The Rationale
Older 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 1:00 A.M.?
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 is 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.
H. Ovens
