Brief ReportEmergency department recidivism in adults older than 65 years treated for fractures☆,☆☆
Introduction
Older adults with fractures present significant challenges to the emergency department (ED) and the US health system as a whole. The number of older adults, 65 years old or older, treated for a fracture in the ED has increased 24% from 2001 to 2008 and continues to rise with the aging population [1]. In contrast to patients with hip fractures who are treated almost exclusively as inpatients, most (50%-70%) older adults with other fractures are treated as outpatients [1], [2]. These patients have increased needs for home health care, subacute rehabilitation, and physical and occupational therapy [3]. A prospective study of 230 older adults with blunt trauma injuries such as fractures, contusions, and sprains found that 40% had functional decline within the first week of discharge from the ED and that 49% required new social services. Patients with extremity fractures had the highest likelihood of requiring new services [4]. A better understanding of the risk factors behind the increased health care needs in this population could help us direct therapy, interventions, and disposition planning.
Both the Society for Academic Emergency Medicine and the American Geriatrics Society recognize the need for identifying risk factors for poor outcomes in older adults and injured older adults in particular [5], [6]. Identifying patients at high risk for poor outcomes after ED discharge could lead to early interventions to improve patient care. One criterion for poor outcomes in the short-term setting is ED recidivism or return to the ED within 72 hours. Although this is not a perfect indicator of patient safety, it does identify a subset of patients who require further care [7], [8]. Older adults are at increased risk for ED recidivism, with an average 72-hour rate of return of 3.2% for all ED patients older than 65 years compared to 0.47% rate for all adults [9]. We hypothesized that the addition of a nonhip fracture would result in increased ED recidivism. Our objectives for this study were to determine the rate of 72-hour returns and any factors associated with an increased likelihood of return for older adults with nonhip fractures.
Section snippets
Study design
This study approved by the institutional review board was a retrospective medical record review designed to identify factors associated with 72-hour return to the ED among older adult patients with fractures.
Study setting and population
Adults at least 65 years old diagnosed with a nonhip extremity or rib fracture and discharged from the ED were included. The study setting was a large, academic hospital with an annual ED census of 120,000 patients. Exclusion criteria included hospital admission, initial treatment at an
Results
Over 12 months, 533 older-adult patients were diagnosed with a rib or a nonhip extremity fracture in the ED, of whom 39.8% (n = 208) were admitted and 60.2% (n = 325) were discharged. In 10 (3%) of these, either the medical records were missing physician notes or the patients were treated first at an outside institution, leaving 315 patients eligible for the study (Table 1). The median age was 77 years (IQR, 69-83), and 77% of patients were women. Most were community-dwelling older adults
Discussion
Adults 65 years and older with fractures deemed safe for discharge from the ED had a 6.3% rate of 72-hour return to the ED and returned mainly for reasons related to the fracture (pain control, cast or splint problems). Although this study was a smaller study focused on patients at a single institution, it is still the largest fracture-specific cohort to our knowledge. Although data from a single institution may limit our reproducibility, they do provide more specific information than national
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Beyond observation: Protocols and capabilities of an Emergency Department Observation Unit
2019, American Journal of Emergency MedicineCitation Excerpt :We did not locate any studies that reported 72-hour return rates for Obs Units, however, Ross et al. studied 14-day return rates for an Obs Unit and observed that many return visits occurred within the first 3 days following discharge [16]. Previously reported 72-hour return rates for the entire ED population range between 1 and 15% depending on the hospital and patient population, which is consistent with our return rate of 5.3% for observation unit patients and comparable to our non-Observation ED patient population (6.2%) [20,21]. This suggests that the unit is providing care that, at least by ED recidivism metrics, is appropriate.
Readmission rates and associated factors following rib cage injury
2019, Journal of Trauma and Acute Care SurgeryHead Trauma from Falling Increases Subsequent Emergency Department Visits More Than Other Fall-Related Injuries in Older Adults
2016, Journal of the American Geriatrics Society
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Prior presentations: none.
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Funding sources/disclosures: Dr Caterino’s work on this project was supported by the National Institute on Aging grant K23AG038351. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the funding agencies. No sponsor had any direct involvement in study design, methods, subject recruitment, data collection, analysis, or manuscript preparation.
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Previously of William Beaumont Hospital, Royal Oak, MI 48073.