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Emergency Department access targets and the older patient: A retrospective cohort study of Emergency Department presentations by people living in Residential Aged Care Facilities
Australasian Emergency Nursing Journal (2012) 15, 211—218
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/aenj
RESEARCH PAPER
Emergency Department access targets and the older patient: A retrospective cohort study of Emergency Department presentations by people living in Residential Aged Care Facilities Maryann Street, PhD a,b,∗ Jonathan R. Marriott, MBBS, FRACP b,c Patricia M. Livingston, PhD a,b a
School of Nursing & Midwifery, Deakin University, Burwood, Victoria 3125, Australia Eastern Health, Box Hill, Victoria 3128, Australia c Bundoora Extended Care Centre, Bundoora, Victoria 3083, Australia b
Received 26 April 2012; received in revised form 11 July 2012; accepted 17 October 2012
KEYWORDS Emergency departments; Aged; Health services research; Health policy; Residential Aged Care Facilities
∗
Summary Background: There is limited research on the effect of emergency access targets on health outcomes for older patients from Residential Aged Care Facilities. The aims were to: (1) identify length of stay for Residential Aged Care patients relative to access targets; and (2) examine hospital admission rates, readmission rates, inpatient costs and mortality. Methods: Retrospective cohort study of all emergency presentations for Residential Aged Care patients in 2009 at one Australian metropolitan health service. Results: The 4637 emergency presentations by 3184 Residential Aged Care patients in 2009 represented 3.4% of all emergency presentations. Mean length of stay was 7.9 hours (SD = 4.5 hours); 84% of Residential Aged Care patients remained in the Emergency Department longer than four hours. Admitted patients were 3.6 times more likely to spend more than eight hours in the Emergency Department compared with those not admitted (p < 0.001). Patients in the urgent triage category were 9.5 times more likely to spend more than eight hours in the Emergency Department compared to patients triaged as non-urgent (p < 0.001). Inpatient costs were associated with length of admission and median cost per day was $AUD 1175. Conclusion: Few Residential Aged Care patients were discharged within the four hours access target. This has implications for health care outcomes and costs associated with providing emergency care for patients living in Residential Aged Care Facilities. © 2012 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
Corresponding author at: Level 2, 5 Arnold Street, Box Hill, Victoria 3128, Australia. Tel.: +61 03 98953496; fax: +61 03 98996810. E-mail address: [email protected] (M. Street).
1574-6267/$ — see front matter © 2012 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.aenj.2012.10.002
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What is known • People living in Residential Aged Care Facilities (RACF) are frequently transferred to the Emergency Department (ED), remain longer in ED than older patients from the community and have a high admission rate. • Concern about excessive waiting time in the ED has led to the introduction of agreed standards, the National Emergency Access Targets, for Australian public hospital EDs by having patients discharged or admitted to hospital within four hours. • Optimal length of stay in ED has not been established and while prolonged time in ED is detrimental to the patient, early discharge or admission may also have adverse consequences.
M. Street et al. when targets mandated that 98% of all ED patients must be seen, treated and leave the department within four hours. The targets were successful in reducing the time patients remained in ED,9 and did not result in an increase in return visits to ED or deaths.10 However concerns about the effect time targets had on the safety and quality of clinical care7,11 and lack of consistent improvement in care8 have led to the four hour target being replaced by quality measures. There is no evidence of the impact of introducing ED time targets on patients transferred from RACF. However, the four hour target in the UK appears to have disadvantaged older patients, who were more likely to be rushed through to unmonitored areas of the hospital just prior to the target or to breach the target altogether.12 RACF patients may be even further disadvantaged due to factors such as delirium, dementia or hearing loss,13 while signs of serious illness may be subtle and atypical resulting in diagnosis delay.14
What this paper adds • The incidence of transfer from RACF to acute care was 48 transfers per 100 beds. • Our study found that 84% of RACF patients remained in ED longer than four hours, with a mean length of stay of almost eight hours. • Admitted patients were 3.6 times more likely to remain longer than eight hours in ED compared with those not admitted. Patients assessed in the urgent triage category on arrival, were 9.5 times more likely to spend longer than eight hours in ED compared to patients triaged as non-urgent. • Two-thirds of RACF patients were admitted to hospital, with a median cost per day of $AUD 1175. • We found that most transfers of RACF patients to ED occurred by ambulance in high acuity patients, with one death in every 19 transfers.
Aims The aims of this study were to determine the proportion of patients transferred from RACF meeting the four hour National Emergency Access Target and identify outcomes, such as hospital admission and readmission rates, inpatient costs and mortality for patients from RACF.
Methods Design This study was a retrospective cohort study for all people transferred from RACF to one metropolitan health service from 1 January to 31 December 2009.
Sample and setting
Introduction There is a high rate of transfer from Residential Aged Care Facilities (RACF) to the Emergency Department (ED) and up to 2.4% of all ED visits are RACF patients.1,2 Emergency care for older people living in RACF is a complex area of health policy.3 Those from RACF have worse health outcomes, including longer length of stay in ED, higher rates of admission and longer hospital stay compared to older patients from the community.2,4,5 Compared to those from the community, people from RACF were more likely to be diagnosed with pneumonia, influenza, urinary tract infection, or hip fractures and less likely to be diagnosed with circulatory system diseases or cancer on presentation to ED, and were more likely to be admitted and to die in hospital.6 Concern about excessive waiting time in the ED has led to the introduction of agreed standards for emergency care quality, including measures of waiting time and length of stay in ED.7 National Emergency Access Targets are currently proposed for Australian public hospitals to ease overcrowding by having patients discharged or admitted to hospital within four hours.8 In the UK, the four hours emergency standard was introduced in 2003 and became fully established by 2008,
The cohort of patients included in this study were people transferred from RACF to any of the health service’s three EDs, representing point of access for emergency care and subsequent admission. There were 4637 emergency presentations by 3184 people from RACF to the health service’s three EDs during the study period. This health service is the second largest health service in Victoria and has the largest geographical catchment area of any metropolitan health service across the state. It delivers more than 800,000 episodes of patient care each year. There are 9585 Residential Aged Care beds within the catchment area of these three hospitals.
Data collection Demographic, administrative and clinical data were collected from the Victorian Emergency Minimum Dataset (VEMD) and Victorian Admitted Episodes Dataset (VAED). VEMD contains data detailing presentations at Victorian public hospitals, while VAED contains data for all admitted patients from Victorian public and private acute hospitals including rehabilitation centres, extended care facilities and day procedure centres. Collection processes are based on standard definitions and collection protocols to ensure
Emergency access by older patients comparability over time and across geographical and agency boundaries. Financial charges, linked to an episode of hospital admission, were an aggregate of allied health, nursing, pathology, pharmacy, imaging, medical — nonsurgical, medical — surgical, intensive care, coronary care, theatre, and ED charges, from 1 January to 30 June 2009. Outcomes are reported in 2009 Australian dollars (AUD). Inpatient charges are prepared by the Decision Support Unit of the Health Service at the end of each financial year for patient admissions during the previous financial year (July to June). Demographic comparison of this sample with the total RACF patients who presented to ED (n = 4637) and those who were admitted showed no significant difference for age and gender. Data collected for this study comprised demographic (age and gender), administrative (usual accommodation and transport to ED), clinical data (diagnoses at discharge from ED, Australian Triage Scale (ATS) category,15 length of stay in ED, departure status, and admission details) and charges for those admitted to hospital. Comparisons were made between this health service and commonwealth department indicators using data available from Your Hospitals. An overview of Public Hospital Activity.16 Proportions of patients presenting to ED by ATS category for this health service were compared to data for all Australian health services combined, obtained from The State of Our Public Hospitals June 2010 report.17 The primary outcome was length of stay in ED, defined as total time from arrival in the ED to admission or discharge, which has been found to be the most robust indicator of performance.18 Secondary outcomes were admission rate, length of admission, mortality and inpatient charges.
Research ethics statement This study adhered to the National Statement on the Conduct of Human Research by the Australian National Health and Medical Research Council, and was approved as a low risk study by the health service’s Research and Ethics Review Panel and Deakin University Human Research Ethics Committee.
Statistical analysis Descriptive statistics (means, standard deviations (SD), medians and interquartile ranges (IQR)) were reported to describe the sample. For statistical comparisons, chi-square tests were used for categorical data and independent ttests or Mann—Whittney rank sum tests for continuous data. Differences in percentage of patients discharged from ED compared to those admitted to hospital by age, gender, triage category and the length of stay in ED (grouped into less than four hours, between four and eight hours and greater than eight hours) were tested by chi-square. Analysis of variance was used to compare mean length of stay in ED and length of hospital admission across the five ATS categories. Length of admission to hospital was not normally distributed, therefore the nonparametric Kruskall Wallace test was used for analysis of this variable. The primary independent variable was discharge destination from ED (RACF or hospital admission).
213 Pearson’s correlation coefficient was used to determine the association between total inpatient charges and the length of admission. Multinomial logistic regression (using the hierarchical stepwise method of model building) was used to obtain adjusted estimates for length of stay in ED in three groups. Presentations which resulted in ED length of stay of four to eight hours or more than eight hours were compared to the reference group of those which resulted in a length of stay of less than four hours, based on the following predictors: age, gender, ATS category and discharge destination from ED. Level of significance was set at p < = 0.001 with 95% confidence limits. Data were analysed using SPSS version 17 (SPSS Inc., Chicago, IL).
Results Emergency Department presentation characteristics There were 4637 emergency presentations by patients from RACF during the study period. This represented 3.4% of the total 137,482 ED presentations to this health service in 2009. Overall, 3184 RACF residents attended an ED on at least one occasion. The median age of these 3184 patients was 85 years (range = 19 years to 103 years), 66% (n = 2160) were female and the preferred language was English for 96% (n = 3055) of patients. Almost three-quarters (72.5%, n = 2307) attended once, 17.0% (n = 541) attended twice, and 10.4% (n = 336) attended three or more times during the year. The number of ED presentations for each patient ranged from 1 to 17. Of the 4637 transfers to the ED, 68% (n = 3150) resulted in hospital admission, while 31% (n = 1448) were discharged to RACF and 1% (n = 33) were pronounced dead on arrival or died in ED (Fig. 1). Overall mortality, including those during hospital admission, was 244 patients; one death in every 19 transfers. The average number of ED discharge diagnoses per RACF patient was 4.5, with a range from one to thirty. Common diagnoses recorded on discharge from ED were cardiovascular disease or event (25%), fractures (23%), pneumonia (19%), urinary tract infection (18%) and cerebrovascular event (13%). Injury following a fall was the reason 19.5% of patients were transferred to ED and 12% of all RACF patients presented with delirium, dementia or confusion.
Assessment by ATS category A higher proportion of RACF patients were triaged in Emergency and Urgent ATS categories (69%) compared to all emergency visits within the health service (45%; 2 = 465.268, df = 4; p < 0.0001) and all Australian Public Hospital ED visits (41%; 2 = 844.420, df = 4; p < 0.0001) (Fig. 2).
Length of stay in ED The mean ED length of stay for patients from RACF was 7.9 hours (SD = 4.5 hours, n = 4637), with a range from 3 minutes to 41.3 hours. The proportion of patients in each time group was: less than 4 hours = 16%; 4 to 8 hours = 47%; more than 8 hours = 37%. ED length of stay rose with increasing age,
214
M. Street et al. 137,482 presentaons to Health Service Emergency Department in 2009
4637 (3.4%) presentaons by RACF residents
1448 (31%) discharged from ED to RACF
3150 (68%) admied to hospital
110 (3.5%) Excluded from analysis of inpaent data due to incomplete data
3040 hospital admissions
2128 (70.0%) discharged from hospital to RACF
33 (1%) DOA or died in ED
691 (22.7%) transferred to another hospital
221 (7.3%) died during hospital admission
Note: Emergency Department discharge destination not recorded for 6 presentations; RACF= Residential Aged Care Facility; DOA = Dead on Arrival.
Fig. 1 Distribution of presentations by discharge destination from the Emergency Department (ED) or hospital. Note: Emergency Department discharge destination not recorded for 6 presentations; RACF, Residential Aged Care Facility; DOA, Dead on Arrival.
increasing clinical urgency on arrival at ED and admission to hospital (Table 1). The results of multinomial logistic regression analysis (Table 2) showed that clinical urgency on arrival on ED and admission to hospital were associated with increased
likelihood of spending more than four hours in ED, with the B coefficients all being significant for both the four to eight hours and over eight hours groups. Being admitted to a ward had a significant effect on length of stay in ED, with a patient being 2.3 times more likely to spend between four
Fig. 2 Proportion of presentations to the Emergency Department for each ATS (triage) category comparing all Australian† , all Health Service and RACF presentations at this Health Service. † Data obtained from The State of Our Public Hospitals June 2010 report.17
Emergency access by older patients
215
Table 1 Proportion of presentations by length of stay in the Emergency Department in three groups (less than four hours, four to eight hours, and more than eight hours). Number Total Age (years) < 70 70—79 80—89 90+ Gender Males Females ATS category Resuscitation Emergency Urgent Semi-urgent Non-urgent Destination from ED Not admitted Admitted a b c d
4598
<4 hrs
4—8 hrs
>8 hrs
16%
47%
37%
p-Value 0.001a,b
470 679 2196 1253
21% 15% 14% 16%
39% 47% 48% 49%
40% 38% 38% 35%
1548 3050
15% 16%
46% 47%
39% 37%
60 631 2095 1753 59
23% 19% 12% 17% 61%
48% 47% 49% 46% 27%
29% 34% 39% 37% 12%
0.423
<0.001a,c
<0.001a,d 1448 3150
26% 11%
47% 47%
27% 42%
Significant difference between Emergency Department length of stay groups. 2 = 21.641, df = 6. 2 = 129.050, df = 8. 2 = 199.529, df = 2.
to eight hours (95%CI, 1.9—2.8) and 3.6 times more likely to spend more than eight hours compared with those not admitted (95%CI, 3.0—4.3). Compared to patients triaged as non-urgent, patients in the urgent triage category were 5.9 times more likely to spend between four and eight hours (95%CI, 3.2—11.0) and 9.5 times more likely to spend more than eight hours in ED (95%CI, 4.1—21.9). The model was significant (2 [18,n = 4598] = 291.130, p < 0.001) and explained between 6.1% (Cox & Snell R squared) and 7.1% (Nagelkerke R Squared) of the variance in length of stay in ED. In 2009, Australian government indicators for Emergency Care Access included benchmarks against which each health service was assessed.14 Comparing patients transferred from RACF to all patients presenting to ED at this health service, the proportion of non-admitted RACF patients whose stay was less than four hours was lower (26% compared to 69%). Similarly, the proportion of RACF patients admitted to hospital within eight hours was lower (58% compared to 70%). The proportion of patients from RACF remaining in ED more than 24 hours was higher (0.28% compared to 0.12%).
ED presentations resulting in a hospital admission During the study period, two-thirds of RACF patients were admitted to hospital (Table 3), which was twice the proportion of admissions for all Victorian hospital ED presentations in the same time period (33%).15 There were no significant differences in the admission rates for patients associated with age or gender. However, significantly more patients classified at higher clinical urgency on arrival at ED were admitted to hospital (p < 0.001; Table 3). The median length of admission was 3.5 days (IQR = 0.7, 8.1 days) with a range
from 5 hours to 102 days. The level of clinical urgency on arrival was not significantly associated with length of hospital admission for RACF patients (n = 3029, F = 1.05, df = 3, p = 0.369). The final destinations for admitted patients were: discharged back to RACF (70%); transferred to another hospital (23%); and died while an inpatient (7%).
In-patient hospital charges Financial charges were available for 1355 presentations in the first six months of 2009 (1 January to 30 June), representing 43% of all admitted patients from RACF in the full year. The average inpatient charges were $5715 (SD = $6197) and median total inpatient costs were $3517 (IQR = $1566, $7681). The average charge per day of admission was $2071 (SD = $2469) and median charge per day was $1175 (IQR = $272, $2079). As expected, inpatient charges up to $30,000 were directly associated with the length of admission (r = 0.94, n = 1336, p < 0.001). However, for the small number of patients, whose inpatient charges were greater than $30,000, there was no association between charges and number of days admission (r = −0.38, n = 19, p = 0.19).
Discussion We have evaluated patient transfers from RACF to public hospital EDs in this study. Approximately 3% of all ED presentations were patients from RACF, whose average length of stay was eight hours. This study revealed that four in every five RACF patients remained in ED longer than four hours and one in three patients remained longer than eight hours.
216
M. Street et al.
Table 2 Results of the multinomial logistic regression predicting likelihood of longer stay in the Emergency Department. Presentations resulting in length of stay of between four and eight hours (Group 1) or longer than eight hours (Group 2) are compared to the reference group of presentations with length of stay less than four hours. Variable
Category
Adjusted odds ratio
Group 1: 4—8 hoursa Age
Less than 70 yrs 70—79 yrs 80—89 yrs 90 yrs or more Gender Male Female ATS category Resuscitation Emergency Urgent Semi-urgent Non-urgent Destination Admitted to hospital Discharged from ED Group 2: More than 8 hoursa Age Less than 70 yrs 70—79 yrs 80—89 yrs 90 yrs or more Gender Male Female ATS category Resuscitation Emergency Urgent Semi-urgent Non-urgent Destination Admitted to hospital Discharged from ED ** a b
0.7 1.0 1.1 1.0b 1.1 1.0b 2.6 3.2 5.9 4.3 1.0b 2.3 1.0 1.1 1.2 1.0b 1.1 1.0b 2.9 4.4 9.5 7.3 1.0b 3.6 1.0b
95% CI
p-Value
0.5—0.9 0.8—1.4 0.9—1.3
0.016 0.832 0.452
0.9—1.3
0.409
1.1—6.5 1.7—6.2 3.2—11.0 2.3—7.9
0.035 0.001** 0.001** 0.001**
1.9—2.8
0.001**
0.7—1.4 0.8—1.5 0.9—1.5
0.900 0.413 0.135
0.9—1.4
0.250
1.0—8.7 1.9—10.4 4.1—21.9 3.2—17.0
0.058 0.001** 0.001** 0.001**
3.0—4.3
0.001**
Significant result compared to reference groupb . Reference is presentations resulting in length of stay less than 4 hours. Reference group is 90 years or more, female, non-urgent and discharged from ED. ATS, Australian Triage Scale.
Table 3 Percentage of presentations by patients transferred from RACF who were not admitted compared to those who were admitted to hospital. Category
Number
Entire sample Age Less than 70 years 70—79 years 80—89 years 90 years or more Gender Male Female ATS category Resuscitation Emergency Urgent Semi-urgent Non-urgent
4598
31.5%
68.5%
473 684 2208 1261
38% 32% 30% 31%
62% 68% 70% 69%
1548 3050
30% 32%
70% 68%
a
Not admitted N = 1448
Admitted N = 3150
p-Value 0.003
0.061
<0.001a 60 631 2095 1753 59
8% 15% 27% 42% 83%
92% 85% 73% 58% 17%
significant result (2 = 275.912, df = 4, p ≤ 0.001); ATS, Australian Triage Scale; RACF, Residential Aged Care Facility.
Emergency access by older patients Although patients transferred from RACF are a small proportion of all ED users, they require more intensive assessment, investigation and management, which takes more time to address the complex nature of their presentation. Increasing age, arriving by ambulance, and being admitted, have been shown to increase the likelihood of remaining in ED for more than eight hours.18 In our study, admitted patients and those in the urgent triage category (ATS 3) remained longer in ED. Crilly and colleagues4 found that being a RACF resident was an independent predictor for remaining in ED longer than six hours. Factors which may have contributed to longer stay in ED for this patient population, include their multiple health conditions, as demonstrated in the current study and others,19 use of several prescription medications and difficulty in assessment at triage.13,14 The small amount of variance explained by the regression model highlights the varied and complex nature of factors impacting on length of stay in EDs. Horwitz et al. found variation in the time to be treated in ED was shown to be largely patient dependant; while variation in length of stay was hospital dependent.20 Extended length of stay in ED can be distressing for older patients, with feelings of mistrust or abandonment and may impact on their ability to provide information.21 Longer stay in ED could have resulted from hospital overcrowding,22 an internationally recognised problem associated with diminished quality of care, increased morbidity and mortality.22—24 While prolonged time in ED is detrimental to the patient, early discharge or admission may also have adverse consequences.20 When caring for older patients in ED, nurses need time to listen. Pressure to discharge a patient within four hours may reduce the quality of nursing care, especially when medical care or routines are prioritised at the expense of spending time with the older patient.25 The need to improve access to emergency care for patients from RACF should be balanced with quality of care standards and may require changes to hospital processes.26 In our study, the incidence of transfer to acute care was 48 per 100 RACF beds within the health service’s catchment area, with a consequent rate of hospital admission of 67%, both of which were higher than previously reported for this patient population.1 The high admission rate, which was twice that for all Victorian patients,16 and higher than reported for patients aged over 65 years,21,27,28 suggests patients from RACF were seriously ill. This is also indicated by our findings that most transfers of RACF patients to ED occurred by ambulance in high acuity patients, assessed as clinically urgent on arrival and with one death in every 19 transfers. Evidence suggests that while the majority of transfers from RACF to ED were appropriate,2,29 some hospital admissions by RACF patients could be avoided by providing alternative strategies and resources,3,30 including advance care planning and outreach programmes. Few studies have examined inpatient and treatment charges associated with the transfer of elderly patients from RACF to acute care. Barker et al.31 found the average charge of $US 5849 associated with hospitalisation from RACF was not significantly higher than for hospitalisations of older persons from the community and Ouslander et al.32 found the average Medicare payment was $US 6796. Our study found the average total charges per admission was $AUD 5715. Inpatient charges increased in proportion to the length of
217 admission, with the median charge per day just over $1000. As prolonged stay in ED is associated with longer hospital admission,5,33,34 strategies to reduce length of stay in ED due to overcrowding may significantly reduce healthcare expenditure and patient morbidity.34 Several limitations of this study are acknowledged. It was not possible to confirm whether the demographic characteristics of patients were similar to the local population of RACF residents. However, comparison to Victorian Government audit data indicate the proportions of all ED presentations to this health service within each time category (less than four hours, four to eight hours and more than 8 hours) were similar to other metropolitan health services.16 This study was conducted at one health service and may not be representative of all health services. The retrospective data may contain inaccuracies or bias from original coding which are not able to be identified. This study cannot determine the extent to which non-clinical aspects, such as overcrowding or delays in transport back to RACF, impacted on the time a patient remained in ED. Despite these limitations, this study has demonstrated that time targets may not be appropriate for this patient group because very few RACF patients were discharged from ED within four hours. Substantial changes would be required to current clinical processes to achieve emergency access targets for this patient group and may not be achievable in the context of increasing demand by older patients.35 Further research is required to determine the impact of the National Emergency Access Targets on RACF patients in terms of the adequacy of clinical assessments, potential clinical risk and potential frustration for patients, families and health care providers. Further studies should also investigate the impact on ED length of stay of providing greater coordination of care for RACF residents, through improved liaison between RACF and health services. The role of advanced care planning and outreach programmes for RACF patients who present to ED also warrants investigation.
Provenance and conflict of interest No author involved in this article has any financial or personal relationships with other people or organisations that could inappropriately bias its content. There is no potential conflict of interest. The study did not receive any external funding and was undertaken as in-kind contribution by Eastern Health, Deakin University and Bundoora Extended Care. This paper was not commissioned.
Funding No external funding was obtained for this study.
Acknowledgement The authors wish to acknowledge Ms GiGi Chan for extraction of data from health service databases.
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References 1. Arendts G, Howard K. The interface between residential aged care and the emergency department: a systematic review. Age Ageing 2010;39:306—12. 2. Finn JC, Flicker L, Mackenzie E, Jacobs IG, Fatovich DM, Drummond S, et al. Interface between Residential Aged Care Facilities and a teaching hospital emergency department in Western Australia. MJA 2006;184:432—5. 3. Arendts G, Reibel T, Codde J, Frankel J. Can transfers from Residential Aged Care Facilities to the Emergency Department be avoided through improved primary care services? Data from qualitative interviews. Australas J Ageing 2010;29:61—5. 4. Crilly J, Chaboyer W, Wallis M, Thalib L, Green D. Predictive outcomes for older people who present to the emergency department. AENJ 2008;11:178—83. 5. Ackroyd-Stolarz S, Read Guernsey J, MacKinnon NJ, Kovacs G. The association between a prolonged stay in the emergency department and adverse events in older patients admitted to hospital: a retrospective cohort study. BMJ Qual Saf 2011;20:564—9. 6. Ingarfield SL, Finn JC, Jacobs IG, Gibson NP, Holman CDAJ, Jelinek GA, et al. Use of emergency departments by older people from residential care: a population based study. Age Ageing 2009;38(3):314—8. 7. Jones P, Schimanski K. The four hour target to reduce emergency department ‘waiting time’: a systematic review of clinical outcomes. EMA 2010;22:391—8. 8. Department of Health Victoria. National Health Reform. Melbourne: State Government of Victoria; 2011. Available from http://www.health.vic.gov.au/search.htm?q=national +health+reform [accessed 09.04.12]. 9. Kelman S, Friedman JN. Performance Improvement and Performance Dysfunction: An Empirical Examination of Distortionary Impacts of the Emergency Room Wait-Time Target in the English National Health Service. J Public Admin Res Theory 2009;19:917—46. 10. Weber EJ, Mason S, Freeman JV, Coster J. Impact of England’s four hour emergency throughput target on quality of care and resource use. Acad Emerg Med 2011;18(5 Supp1):S6. 11. Gillen S. Quality indicators expected as care standard is F relaxed. Emerg Nurse 2010;18:6—7. 12. Mason S. The impact of a time target on older patients attending the emergency department. Emerg Med J 2010;27:A2. 13. Australian and New Zealand Society for Geriatric Medicine. The management of older patients in the emergency department. Position Statement No. 14, Sydney, 2008. 14. Wolf L. How normal are ‘‘normal vital signs’’? Effective triage of the older patient. J Emerg Nurs 2007;33:587—9. 15. Australasian College for Emergency Medicine. Policies, guidelines, statements and documents endorsed by ACEM. Melbourne: Australasian College for Emergency Medicine; 2006. 16. Department of Health (VIC). Your Hospitals. A report of Victorian public hospitals July 2009 to June 2010. Melbourne: Published by the Hospital and Health Service Performance Division. Available from http://www.health.vic.gov.au/performance/downloads.htm [accessed 05.04.12]. 17. Australian Government. The State of Our Hospitals. Canberra: Australian Government; 2010. Available from http://www.health.gov.au/internet/main/publishing.nsf/ Content/sooph10 [accessed 05.04.12].
M. Street et al. 18. Downing A, Wilson RC, Cooke MW. Which patients spend more than 4 hours in the Accident and Emergency department? J Public Health 2004;26:172—6. 19. Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Morlock LL. Defining and measuring patient safety. Crit Care Clin 2005;21:1—19. 20. Horwitz L, Green J, Bradley EH. US Emergency Department Performance on Wait Time and Length of Visit. Ann Emerg Med 2010;55:133—41. 21. Considine J, Smith R, Hill K, Weiland T, Gannon J, Behm C, et al. Older peoples’ experience of accessing emergency care. AENJ 2010;13:61—9. 22. Australasian College for Emergency Medicine. ACEM Statement on Emergency Department Overcrowding. 2009. Available from http://www.acem.org.au/media/policies and guidelines/ S57 - Statement on ED Overcr.pdf [accessed 05.04.12]. 23. Plunkett PK, Byrne DG, Breslin TS, Bennett K, Silke B. Increasing wait times predict increasing mortality foremergency medical admissions. Eur J Emerg Med 2011;18(4):192—6. 24. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. MJA 2006;184:213—6. 25. Larsson Kihlgren A, Nilsson M, Sorlie V. Caring for older patients at an emergency department — emergency nurses’ reasoning. J Clin Nurs 2005;14:601—8. 26. O’Connell TJ, Bassham JE, Bishop RO, Clarke CW, Hullick CJ, King DL, et al. Clinical process redesign for unplanned arrivals in hospitals. MJA 2008;188:S18—22. 27. Amindazeh F, Dalziel W. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes and effectiveness of interventions. Ann Emerg Med 2002;39:238—47. 28. George G, Jell C, Todd BS. Effect of population ageing on emergency department speed and efficiency: a historical perspective from a district general hospital in the UK. EMJ 2006;23: 379—83. 29. Jensen PM, Fraser F, Shankardass K, Epstein R, Khera J. Are long-term care residents referred appropriately to hospital emergency departments? Can Fam Physician 2009;55:500—5. 30. Salvi F, Morichi V, Grilli A, Giorgi R, De Tommaso G, DessÃFulgheri P. The elderly in the emergency department: a critical review of problems and solutions. Intern Emerg Med 2007;2:292—301. 31. Barker WH, Zimmer JG, Hall WJ, Ruff BC, Freundlich CB, Eggert GM. Rates, patterns, causes, and costs of hospitalization of nursing home residents: a population-based study. Am J Public Health 1994;84(10):1615—20. 32. Ouslander JG, Lamb G, Perloe M, Givens J-V, Kluge L, Rutland T, et al. Potentially avoidable hospitalizations of nursing home residents: frequency, causes and costs. J Am Geriatr Soc 2010;58:627—35. 33. Arendts G, Dickson C, Howard K, Quine S. Transfer from residential aged care to emergency departments: an analysis of patient outcomes. Intern Med J 2012;42(1): 75—82. 34. Liew D, Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. MJA 2003;179:524—6. 35. Lowthian JA, Curtis AJ, Jolley DJ, Stoelwinder JU, McNell JJ, Cameron PA. Demand at the emergency department front door: 10-year trends in presentations. MJA 2012;196:128—32.
Available online at www.sciencedirect.com
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RESEARCH PAPER
Emergency Department access targets and the older patient: A retrospective cohort study of Emergency Department presentations by people living in Residential Aged Care Facilities Maryann Street, PhD a,b,∗ Jonathan R. Marriott, MBBS, FRACP b,c Patricia M. Livingston, PhD a,b a
School of Nursing & Midwifery, Deakin University, Burwood, Victoria 3125, Australia Eastern Health, Box Hill, Victoria 3128, Australia c Bundoora Extended Care Centre, Bundoora, Victoria 3083, Australia b
Received 26 April 2012; received in revised form 11 July 2012; accepted 17 October 2012
KEYWORDS Emergency departments; Aged; Health services research; Health policy; Residential Aged Care Facilities
∗
Summary Background: There is limited research on the effect of emergency access targets on health outcomes for older patients from Residential Aged Care Facilities. The aims were to: (1) identify length of stay for Residential Aged Care patients relative to access targets; and (2) examine hospital admission rates, readmission rates, inpatient costs and mortality. Methods: Retrospective cohort study of all emergency presentations for Residential Aged Care patients in 2009 at one Australian metropolitan health service. Results: The 4637 emergency presentations by 3184 Residential Aged Care patients in 2009 represented 3.4% of all emergency presentations. Mean length of stay was 7.9 hours (SD = 4.5 hours); 84% of Residential Aged Care patients remained in the Emergency Department longer than four hours. Admitted patients were 3.6 times more likely to spend more than eight hours in the Emergency Department compared with those not admitted (p < 0.001). Patients in the urgent triage category were 9.5 times more likely to spend more than eight hours in the Emergency Department compared to patients triaged as non-urgent (p < 0.001). Inpatient costs were associated with length of admission and median cost per day was $AUD 1175. Conclusion: Few Residential Aged Care patients were discharged within the four hours access target. This has implications for health care outcomes and costs associated with providing emergency care for patients living in Residential Aged Care Facilities. © 2012 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
Corresponding author at: Level 2, 5 Arnold Street, Box Hill, Victoria 3128, Australia. Tel.: +61 03 98953496; fax: +61 03 98996810. E-mail address: [email protected] (M. Street).
1574-6267/$ — see front matter © 2012 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.aenj.2012.10.002
212
What is known • People living in Residential Aged Care Facilities (RACF) are frequently transferred to the Emergency Department (ED), remain longer in ED than older patients from the community and have a high admission rate. • Concern about excessive waiting time in the ED has led to the introduction of agreed standards, the National Emergency Access Targets, for Australian public hospital EDs by having patients discharged or admitted to hospital within four hours. • Optimal length of stay in ED has not been established and while prolonged time in ED is detrimental to the patient, early discharge or admission may also have adverse consequences.
M. Street et al. when targets mandated that 98% of all ED patients must be seen, treated and leave the department within four hours. The targets were successful in reducing the time patients remained in ED,9 and did not result in an increase in return visits to ED or deaths.10 However concerns about the effect time targets had on the safety and quality of clinical care7,11 and lack of consistent improvement in care8 have led to the four hour target being replaced by quality measures. There is no evidence of the impact of introducing ED time targets on patients transferred from RACF. However, the four hour target in the UK appears to have disadvantaged older patients, who were more likely to be rushed through to unmonitored areas of the hospital just prior to the target or to breach the target altogether.12 RACF patients may be even further disadvantaged due to factors such as delirium, dementia or hearing loss,13 while signs of serious illness may be subtle and atypical resulting in diagnosis delay.14
What this paper adds • The incidence of transfer from RACF to acute care was 48 transfers per 100 beds. • Our study found that 84% of RACF patients remained in ED longer than four hours, with a mean length of stay of almost eight hours. • Admitted patients were 3.6 times more likely to remain longer than eight hours in ED compared with those not admitted. Patients assessed in the urgent triage category on arrival, were 9.5 times more likely to spend longer than eight hours in ED compared to patients triaged as non-urgent. • Two-thirds of RACF patients were admitted to hospital, with a median cost per day of $AUD 1175. • We found that most transfers of RACF patients to ED occurred by ambulance in high acuity patients, with one death in every 19 transfers.
Aims The aims of this study were to determine the proportion of patients transferred from RACF meeting the four hour National Emergency Access Target and identify outcomes, such as hospital admission and readmission rates, inpatient costs and mortality for patients from RACF.
Methods Design This study was a retrospective cohort study for all people transferred from RACF to one metropolitan health service from 1 January to 31 December 2009.
Sample and setting
Introduction There is a high rate of transfer from Residential Aged Care Facilities (RACF) to the Emergency Department (ED) and up to 2.4% of all ED visits are RACF patients.1,2 Emergency care for older people living in RACF is a complex area of health policy.3 Those from RACF have worse health outcomes, including longer length of stay in ED, higher rates of admission and longer hospital stay compared to older patients from the community.2,4,5 Compared to those from the community, people from RACF were more likely to be diagnosed with pneumonia, influenza, urinary tract infection, or hip fractures and less likely to be diagnosed with circulatory system diseases or cancer on presentation to ED, and were more likely to be admitted and to die in hospital.6 Concern about excessive waiting time in the ED has led to the introduction of agreed standards for emergency care quality, including measures of waiting time and length of stay in ED.7 National Emergency Access Targets are currently proposed for Australian public hospitals to ease overcrowding by having patients discharged or admitted to hospital within four hours.8 In the UK, the four hours emergency standard was introduced in 2003 and became fully established by 2008,
The cohort of patients included in this study were people transferred from RACF to any of the health service’s three EDs, representing point of access for emergency care and subsequent admission. There were 4637 emergency presentations by 3184 people from RACF to the health service’s three EDs during the study period. This health service is the second largest health service in Victoria and has the largest geographical catchment area of any metropolitan health service across the state. It delivers more than 800,000 episodes of patient care each year. There are 9585 Residential Aged Care beds within the catchment area of these three hospitals.
Data collection Demographic, administrative and clinical data were collected from the Victorian Emergency Minimum Dataset (VEMD) and Victorian Admitted Episodes Dataset (VAED). VEMD contains data detailing presentations at Victorian public hospitals, while VAED contains data for all admitted patients from Victorian public and private acute hospitals including rehabilitation centres, extended care facilities and day procedure centres. Collection processes are based on standard definitions and collection protocols to ensure
Emergency access by older patients comparability over time and across geographical and agency boundaries. Financial charges, linked to an episode of hospital admission, were an aggregate of allied health, nursing, pathology, pharmacy, imaging, medical — nonsurgical, medical — surgical, intensive care, coronary care, theatre, and ED charges, from 1 January to 30 June 2009. Outcomes are reported in 2009 Australian dollars (AUD). Inpatient charges are prepared by the Decision Support Unit of the Health Service at the end of each financial year for patient admissions during the previous financial year (July to June). Demographic comparison of this sample with the total RACF patients who presented to ED (n = 4637) and those who were admitted showed no significant difference for age and gender. Data collected for this study comprised demographic (age and gender), administrative (usual accommodation and transport to ED), clinical data (diagnoses at discharge from ED, Australian Triage Scale (ATS) category,15 length of stay in ED, departure status, and admission details) and charges for those admitted to hospital. Comparisons were made between this health service and commonwealth department indicators using data available from Your Hospitals. An overview of Public Hospital Activity.16 Proportions of patients presenting to ED by ATS category for this health service were compared to data for all Australian health services combined, obtained from The State of Our Public Hospitals June 2010 report.17 The primary outcome was length of stay in ED, defined as total time from arrival in the ED to admission or discharge, which has been found to be the most robust indicator of performance.18 Secondary outcomes were admission rate, length of admission, mortality and inpatient charges.
Research ethics statement This study adhered to the National Statement on the Conduct of Human Research by the Australian National Health and Medical Research Council, and was approved as a low risk study by the health service’s Research and Ethics Review Panel and Deakin University Human Research Ethics Committee.
Statistical analysis Descriptive statistics (means, standard deviations (SD), medians and interquartile ranges (IQR)) were reported to describe the sample. For statistical comparisons, chi-square tests were used for categorical data and independent ttests or Mann—Whittney rank sum tests for continuous data. Differences in percentage of patients discharged from ED compared to those admitted to hospital by age, gender, triage category and the length of stay in ED (grouped into less than four hours, between four and eight hours and greater than eight hours) were tested by chi-square. Analysis of variance was used to compare mean length of stay in ED and length of hospital admission across the five ATS categories. Length of admission to hospital was not normally distributed, therefore the nonparametric Kruskall Wallace test was used for analysis of this variable. The primary independent variable was discharge destination from ED (RACF or hospital admission).
213 Pearson’s correlation coefficient was used to determine the association between total inpatient charges and the length of admission. Multinomial logistic regression (using the hierarchical stepwise method of model building) was used to obtain adjusted estimates for length of stay in ED in three groups. Presentations which resulted in ED length of stay of four to eight hours or more than eight hours were compared to the reference group of those which resulted in a length of stay of less than four hours, based on the following predictors: age, gender, ATS category and discharge destination from ED. Level of significance was set at p < = 0.001 with 95% confidence limits. Data were analysed using SPSS version 17 (SPSS Inc., Chicago, IL).
Results Emergency Department presentation characteristics There were 4637 emergency presentations by patients from RACF during the study period. This represented 3.4% of the total 137,482 ED presentations to this health service in 2009. Overall, 3184 RACF residents attended an ED on at least one occasion. The median age of these 3184 patients was 85 years (range = 19 years to 103 years), 66% (n = 2160) were female and the preferred language was English for 96% (n = 3055) of patients. Almost three-quarters (72.5%, n = 2307) attended once, 17.0% (n = 541) attended twice, and 10.4% (n = 336) attended three or more times during the year. The number of ED presentations for each patient ranged from 1 to 17. Of the 4637 transfers to the ED, 68% (n = 3150) resulted in hospital admission, while 31% (n = 1448) were discharged to RACF and 1% (n = 33) were pronounced dead on arrival or died in ED (Fig. 1). Overall mortality, including those during hospital admission, was 244 patients; one death in every 19 transfers. The average number of ED discharge diagnoses per RACF patient was 4.5, with a range from one to thirty. Common diagnoses recorded on discharge from ED were cardiovascular disease or event (25%), fractures (23%), pneumonia (19%), urinary tract infection (18%) and cerebrovascular event (13%). Injury following a fall was the reason 19.5% of patients were transferred to ED and 12% of all RACF patients presented with delirium, dementia or confusion.
Assessment by ATS category A higher proportion of RACF patients were triaged in Emergency and Urgent ATS categories (69%) compared to all emergency visits within the health service (45%; 2 = 465.268, df = 4; p < 0.0001) and all Australian Public Hospital ED visits (41%; 2 = 844.420, df = 4; p < 0.0001) (Fig. 2).
Length of stay in ED The mean ED length of stay for patients from RACF was 7.9 hours (SD = 4.5 hours, n = 4637), with a range from 3 minutes to 41.3 hours. The proportion of patients in each time group was: less than 4 hours = 16%; 4 to 8 hours = 47%; more than 8 hours = 37%. ED length of stay rose with increasing age,
214
M. Street et al. 137,482 presentaons to Health Service Emergency Department in 2009
4637 (3.4%) presentaons by RACF residents
1448 (31%) discharged from ED to RACF
3150 (68%) admied to hospital
110 (3.5%) Excluded from analysis of inpaent data due to incomplete data
3040 hospital admissions
2128 (70.0%) discharged from hospital to RACF
33 (1%) DOA or died in ED
691 (22.7%) transferred to another hospital
221 (7.3%) died during hospital admission
Note: Emergency Department discharge destination not recorded for 6 presentations; RACF= Residential Aged Care Facility; DOA = Dead on Arrival.
Fig. 1 Distribution of presentations by discharge destination from the Emergency Department (ED) or hospital. Note: Emergency Department discharge destination not recorded for 6 presentations; RACF, Residential Aged Care Facility; DOA, Dead on Arrival.
increasing clinical urgency on arrival at ED and admission to hospital (Table 1). The results of multinomial logistic regression analysis (Table 2) showed that clinical urgency on arrival on ED and admission to hospital were associated with increased
likelihood of spending more than four hours in ED, with the B coefficients all being significant for both the four to eight hours and over eight hours groups. Being admitted to a ward had a significant effect on length of stay in ED, with a patient being 2.3 times more likely to spend between four
Fig. 2 Proportion of presentations to the Emergency Department for each ATS (triage) category comparing all Australian† , all Health Service and RACF presentations at this Health Service. † Data obtained from The State of Our Public Hospitals June 2010 report.17
Emergency access by older patients
215
Table 1 Proportion of presentations by length of stay in the Emergency Department in three groups (less than four hours, four to eight hours, and more than eight hours). Number Total Age (years) < 70 70—79 80—89 90+ Gender Males Females ATS category Resuscitation Emergency Urgent Semi-urgent Non-urgent Destination from ED Not admitted Admitted a b c d
4598
<4 hrs
4—8 hrs
>8 hrs
16%
47%
37%
p-Value 0.001a,b
470 679 2196 1253
21% 15% 14% 16%
39% 47% 48% 49%
40% 38% 38% 35%
1548 3050
15% 16%
46% 47%
39% 37%
60 631 2095 1753 59
23% 19% 12% 17% 61%
48% 47% 49% 46% 27%
29% 34% 39% 37% 12%
0.423
<0.001a,c
<0.001a,d 1448 3150
26% 11%
47% 47%
27% 42%
Significant difference between Emergency Department length of stay groups. 2 = 21.641, df = 6. 2 = 129.050, df = 8. 2 = 199.529, df = 2.
to eight hours (95%CI, 1.9—2.8) and 3.6 times more likely to spend more than eight hours compared with those not admitted (95%CI, 3.0—4.3). Compared to patients triaged as non-urgent, patients in the urgent triage category were 5.9 times more likely to spend between four and eight hours (95%CI, 3.2—11.0) and 9.5 times more likely to spend more than eight hours in ED (95%CI, 4.1—21.9). The model was significant (2 [18,n = 4598] = 291.130, p < 0.001) and explained between 6.1% (Cox & Snell R squared) and 7.1% (Nagelkerke R Squared) of the variance in length of stay in ED. In 2009, Australian government indicators for Emergency Care Access included benchmarks against which each health service was assessed.14 Comparing patients transferred from RACF to all patients presenting to ED at this health service, the proportion of non-admitted RACF patients whose stay was less than four hours was lower (26% compared to 69%). Similarly, the proportion of RACF patients admitted to hospital within eight hours was lower (58% compared to 70%). The proportion of patients from RACF remaining in ED more than 24 hours was higher (0.28% compared to 0.12%).
ED presentations resulting in a hospital admission During the study period, two-thirds of RACF patients were admitted to hospital (Table 3), which was twice the proportion of admissions for all Victorian hospital ED presentations in the same time period (33%).15 There were no significant differences in the admission rates for patients associated with age or gender. However, significantly more patients classified at higher clinical urgency on arrival at ED were admitted to hospital (p < 0.001; Table 3). The median length of admission was 3.5 days (IQR = 0.7, 8.1 days) with a range
from 5 hours to 102 days. The level of clinical urgency on arrival was not significantly associated with length of hospital admission for RACF patients (n = 3029, F = 1.05, df = 3, p = 0.369). The final destinations for admitted patients were: discharged back to RACF (70%); transferred to another hospital (23%); and died while an inpatient (7%).
In-patient hospital charges Financial charges were available for 1355 presentations in the first six months of 2009 (1 January to 30 June), representing 43% of all admitted patients from RACF in the full year. The average inpatient charges were $5715 (SD = $6197) and median total inpatient costs were $3517 (IQR = $1566, $7681). The average charge per day of admission was $2071 (SD = $2469) and median charge per day was $1175 (IQR = $272, $2079). As expected, inpatient charges up to $30,000 were directly associated with the length of admission (r = 0.94, n = 1336, p < 0.001). However, for the small number of patients, whose inpatient charges were greater than $30,000, there was no association between charges and number of days admission (r = −0.38, n = 19, p = 0.19).
Discussion We have evaluated patient transfers from RACF to public hospital EDs in this study. Approximately 3% of all ED presentations were patients from RACF, whose average length of stay was eight hours. This study revealed that four in every five RACF patients remained in ED longer than four hours and one in three patients remained longer than eight hours.
216
M. Street et al.
Table 2 Results of the multinomial logistic regression predicting likelihood of longer stay in the Emergency Department. Presentations resulting in length of stay of between four and eight hours (Group 1) or longer than eight hours (Group 2) are compared to the reference group of presentations with length of stay less than four hours. Variable
Category
Adjusted odds ratio
Group 1: 4—8 hoursa Age
Less than 70 yrs 70—79 yrs 80—89 yrs 90 yrs or more Gender Male Female ATS category Resuscitation Emergency Urgent Semi-urgent Non-urgent Destination Admitted to hospital Discharged from ED Group 2: More than 8 hoursa Age Less than 70 yrs 70—79 yrs 80—89 yrs 90 yrs or more Gender Male Female ATS category Resuscitation Emergency Urgent Semi-urgent Non-urgent Destination Admitted to hospital Discharged from ED ** a b
0.7 1.0 1.1 1.0b 1.1 1.0b 2.6 3.2 5.9 4.3 1.0b 2.3 1.0 1.1 1.2 1.0b 1.1 1.0b 2.9 4.4 9.5 7.3 1.0b 3.6 1.0b
95% CI
p-Value
0.5—0.9 0.8—1.4 0.9—1.3
0.016 0.832 0.452
0.9—1.3
0.409
1.1—6.5 1.7—6.2 3.2—11.0 2.3—7.9
0.035 0.001** 0.001** 0.001**
1.9—2.8
0.001**
0.7—1.4 0.8—1.5 0.9—1.5
0.900 0.413 0.135
0.9—1.4
0.250
1.0—8.7 1.9—10.4 4.1—21.9 3.2—17.0
0.058 0.001** 0.001** 0.001**
3.0—4.3
0.001**
Significant result compared to reference groupb . Reference is presentations resulting in length of stay less than 4 hours. Reference group is 90 years or more, female, non-urgent and discharged from ED. ATS, Australian Triage Scale.
Table 3 Percentage of presentations by patients transferred from RACF who were not admitted compared to those who were admitted to hospital. Category
Number
Entire sample Age Less than 70 years 70—79 years 80—89 years 90 years or more Gender Male Female ATS category Resuscitation Emergency Urgent Semi-urgent Non-urgent
4598
31.5%
68.5%
473 684 2208 1261
38% 32% 30% 31%
62% 68% 70% 69%
1548 3050
30% 32%
70% 68%
a
Not admitted N = 1448
Admitted N = 3150
p-Value 0.003
0.061
<0.001a 60 631 2095 1753 59
8% 15% 27% 42% 83%
92% 85% 73% 58% 17%
significant result (2 = 275.912, df = 4, p ≤ 0.001); ATS, Australian Triage Scale; RACF, Residential Aged Care Facility.
Emergency access by older patients Although patients transferred from RACF are a small proportion of all ED users, they require more intensive assessment, investigation and management, which takes more time to address the complex nature of their presentation. Increasing age, arriving by ambulance, and being admitted, have been shown to increase the likelihood of remaining in ED for more than eight hours.18 In our study, admitted patients and those in the urgent triage category (ATS 3) remained longer in ED. Crilly and colleagues4 found that being a RACF resident was an independent predictor for remaining in ED longer than six hours. Factors which may have contributed to longer stay in ED for this patient population, include their multiple health conditions, as demonstrated in the current study and others,19 use of several prescription medications and difficulty in assessment at triage.13,14 The small amount of variance explained by the regression model highlights the varied and complex nature of factors impacting on length of stay in EDs. Horwitz et al. found variation in the time to be treated in ED was shown to be largely patient dependant; while variation in length of stay was hospital dependent.20 Extended length of stay in ED can be distressing for older patients, with feelings of mistrust or abandonment and may impact on their ability to provide information.21 Longer stay in ED could have resulted from hospital overcrowding,22 an internationally recognised problem associated with diminished quality of care, increased morbidity and mortality.22—24 While prolonged time in ED is detrimental to the patient, early discharge or admission may also have adverse consequences.20 When caring for older patients in ED, nurses need time to listen. Pressure to discharge a patient within four hours may reduce the quality of nursing care, especially when medical care or routines are prioritised at the expense of spending time with the older patient.25 The need to improve access to emergency care for patients from RACF should be balanced with quality of care standards and may require changes to hospital processes.26 In our study, the incidence of transfer to acute care was 48 per 100 RACF beds within the health service’s catchment area, with a consequent rate of hospital admission of 67%, both of which were higher than previously reported for this patient population.1 The high admission rate, which was twice that for all Victorian patients,16 and higher than reported for patients aged over 65 years,21,27,28 suggests patients from RACF were seriously ill. This is also indicated by our findings that most transfers of RACF patients to ED occurred by ambulance in high acuity patients, assessed as clinically urgent on arrival and with one death in every 19 transfers. Evidence suggests that while the majority of transfers from RACF to ED were appropriate,2,29 some hospital admissions by RACF patients could be avoided by providing alternative strategies and resources,3,30 including advance care planning and outreach programmes. Few studies have examined inpatient and treatment charges associated with the transfer of elderly patients from RACF to acute care. Barker et al.31 found the average charge of $US 5849 associated with hospitalisation from RACF was not significantly higher than for hospitalisations of older persons from the community and Ouslander et al.32 found the average Medicare payment was $US 6796. Our study found the average total charges per admission was $AUD 5715. Inpatient charges increased in proportion to the length of
217 admission, with the median charge per day just over $1000. As prolonged stay in ED is associated with longer hospital admission,5,33,34 strategies to reduce length of stay in ED due to overcrowding may significantly reduce healthcare expenditure and patient morbidity.34 Several limitations of this study are acknowledged. It was not possible to confirm whether the demographic characteristics of patients were similar to the local population of RACF residents. However, comparison to Victorian Government audit data indicate the proportions of all ED presentations to this health service within each time category (less than four hours, four to eight hours and more than 8 hours) were similar to other metropolitan health services.16 This study was conducted at one health service and may not be representative of all health services. The retrospective data may contain inaccuracies or bias from original coding which are not able to be identified. This study cannot determine the extent to which non-clinical aspects, such as overcrowding or delays in transport back to RACF, impacted on the time a patient remained in ED. Despite these limitations, this study has demonstrated that time targets may not be appropriate for this patient group because very few RACF patients were discharged from ED within four hours. Substantial changes would be required to current clinical processes to achieve emergency access targets for this patient group and may not be achievable in the context of increasing demand by older patients.35 Further research is required to determine the impact of the National Emergency Access Targets on RACF patients in terms of the adequacy of clinical assessments, potential clinical risk and potential frustration for patients, families and health care providers. Further studies should also investigate the impact on ED length of stay of providing greater coordination of care for RACF residents, through improved liaison between RACF and health services. The role of advanced care planning and outreach programmes for RACF patients who present to ED also warrants investigation.
Provenance and conflict of interest No author involved in this article has any financial or personal relationships with other people or organisations that could inappropriately bias its content. There is no potential conflict of interest. The study did not receive any external funding and was undertaken as in-kind contribution by Eastern Health, Deakin University and Bundoora Extended Care. This paper was not commissioned.
Funding No external funding was obtained for this study.
Acknowledgement The authors wish to acknowledge Ms GiGi Chan for extraction of data from health service databases.
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