Elderly patients with non-specific complaints at the emergency department have a high risk for admission and 30-days mortality.

BACKGROUND: Older adults have complex medical needs that causes increased use of resources at the emergency department (ED). The prevalence of non-specific complaint (NSC) as a chief-complaint in the ED is common among older adults and is not prioritized even though possibly having worse clinical outcome. The objective was to study hospital admission and mortality for older adults visiting the ED with NSC compared to specific complaints such as dyspnea, chest pain and abdominal pain. METHODS: A retrospective observational study of older adults visiting the ED with NSC and specific complaints; dyspnea, chest pain and abdominal pain was performed. Chief-complaint were collected from electronic medical records. Fatigue, confusion, non-specific complaints, generalized weakness and risk of falling were defined as non-specific complaint (NSC) when registered as chief-complaint at the ED. Admission rate and 30-days mortality were the primary outcomes. RESULTS: A total of 4927 patients were included in the study based on chief-complaint; patients with chest pain 1599 (32%), dyspnea 1343 (27%), abdominal pain 1460 (30%) and NSC 525 (11%). Patients with dyspnea and NSC had the highest hospital admission rate 79% vs 70% compared to patients with chest pain (63%) and abdominal pain (61%) (p = < 0.001). Patients with NSC had a mean LOS 4.7 h at the ED which was significantly higher compared to chest pain, dyspnea and abdominal pain. Mean bed-days for the whole population was 4.2 days compared to patients with NSC who had a mean LOS of 5.6 days. NSC and dyspnea were both associated with the highest 30-day mortality. CONCLUSION: Older patients who present with NSC at the ED are associated with a high risk for admission and 30-days mortality. In addition, patients with NSC have a longer LOS at the ED, a high admission rate and the highest number of bed-days once admitted. This study indicates that ED staff should be more vigilant when an elderly patient presents with NSC at the ED. Further studies and guidelines are needed to improve the management of these individuals.

Primary triage nurses do not divert patients away from the emergency department at times of high in-hospital bed occupancy - a retrospective cohort study.

BACKGROUND: Emergency department (ED) overcrowding is frequently described in terms of input- throughput and output. In order to reduce ED input, a concept called primary triage has been introduced in several Swedish EDs. In short, primary triage means that a nurse separately evaluates patients who present in the Emergency Department (ED) and either refers them to primary care or discharges them home, if their complaints are perceived as being of low acuity. The aim of the present study is to elucidate whether high levels of in-hospital bed occupancy are associated with decreased permeability in primary triage. The appropriateness of discharges from primary triage is assessed by 72-h revisits to the ED. METHODS: The study is a retrospective cohort study on administrative data from the ED at a 420-bed hospital in southern Sweden from 2011-2012. In addition to crude comparisons of proportions experiencing each outcome across strata of in-hospital bed occupancy, multivariate models are constructed in order to adjust for age, sex and other factors. RESULTS: A total of 37,129 visits to primary triage were included in the study. 53.4 % of these were admitted to the ED. Among the cases referred to another level of care, 8.8 % made an unplanned revisit to the ED within 72 h. The permeability of primary triage was not decreased at higher levels of in-hospital bed occupancy. Rather, the permeability was slightly higher at occupancy of 100-105 % compared to <95 % (OR 1.09 95 % CI 1.02-1.16). No significant association between in-hospital bed occupancy and the probability of 72-h revisits was observed. CONCLUSIONS: The absence of a decreased permeability of primary triage at times of high in-hospital bed occupancy is reassuring, as the opposite would have implied that patients might be denied entry not only to the hospital, but also to the ED, when in-hospital beds are scarce.

The probability of readmission within 30 days of hospital discharge is positively associated with inpatient bed occupancy at discharge--a retrospective cohort study.

BACKGROUND: Previous work has suggested that given a hospital's need to admit more patients from the emergency department (ED), high inpatient bed occupancy may encourage premature hospital discharges that favor the hospital's need for beds over patients' medical interests. We argue that the effects of such action would be measurable as a greater proportion of unplanned hospital readmissions among patients discharged when the hospital was full than when not. In response, the present study tested this hypothesis by investigating the association between inpatient bed occupancy at the time of hospital discharge and the 30-day readmission rate. METHODS: The sample included all inpatient admissions from the ED at a 420-bed emergency hospital in southern Sweden during 2011-2012 that resulted in discharge before 1 December 2012. The share of unplanned readmissions within 30 days was computed for levels of inpatient bed occupancy of <95%, 95-100%, 100-105% and >105% at the hour of discharge. A binary logistic regression model was constructed to adjust for age, time of discharge, and other factors that could affect the outcome. RESULTS: In all, 32,811 visits were included in the study, 9.9% of which resulted in an unplanned readmission within 30 days of discharge. The proportion of readmissions was 9.0% for occupancy levels of <95% at the patient's discharge, 10.2% for 95-100% occupancy, 10.8% for 100-105% occupancy, and 10.5% for >105% occupancy (p = 0.0001). Results from the multivariate models show that the OR (95% CI) of readmission was 1.11 (1.01-1.22) for patients discharged at 95-100% occupancy, 1.17 (1.06-1.29) at 100-105% occupancy, and 1.15 (0.99-1.34) at >105% occupancy. CONCLUSIONS: Results indicate that patients discharged from inpatient wards at times of high inpatient bed occupancy experience an increased risk of unplanned readmission within 30 days of discharge.