CME/CE: Outcomes After ED Discharge of the Elderly

CME/CE: Outcomes After ED Discharge of the Elderly
Author Information (click to view)

Gelareh Z. Gabayan, MD, MSHS, FACEP

Gelareh Z. Gabayan, MD, MSHS, FACEP
Assistant Professor of Medicine/Emergency Medicine
UCLA School of Medicine
VA Greater Los Angeles HealthCare System

Gelareh Z. Gabayan, MD, MSHS, FACEP, has indicated to Physician’s Weekly that she has or has had no financial interests to report.

Figure 1 (click to view)
Target Audience (click to view)

This activity is designed to meet the needs of physicians and nurses.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

 

  • Discuss the findings of a study for which researchers identified patient and process-of-care factors that may be associated with early death or ICU admission within 7 days of discharge from the ED visit among elderly patients.

Method of Participation(click to view)

Release Date: 5/24/2017
Expiration Date: 5/24/2018

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at https://lms.physiciansweekly.com/course/view.php?id=8.  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. dcotterman@akhcme.com.

Credit Available(click to view)

AKH

CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physician Assistants
NCCPA accepts AMA PRA Category 1 Credit™ from organizations accredited by ACCME.

 

Nursing
AKH Inc., Advancing Knowledge in Healthcare is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

This activity is awarded 0.5 contact hours.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

Keith D’Oria – Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Gelareh Z. Gabayan, MD, MSHS, FACEP
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH and PHYSICIAN WEEKLY’S STAFF/REVIEWERS
Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH planners and reviewers have no relevant financial relationships to disclose.

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Gelareh Z. Gabayan, MD, MSHS, FACEP (click to view)

Gelareh Z. Gabayan, MD, MSHS, FACEP

Gelareh Z. Gabayan, MD, MSHS, FACEP
Assistant Professor of Medicine/Emergency Medicine
UCLA School of Medicine
VA Greater Los Angeles HealthCare System

Gelareh Z. Gabayan, MD, MSHS, FACEP, has indicated to Physician’s Weekly that she has or has had no financial interests to report.

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Poor mental status or change in cognition and changes in disposition plans appear to be important risk factors that can impact mortality and ICU admission risk among patients older than 65 early after they are discharged from the ED.
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According to published research, the elderly have the highest rate of ED use among all adult patient groups. Poor outcomes, such as death or an ICU admission shortly after discharge from the ED, can be catastrophic events. Data on outcomes after elderly patients are discharged from the ED are important patient safety and quality of care issues, but few analyses have investigated the specific risk factors that lead to these events.

Previous studies have used clinical data to identify predictors of poor outcomes after discharge from the ED. While this is an important first step in understanding the problem, previous research has been limited. “Most studies on this issue do not have follow-up information because the elderly may go to other hospitals or EDs to receive care after they are discharged,” explains Gelareh Z. Gabayan, MD, MSHS, FACEP. Much of the available research lacks direct access to patient records and cannot identify patient and process-of-care characteristics that were inherent to ED encounters.

For a study published in Annals of Emergency Medicine, Dr. Gabayan and colleagues extracted data from patient records by using a matched case-control review analysis among elderly ED patient visits. The authors randomly chose 300 patients who experienced the combined outcome of either death or an ICU admission within 7 days of discharge and matched case patients to controls who did not experience these outcomes. They then identified patient and process-of-care factors that may be associated with early death or ICU admission within 7 days of discharge from the ED visit. The study team evaluated charts of 600 ED visit records among adults older than age 65 that resulted in an ED discharge from any of 13 hospitals within an integrated health system in 2009 to 2010. The original sample included 1.4 million ED visits in the investigation.

 

Key Factors Identified

“Results of our study showed that the presence of cognitive impairment or mental status changes and changes in disposition plans from admission to discharge were associated with a poor outcome of either death or ICU admission,” says Dr. Gabayan (Table). Other factors that somewhat impacted either outcome included a fall in the 30 days prior to an ED visit, use of specialty consultants, having a systolic blood pressure of less than 120 mm Hg, and having a pulse rate higher than 90 beats per minute.

The study also examined the role of race and ethnicity with regard to the risk of death or an ICU admission within 7 days of ED discharge among elderly patients. When compared with non-Hispanic whites, the investigators found that Asian/Pacific Islanders were more likely to experience either poor outcome. These data suggest that older adults of different ethnicities may have differing social support services and a different threshold for visiting the ED.

 

Important Implications

“Identifying factors that may be associated with early death or ICU admission after an ED discharge is important to improving both ED care as well as follow-up care,” Dr. Gabayan says. “Our study identifies clinical characteristics and management decisions that are associated with poor outcomes after ED discharge.” She adds that the findings also reaffirm the importance of vital signs when evaluating records of ED visits of patients aged 65 or older.

“When coupling data from this study with that of others, it’s apparent that the clinical judgment of emergency providers about admitting versus discharging patients should be given special attention,” says Dr. Gabayan. This should occur regardless of the event that initially causes changes in disposition status. In light of the results, ED provider decisions should not be based solely on consultant recommendations and should also include their intuition.

In many cases, ED providers and ancillary staff may not have a predetermined plan about how to manage these patients, according to Dr. Gabayan. “As such, it’s important that EDs, managers, and follow-up services consider creating preset disposition plans to optimize the care of these patients,” she says. “Emergency physicians should also take extra steps to ensure that the elderly have good cognition and understand what they should be doing after they’re discharged. We should write down and print out any specific discharge instructions before they leave the ED.”

Ultimately, results of the study suggest that emergency physicians should use higher scrutiny when managing the elderly who are cared for in the ED. “Based on our results, emergency providers should address cognition and specific abnormal vital signs before patients are discharged,” Dr. Gabayan adds. “At the same time, we need to be especially cautious when we change disposition plans. By making concerted efforts to address these issues, we may be able to reduce the risk of catastrophic events like death or ICU admissions shortly after the elderly are discharged from the ED.”

Readings & Resources (click to view)

Gabayan GZ, Gould MK, Weiss RE, et al. Poor outcomes after emergency department discharge of the elderly: a case-control study. Ann Emerg Med. 2016 Feb 29 [Epub ahead of print]. Available at: http://www.annemergmed.com/article/S0196-0644(16)00008-1/fulltext.

Gabayan GZ, Sun BC, Asch SM, et al. Qualitative factors in patients who die shortly after emergency department discharge. Acad Emerg Med. 2013;20:778-785.

Gabayan GZ, Derose SF, Asch SM, et al. Patterns and predictors of short-term death after emergency department discharge. Ann Emerg Med. 2011;58:551-558.e552.

Gabayan GZ, Sarkisian CA, Liang LJ, et al. Predictors of admission after emergency department discharge in older adults. J Am Geriatr Soc. 2015;63:39-45.

Gabayan GZ, Asch SM, Hsia RY, et al. Factors associated with shortterm bounce-back admissions after emergency department discharge. Ann Emerg Med. 2013;62:136-14

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