Article, Orthopedics

Emergency department recidivism in adults older than 65 years treated for fractures

a b s t r a c t

Objectives: Fractures in older adults are a commonly diagnosed injury in the emergency department (ED). We performed a retrospective medical record review to determine the rate of return to the same ED within 72 hours (returns) and the risk factors associated with returning.

Methods: A retrospective medical record review of patients at least 65 years old discharged from a large, academic ED with a new diagnosis of upper extremity, lower extremity, or rib fractures was performed. Risk factors analyzed included demographic data, type of fracture, analgesic prescriptions, assistive devices provided, other concurrent injuries, and comorbidities (Charlson Comorbidity Index). Our primary outcome was return to the ED within 72 hours.

Results: Three hundred fifteen patients qualified. Most fractures were in the upper extremity (64% [95% confidence interval {CI}, 58%-69%]). Twenty patients (6.3% [95% CI, 3.9%-9.6%]) returned within 72 hours. Most returns (15/20, 75%) were for reasons associated with the fracture itself, such as cast problems and inadequate pain control. Only 3 (b 1% of all patients) patients returned for cardiac etiologies. Patients with distal forearm fractures had higher return rates (10.7% vs 4.5%, P = .03), and most commonly returned for cast or splint problems. Age, sex, other injuries, assistive devices, and Charlson Comorbidity Index score (median, 1 [interquartile range, 1-2] for both groups) did not predict 72-hour returns.

Conclusion: Older adults with distal forearm fractures may have more unscheduled health care usage in the first 3 days after fracture diagnosis than older adults with other fracture types. Overall, revisits for cardiac reasons or Repeat falls were rare (b 1%).

(C) 2014

Introduction

Older adults with fractures present significant challenges to the emergency department (ED) and the US health system as a whole. The number of older adults, 65 years old or older, treated for a fracture in the ED has increased 24% from 2001 to 2008 and continues to rise with the aging population [1]. In contrast to patients with Hip fractures who are treated almost exclusively as inpatients, most (50%- 70%) older adults with other fractures are treated as outpatients [1,2]. These patients have increased needs for home health care, subacute rehabilitation, and physical and occupational therapy [3]. A prospective study of 230 older adults with blunt trauma injuries such as fractures,

? Prior presentations: none.

?? Funding sources/disclosures: Dr Caterino’s work on this project was supported by the National Institute on Aging grant K23AG038351. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the funding agencies. No sponsor had any direct involvement in study design, methods, subject recruitment, data collection, analysis, or manuscript preparation.

* Corresponding author. Department of Emergency Medicine, Ohio State University, Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210. Fax: +1 614 293 3124.

E-mail address: [email protected] (L.T. Southerland).

1 Previously of William Beaumont Hospital, Royal Oak, MI 48073.

contusions, and sprains found that 40% had functional decline within the first week of discharge from the ED and that 49% required new social services. Patients with extremity fractures had the highest likelihood of requiring new services [4]. A better understanding of the risk factors behind the increased Health care needs in this population could help us direct therapy, interventions, and disposition planning.

Both the Society for Academic Emergency Medicine and the American Geriatrics Society recognize the need for identifying risk factors for poor outcomes in older adults and injured older adults in particular [5,6]. Identifying patients at high risk for poor outcomes after ED discharge could lead to early interventions to improve patient care. One criterion for poor outcomes in the short-term setting is ED recidivism or return to the ED within 72 hours. Although this is not a perfect indicator of patient safety, it does identify a subset of patients who require further care [7,8]. Older adults are at increased risk for ED recidivism, with an average 72-hour rate of return of 3.2% for all ED patients older than 65 years compared to 0.47% rate for all adults [9]. We hypothesized that the addition of a nonhip fracture would result in increased ED recidivism. Our objectives for this study were to determine the rate of 72-hour returns and any factors associated with an increased likelihood of return for older adults with nonHip fractures.

http://dx.doi.org/10.1016/j.ajem.2014.05.005

0735-6757/(C) 2014

1090 L.T. Southerland et al. / American Journal of Emergency Medicine 32 (2014) 10891092

Methods

Study design

This study approved by the institutional review board was a retrospective medical record review designed to identify factors associated with 72-hour return to the ED among older adult patients with fractures.

Study setting and population

Adults at least 65 years old diagnosed with a nonhip extremity or rib fracture and discharged from the ED were included. The study setting was a large, academic hospital with an annual ED census of 120,000 patients. Exclusion criteria included hospital admission, initial treatment at an outside facility, or incomplete ED medical record (defined as N 2 major data points missing, ie, physical examination, physician medical record note, diagnosis).

Study protocol

The hospital’s electronic medical record system (EPIC; Epic Systems Corporation, Verona, WI), a direct computer data entry system, was queried for International Classification of Diseases, Ninth Revision, codes 807, 810 to 818, and 820 to 826, and discharged status for a 12-month period (August 2010-July 2011) in ED patients at least 65 years of age. Patient demographics, fracture type, treatment, prescriptions, and comorbidities were examined. Comorbidities not in the medical record were presumed to be absent. Patients in private residence were defined as those not in a skilled nursing or assisted living facility (as there is no formal definition of assisted living, we used this term if it was so documented). The medical records were reviewed by trained, nonblinded study physicians (LS, RS) and documented on a standardized abstraction form.

Measurements

The International Classification of Diseases, Ninth Revision, fracture diagnoses were confirmed by radiographic interpretation of an attending radiologist. The Ageless Charlson Comorbidity Index, a weighted numerical tally of comorbidities validated in ED patients, was calculated [10,11]. The primary outcome was 72-hour return to the ED.

Data analysis

Data was analyzed using Stata v.12 (StataCorp, College Station, TX). Descriptive statistics included means with standard deviation, median with interquartile range (IQR), and proportions with 95% confidence intervals (CIs) as appropriate. Comparisons were made using the Student t test, with a sensitivity of P b .05 considered significant. Ten percent of medical records were abstracted twice, and interrater reliability on the primary end points of fracture type (? = 0.80) and 72-hour returns (? = 0.80) was good. However, agreement on individual comorbidities was lower (? = 0.4).

Results

Over 12 months, 533 older-adult patients were diagnosed with a rib or a nonhip extremity fracture in the ED, of whom 39.8% (n = 208) were admitted and 60.2% (n = 325) were discharged. In 10 (3%) of these, either the medical records were missing physician notes or the patients were treated first at an outside institution, leaving 315 patients eligible for the study (Table 1). The median age was 77 years (IQR, 69-83), and 77% of patients were women. Most were community-dwelling older adults (95%), with only 4% returning to skilled nursing facilities and 1% to assisted living. The Ageless Charlson Comorbidity Index was low (median 1 [IQR, 1-2]; range, 0-7). Formal cognitive assessment was not done; however, the diagnosis of dementia as a documented comorbidity was noted in 11% of patients. Among the 315 study patients, most fractures (64% [95% CI, 58%- 69%]) were located in the upper extremity, most commonly distal forearm fractures (n = 93). Patients with rib fractures made up 12% (95% CI, 8.6%-16%) of the patients discharged, and the remaining 24% (95% CI, 19%-29%) of patients had lower extremity fractures (Table 1). The overall rate of return within 72 hours was 6.3% (95% CI, 3.9-9.6%)

(n = 20). No patients returned more than once to the ED within that frame. Reasons for return included cast or splint problems (n = 11, 55%), pain control (n = 4, 20%), cardiac complaints (n = 3, 15%), fall with another fracture (n = 1, 5%), and need for higher level of care (n = 1, 5%). The highest rate of returns was seen in patients with distal forearm (11%, n = 10/93), ankle (12%, n = 4/39), and hand fractures (13%, n = 3/24); however, the proportions of patients with ankle and hand fractures were much lower, and therefore the 95% CIs are broad. Patients with rib and upper arm fractures had lower return rates. The admission rate among those returning was 35% (n = 7/20), with 3 admissions for cardiac issues (atrial fibrillation with rapid ventricular rate in 2 patients and chest pain in a third patient). Other admissions were for uncontrolled pain, inability to care for self, fall with new fracture, and possible compartment syndrome. Risk factor analysis did not demonstrate any significance of age, sex, comorbidity index overall or dementia in particular, assistive devices, or concurrent injuries (Table 2). Charlson Comorbidity Index was low and not associated with returns (means, 1.45 +- 0.02 for returning patients and 1.47 +- 0.01 for nonreturning patients). Most patients (78% [95% CI, 73%-82%]) were given either a prescription or a recommendation for pain control at home, with the majority receiving an opioid analgesic (n = 192, 60% [95% CI, 56%-67%]). Lack of analgesia did not appear to be a factor in predicting 72-hour return rate, as the patients returning had a higher rate of opioid analgesic prescription than those who did not return (17/20 returns, 85%, vs 175/295 nonreturns, 59%; P = .02). However, those that received a prescription for opioid analgesics were not more likely to return than those prescribed acetaminophen or a nonsteroidal anti- inflammatory drug (P = .20). Although several patients returned for inadequate pain control, there were no returns from complications of

analgesics such as respiratory depression, overdose, or constipation.

Almost half of patients (47.3% [95% CI, 42%-53%]) received assistive devices upon discharge. Slings were the most common device (29% of patients), and 20% received devices to aid mobility (wheelchairs,

Table 1

discharge rates and 72-hour return rates stratified by fracture type in older adults discharged from the ED

Anatomical group

Total number (discharged and admitted)

Patients discharged (% of fracture type discharged)

72-h returns (percentage of those discharged returning)

Upper arm

128

85 (66%)

2 (2.4%) [95% CI, 0.01%-8.2%]

Distal forearm

105

93 (87%)

10 (11%) [95% CI, 5.3%-19%]

Hand

26

24 (92%)

3 (13%) [95% CI, 2.6%-34%]

Ribs

95

38 (40%)

0 (0%) [95% CI, 0%-9.2%]

Upper leg

54

9 (17%)

1 (11%) [95% CI, 0.3%-48%]

Ankle

70

39 (56%)

4 (10%) [95% CI, 2.9%-24%]

Foot

31

27 (87%)

0 (0%) [95% CI, 0%-13%]

Total

523

315 (60%)

20 (6.3%) [95% CI, 3.9%-9.6%]

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Table 2

Demographics and comorbidities do not predict 72-hour return to the ED in patients with nonhip extremity or rib fractures

patients from returning to the ED. Other subgroups such as patients with rib fractures, foot fractures, or Proximal humerus fractures had lower return rates and may be more appropriate for the current

Nonreturning patients (n = 295)

Returning patients (n = 20)

P value

standard of care of later follow-up. This study is underpowered to find the reason behind the increased rate in hand and ankle fractures, as

Age 77.1 77.3 .93

Sex (female) 228 (77.3%) 17 (85%) .74

we had less than 40 patients in each of these groups. However, more than 90 patients had distal forearm fractures; and the reason behind

Ageless Charlson

Comorbidity Index

1.5 (median 1) 1.5 (median 1) .60

the increase in unscheduled Health care use for these patients is not

definitively clear. Assistive devices, other injuries, and comorbidity

Dementia 31 (11%) 3 (15%) .56

Cardiac disease (MI or CHF)

69 (23%) 3 (15%) .36

score did not correlate with return visits. The patients who returned did have a trend toward receiving opioid analgesic prescriptions;

Analgesics (any) 246 (83%) 19 (95%) .07

Opioid prescribed 175 (59%) 17 (85%) .02

Assistive devices

140 (47%)

8 (40%)

.52

Concurrent

83 (28%)

2 (10%)

.05

injuries (any)

Head trauma 25 (8%) 1 (5%) .62 MI, myocardial infarction; CHF, congestive heart failure.

walkers, and crutches). Assisted devices were not protective for or associated with 72-hour returns (Table 2). Eighty-five (27% [95% CI, 22%-32%]) patients had other injuries diagnosed; hematomas (35% of injuries) and abrasions (27% of injuries) were the most common. Additional injuries were not associated with returning (Table 2). Head trauma was noted in only 7.3% (n = 23) of patients; and therefore, the study was underpowered to make an association between head trauma and 72-hour return rates.

Discussion

Adults 65 years and older with fractures deemed safe for discharge from the ED had a 6.3% rate of 72-hour return to the ED and returned mainly for reasons related to the fracture (pain control, cast or splint problems). Although this study was a smaller study focused on patients at a single institution, it is still the largest fracture-specific cohort to our knowledge. Although data from a single institution may limit our reproducibility, they do provide more specific information than national studies that combine all fractures treated as outpatients together or combine all injuries. Prior studies have found that the average rate of 72-hour return for older-adult patients is 3.2%; and in this selection of patients with extremity fractures, the rate was almost double at 6.3% [9]. We found a low rate of cardiac complications or further falls (1% of patients). These data support the hypothesis that, in the short-term setting, outpatient care is likely appropriate for most older adults with nonhip fractures. The patients in this study tended to be community dwelling with low Charlson Comorbidity Index scores, suggesting that those considered safe for discharge had relatively few or less severe chronic comorbidities and were high functioning at baseline. Our rate of documented dementia was slightly lower than the national prevalence, 11% vs 13.9% [12], which suggests that this patient population was healthier than average for age. This is consistent with prior research suggesting that older adults who fall and sustain a fracture have better baseline health and function than those who fall without fractures [13].

The 72-hour return admission rate was 2.2%; other studies have found a return admission rate of 1.4% for adult patients older than 18 with any Sprains or fractures [14]. Although our number of revisits is relatively small, our admission rate at return presentation was also higher than the national average (35% compared to 13% nationally) [7]. This suggests that older adults with fractures may require more inpatient care than older adults with other diagnoses.

Certain fractures in older adults may require more prompt outpatient follow-up, as more than 10% of patients with distal forearm, ankle, and hand fractures required a subsequent ED visit. A cast or splint check within 48 hours would have prevented many

however, in a medical record review study, we cannot know if they were filled or taken. The overall analgesic prescription rate was 78%, with 61% of patients receiving opioids. In comparison, nationally, in adults older than 70 years with fracture, only 58% receivED analgesia, including only 41% who received opioids [15]. Although that is still likely undertreatment, the relatively low rate of return for analgesia only (4/315 patients or 1%) suggests that, in this study, patients’ pain was reasonably addressed.

This study is limited by its dependence on accurate medical recording and the imprecision of our primary end point of 72-hour ED recidivism as a proxy for poor recovery at home. Additionally, the retrospective review does not allow for full cognitive or gait assessment, which could be significant risk factors. The final analysis is also limited by the low number of return patients and does not identify patients who sought follow-up in another ED or orthopedic office within 72 hours. Further prospective multicenter studies are needed to identify the risk factors for increased acute and subacute health care needs in older adults with fractures.

In conclusion, older adults with fractures who are discharged are a higher-risk population for short-term return to the ED. The overall rate of return to the same ED of 6.3% suggests that most of these patients are recovering well in the short term, but certain fracture types such as distal forearm fractures may be associated with increased health care needs. Further prospective research is needed into risk factors for poor outcomes and interventions to assist this high-risk population and to improve the long-term outcomes of older- adult patients with fractures.

Appendix A. Supplementary data

Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2014.05.005.

References

  1. Orces CH. Emergency department visits for fall-related fractures among older adults in the USA: a retrospective cross-sectional analysis of the National Electronic Injury Surveillance System All Injury Program, 2001-2008. BMJ Open 2013;3.
  2. Owens PL, Russo CA, Spector W, Mutter R. Emergency department visits for injurious falls among the elderly, 2006. Healthcare cost and utilization project statistical brief #80. Agency for Healthcare Research and Quality; 2009;1-11.
  3. Becker DJ, Yun H, Kilgore ML, Curtis JR, Delzell E, Cary LC, et al. Health services utilization after fractures: evidence from Medicare. J Gerontol A Biol Sci Med Sci 2010;65:1012-20.
  4. Wilber ST, Blanda M, Gerson LW, Allen KR. Short-term functional decline and service use in older emergency department patients with Blunt injuries. Acad Emerg Med 2010;17:679-86.
  5. Carpenter CR, Heard K, Wilber S, Ginde AA, Stiffler K, Gerson LW, et al. Research priorities for high-quality Geriatric EMergency care: medication management, screening, and prevention and functional assessment. Acad Emerg Med 2011;18:644-54.
  6. Wilber S, editor. Geriatric emergency medicine; 2007;45-71.
  7. Pham JC, Kirsch TD, Hill PM, DeRuggerio K, Hoffmann B. Seventy-two-hour returns may not be a good indicator of safety in the emergency department: a national study. Acad Emerg Med 2011;18:390-7.
  8. Abualenain J, Frohna WJ, Smith M, Pipkin M, Webb C, Milzman D, et al. The prevalence of quality issues and adverse outcomes among 72-hour return admissions in the emergency department. J Emerg Med 2013;45:281-8.
  9. Martin-Gill C, Reiser RC. Risk factors for 72-hour admission to the ED. Am J Emerg Med 2004;22:448-53.

    1092 L.T. Southerland et al. / American Journal of Emergency Medicine 32 (2014) 10891092

    Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol 1994;47:1245-51.

  10. Wang HY, Chew G, Kung CT, Chung KJ, Lee WH. The use of Charlson comorbidity index for patients revisiting the emergency department within 72 hours. Chang Gung Med J 2007;30:437-44.
  11. Plassman BL, Langa KM, Fisher GG, Heeringa SG, Weir DR, Ofsteda MB, et al. Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology 2007;29:125-32.
  12. Keegan TH, Kelsey JL, King AC, Quesenberry Jr CP, Sidney S. Characteristics of fallers who fracture at the foot, distal forearm, proximal humerus, pelvis, and shaft of the tibia/fibula compared with fallers who do not fracture. Am J Epidemiol 2004;159:192-203.
  13. Gabayan GZ, Asch SM, Hsia RY, Zingmond D, Liang LJ, Han W, et al. Factors associated with short-term bounce-back admissions after emergency department discharge. Ann Emerg Med 2013;62:136-144.e1.
  14. Brown JC, Klein EJ, Lewis CW, Johnston BD, Cummings P. Emergency department analgesia for fracture pain. Ann Emerg Med 2003;42:197-205.