A Rationale for a “Hold Overnight” Policy for Complex Older Patients
Elderly patients often have non-specific presentations that raise complex medical and psychosocial questions relating to etiology and safe disposition. Falls and changes in behavior, such as confusion, agitation, or wandering, are a few examples. The ED is well resourced to assess possible medical causes rapidly including 24/7 access to imaging, labs and medical consults. If no acute medical problem requiring admission is found though, then what? Deciding on a safe discharge plan often benefits from a multi-disciplinary (“Mu-D”) approach. In our ED that routinely includes OT and PT, social work, a GEM nurse, and a home care coordinator. However, rarely is it feasible to staff a full multi-disciplinary team 24 hours/day. So, what to do if a patient is “cleared” medically at say 1 am?
Discharge home pending Mu-D assessment is risky. There must be a safe interim plan and logistically getting the team together in the home to discuss their assessments/plans is a challenge. Admission is more frequently the approach. However, when this occurs, the assessment becomes less urgent, patients are exposed to the hazards of hospitalization including nosocomial infection, deconditioning, med errors, etc., . . . and patients and families may get too comfortable, creating further barriers to discharge.
Our approach for several years is to hold these patients overnight to have a Mu-D assessment urgently the next morning in the ED. The benefits include the fastest possible completion of the assessment to inform the disposition In our jurisdiction, admission avoidance is a major consideration as we also decrease the risk of patients becoming “ALC” – stuck in hospital waiting for an alternate level of care. Downsides and risks include more clinical handovers and the distress of keeping a patient in the uncomfortable environment of the ED.
To be successful you need;
- A hold over order set (see ours as an example you are free to use);
- A physician group willing to do a careful handover and accept the responsibility to reassess patients and complete forms next day on patients they inherit;
- An ED that committed to making the stay in the ED “senior friendly”;
- A high-functioning Mu-D team that is able to complete these assessments in a timely fashion the next morning.
Our experience is that this approach can be managed safely, be accepted well by patients and families, and lead to a much more precise discharge plan including transfer to other facilities direct from ED. Many admissions are avoided. Anecdotally we have had few if any adverse outcomes.
References and Resources
- Creditor MD. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118: 219-223.
- Sinha SK, Bessman ES, Flomenbaum N, et al. A systematic review and qualitative analysis to inform the development of a new emergency department-based geriatric case management model. Ann Emerg Med. 2011;57: 672-682.
- Brazil K, Bolton C, Ulrichsen D, et al. Substituting home care for hospitalization: the role of a quick response service for the elderly. J Community Health.