Emergency department admissions, older people, functional decline, and length of stay in hospital

Objective: Early identification of patients at risk of a prolonged admission to the hospital may allow targeted management decisions and discharge planning to begin in the emergency department. The aim of this study was to evaluate the effect of recent decline in function, measured in the emergency department, on length of stay (LOS) in the hospital. Methods: A total of 469 patients with a mean age of 79.4 years presenting to the emergency department of a tertiary hospital were comprehensively assessed by a nurse practitioner. The Modified Barthel Index (MBI) was used to measure recent decline in function (MBI‐change, the decline in MBI in the month before the emergency visit). Other measures included recent decline in instrumental activities of daily living (IADL‐change, using the Lawton IADL Scale), Folstein Mini Mental State Examination, Geriatric Depression Scale (GDS), Waterlow Scale, Social Support Instrument (SSI), principal medical diagnosis, living arrangement, care needs, and self‐rated health. Using multivariate survival analysis, the influence of MBI‐change on LOS was modelled in 249 randomly selected patients, and validated in the remaining 220. Results: In total, 327 patients (69.7%) were admitted to the hospital, for a median LOS of 10 days. In the modelling sample, variables significantly associated with LOS included MBI‐change (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.85–0.98), IADL‐change (HR 1.14, 95% CI 1.02–1.28), whether known to the Aged Care Assessment Team (ACAT) (HR 1.65, 95% CI 1.04–2.59) and Waterlow score (HR 0.95, 95% CI 0.90–0.99). MBI‐change (HR 0.94, 95% CI 0.88–0.99) and Waterlow score (HR 0.95, 95% CI 0.91–0.99) were also significant predictors of LOS in the validation sample. Conclusions: Recent decline in function predicts LOS in the hospital, is easy to measure in the emergency department, and may prove useful across the full spectrum of disease. It should be considered when formulating diagnostic and management plans, and when developing funding models.