AGE AND TIME SPENT IN THE EMERGENCY DEPARTMENT OF AN URBAN TEACHING HOSPITAL IN ITALY (2010)

To the Editor: Older age is associated with longer time spent in the emergency department (ED).1 To investigate the age-related duration of the various phases of an ED visit, from triage to discharge or hospitalization, all of the admissions to the medical and surgical ED of a teaching hospital in Milan, Italy, in 2007 were considered. After excluding admissions involving children (<10), subjects who died in the ED, and subjects who spontaneously left the facility, 34,848 admissions of 36,161 were analyzed. From the ED's computerized database the total length of stay in the ED (Phases 1–4) was retrieved for all admissions, whereas the following specific temporal parameters were available for 28,839 admissions: time from triage to entry into the examination room (Phase 1), time from entry into the examination room to the first request for a diagnostic procedure (Phase 2), time between the first and last diagnostic request (Phase 3), and time from the last diagnostic request to the discharge or hospitalization of the patient (Phase 4). Admissions were stratified according to patient age, and the mean lengths of the four temporal phases were compared using one-way analysis of variance. Two linear regression multivariate analyses were performed using the logarithmic transformation of the dependent variable “duration of ED stay”; the first considered the total duration of the stay, and the second considered the duration of Phase 4. With older age, the duration of Phase 1 (P<.001) was found to be shorter and that of Phases 3 (P<.001) and 4 (P<.001) to be longer (Figure 1). With multivariate analysis (n=34,848), the total length of the ED visit was independently associated with patient age, starting from the age of 50, after correction for patient age and sex, season and time of access to the ED, clinical severity at triage (on a 4-level scale), number of diagnostic procedures, final destination of the patient in terms of discharge or hospital admission, and ward of admission. In subjects aged 80 and older, the ED visit lasted 25% longer than in subjects aged 10 to 50, regardless of all other covariates. The duration of Phase 4 was also independently correlated with patient age, in this case starting from the age of 40. Time spent in the emergency department (ED) according to age (N=28,839). Phase 1: Triage to ED admission; Phase 2: ED admission to first diagnostic procedure; Phase 3: First to last diagnostic procedure; Phase 4: Last diagnostic procedure to hospitalization or discharge. Sample size of the age groups: 10 to 19, n=978; 90 and older, n=874, all other groups, n>3,000 each. Older age was associated with longer overall ED stay and specifically with longer duration of the last two phases—diagnostic examination (Phase 3) and final evaluation (Phase 4)—independent of clinical severity at triage, larger consumption of diagnostic tests, and more-frequent hospitalization. The longer time required for diagnostic procedures because of the greater clinical complexity and the frequently lower autonomy of such patients might explain the increased length of Phase 3 in older people. The longer duration of Phase 4 may have different explanations; in hospitalized patients, a longer time may be required to achieve clinical stability, whereas in discharged patients, the longer stay could be accounted for by socioenvironmental factors such as social marginalization, lack of a caregiver, and cognitive decline,2,3 but organizational factors and hospital bed space availability may also be reasons.4,5 This study has two main limitations. Discharge diagnoses could not be considered because they were seldom coded in the ED database according to a standardized system such as the International Classification of Diseases, Ninth Revision, Clinical Modification, although there is evidence that ED discharge diagnoses tend to be somewhat inaccurate, especially in older subjects,6,7 who are at higher risk of unfavorable outcomes (hospitalization, functional decline, nursing home placement, and death) after being discharged from an ED.8,9 The second limitation was that the main functional and social characteristics of the patients were not available for analysis; little attention is paid to functional status during clinical assessment in the ED.10 In conclusion, this study highlights the need for a systematic assessment of the functional and social characteristics of elderly subjects in the ED. This could provide some insight into the causes of the age-related longer ED stay and could favor the development of protocols involving close cooperation with community-based services. We would like to thank Dario Consonni, Department of Preventive Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy, for the statistical counselling. Conflict of Interests: None. Author Contribution: Study concept and design: PDR, LB, CB, CV. Acquisition of data: PDR, FP, VM. Analysis of data: PDR, CB. Interpretation of data: PDR, LB, CB, FP, VM, CV. Preparation and editing of the manuscript: CB, PDR. Sponsor's Role: None.