Identification of older patients at risk of unplanned readmission after discharge from the emergency department

Abstract

STUDY HYPOTHESIS: The Identification of Senior At Risk (ISAR) and the Triage Risk Stratification Tool (TRST) are the two most studied screening tools to detect high-risk patients for unplanned readmission after an emergency department (ED)-visit. Since their performance was unclear among ED-patients over 75 years, we evaluated their capacities to predict readmission at 1, 3, 6 and 12 months as well as their usefulness in avoiding unnecessary further comprehensive geriatric assessment (CGA) in negative screened patients. METHODS: Historical cohort study with systematic routine data collection of functional status, comorbid conditions and readmission rate of patients released home after an ED-visit between 2007 and 2009 at the Geneva University Hospitals. RESULTS: 345 patients were included (mean age 84y; 63% female). Readmission rates were 25%, 38%, 49%, and 60% at 1, 3, 6, and 12 months, respectively. Positive ISAR (≥2/6) and TRST (≥2/5) predicted modestly unplanned readmission at each time point (AUC range: 0.607–0.664). Prediction of readmission with ISAR or TRST was not modified after adjustment for variables significantly associated with readmission (being male, having poor functional or comorbid scores). In case of negative ISAR or TRST, their high negative predictive values (NPV) would safely allow avoiding 64 useless CGA (ISAR <2: 7/64 readmissions at 1 month). CONCLUSIONS: Both ISAR and TRST tools predicted modestly unplanned readmission after an ED-visit among patients over 75 years. Nevertheless, due to their low specificity and high NPV these screening tools are useful to select elderly ED-patients who can safely return home without any further CGA.

Keywords

• emergency department
• geriatric outcomes
• high-risk patients
• screening tools