Geriatric patient emergency visits. Part I: Comparison of visits by geriatric and younger patients.

OBJECTIVES: To describe emergency department use by the elderly, to define problems associated with emergency care of the elderly, and to compare these results with those for younger adult patients. DESIGN: Retrospective, controlled chart review. SETTING: Six geographically distinct US hospital EDs. PARTICIPANTS: From each site, a stratified sample (approximately 7:3) of elderly (65 years or older) and nonelderly (21 to 64 years old) control patients treated during the same time period was used. METHODS: Standardized review of ED records and billing charges. Comparisons of elderly and control patient groups using chi 2 analysis and Mann-Whitney U test (alpha = 0.05). RESULTS: Four hundred eighteen elderly patients and 175 nonelderly controls were entered into the study. The elderly were more likely to arrive by ambulance (35% versus 11%; P less than .00001). More elderly than controls presented with conditions of either high or intermediate urgency (78% versus 61%; P less than .0003). The elderly more frequently presented with comorbid diseases (94% versus 63%; P less than .00001). Other findings for the elderly included a longer mean stay in the ED (185 versus 155 minutes; P less than .003), higher laboratory (78% versus 53%; P less than .00001) and radiology (77% versus 52%; P less than .00001) test rates, higher mean overall care charges ($471 versus $344; P less than .00001), and an admission rate (47% versus 19%; P less than .00001) twice that of younger adults. CONCLUSION: Resource use and charges associated with emergency care are higher for the elderly than for younger patients. Increases in emergency resources and personnel or improvement in efficiency will be needed to maintain emergency care at present levels as the US population continues to grow and age.

Geriatric patient emergency visits. Part II: Perceptions of visits by geriatric and younger patients.

OBJECTIVES: To compare group perceptions of reasons for emergency department care, ED use patterns, and the effect of illness on self-care ability for elderly and younger adult patients. DESIGN: Patient survey. SETTING: Six geographically distinct US hospital EDs. PARTICIPANTS: From each site, a stratified sample (approximately 7:3) of elderly (65 years and older) and nonelderly (21 to 64 years old) control ED patients treated during the same time period was contacted. METHODS: Three hundred ninety-nine elderly patients and 172 adult controls were interviewed using a structured survey instrument. Groups were compared using chi 2 analysis and the Mann-Whitney U test. RESULTS: Both the elderly and the control patients (49% versus 38%) commonly stated that the most important reason for coming to the ED was because they were "too sick to wait for an office visit." Of patients with a regular physician, both groups often were referred to the ED by their primary care provider (35% versus 26%). While the elderly had more visits to their primary care provider (3.3 versus 2.9 visits; P less than .00001), there was no difference in the number of ED visits (1.5 versus 1.6 visits) during the preceding six months. Of those released from the ED, more elderly noted deterioration in their ability to care for themselves as a result of their illness (21% versus 11%; P less than .03). CONCLUSION: The elderly use the ED for reasons similar to those for younger adults. Often they feel too ill to wait for an office visit or are referred in by their primary care provider. Elderly patients more commonly have difficulty with self care after release home, and emergency physicians must plan accordingly.

Efficacy of the stat serum electrolyte panel in the management of older emergency patients.

The serum electrolyte panel (SEP) is commonly ordered in the workup of the emergency department (ED) patient. This study was done: 1) to evaluate the efficacy of the SEP in terms of the identification of clinically significant abnormals (yield) and the impact on therapeutic plan (impact); 2) to evaluate the reasons that the test was ordered; and 3) to compare the expected and realized contributions of the test to patient care. Pretest and posttest questionnaires were administered to physicians managing 800 ED patients greater than or equal to 55 years old for whom SEPs were ordered. The yield of significant abnormals was 16%. Fluid and electrolyte treatment plans were modified after the SEP results became known in 35% of cases. This modification was associated with a normal SEP 48% of the time. Both the yield and the impact of the SEP were related to the reason that the test was ordered. The most common reason given was "to look for an unexpected abnormality" (50%). Physicians' expectations for the contribution of the SEP to patient care decisions were greater than the contributions realized after the results were known. However, in 115 cases, the test contributed more than expected. Physicians predicted that 13% of the tests would contribute nothing to patient care. After the results were known, they felt that 38% had made no contribution. Physicians tend to overestimate the potential impact of the SEP but are occasionally surprised by a result that contributes more than expected. Thus, there is considerable pretest uncertainty about treatment decisions and normal results appear to have a substantial impact.

Prediction of electrolyte abnormalities in elderly emergency patients.

STUDY OBJECTIVES: To evaluate the operating characteristics of a previously published decision rule (Lowe's criteria) for the ordering of the stat serum electrolyte panel (SEP) and to identify features from the history and physical examination that are predictive for clinically significant electrolyte abnormalities (CSEA) in older emergency patients. DESIGN: A cross-sectional study using a physician questionnaire, record review, and telephone follow-up. SETTING: An urban, university hospital emergency department with approximately 70,000 patient visits a year. TYPE OF PARTICIPANTS: A convenience sample of patients 55 years of age or older who presented for care for any reason were identified by a research associate stationed in the ED. INTERVENTIONS: Physicians managing 1,766 patients were interviewed to determine the presence or absence of 20 dichotomous clinical variables, ten of which constitute Lowe's criteria set. All patients were followed by chart review and/or telephone interview. MEASUREMENTS AND MAIN RESULTS: The determination of clinical significance was made on record review using pre-established guidelines. The SEP was ordered on 800 of the patients on the index visit. The yield of CSEA in this group was 16%. Lowe's criteria operated with a sensitivity of 0.95 (95% confidence intervals, 0.89-0.98) and a specificity of 0.10 (95% confidence intervals, 0.07-0.12) for predicting CSEAs in this population. Logistic regression analysis showed that impaired ability to communicate, acute seizures, vomiting, and prior abnormal electrolytes were independent predictors for CSEA. CONCLUSION: Lowe's criteria showed useful sensitivity but poor specificity in this population. The criteria may be used to encourage selective test ordering by physicians when a low pretest probability for CSEA exists and as part of an algorithm for emergency nurses who order tests to expedite patient care.

The impact of a rapid screen for streptococcal pharyngitis on clinical decision making in the emergency department.

The impact of a rapid streptococcal screening test (RSS) on clinical decision making in the management of patients with acute pharyngitis was evaluated. Physicians managing 95 ambulatory patients with the complaint of sore throat were asked to estimate the probability of group A beta-hemolytic streptococcal pharyngitis (GRABS) in each patient and whether they intended to treat with antibiotics both before and after the results of the RSS were known. Simultaneous throat cultures were obtained for 80 patients at the discretion of the treating physicians. Regression analysis revealed that the RSS result was an important independent predictor for the posttest decision to treat with antibiotics and for the estimated probability of disease. The mean absolute log-likelihood ratio was used to quantify the effect of the RSS on diagnostic certainty; a greater contribution to diagnostic certainty occurred when the RSS was positive. Physicians would have prescribed an antibiotic 49 times without the benefit of the RSS and prescribed an antibiotic 48 times given the RSS result. Without the RSS, the treatment decision contradicted the throat culture result in 25 cases. With the RSS, this occurred in 26 cases. The RSS, while influencing decision making, especially when positive, did not decrease the use of antibiotics.

Decision rules and clinical prediction of pneumonia: evaluation of low-yield criteria.

Prediction rules have been recommended for guiding the ordering of diagnostic tests. Such rules can be used to define low-yield criteria (LYC) for the purpose of identifying patients with an extremely low probability of disease and hence discouraging test ordering by the physician on patients meeting LYC. In this study, community hospital emergency department populations of adults (n = 255) and children (n = 78) were evaluated prospectively for the presence of predictive clinical parameters and the physician's estimate of pneumonia prior to obtaining a chest film. We developed LYC and analyzed published LYC for obtaining chest films on patients considered at risk for pneumonia by means of logistic regression, receiver operating characteristics curve, and negative predictive value analyses. We were unable to derive or validate clinically useful LYC to improve on the seasoned clinician's probability estimate of pneumonia. We discuss the inherent limitations in the development and application of LYC that must be understood by those who seek to limit the ordering of chest films by the application of guidelines developed from decision rules.