I work in a major trauma center ED, seeing around 350 patients a day. I don't do thoracotomies very often, and I don't do cricothyroidotomies or hysterotomies. I do some major trauma, but most of my time is spent managing minor illnesses, minor injuries, and the elderly. That is my bread and butter.
I wanted to do ENT when I was younger, and somebody said to me, “If you want to be an ENT surgeon, you have to like taking wax out of people's ears because that's what you do a lot of.” I decided to become an emergency physician, and one of the things you have to love is the elderly.
This is not a sexy topic: There are few gizmos and gadgets, but it is something that should interest us all. Some of it is very tedious: It's about looking at patients' toenails, and seeing things you never thought you would.
Why is that? It's not just because they want them that way. It's because there's a problem, and it's part of looking for clues to help us manage patients who are frail. I want us to think about how big this problem is, how big it is becoming, and what we are doing about it. Hopefully I can stimulate some thought about how we could do this better because we are not doing this well at all.
I have recently been working on data that represent about a million ED visits over a three-year period from Yorkshire, a mixed urban-rural area in the United Kingdom. Some EDs like mine are large; some are smaller and rural. We broke down our patients by age, and patients over 65 represent about a quarter of our visits.
Almost two-thirds of them arrive by ambulance, and we looked at whether these patients needed to come to the ED. An unnecessary visit was defined as a patient who comes to the ED, has no investigations, is prescribed no treatments, is not admitted, and is not referred to any other specialty. The older the patients get, the more necessary is their visit. Around 20 percent of those patients could perhaps be seen and treated elsewhere. This is all about debulking our departments and reducing crowding.
Just more than 50 percent of the over-65s are admitted to the hospital. As many of you know, we have a four-hour target in the United Kingdom: We have to see and treat 95 percent of our patients within four hours of their arrival. We found a huge spike, of course, in the last 20 minutes before we hit four hours, when everybody panics and tries to get patients out of the department. Around 20 percent of those over 65 are moved somewhere in those 20 minutes. This is not good patient care, and it is not satisfactory for any of us. We also know these elderly patients generally spend an hour longer in the ED than their younger counterparts, probably because more of them are admitted, and we suffer from exit block in our ED, so we can't get them out.
We saw that visits were gradually going up over the three-year period we studied. What's most interesting here is that just more than 40 percent of over-65s are actually admitted for a short period, less than 48 hours. I started to think, is this really good? Is there something else we could do to prevent that admission, save some money, and also give the patient a better experience? As patients get older, their problems become much more chronic and difficult to cure. They have circulatory problems, respiratory problems, or cancer. It's difficult for us to manage these patients and actually do something positive for them.
A Cautionary Tale
We had a patient, Mrs. Andrews, who fell in her bathroom on a Friday evening. EMTs brought her to the ED and arranged for a hip x-ray. She didn't have a fracture, but blood and urine tests showed she was dehydrated and possibly had a urinary tract infection. She was moved to the acute medical unit (AMU) because she was getting close to breaching the four-hour target. We put up a drip and gave her antibiotics. On Saturday morning, she was seen by the on-call medical consultant, and before we could look at her mobility, the patient flow team insisted we move her to a medical bed. She was not reviewed again medically until Monday. There is no routine physiotherapy or occupational therapy on weekends, so we couldn't refer her to the home rehabilitation team before then. By Monday, Mrs. Andrews had been on a gurney or in a bed for three nights because she was deemed to be at high risk for a fall, and the nurses had inserted a urinary catheter. She was seen that Monday morning by the physiotherapist, who got her out of bed with the aid of a walker.
Her review team discovered that her blood pressure was dropping when she stood up — postural hypertension, which often leads to falls and faints in older people. We stopped a couple of her cardiac medications to try to resolve this. By Wednesday, she was able to stand with assistance. The physios came to see her, and a plan was made to refer her for ongoing rehabilitation in the local community hospital before going home. There were no community beds, and by the 10th day of her admission, the cardiology ward desperately needed beds for acute cardiac patients, and she was moved to an escalation ward.
After all those moves, Mrs. Andrews had become confused and agitated. She had another fall, sprained her wrist, and required two nurses to transfer her from bed to bed. By day 12 of her admission, the community hospital phoned back saying she had no rehab potential and should have a care package instead. She was referred to social services with a target discharge date for Friday. But the package couldn't be put in place until the following Tuesday. Seven weeks after her discharge from the hospital, Mrs. Andrews had fallen twice more, her memory was worsening, and her husband was stressed, concerned, and exhausted. She ended up being admitted to a nursing home. She never got back to her own home.
We should have more care and support for older people like her outside the hospital, and those services need to respond much sooner to people's needs. But the way we treated her in the hospital and our difficulty getting her back on her feet and home again didn't help. With so many frail older people coming into the hospital, we have to get this stuff right for everyone. Mrs. Andrews had some potential underlying problems, but we certainly did not do her any favors by keeping her in the hospital. And there were several opportunities to take Mrs. Andrews down a different path.
Was the admission avoidable? Falls are common, and most people who fall will fall again, and eventually, some will die. We cannot keep them from falling completely, but we may be able to treat medical problems and make sure they have an environment that's more frail-safe.
Keep the Elderly Home
A number of studies have looked at fall management by ambulance services or other professionals in the community. A study I did trained paramedics in assessing and managing elderly fallers. (Emerg Med J 2009;26:446.) They would go into the home when the patient had fallen, assess them for injury and illness, treat any minor problem, and leave the patient at home.
The study involved nearly 5,000 patients, and it actually reduced ED visits in these patients by 25 percent. One of the things we hadn't anticipated was it actually reduced subsequent hospital admissions by six percent, which was highly significant. This saved money because it saved bed days. More patients didn't die, and we found the service to be safe. These were fairly low-level problems that these elderly patients had, and satisfaction with the service was high.
Comprehensive geriatric assessments for managing the elderly with a multidisciplinary team has been tested in the ward and acute settings but not in the ED. A number of studies have shown that this seems to benefit patients, so outcomes are improved, hospital stays shortened, and complications reduced.
What can we do in the ED to change the journey for that patient? The evidence is mixed when the ED initiates something by discharging the patient to have an assessment in the community, and only two studies showed any benefit. Many of the studies were underpowered and small.
Most of us have observation and assessment wards; we should be using them. The studies that have used them and a comprehensive geriatric assessment have shown some reduction in readmission and revisits of these patients. (J Accid Emerg Med 1997;14:151; Emerg Med J 2003;20:138.) My instinct is that we all need to be taking ownership of this. We need to learn to love these patients and to deal with them because we are available 24/7.
Ditch the Gizmos
I have a light touch with these patients, particularly the very frail, the over-85s. I walk into their rooms and say, “What can I do for this patient?” I look at their toenails, smell them, and look at how clean they are. I look at whether they're coping at home; I talk to them. We don't do that anymore; we just put them through the CT scanner.
Fundamentally for this patient group, I think this is completely wrong. Yet, I have many younger colleagues who just cannot resist using gadgets and gizmos. They put them all on a gurney when they arrive, which we should not do unless they are acutely unwell. Most of these patients should be in a chair and encouraged to mobilize when they can. The longer they lie on a gurney, which is many hours in my department, the more difficult it will be to get them home because they become stiff, dehydrated, weak, and quickly immobile.
Amal Mattu, MD, taught me a great thing. He said, “Most of these patients coming through your door will be dehydrated. You'll do no harm at all by just giving them a liter of fluid.” I routinely do that, and it works brilliantly, particularly if they have a drop when you're measuring their blood pressure. Many junior doctors come to me and say, “Oh, he has a drop. We're doing lying-standing blood pressure and there's a drop so we need to admit him.” I'll say, “Has he had anything to eat and drink? Put him on the observation ward, give him something to eat and drink, even give him some IV fluids, and then let's check it again.” We overtreat these patients.
If the patient has symptoms of a urinary tract infection or signs of sepsis, I will treat him, but I don't give blanket treatment to these patients. Use your assessment areas, buy a bit of time, and think about what you're doing. Do they really need to come into the hospital? I can guarantee you we will not be doing the majority of them any favors.
We also have many patients coming in from care homes who are bed-bound with dementia and advanced disease, with do-not-resuscitate orders. Many of these patients get put into our resuscitation room, and I fundamentally think that is the wrong thing for those patients. They are approaching the end of their lives, and we need to respect and manage that. We need to work with the family and the patient to manage that situation.
I do not believe that these patients should be over-investigated and over-resuscitated. We need to take responsibility with patients for that. Put yourself in their shoes, and you may actually say we have reached a ceiling for how far we're going to go with the treatment. Communication is key here. We will be clogging up our departments unnecessarily with patients who are being over-investigated and over-treated when they have simply reached the end of the road.