Factors influencing the presentation and care of elderly people in the emergency department.

Objective: To provide Australian data from a community setting on the use of the Emergency Department by elderly persons.
Design: The paper describes three studies. Study 1 analyses patient admission patterns, and clinical data taken retrospectively from medical records for 1987. Studies 2 and 3 prospectively survey referral, transport, demographic profiles and clinical management practices in two patient samples taken during 1987 and 1988.
Setting: The Emergency Department of Sutherland Hospital, Sydney--a community based hospital of 374 beds.
Patients: In study 1, we assessed 4609 hospital admissions of patients aged 60 years or more using ICD-9-CM coding. In Studies 2 and 3, samples of 74 patients aged 65 years or more and 100 patients aged 70 years or more who presented to the Emergency Department were assessed consecutively and prospectively.
Interventions: No specific interventions outside of usual Emergency Department routines were undertaken except for collection of demographic data.
Main Outcome Measures: Demographic characteristics, diagnostic categories, and referral, admissions and hospital separation data.
Results: In Study 1, of 4609 patients aged 60 years or more 3182 (69%) entered hospital via the Emergency Department. These 3182 represented 29% of total hospital admissions for that year. In Study 2 the male to female ratio was 32 to 42; the mean age was 78.16 years; 88% were pensioners; 20% had additional private insurance; 76% of women were widowed compared with 32% of men; 84% of the group lived in their own homes but, of these, 51% of women lived alone compared with 7.7% of men. The disease profile was that of acute organic disease in 97% of presentations. Ambulance transport to the Emergency Department was used by 65% of patients and Emergency Department facilities were used mostly during "working hours"; 64% of patients were admitted to hospital. The pre-hospital "activities of daily living" (ADL) functioning was assessed as being independent in 85%. In Study 3, the social and demographic profile was similar to Study 2. Fifty seven of the 100 patients used ambulance transport to the Emergency Department and this was initiated by a general practitioner in 13 instances. The general practitioner was the referring source in 28% of cases. Waiting times in the Emergency Department demonstrated a mean time from arrival to assessment by a medical officer of 30 minutes and a total time spent in the Emergency Department of 3 hours 4 minutes for those discharged home and 4 hours 24 minutes for those admitted.
Conclusion: These studies demonstrate that the Emergency Department is a major area for care of the elderly and entry into the hospital system. Referral from a general practitioner and the use of ambulance transport from home to the Emergency Department are frequent pathways of care that may have important cost-benefit implications and deserve further study. The elderly in these studies appear to use the Emergency Department appropriately for acute medical/surgical need. The social profiles suggest that widowed women present a special case in terms of discharge plans for management.