Short Attention Span Summary
Caution: ED visits may be hazardous to your health
This was a retrospective review of Medicare claims and death certificates which found that >10,000 people a year in the US die within a week of ED discharge, despite not having a life-threatening discharge diagnosis. Leading causes of death were CAD, MI, and COPD. Busier EDs with higher charges (i.e. doing more stuff) and higher admission rates had lower numbers of patients who died in the week following. Visits for altered mental status, dyspnea, or malaise/fatigue were complaints most closely associated with early death. Lower volume, non-academic EDs that had lower charges and had higher discharge rates had the highest rate of early death. Almost 300 of these early deaths were from narcotic overdose after presentation for a musculoskeletal complaint, which is totally preventable. The authors astutely note, "Policies designed to reduce overuse, whether in the setting of National Health Service budget constraints in the UK or the Affordable Care Act in the US, could exacerbate this problem."
When in doubt, err on the side of admission - even if you get push back from the hospitalist, administrator, or your own government. When people feel bad enough to come to the ED, it often means something is really wrong, even if it's not apparent on a surface level. Also, err on the side of ordering a few more tests when you're not sure, especially in patients who are altered, dyspneic, or have generalized malaise.
BMJ. 2017 Feb 1;356:j239. doi: 10.1136/bmj.j239.
1Department of Emergency Medicine, Harvard Medical School, Boston, MA 02115, USA firstname.lastname@example.org.
2Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA.
3Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
4Department of Emergency Medicine, Harvard Medical School, Boston, MA 02115, USA.
5Department of Economics, Harvard University, Cambridge, MA 02138, USA.
To measure incidence of early death after discharge from emergency departments, and explore potential sources of variation in risk by measurable aspects of hospitals and patients.
Retrospective cohort study.
Claims data from the US Medicare program, covering visits to an emergency department, 2007-12.
Nationally representative 20% sample of Medicare fee for service beneficiaries. As the focus was on generally healthy people living in the community, patients in nursing facilities, aged ≥90, receiving palliative or hospice care, or with a diagnosis of a life limiting illnesses, either during emergency department visits (for example, myocardial infarction) or in the year before (for example, malignancy) were excluded.
MAIN OUTCOME MEASURE:
Death within seven days after discharge from the emergency department, excluding patients transferred or admitted as inpatients.
Among discharged patients, 0.12% (12 375/10 093 678, in the 20% sample over 2007-12) died within seven days, or 10 093 per year nationally. Mean age at death was 69. Leading causes of death on death certificates were atherosclerotic heart disease (13.6%), myocardial infarction (10.3%), and chronic obstructive pulmonary disease (9.6%). Some 2.3% died of narcotic overdose, largely after visits for musculoskeletal problems. Hospitals in the lowest fifth of rates of inpatient admission from the emergency department had the highest rates of early death (0.27%)-3.4 times higher than hospitals in the highest fifth (0.08%)-despite the fact that hospitals with low admission rates served healthier populations, as measured by overall seven day mortality among all comers to the emergency department. Small increases in admission rate were linked to large decreases in risk. In multivariate analysis, emergency departments that saw higher volumes of patients (odds ratio 0.84, 95% confidence interval 0.81 to 0.86) and those with higher charges for visits (0.75, 0.74 to 0.77) had significantly fewer deaths. Certain diagnoses were more common among early deaths compared with other emergency department visits: altered mental status (risk ratio 4.4, 95% confidence interval 3.8 to 5.1), dyspnea (3.1, 2.9 to 3.4), and malaise/fatigue (3.0, 2.9 to 3.7).
Every year, a substantial number of Medicare beneficiaries die soon after discharge from emergency departments, despite no diagnosis of a life limiting illnesses recorded in their claims. Further research is needed to explore whether these deaths were preventable.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
PMID: 28148486 [PubMed - in process]