In patients aged 65 and over presenting to an ED, we have found that the early use of multidisciplinary allied health teams influences hospital admission rates in a small number of index diagnoses (angina and grouped musculoskeletal conditions) and these results were of borderline statistical significance. Our study, with over 5000 enrolments, is one of the largest trials of allied health practices in older people and adequately powered to detect the overall small difference found.
A number of studies have evaluated programs to look at ED discharge, largely from the perspective of reducing post-discharge risk. We are not aware of any study that has looked specifically at the impact of allied health staff on the admission decision. Enhanced identification of an at- risk discharged group and referral of that group to community care givers had some benefit in reducing short term functional decline post discharge [16
]. More comprehensive geriatric assessment by additional care providers outside the primary care physician have shown conflicting results but have also found benefit on functional status [17
], but not necessarily ED usage [18
It appears that the benefit of CCT intervention on admission reduction is confined to musculoskeletal conditions such as back pain (OR 0.56) and lower limb pain (OR 0.63); or to conditions likely to be episodic and resolved by the time the patient has arrived in ED such as angina (OR 0.71). Our study shows no benefit accrues from CCT intervention in medical conditions with ongoing significant symptoms such as pneumonia, cardiac failure and delirium. Though these findings are robust, any subgroup analysis should be interpreted with caution due to the possibility of type II error. We had hypothesised that CCT input would reduce admission rates across all of the selected conditions studied. The lack of any intervention effect in conditions such as pneumonia or cardiac failure shows that almost all patients with these conditions presenting to ED are admitted, and that discharge of such patients is not enhanced by CCT input. The underlying medical condition of the patient rather than unmet community or functional needs is presumably more influential in the decision to admit in these subgroups. This has implications for workforce deployment; CCT like services should concentrate resources on patient groups where they are likely to produce a beneficial reduction in admission rather than those where admission rates are unchanged by their input.
We have confirmed that admission rates in the older ED patient are high. With population ageing a worldwide phenomenon, measures to safely reduce hospital admission rates in patients presenting to an ED are important in the quest to maximise efficient use of scarce inpatient beds. Even small changes in admission rates at the front door will result in meaningful reductions in hospital occupancy and improve system capacity. The use of allied health personnel working as a CCT in ED appears to support this aim.
In our study we included ED observation unit patients as admitted patients. Such patients typically have brief admissions of less than 24 h though there is evidence that at least 15% of such patients need longer inpatient stays [19
]. By including short stay observation unit stays in the same group as inpatient admissions, we may have missed an additional benefit of CCT intervention if CCT increased the proportion of admissions that are observation unit admissions as opposed to ward admissions, where there is typically a longer length of stay. This was not part of our original hypothesis and so not analysed, but would be worthy of future research.
We have concentrated on admission avoidance, underpinned by an assumption of the clinical, economic and qualitative benefits of avoiding hospitalisation in carefully selected older patients. However, there are also risks involved with the discharge of older people from the ED - early functional decline, re-presentation and unanticipated death are all described [20
]. In fact, other researchers have similarly used geriatric teams in ED to prevent inappropriate ED discharge
]. The nature of a community's support services, the capacity of these services to consistently respond to referrals and the hospital's appetite for risk at point of discharge will all influence whether a patient is sent home from the ED. The decision to discharge or admit an older person, therefore, is sometimes a fine balance between the feasibility, risks and benefits of discharge.
Our study is noteworthy because we used assessment by CCT soon after arrival in the ED, before a decision on the disposition of the patient had been made, to assess the impact of early intervention on discharge rates. We did not attempt to assess the outcome of patients following discharge. Post discharge outcomes have been subject to a number of studies summarised in a recent systematic review which found some evidence of improved short term functional outcomes and reduced readmission rates with geriatric intervention at or after discharge [24
]. A feature of these trials is that the referral to the geriatric team occurs after the decision to discharge has already been made [17
In addition to admission avoidance, a number of other clinical benefits are likely to be derived from the location of experienced allied health teams within the ED. Studies have shown the functional needs of older people are often poorly recognised within the ED [25
]. Communication between the ED and community care providers can be poor [27
]. Coordination of care for patients with complex needs post discharge may be enhanced by specific planning [11
Our study has several clear limitations. As the mechanism of allocation to intervention and control was not randomised, selection bias may have occurred. We attempted to adjust for this through the use of propensity score matching but this may have been insufficient. Because we have not included follow up data on patients that were discharged in our study, we cannot assume that patients discharged in the intervention group did not suffer a higher rate of short term adverse outcome compared to control group patients. However, the competence of allied health teams in facilitating safe discharge of ED patients has been well established in a systematic review of the literature [24
], hence we sought to answer another question that had not previously been addressed. Because many factors influence decisions to discharge patients home from ED, the generalisability of our results to different settings or populations cannot be assumed. We have not included a formal cost effectiveness analysis in this paper but that is worthy of further research.