Mortality Associated With Emergency Department Boarding Exposure: Are There Differences Between Patients Admitted to ICU and Non-ICU Settings?

BACKGROUND: Emergency Department (ED) boarding threatens patient safety. It is unclear whether boarding differentially affects patients admitted to intensive care units (ICUs) versus non-ICU settings. RESEARCH DESIGN AND SUBJECTS: We performed a 2-hospital, 18-month, cross-sectional, observational, descriptive study of adult patients admitted from the ED. We used Kaplan-Meier estimation and Cox Proportional Hazards regression to describe differences in boarding time among patients who died during hospitalization versus those who survived, controlling for covariates that could affect mortality risk or boarding exposure, and separately evaluating patients admitted to ICUs versus non-ICU settings. MEASURES: We extracted age, race, sex, time variables, admission unit, hospital disposition, and Elixhauser comorbidity measures and calculated boarding time for each admitted patient. RESULTS: Among 39,781 admissions from the EDs (21.3% to ICUs), non-ICU patients who died in-hospital had a 1.2-fold risk (95% confidence interval, 1.03-1.36; P=0.016) of having experienced longer boarding times than survivors, accounting for covariates. We did not observe a difference among patients admitted to ICUs. CONCLUSIONS: Among non-ICU patients, those who died during hospitalization were more likely to have had incrementally longer boarding exposure than those who survived. This difference was not observed for ICU patients. Boarding risk mitigation strategies focused on ICU patients may have accounted for this difference, but we caution against interpreting that boarding can be safe. Segmentation by patients admitted to ICU versus non-ICU settings in boarding research may be valuable in ensuring that the safety of both groups is considered in hospital flow and boarding care improvements.

Cost comparison between home telemonitoring and usual care of older adults: a randomized trial (Tele-ERA).

BACKGROUND: From 1992 to 2008, older adults in the United States incurred more healthcare expense per capita than any other age group. Home telemonitoring has emerged as a potential solution to reduce these costs, but evidence is mixed. The primary aim of the study was to evaluate whether the mean difference in total direct medical cost consequence between older adults receiving additional home telemonitoring care (TELE) (n=102) and those receiving usual medical care (UC) (n=103) were significant. Inpatient, outpatient, emergency department, decedents, survivors, and 30-day readmission costs were evaluated as secondary aim. MATERIALS AND METHODS: Multivariate generalized linear models (GLMs) and parametric bootstrapping method were used to model cost and to determine significance of the cost differences. We also compared the differences in arithmetic mean costs. RESULTS: From the conditional GLMs, the estimated mean cost differences (TELE versus UC) for total, inpatient, outpatient, and ED were -$9,537 (p=0.068), -$8,482 (p =0.098), -$1,160 (p=0.177), and $106 (p=0.619), respectively. Mean postenrollment cost was 11% lower than the prior year for TELE versus 22% higher for UC. The ratio of mean cost for decedents to survivors was 2.1:1 (TELE) versus 12.7:1 (UC). CONCLUSIONS: There were no significant differences in the mean total cost between the two treatment groups. The TELE group had less variability in cost of care, lower decedents to survivors cost ratio, and lower total 30-day readmission cost than the UC group.

Effects of home telemonitoring on transitions between frailty states and death for older adults: a randomized controlled trial.

BACKGROUND: Two primary objectives when caring for older adults are to slow the decline to a worsened frailty state and to prevent disability. Telemedicine may be one method of improving care in this population. We conducted a secondary analysis of the Tele-ERA study to evaluate the effect of home telemonitoring in reducing the rate of deterioration into a frailty state and death in older adults with comorbid health problems. METHODS: This trial involved 205 adults over the age of 60 years with a high risk of hospitalization and emergency department visits. For 12 months, the intervention group received usual medical care and telemonitoring case management, and the control group received usual care alone. The primary outcome was frailty, which was based on five criteria, ie, weight loss, weakness, exhaustion, low activity, and slow gait speed. Participants were classified as frail if they met three or more criteria; prefrail if they met 1-2 criteria; and not frail if they met no criteria. Both groups were assessed for frailty at baseline, and at 6 and 12 months. Frailty transition analyses were performed using a multiple logistic regression method. Kaplan-Meier and Cox proportional hazards methods were used to evaluate each frailty criteria for mortality and to compute unadjusted hazard ratios associated with being telemonitored, respectively. A retrospective power analysis was computed. RESULTS: During the first 6 months, 19 (25%) telemonitoring participants declined in frailty status or died, compared with 17 (19%) in usual care (odds ratio 1.41, 95% confidence interval [CI] 0.65-3.06, P = 0.38). In the subsequent 6 months, there was no transition to a frailty state, but seven (7%) participants from the telemonitoring and one (1%) from usual care group died (odds ratio 5.94, 95% CI 0.52-68.48, P = 0.15). Gait speed (hazards ratio 3.49, 95% CI 1.42-8.58) and low activity (hazards ratio 3.10, 95% CI 1.25-7.71) were shown to predict mortality. CONCLUSION: This study did not provide sufficient evidence to show that the telemonitoring group did better than usual care in reducing the decline of frailty states and death. Transitions occurred primarily in the first 6 months.

A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits.

BACKGROUND: Efficiently caring for frail older adults will become an increasingly important part of health care reform;telemonitoring within homes may be an answer to improve outcomes. This study sought to assess differences in hospitalizations and emergency department (ED) visits among older adults using telemonitoring vs usual care. METHODS: A randomized controlled trial was performed among adults older than 60 years at high risk for rehospitalization. Participants were randomized to telemonitoring (with daily input) or to patient-driven usual care. Telemonitoring was accomplished by daily biometrics,symptom reporting, and videoconference. The primary outcome was a composite end point of hospitalizations and ED visits in the 12 months following enrollment. Secondary end points included hospitalizations,ED visits, and total hospital days. Intent-to-treat analysis was performed. RESULTS: Two hundred five participants were enrolled,with a mean age of 80.3 years. The primary outcome of hospitalizations and ED visits did not differ between the telemonitoring group (63.7%) and the usual care group(57.3%) (P=.35). No differences were observed in secondary end points, including hospitalizations, ED visits,and total hospital days. No significant group differences in hospitalizations and ED visits were found between the pre-enrollment period vs the post-enrollment period. Mortality was higher in the telemonitoring group (14.7%)than in the usual care group (3.9%) (P=.008). CONCLUSIONS: Among older patients, telemonitoring did not result in fewer hospitalizations or ED visits. Secondary outcomes demonstrated no significant differences between the telemonitoring group and the usual care group.The cause of greater mortality in the telemonitoring group is unknown.