Implementation of an Emergency Department Observation Unit for Elderly Adults in a University‐Affiliated Hospital in Spain: A 6‐Year Analysis of Data

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A study was conducted in an emergency department (ED) observation unit (EDOU) for elderly adults of a tertiary-care urban hospital in Guadalajara, Spain. In 2011, 91,528 individuals were seen in the ED, 22.4% of whom were aged 65 and older. The EDOU for elderly adults, which opened in January 2005, has six beds (two rooms) and is visited by a geriatrician twice a day. People are admitted because of an acute medical condition or worsening of a chronic disease without signs of extreme severity and when early hospital discharge and geriatric outpatient follow-up may be anticipated. EDOU objectives include providing diagnostic specificity through multidimensional geriatric assessment (evaluation of clinical problems, physical and cognitive status, and social situation) of older adults in the ED, optimizing the use of different outpatient levels of the Geriatrics Service, and avoiding unnecessary hospital admission or discharge planning of frail elderly adults without follow-up care. Individuals are admitted to the unit at the discretion of emergency physicians, following the criteria of aged 75 and older with multiple comorbidities, dementia, or physical impairment with acute illness that can be treated in less than 72 hours. No screening tests were used. If discharge is not possible, the individual is admitted to the geriatric ward. The EDOU is not usually used as support while waiting for a bed on the geriatric ward. After geriatric assessment, the individual receives individualized treatment but with no access to rehabilitation in such a short period of time. Between January 2006 and December 2011, 5,571 individuals aged 75 and older were admitted to the EDOU for elderly adults and had a mean length of stay of 32.2 hours. The mean age of the patients was 87.4. Nursing home residents accounted for 35% of those admitted. Most individuals had moderate to severe physical disability (70%) and mild to moderate cognitive impairment (70%) measured using the Barthel Index and the Geriatric Dementia Scale. Only 6% were totally independent, and 19% were free of cognitive impairment. Mean Barthel Index score was 48.5 ± 33.0. Almost one-third (31.6%) were admitted to the geriatric ward for inpatient care, mostly because of cardiorespiratory episodes that failed to improve with 72 hours of treatment. A summary of the study findings are shown in Table 1. Of the 68.4% of individuals discharged from the EDOU, 32% were referred to the outpatient clinics of the Geriatrics Service, their nursing home or primary care physician (20%), geriatric home care (11%), or consultation with other specialties for further management (6%); 2.8% of individuals discharged from the unit were readmitted for inpatient care within 48 hours and 5.1% within 7 days, figures comparable with short-stay units for younger adults in Spain. In recent years, the number of individuals aged 75 and older in the population assigned to this hospital for health assistance has progressively increased, from 16,156 in 1999 to 22,570 in 2011. However, since the development of the EDOU, the percentage of individuals requiring admission to the geriatric ward stabilized after a period of progressively increasing and was accompanied by a decrease in mean length of hospital stay from 9.9 days in 2006 to 7.6 days in 2011. Other factors may be involved, such as better qualification of nursing home medical staff or easier access to geriatric clinics in case of destabilization of chronic illnesses. In summary, the development and implementation of a geriatric observation unit in the ED for individuals aged 75 and older with a geriatrician on call was effective at preventing admission to the hospital in a large percentage of elderly adults. A decrease in the mean length of hospital stay also occurred. Specialized geriatric assessment in the EDOU provides higher-quality health care, minimizing the deleterious effects of hospitalization in older adults and optimizing the use of resources. The authors thank Mr. Rogelio Hernández Tercero and Mr. Anonio Clemente Alonso from the Health Care Information Service of Hospital Universitario de Guadalajara for their contribution to the study and Marta Pulido, MD, for editing the manuscript and editorial assistance. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Pareja-Sierra: study concept and design, acquisition of subjects and data analysis, interpretation of data, and writing of the manuscript. Hornillos-Calo, Rodríguez-Solís, Sepúlveda-Moya, Bassy-Iza, Martínez-Peromingo, Rodríguez-Couso, Esteban-Dombriz, Jiménez-Jiménez: acquisition of subjects and clinical information. All authors: review and approval of the final draft. Sponsor's Role: None.

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