Estimating the risk of functional decline in the elderly after discharge from an Australian public tertiary hospital emergency department
Authors: Grimmer Karen , Beaton Kate , Kumar Saravana , Hendry Kevan , Moss John , Hillier Susan , Forward John , Gordge Louise 
Published: May 2013

Objective.
To estimate the risk of functional decline after discharge for older people presenting to, and discharged from, a large emergency department (ED) of a tertiary hospital.

Methods.
The cohort was generated by consecutive sampling of non-Indigenous males and females aged 65 years or over or Aboriginal and Torres Strait Islander males and females aged 45 years or more, without diagnosed dementia, who were living independently in the community before presenting at ED and who were not admitted to hospital as an inpatient after presenting to ED. The hospital assessment risk profile (HARP) was administered to all eligible participants. Sociodemographic information was collected.

Results.
Approximately 40 patients per day over two 14-week data collection periods were potentially eligible for inclusion in the study. In total, 597 (17.6% of individuals who presented to ED) were eligible, agreed to participate and continued to be eligible on discharge from ED. Their HARP scores suggested that ~52% were at-risk of functional decline (14.1% high risk, 38.5% intermediate risk).

Conclusions.
Elderly patients present to and are discharged from ED every day. The routinely administered HARP instrument scores suggested that approximately half these individuals were at-risk of functional decline in one large hospital ED. Given this instrument’s moderate diagnostic accuracy, the true figure may be higher. We suggest that all over-65 year olds presenting at ED without being admitted as an inpatient should be considered for routine screening for potential downstream functional decline, and for intervention if indicated.

What is known about the topic?
Older individuals often present to ED in lieu of consulting a general medical practitioner, and are not admitted to a hospital bed. Patient demographics, functional and mental capacity and reasons for presentation may be flags for functional decline in the coming months. These could be used by ED staff to implement targeted assessment and intervention.

What does this paper add?
This paper highlights the high percentage of older individuals who, at time of ED presentation, are at-risk of downstream functional decline.

What are the implications for practitioners?
Older people who are discharged from ED without a hospital admission may ‘slip through the net’, as an ED presentation presents a limited window of opportunity for ED staff to undertake targeted assessment, and intervention, to address the potential for downstream functional decline. The busy nature of ED, resource implications and the range of presenting conditions of older people may preclude this. This research suggests a reality that a large percentage of older people who present at ED but do not require a subsequent hospital admission have the potential for functional decline after discharge. Addressing this, in terms of specific screening processes and interventions, requires a rethink of hospital and community resources, and relationships.