This study provides original information on current ED use in the elderly population and highlights the growing importance of older patients in this health care setting.
A unique contribution of the current study is the provision of specific information about ED use among the oldest-old segment of the elderly population aged over 85 years. The volume of ED visits attributed to this population group is substantial, both overall and among the 65+ age groups where it accounts for a quarter of ED visits. Given the sharp increase in this specific segment of the elderly population expected in the next 20 years, the current aging of the elderly ED population is likely to show further expansion.
Besides the demographic expansion of the population aged 85+ y, this evolution also results from an increased incidence rate of ED use among this population over the timeframe covered by this study, a trend that was further confirmed in 2011 (data not shown). According to our estimated incidence rates for ED visits, inhabitants aged 85+ y were twice as likely to visit ED as inhabitants aged 65-84 y. This trend may reflect the chronological trend of disabled elderly persons to remain at home for longer rather than to be institutionalized. Alternatively, overuse for non-urgent conditions is sometimes mentioned to explain increased ED use in older persons [13, 14]. However, the results from this study do not support this hypothesis, as there was no indication of any increased inappropriate use for non-urgent conditions or high readmission rates in the study population. Rather, there was a high proportion of patients in triage levels 1 and 2, i.e. requiring care within 15 minutes, a finding likely explained by the selective reorientation of some patients from triage levels 4 and 5 to the outpatient consultation service when felt appropriate.
Interestingly, incidence rates for ED use observed in this study were lower than those reported in previous studies (173 and 387/1,000 inhabitants aged 65-84 y and 85+ y, respectively, in this study vs. 450 and 820/1,000) [2, 15, 16]. The high density of primary care providers in Lausanne, with free access provided by the universal insurance coverage, as well as the good network of easily accessible home care services, may explain these lower figures observed in the current study. Nevertheless, these differences are unlikely to buffer the ongoing and future increase in the oldest-old ED population. Therefore, results from the current study further emphasize the need for ED staff to continuously adapt their process of care and acquire specific geriatric skills.
The current study expands previous findings that showed higher resource utilization and poorer outcomes in patients aged 65+ y compared to younger patients [4, 6]. To our knowledge, this study is indeed the first to report the persistence of an age gradient in ED use among patients aged 65+ years. Moreover, this study extends our knowledge in highlighting diverging trends between youngest- and oldest-old patients over time in hospital admission and length of ED stay. Results show that, once presenting to the ED, oldest-olds patients were more likely to be admitted to the hospital than younger ones, a difference that increased over time from 2005 to 2010. Differences in hospital admission rates are essentially due to a decreased rate for patients aged 65-84 y, whereas this rate remained stable over time among those aged 85+ y. Likely, youngest patients may have benefited more from the shift from previously in-hospital activities and interventions to outpatient services. Further investigations are required to confirm this explanation. Of note, because of the overall aging of the population, despite the decreased admission rate observed in patients aged 65-84 y, the absolute number of admissions in this age group actually increased.
Similarly, this study provides original information on the chronologic trends in ED length of stay. Previous studies described longer ED stays for patients 65+ y when compared to younger patients [6, 17–19]. The current study adds to these observations in showing that both age groups were significantly affected over time, but in opposite directions: while ED length of stay shortened in younger patients from 2005 to 2010, it lengthened in older ones. Hypotheses proposed to explain the differences observed between younger and overall 65+ ED users are likely to apply in the oldest-old age group. Firstly, medical evaluation of oldest-old patients is more complex and time-consuming [6, 17]. Secondly, the lack of available hospital beds downstream may prolong ED stay . In our study, the significant drop in length of ED stay observed in patients aged 65-84 y, combined with the decrease in their hospital admission rates after ED stay, may support this hypothesis. Thirdly, hospital beds are traditionally freed at the end of the afternoon, whereas about one half of older patients are admitted to ED between early morning and early afternoon . Finally, discharges of oldest-old patients to their home or other health institutions require thorough and time-consuming coordination to ensure adequate transitions.
Nevertheless, attention should be paid to the evolving gap between both age groups with respect to length of ED stay over time. This trend may reflect an emerging mismatch between the services offered by ED units and the complex needs of geriatric patients [16, 22, 23]. Furthermore, ED structures may be deleterious for these patients when, for instance, limited access to natural light promotes delirium in cognitively impaired patients and a cluttered environment may represent a fall hazard .
ED ward managers should bear in mind that the ongoing increase in ED geriatric patient numbers will lead to an aging of their patient mix. Multimorbidity, functional, sensory and cognitive impairments will become prevailing issues, resulting in more heterogeneous care needs. These changes will have serious consequences on the organization and working procedures of ED teams, requiring urgent modification of the training curricula and care delivery process [16, 25].
Only few studies have been conducted to optimize care provided in the ED to oldest-old patients. For instance, comprehensive geriatric assessment and management was shown in some studies to improve health outcome and decrease readmission in older ED patients discharged to their home [26–30]. Additional studies also investigated the benefits from best practices implementation within the ED to better meet the needs of the oldest-old patients with mixed results . However, these studies focused mainly on health outcomes and incidence of specific geriatric conditions such as delirium or falls, rather than ED length of stay.
Our study presents several limitations. Firstly, this work was based on administrative databases that do not contain information on morbidity or investigations performed during the ED stay. Secondly, data are reported from a single institution and generalization is, as always, questionable. For instance, the higher proportion of high priority patients might result from local practice to re-orient some lowest priority patients to the outpatient clinic. However, trends observed in this study are much more likely to be related to demographic and epidemiological changes rather than the hospital’s practices and environment. Thirdly, as readmission rates were purposely calculated for each year separately, ED returns occurring in a different year than the year of first ED admission were missed, leading to a slight underestimation of the readmission rate.