The Association between Emergency Department Length of Stay and In-Hospital Mortality in Older Patients Using Machine Learning: An Observational Cohort Study.

The association between emergency department (ED) length of stay (EDLOS) with in-hospital mortality (IHM) in older patients remains unclear. This retrospective study aims to delineate the relationship between EDLOS and IHM in elderly patients. From the ED patients (n = 383,586) who visited an urban academic tertiary care medical center from January 2010 to December 2016, 78,478 older patients (age ≥60 years) were identified and stratified into three age subgroups: 60-74 (early elderly), 75-89 (late elderly), and ≥90 years (longevous elderly). We applied multiple machine learning approaches to identify the risk correlation trends between EDLOS and IHM, as well as boarding time (BT) and IHM. The incidence of IHM increased with age: 60-74 (2.7%), 75-89 (4.5%), and ≥90 years (6.3%). The best area under the receiver operating characteristic curve was obtained by Light Gradient Boosting Machine model for age groups 60-74, 75-89, and ≥90 years, which were 0.892 (95% CI, 0.870-0.916), 0.886 (95% CI, 0.861-0.911), and 0.838 (95% CI, 0.782-0.887), respectively. Our study showed that EDLOS and BT were statistically correlated with IHM (p < 0.001), and a significantly higher risk of IHM was found in low EDLOS and high BT. The flagged rate of quality assurance issues was higher in lower EDLOS ≤1 h (9.96%) vs. higher EDLOS 7 h

Length-of-Stay in the Emergency Department and In-Hospital Mortality: A Systematic Review and Meta-Analysis.

The effect of emergency department (ED) length of stay (EDLOS) on in-hospital mortality (IHM) remains unclear. The aim of this systematic review and meta-analysis was to determine the association between EDLOS and IHM. We searched the PubMed, Medline, Embase, Web of Science, Cochrane Controlled Register of Trials, CINAHL, PsycInfo, and Scopus databases from their inception until 14−15 January 2022. We included studies reporting the association between EDLOS and IHM. A total of 11,337 references were identified, and 52 studies (total of 1,718,518 ED patients) were included in the systematic review and 33 in the meta-analysis. A statistically significant association between EDLOS and IHM was observed for EDLOS over 24 h in patients admitted to an intensive care unit (ICU) (OR = 1.396, 95% confidence interval [CI]: 1.147 to 1.701; p < 0.001, I2 = 0%) and for low EDLOS in non-ICU-admitted patients (OR = 0.583, 95% CI: 0.453 to 0.745; p < 0.001, I2 = 0%). No associations were detected for the other cut-offs. Our findings suggest that there is an association between IHM low EDLOS and EDLOS exceeding 24 h and IHM. Long stays in the ED should not be allowed and special attention should be given to patients admitted after a short stay in the ED.

Purchasing or providing nursing home care: can quality of care data provide guidance.

OBJECTIVES: To examine whether quality of care differed for veterans in Department of Veterans Affairs (VA) nursing homes and those on contract in community nursing homes, and whether the VA was contracting with nursing homes providing better quality of care than other nursing homes. DESIGN: Observational study using administrative databases from 1997 to 1999. SETTING: Ten VA and 650 community nursing homes in New York state. PARTICIPANTS: Four thousand seven hundred sixty-three veteran and 195,438 nonveteran residents of these nursing homes. MEASUREMENTS: Risk-adjusted rates of pressure ulcer development, functional decline, behavioral decline, and mortality. RESULTS: Veterans in VA nursing homes were significantly (P< .05) less likely to develop a pressure ulcer (odds ratio (OR)=0.63) but more likely to experience functional decline (OR=1.6) than veterans in community nursing homes. Residents of community nursing homes with VA contracts were significantly (P< .05) less likely to develop a pressure ulcer (OR=0.91) but more likely to die than residents in noncontract homes. Few nursing homes were consistently among the best or worst performers on all measures; only seven of 650 nursing homes were in the top or bottom decile and 34 in the top or bottom quartile for each measure. CONCLUSION: Large purchasers and providers of nursing home care such as the VA are unlikely to find information on quality of care useful in making decisions on whether they should "make" or "buy" care. Nursing homes performing well on one quality measure may perform poorly on another, and it is difficult to identify nursing homes that are consistently among the best or worst. Other consumers may encounter similar difficulties when using data on nursing home quality.

Patient safety in geriatrics: a call for action.

Patient safety has become a major public health concern following the publication of the landmark report, To Err Is Human, by the Institute of Medicine in 1999. This report, along with a subsequent report, Crossing the Quality Chasm, recommended the design of a safer health care system by integrating well-established safety methods to avert medical errors. However, neither patient safety report specifically addressed the implications of safety for elderly patients. This article examines those implications by describing the association between aging and medical errors, identifying geriatric syndromes as medical errors, and focusing on six recommendations that will improve the safety of geriatric care. These six recommendations include the detection and reporting of geriatric syndromes, identifying system failures when geriatric syndromes occur, establishing dedicated geriatric units, improving the continuity of care, reducing adverse drug events, and improving geriatric training programs.