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Factors That Influence Length of Visit in the Emergency Department for Patients with Congestive Heart Failure
Research Forum Abstracts
414
Factors That Influence Length of Visit in the Emergency Department for Patients with Congestive Heart Failure
Schears RM, Varadachari CJ, Stead LG, Weaver AL, Mayo Clinic, Rochester, MN
Study Objectives: To determine whether the duration of emergency department (ED) length of visit (LOV) is associated with any of the routinely obtained laboratory or electrocardiographic parameters in patients with congestive heart failure (CHF). Methods: This IRB approved study was conducted at an academic medical center with an annual ED census of 75,000. The study population consisted of all patients during a 2 year period who presented to the ED and were hospitalized for CHF. Serum laboratory and ECG values were considered as potential factors influencing ED LOV. Laboratory values were categorized according to whether the levels were low, normal, or high. Linear regression models were fit to evaluate the association of LOV and each of the laboratory and ECG values, after adjusting for age. LOV was evaluated after applying a logarithmic transformation. Generalized estimating equation methods were used to handle the multiple, correlated visits per patient using PROC GENMOD in SAS. As part of this method, an exchangeable correlation structure was specified to model the correlation between multiple ED visits per patient. Results: During the 2-year study period, 681 patients had a total of 842 ED visits that resulted in hospital admission for CHF. For a given visit, the LOV ranged from 41 minutes to 13.4 hours with a median of 2.8 hours (mean 3.0; SD 1.3 hours). Tachycardia, high troponin, and normal sodium (vs. low) were identified as being jointly associated with having a shorter LOV (each p\0.05) (see Table). Conclusion: Tachycardia, elevated troponin and a normal sodium are jointly associated with a statistically significant shorter length of visit. Clinically, this likely reflects patients in whom clear disposition would likely decrease LOV. The increased LOV in ED patients with hyponatremia requires further investigation.
415
Age Is Associated with Hospital Length-of-Stay but Not with Admission Rates, Anemia, or Mortality in Emergency Department Patients with Elevated International Normalization Ratios
SD 11.7 (p=0.87). There were no differences in levels of anemia between admitted and discharged groups. No subjects died in this study. Age is compared to INR, anemia, and LOS as calculated by Spearman rank correlation in the table below. Conclusion: In our emergency department study in patients with elevated INR’s, there were no statistically significant differences on admission rates, anemia, and mortality between the elderly and their younger counterparts. However, age did correlate with length of stay. It remains unclear if age is a factor in the severity of illness in patients with elevated INR’s. Other outcome measures such as need for blood products, and surgery are presently being investigated.
416
Prescription Use and Survival Among Nonagenarians Presenting to the Emergency Department
Mooney RL, Schears RM, Weaver AL, Mayo Clinic, Rochester, MN
Study Objectives: The goal of this study is to characterize prescription medication use and survival impact in patients at least 90 years old at the time of emergency department (ED) visit. Methods: A structured medical record review was performed on all nonagenarians presenting to a large urban, academic ED in 2002. The main outcome measures were number and category of admission and discharge medications and survival. Most agents available without a prescription, (i.e., topicals, dietary supplements, antidiarrheals, and laxatives) were excluded from analysis. The change in the median number of medications at admission vs. discharge was evaluated with the Wilcoxon signed rank test. For 6 different classes of medications, usage (yes/no) was compared at admission versus discharge using McNemars test for comparing correlated proportions. Survival was estimated using the Kaplan-Meier method; associations were summarized using risk ratios estimated from Cox proportional hazards models. All calculated p-values were two-sided and p-values less than 0.05 were considered statistically significant. Results: The study included 597 patients, 72.9% female, and half arriving to the ED via medical transport (50.8%). Residency included 54.3% at home, 30.8% in a nursing home, and 14.9% in assisted living. Overall on admission, 3.2% were taking no medications, 34.8% were taking 1-4 medications, 51.9% were taking 5-9 medications, with 10.1% were taking 10 or more medications (median=5). The median number of medications increased by 1 at discharge (p\0.001). Interestingly, the proportion patients discharged with analgesics, antipsychotics, anxiolytics, and mood stabilizers, was significantly greater than those on admission. Survival at 6 months, 1, 2, and 3 years was 73.5%, 62.1%, 45.9%, and 26.3%, respectively. Among those alive at last follow-up, the median follow-up was 2.3 years. Patients discharged with opioids were 1.6 times more likely to die than those not discharged on opioids; a similar risk ratio was observed for antipsychotics (see Tables). Conclusions: Overall, prescription medications were increased at either ED disposition or following hospitalization for these elders. Significant increases in analgesics, antipsychotics, anxiolytics, and mood stabilizers were noted. Opioids and antipsychotics significantly impact survival in nonagenarians. No excess mortality was detected for patients on benzodiazepines.
Lee DC, Johnson AB, Rudolph GS, North Shore University Hospital, Manhasset, NY
Study Objectives: With the increasing indications for long-term anticoagulation combined with the aging of the population, there has been an increasing incidence of over-anticoagulation in the elderly. There is scant literature describing the morbidity and mortality of over-anticoagulation in this group. Our hypothesis is that increasing age correlates with increasing morbidity and mortality, thus elderly patients are sicker and have poorer outcomes compared to their younger counterparts. We defined these outcomes as initial admission rates, length of hospital stay (LOS), initial hemoglobin levels (HGB1), hemoglobin levels on the third day after presentation (HGB3), and mortality. Methods: We performed an IRB-approved, retrospective, chart review on a consecutive cohort of patients presenting to a tertiary care, suburban, academic emergency department who had an initial International Normalization Ratio (INR) that was equal to or greater than 4.0. This emergency department has an annual census of 60,000. Patients who presented in a 1-year period between December 2002 to November 2003 were included. All charts were reviewed by physician/investigators in a standardized fashion. Data collected included: demographics, initial laboratory values, and hospital course. Data was analyzed by student t-test and Spearman rank correlation where appropriate. A p\0.05 was considered significant. Results: 269 charts were identified. There were 135 males and 134 females. There were no differences in the age of admitted and discharged groups; 246 were admitted with a mean age of 73.1, SD 13.9 and 23 were discharged with a mean age 72.6,
Volume 46, no. 3 : September 2005
Annals of Emergency Medicine S117
414
Factors That Influence Length of Visit in the Emergency Department for Patients with Congestive Heart Failure
Schears RM, Varadachari CJ, Stead LG, Weaver AL, Mayo Clinic, Rochester, MN
Study Objectives: To determine whether the duration of emergency department (ED) length of visit (LOV) is associated with any of the routinely obtained laboratory or electrocardiographic parameters in patients with congestive heart failure (CHF). Methods: This IRB approved study was conducted at an academic medical center with an annual ED census of 75,000. The study population consisted of all patients during a 2 year period who presented to the ED and were hospitalized for CHF. Serum laboratory and ECG values were considered as potential factors influencing ED LOV. Laboratory values were categorized according to whether the levels were low, normal, or high. Linear regression models were fit to evaluate the association of LOV and each of the laboratory and ECG values, after adjusting for age. LOV was evaluated after applying a logarithmic transformation. Generalized estimating equation methods were used to handle the multiple, correlated visits per patient using PROC GENMOD in SAS. As part of this method, an exchangeable correlation structure was specified to model the correlation between multiple ED visits per patient. Results: During the 2-year study period, 681 patients had a total of 842 ED visits that resulted in hospital admission for CHF. For a given visit, the LOV ranged from 41 minutes to 13.4 hours with a median of 2.8 hours (mean 3.0; SD 1.3 hours). Tachycardia, high troponin, and normal sodium (vs. low) were identified as being jointly associated with having a shorter LOV (each p\0.05) (see Table). Conclusion: Tachycardia, elevated troponin and a normal sodium are jointly associated with a statistically significant shorter length of visit. Clinically, this likely reflects patients in whom clear disposition would likely decrease LOV. The increased LOV in ED patients with hyponatremia requires further investigation.
415
Age Is Associated with Hospital Length-of-Stay but Not with Admission Rates, Anemia, or Mortality in Emergency Department Patients with Elevated International Normalization Ratios
SD 11.7 (p=0.87). There were no differences in levels of anemia between admitted and discharged groups. No subjects died in this study. Age is compared to INR, anemia, and LOS as calculated by Spearman rank correlation in the table below. Conclusion: In our emergency department study in patients with elevated INR’s, there were no statistically significant differences on admission rates, anemia, and mortality between the elderly and their younger counterparts. However, age did correlate with length of stay. It remains unclear if age is a factor in the severity of illness in patients with elevated INR’s. Other outcome measures such as need for blood products, and surgery are presently being investigated.
416
Prescription Use and Survival Among Nonagenarians Presenting to the Emergency Department
Mooney RL, Schears RM, Weaver AL, Mayo Clinic, Rochester, MN
Study Objectives: The goal of this study is to characterize prescription medication use and survival impact in patients at least 90 years old at the time of emergency department (ED) visit. Methods: A structured medical record review was performed on all nonagenarians presenting to a large urban, academic ED in 2002. The main outcome measures were number and category of admission and discharge medications and survival. Most agents available without a prescription, (i.e., topicals, dietary supplements, antidiarrheals, and laxatives) were excluded from analysis. The change in the median number of medications at admission vs. discharge was evaluated with the Wilcoxon signed rank test. For 6 different classes of medications, usage (yes/no) was compared at admission versus discharge using McNemars test for comparing correlated proportions. Survival was estimated using the Kaplan-Meier method; associations were summarized using risk ratios estimated from Cox proportional hazards models. All calculated p-values were two-sided and p-values less than 0.05 were considered statistically significant. Results: The study included 597 patients, 72.9% female, and half arriving to the ED via medical transport (50.8%). Residency included 54.3% at home, 30.8% in a nursing home, and 14.9% in assisted living. Overall on admission, 3.2% were taking no medications, 34.8% were taking 1-4 medications, 51.9% were taking 5-9 medications, with 10.1% were taking 10 or more medications (median=5). The median number of medications increased by 1 at discharge (p\0.001). Interestingly, the proportion patients discharged with analgesics, antipsychotics, anxiolytics, and mood stabilizers, was significantly greater than those on admission. Survival at 6 months, 1, 2, and 3 years was 73.5%, 62.1%, 45.9%, and 26.3%, respectively. Among those alive at last follow-up, the median follow-up was 2.3 years. Patients discharged with opioids were 1.6 times more likely to die than those not discharged on opioids; a similar risk ratio was observed for antipsychotics (see Tables). Conclusions: Overall, prescription medications were increased at either ED disposition or following hospitalization for these elders. Significant increases in analgesics, antipsychotics, anxiolytics, and mood stabilizers were noted. Opioids and antipsychotics significantly impact survival in nonagenarians. No excess mortality was detected for patients on benzodiazepines.
Lee DC, Johnson AB, Rudolph GS, North Shore University Hospital, Manhasset, NY
Study Objectives: With the increasing indications for long-term anticoagulation combined with the aging of the population, there has been an increasing incidence of over-anticoagulation in the elderly. There is scant literature describing the morbidity and mortality of over-anticoagulation in this group. Our hypothesis is that increasing age correlates with increasing morbidity and mortality, thus elderly patients are sicker and have poorer outcomes compared to their younger counterparts. We defined these outcomes as initial admission rates, length of hospital stay (LOS), initial hemoglobin levels (HGB1), hemoglobin levels on the third day after presentation (HGB3), and mortality. Methods: We performed an IRB-approved, retrospective, chart review on a consecutive cohort of patients presenting to a tertiary care, suburban, academic emergency department who had an initial International Normalization Ratio (INR) that was equal to or greater than 4.0. This emergency department has an annual census of 60,000. Patients who presented in a 1-year period between December 2002 to November 2003 were included. All charts were reviewed by physician/investigators in a standardized fashion. Data collected included: demographics, initial laboratory values, and hospital course. Data was analyzed by student t-test and Spearman rank correlation where appropriate. A p\0.05 was considered significant. Results: 269 charts were identified. There were 135 males and 134 females. There were no differences in the age of admitted and discharged groups; 246 were admitted with a mean age of 73.1, SD 13.9 and 23 were discharged with a mean age 72.6,
Volume 46, no. 3 : September 2005
Annals of Emergency Medicine S117