A Modern‐Day Purgatory: Older Adults in the Emergency Department with Nonoperative Injuries

Abstract

Older adults frequently present to the emergency department (ED) with injuries that do not require operative treatment but are sufficiently severe to make it unsafe for them to return home. These patients typically do not meet criteria for an ‘inpatient’ hospital admission. However, because of the limited reimbursement for observation patients, admitting physicians are often reluctant to accept these patients in to observation. Admission to a skilled nursing or assisted living facility from the ED or rapid access to additional in-home care is also often difficult or impossible. As a result, older patients with non-operative injuries often spend a long time in the ED waiting for an appropriate disposition. We describe the challenges of identifying an appropriate disposition for these patients, the consequences for patients, and some potential solutions to this commonly encountered problem.

Decline in Activities of Daily Living After a Visit to a Canadian Emergency Department for Minor Injuries in Independent Older Adults: Are Frail Older Adults with Cognitive Impairment at Greater Risk?

“…In addition, the effect of some potential confounding variables on ADL decline, such as a change in frailty or cognitive status over time, was not verified. Finally, the results of this study might not be generalizable to settings other than large urban EDs in Canada, where time spent in the ED is generally longer than in U.S. EDs …”

Is Cognitive Function a Concern in Independent Elderly Adults Discharged Home from the Emergency Department in Canada After a Minor Injury?

“…In terms of limitations, the results of this study might not be generalizable to settings other than large urban EDs in Canada, where time spent in the ED is generally longer than in U.S. EDs; 32,33 individuals may be kept in the ED without being hospitalized or admitted for up to approximately 48 hours, whereas in the United States, they would be admitted to the hospital for observation or as an inpatient after 4 hours or discharged home or to an alternate setting. 34 Recent Canadian data indicate that median time spent in the ED is approximately 4.4 hours for nonadmitted ambulatory individuals, with 90% of individuals being discharged within 8 hours. 35 Longer times (median~10 hours) are reported for nonambulatory individuals or those who are eventually admitted.…”

Life after PACE (Program of All‐Inclusive Care for the Elderly)

“…In addition, the stress of injury and hospitalization can result in significant deconditioning in older adults (Krumholz, ). For example, older adults have over 4 million injury‐related ED visits each year, many resulting in significant functional limitations that may prevent a safe return home without additional assistance (Platts‐Mills, Owens, & Mcbride, ). It is also becoming more difficult for older adults to meet hospital admission criteria, which often do not account for cognitive or functional limitations, leading to prolonged ED visits as providers struggle to determine the best disposition for the patient—a “modern‐day purgatory” (Platts‐Mills et al., ).…”

“…For example, older adults have over 4 million injury‐related ED visits each year, many resulting in significant functional limitations that may prevent a safe return home without additional assistance (Platts‐Mills, Owens, & Mcbride, ). It is also becoming more difficult for older adults to meet hospital admission criteria, which often do not account for cognitive or functional limitations, leading to prolonged ED visits as providers struggle to determine the best disposition for the patient—a “modern‐day purgatory” (Platts‐Mills et al., ). If an older adult is “lucky” enough to be admitted to the hospital, deconditioning places them at high risk for adverse events after discharge, the “posthospital syndrome” (Krumholz, ).…”