUM ABSTRACTS
successful placement, and 1 (4.5%) because of decreased complications. The number of laboratories attended or level of training did not reveal any particular trend. Conclusion: Emergency physicians preferred the Jamshidi-type needles over Cook. Limitations were the animal model and small numbers.
221
The Usefulness of Abdominal Computed Tomography in Diagnostic and Disposition Decisionmaking in the Emergency Evaluation of Elderly Patients With Abdominal Pain
Ross LM, Banet GA, Meldon SW, Hustey FM/Washington University in St. Louis, St. Louis, MO; MetroHealth Medical Center, Cleveland, OH; The Cleveland Clinic Foundation, Cleveland, OH Study objectives: We determine whether the use of abdominal computed tomography (CT) alters diagnosis and disposition in elderly patients presenting to the emergency department (ED) with abdominal pain. Methods: This prospective, observational, multicenter study consisted of a convenience sample of patients aged 60 years and older presenting to 1 of 4 participating EDs with abdominal pain. Patients with abdominal trauma or surgery within the previous 4 weeks were excluded. We analyzed the overall rate of CT use and compared the concordance of ED diagnosis (diagnosis) to final diagnosis (discharge or 2-week follow-up). ED diagnosis was considered concordant to final diagnosis if the ED diagnosis was included among the final diagnoses. In a subgroup of patients (N=100), we used a real-time questionnaire to determine percentage of change (95% confidence interval [CI]) in diagnosis and disposition after CT scan results. Results: Four hundred thirty-eight (87%) of 501 consenting patients were enrolled. Of these, 179 (41%) patients had a CT scan as part of their evaluation. Concordance of ED diagnosis to final diagnosis in admitted patients was 74.1% (95% CI 65.0% to 81.6%) in those receiving CT versus 74.5% (95% CI 66.1% to 81.3%) in those without CT. In the subgroup of patients with real-time questionnaire information, 54 (54%) had CT performed. The percentage of change in diagnosis or disposition after CT in this group was 17 of 54 (32%, 95% CI 19.9% to 45.7%) and 19 of 54 (35%, 95% CI 23.0% to 49.4%), respectively. Conclusion: CT is used for more than 40% of elderly patients treated in the ED for abdominal pain. No difference was observed in concordance of ED to final diagnosis between patients with or without CT. Diagnosis and disposition were each altered about one third of the time in patients for whom CT was obtained.
222
Death Trajectories of Emergency Department Patients and Palliative Care Service Utilization
Zalenski RJ, Compton S/Wayne State University, Detroit, MI Study objectives: Although the emergency department (ED) is recognized as a common portal of hospital entry for dying patients, early recognition of dying trajectories may improve care by fostering timely initiation of end-of-life planning and palliative service discussions. We compare documented palliative care among ED patients on known dying trajectories versus those who die of sudden acute illness. Methods: A list of all ED patients who died after hospital admission in 2002 was generated for a large, Midwestern, suburban teaching hospital. A simple random sample of 48 patients who were older than 55 years and who survived more than 48 hours from ED presentation were selected for medical record review. Patients were classified either as a sudden unexpected death (SUDDEN) or on a known previous dying trajectory (KNOWN). The dying trajectories were (1) cancer (solid organ tumor with evidence of distant metastases); (2) frailty (bed-bound with incontinence and cognitive impairment); (3) organ failure ($2 hospitalizations in past 12 months for cirrhosis of the liver, congestive heart failure, or chronic obstructive pulmonary disease on home oxygen); or (4) other. SUDDEN patients were compared with KNOWN patients using x2 analysis, Fisher’s exact test, and Wilcoxon rank sum tests, and 95% confidence intervals (CIs) are reported for proportions. Results: Seven hundred forty-two patients met eligibility, of which 48 records were reviewed. Dying trajectories were noted as follows: KNOWN: cancer 25.0% (95% CI 14.1% to 39.9%); frailty 18.8% (95% CI 9.4% to 33.1%); organ failure 4.2% (95% CI 0.7% to 15.4%); and other 12.5% (95% CI 5.2% to 25.9%); and SUDDEN
S 6 8
39.6% (95% CI 26.1% to 54.7%). KNOWN and SUDDEN patients were similar in respect to age (78.9 versus 76.3 years), presence of an advance directive (14.3% versus 16.7%), and documented goals of care discussions (89.7% versus 89.5%). KNOWN patients tended to make more pain declarations (65.5% versus 42.1%; P=.11), and fewer reports of depression (0% versus 25.9%; P=.03). KNOWN patients were identified as dying and made do-not-resuscitate (DNR) status earlier in their hospital stay (median 2.5 days versus 8.1; P=.07). KNOWN patients were less likely to die on withdrawal of life support (35.7% versus 55.6%; P=.185) and died less quickly after DNR order (median 3.9 days versus 1.0; P=.04). Conclusion: Most patients who are admitted from the ED and die inhospital do not have unexpected deaths but are on known dying trajectories, and this was recognized by the timing of the DNR order. Patients on a dying trajectory were more commonly in pain, but depression seems to be underreported in KNOWN patients and is not an insignificant problem in the SUDDEN group.
223
Advanced Directives in an Emergency Department Nonagenarian Population
Vedula KC, Ganti SN, Schears RM/University of Washington, Seattle, WA; University of Minnesota, Minneapolis, MN, Mayo Clinic, Rochester, MN Study objectives: We determine how many persons close to the end of life have actual, formalized advanced directives. Methods: The records of 849 visits of patients aged 90 years and older presenting to the Saint Mary’s Hospital emergency department (ED) between January 1, 2002, and December 31, 2002, were reviewed. Data on the presence and details of any advanced directives were abstracted. There is no standard screen for the presence of these on our ED record, so information was gathered by reading the entire ED record, as well as the remainder of the general medical record within the past year (current visit information form). In addition to ascertaining whether advanced directives were in place, the details of these directives were catalogued. Also, for those who did not have advanced directives, information on whether they wished to receive further information on the topic was also collected. Results: A total of 363 (43%) patient encounters had formal advanced directives. Of the 238 that specified their advanced directives, 8 (3%) encounters were do not resuscitate (DNR), 2 (1%) encounters were do not intubate (DNI), and 21 (9%) encounters were DNR and DNI. A small minority (3%) indicated interest in organ donation, whereas 5 (2%) made a request or gave permission for an autopsy. The most common ultimate diagnoses resulting from these ED visits were pneumonia or pneumonitis, acute coronary syndrome, cardiac arrhythmia, congestive heart failure, and extremity fracture. Everyone who was asked whether he or she would like to receive more information about advanced directives answered yes. Conclusion: Less than half of all patients aged 90 years and older who presented to the ED had formal advanced directives in place. In addition to these patients being toward the end of life by virtue of their age, the most common presenting complaints were all of an acute nature with real potential life threat. Furthermore, from the patients’ standpoint, there appears to be a clear interest in receiving more information on advanced directives. This study highlights the need to address the issue of advanced directives with elderly patients presenting to the ED; possibly, this may best be achieved by way of a mandatory screen on the ED record.
224
The Use of a Two-Question Depression Screen for the Detection of Depression in Older Emergency Department Patients
Hustey FM, Meldon SW/The Cleveland Clinic Foundation, Cleveland, OH; MetroHealth Medical Center, Cleveland, OH Study objectives: We determine the sensitivity and specificity of a brief 2-question depression screen for the detection of depression in older emergency department (ED) patients. Methods: This was a prospective, observational study. Participants were a convenience sampling of ED patients 70 years and older presenting to an urban teaching hospital over a 17-month period. Exclusions included refusal, inability to communicate, and critical illness. Patients were screened for depression with the previously validated short-form geriatric depression scale (SFGDS). Standardized scores on the SFGDS were used to determine the prevalence of depression. Patients
ANNALS OF EMERGENCY MEDICINE
44:4
OCTOBER 2004
successful placement, and 1 (4.5%) because of decreased complications. The number of laboratories attended or level of training did not reveal any particular trend. Conclusion: Emergency physicians preferred the Jamshidi-type needles over Cook. Limitations were the animal model and small numbers.
221
The Usefulness of Abdominal Computed Tomography in Diagnostic and Disposition Decisionmaking in the Emergency Evaluation of Elderly Patients With Abdominal Pain
Ross LM, Banet GA, Meldon SW, Hustey FM/Washington University in St. Louis, St. Louis, MO; MetroHealth Medical Center, Cleveland, OH; The Cleveland Clinic Foundation, Cleveland, OH Study objectives: We determine whether the use of abdominal computed tomography (CT) alters diagnosis and disposition in elderly patients presenting to the emergency department (ED) with abdominal pain. Methods: This prospective, observational, multicenter study consisted of a convenience sample of patients aged 60 years and older presenting to 1 of 4 participating EDs with abdominal pain. Patients with abdominal trauma or surgery within the previous 4 weeks were excluded. We analyzed the overall rate of CT use and compared the concordance of ED diagnosis (diagnosis) to final diagnosis (discharge or 2-week follow-up). ED diagnosis was considered concordant to final diagnosis if the ED diagnosis was included among the final diagnoses. In a subgroup of patients (N=100), we used a real-time questionnaire to determine percentage of change (95% confidence interval [CI]) in diagnosis and disposition after CT scan results. Results: Four hundred thirty-eight (87%) of 501 consenting patients were enrolled. Of these, 179 (41%) patients had a CT scan as part of their evaluation. Concordance of ED diagnosis to final diagnosis in admitted patients was 74.1% (95% CI 65.0% to 81.6%) in those receiving CT versus 74.5% (95% CI 66.1% to 81.3%) in those without CT. In the subgroup of patients with real-time questionnaire information, 54 (54%) had CT performed. The percentage of change in diagnosis or disposition after CT in this group was 17 of 54 (32%, 95% CI 19.9% to 45.7%) and 19 of 54 (35%, 95% CI 23.0% to 49.4%), respectively. Conclusion: CT is used for more than 40% of elderly patients treated in the ED for abdominal pain. No difference was observed in concordance of ED to final diagnosis between patients with or without CT. Diagnosis and disposition were each altered about one third of the time in patients for whom CT was obtained.
222
Death Trajectories of Emergency Department Patients and Palliative Care Service Utilization
Zalenski RJ, Compton S/Wayne State University, Detroit, MI Study objectives: Although the emergency department (ED) is recognized as a common portal of hospital entry for dying patients, early recognition of dying trajectories may improve care by fostering timely initiation of end-of-life planning and palliative service discussions. We compare documented palliative care among ED patients on known dying trajectories versus those who die of sudden acute illness. Methods: A list of all ED patients who died after hospital admission in 2002 was generated for a large, Midwestern, suburban teaching hospital. A simple random sample of 48 patients who were older than 55 years and who survived more than 48 hours from ED presentation were selected for medical record review. Patients were classified either as a sudden unexpected death (SUDDEN) or on a known previous dying trajectory (KNOWN). The dying trajectories were (1) cancer (solid organ tumor with evidence of distant metastases); (2) frailty (bed-bound with incontinence and cognitive impairment); (3) organ failure ($2 hospitalizations in past 12 months for cirrhosis of the liver, congestive heart failure, or chronic obstructive pulmonary disease on home oxygen); or (4) other. SUDDEN patients were compared with KNOWN patients using x2 analysis, Fisher’s exact test, and Wilcoxon rank sum tests, and 95% confidence intervals (CIs) are reported for proportions. Results: Seven hundred forty-two patients met eligibility, of which 48 records were reviewed. Dying trajectories were noted as follows: KNOWN: cancer 25.0% (95% CI 14.1% to 39.9%); frailty 18.8% (95% CI 9.4% to 33.1%); organ failure 4.2% (95% CI 0.7% to 15.4%); and other 12.5% (95% CI 5.2% to 25.9%); and SUDDEN
S 6 8
39.6% (95% CI 26.1% to 54.7%). KNOWN and SUDDEN patients were similar in respect to age (78.9 versus 76.3 years), presence of an advance directive (14.3% versus 16.7%), and documented goals of care discussions (89.7% versus 89.5%). KNOWN patients tended to make more pain declarations (65.5% versus 42.1%; P=.11), and fewer reports of depression (0% versus 25.9%; P=.03). KNOWN patients were identified as dying and made do-not-resuscitate (DNR) status earlier in their hospital stay (median 2.5 days versus 8.1; P=.07). KNOWN patients were less likely to die on withdrawal of life support (35.7% versus 55.6%; P=.185) and died less quickly after DNR order (median 3.9 days versus 1.0; P=.04). Conclusion: Most patients who are admitted from the ED and die inhospital do not have unexpected deaths but are on known dying trajectories, and this was recognized by the timing of the DNR order. Patients on a dying trajectory were more commonly in pain, but depression seems to be underreported in KNOWN patients and is not an insignificant problem in the SUDDEN group.
223
Advanced Directives in an Emergency Department Nonagenarian Population
Vedula KC, Ganti SN, Schears RM/University of Washington, Seattle, WA; University of Minnesota, Minneapolis, MN, Mayo Clinic, Rochester, MN Study objectives: We determine how many persons close to the end of life have actual, formalized advanced directives. Methods: The records of 849 visits of patients aged 90 years and older presenting to the Saint Mary’s Hospital emergency department (ED) between January 1, 2002, and December 31, 2002, were reviewed. Data on the presence and details of any advanced directives were abstracted. There is no standard screen for the presence of these on our ED record, so information was gathered by reading the entire ED record, as well as the remainder of the general medical record within the past year (current visit information form). In addition to ascertaining whether advanced directives were in place, the details of these directives were catalogued. Also, for those who did not have advanced directives, information on whether they wished to receive further information on the topic was also collected. Results: A total of 363 (43%) patient encounters had formal advanced directives. Of the 238 that specified their advanced directives, 8 (3%) encounters were do not resuscitate (DNR), 2 (1%) encounters were do not intubate (DNI), and 21 (9%) encounters were DNR and DNI. A small minority (3%) indicated interest in organ donation, whereas 5 (2%) made a request or gave permission for an autopsy. The most common ultimate diagnoses resulting from these ED visits were pneumonia or pneumonitis, acute coronary syndrome, cardiac arrhythmia, congestive heart failure, and extremity fracture. Everyone who was asked whether he or she would like to receive more information about advanced directives answered yes. Conclusion: Less than half of all patients aged 90 years and older who presented to the ED had formal advanced directives in place. In addition to these patients being toward the end of life by virtue of their age, the most common presenting complaints were all of an acute nature with real potential life threat. Furthermore, from the patients’ standpoint, there appears to be a clear interest in receiving more information on advanced directives. This study highlights the need to address the issue of advanced directives with elderly patients presenting to the ED; possibly, this may best be achieved by way of a mandatory screen on the ED record.
224
The Use of a Two-Question Depression Screen for the Detection of Depression in Older Emergency Department Patients
Hustey FM, Meldon SW/The Cleveland Clinic Foundation, Cleveland, OH; MetroHealth Medical Center, Cleveland, OH Study objectives: We determine the sensitivity and specificity of a brief 2-question depression screen for the detection of depression in older emergency department (ED) patients. Methods: This was a prospective, observational study. Participants were a convenience sampling of ED patients 70 years and older presenting to an urban teaching hospital over a 17-month period. Exclusions included refusal, inability to communicate, and critical illness. Patients were screened for depression with the previously validated short-form geriatric depression scale (SFGDS). Standardized scores on the SFGDS were used to determine the prevalence of depression. Patients
ANNALS OF EMERGENCY MEDICINE
44:4
OCTOBER 2004