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A comparison of emergency department
utilization by elderly and younger adult
patients presenting to three hospitals in Hong
Kong
Article in International Journal of Emergency Medicine · May 2009
DOI: 10.1007/s12245-009-0087-x · Source: PubMed
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Int J Emerg Med (2009) 2:19–24
DOI 10.1007/s12245-009-0087-x
ORIGINAL ARTICLE
A comparison of emergency department utilization
by elderly and younger adult patients presenting to three
hospitals in Hong Kong
Veronica W. T. Yim & Colin A. Graham &
Timothy H. Rainer
Received: 13 November 2008 / Accepted: 8 January 2009 / Published online: 14 February 2009
# Springer-Verlag London Ltd 2009
Abstract
Background The elderly population is increasing in absolute and relative terms in most developed countries, and this
is protected to have a major impact on the delivery of health
care, particularly acute and emergency services. The aim of
this study is to describe the pattern of utilization of
emergency department (ED) services in Hong Kong by the
elderly and to compare it to the utilization by younger adults.
Methods Data on ED visits to three acute hospitals in the
eastern New Territories were retrieved from a central
computerized database of ED attendances. Data on all adult
patients (aged ≥15 years) who attended the three EDs in
2006 were analyzed retrospectively. Patients aged 15 to
64 years were defined as younger adults; patients aged
≥65 years were defined as elderly. The attendance rate, ED
consultation process, hospital admission rate and disease
pattern of the two age groups were compared.
Results Elderly patients required significantly more emergency care resources than younger adults. Elderly ED patients
were brought to hospital more frequently by ambulance
(42.8% vs. 14.8%, p<0.0001) and required hospital admission
more often (45.0% vs. 15.5%, p<0.0001) than younger
adults. A significantly higher proportion of elderly patients
were triaged as being in the critical, emergency or urgent
categories compared to younger adults (44.4% vs. 18.2%,
p<0.0001). Laboratory tests, radiography and CT scanning
V. W. T. Yim (*) : C. A. Graham : T. H. Rainer
Accident & Emergency Medicine Academic Unit,
Chinese University of Hong Kong, Prince of Wales Hospital,
Shatin, New Territories, Hong Kong SAR
e-mail: veronyim@hotmail.com
C. A. Graham
e-mail: cagraham@cuhk.edu.hk
T. H. Rainer
e-mail: thrainer@cuhk.edu.hk
were performed on elderly patients more frequently than
on younger adults (p<0.0001), and their lengths of stay in
EDs and emergency wards were significantly longer (p<
0.0001). Neurological symptoms and chest pain were the
most common presenting symptoms in elderly ED patients.
Conclusion With the foreseeable rapid growth of the elderly
population, ED utilization by the elderly will increase.
Health service delivery, including that in the ED, needs to
take account of the specific features and requirements of
the elderly population in each locale.
Keywords Elderly . Emergency department .
Acute services . Hong Kong . Epidemiology
Introduction
The increasing proportion of aged population is a worldwide
concern. In 2003, 12.5% of the population in Hong Kong was
aged over 65 years. It is postulated that by 2033, the
proportion of the population that is elderly (defined as
≥65 years old) will increase to 25% [1]. The impact of this
demographic change on the use of medical services is of
great interest to health-care planners. Emergency departments
(EDs) in Hong Kong are often utilized as the gateway to
medical care. Local data from one large teaching hospital
(Prince of Wales Hospital) suggested that 25% of ED patients
were aged ≥65 years. Elderly patients constitute a disproportionately large group of ED attenders with respect to the
proportion of elderly people in the general population. With
its rapid growth, the consequences of the increasing aging
population on ED service utilization need to be addressed.
The aim of this study is to describe the pattern of ED
utilization of the elderly in the eastern New Territories in
Hong Kong. Differences in ED service utilization and the
20
ED consultation process in elderly patients (aged ≥65 years)
and younger adults (aged 15 to 64) will be compared. This
may provide a basis for planning the development of
geriatric emergency medical services in the future in Hong
Kong by identifying the emergency care needs of this
special population.
Methods
Setting
The hospitals included in this study were those acute
hospitals of the New Territories East cluster, namely Prince
of Wales Hospital (PWH), Alice Ho Mui Ling Nethersole
Hospital (AHNH) and North District Hospital (NDH).
PWH is an acute general hospital with 1,200 beds and is
the primary teaching hospital of the Chinese University of
Hong Kong. PWH functions as the regional major trauma
center for the northeast New Territories, with all medical,
surgical and intensive care facilities on site. It is the tertiary
referral center for the New Territories East cluster. The ED
has an annual attendance of around 150,000 patients. The
Emergency Ward can accommodate 16 patients.
NDH is an acute district general hospital situated near
the Hong Kong-China border. It has 600 beds with four
in-patient specialties: general medicine, general surgery,
orthopedics and pediatrics. The annual ED attendance is
around 110,000 patients. The Emergency Ward can accommodate 26 patients.
AHNH is an acute general hospital with 400 in-patient
beds, providing clinical services in general medicine,
surgery, pediatrics, ophthalmology, otorhinolaryngology and
orthopedics. The annual ED attendance is around 120,000.
There are eight beds in the Emergency Ward in AHNH.
Int J Emerg Med (2009) 2:19–24
Data source
Data were retrieved from the Clinical Data Analysis and
Reporting System (CDARS) of the Hospital Authority of
Hong Kong. CDARS is a computerized database that
allows retrieval of clinical information captured through
other computer systems in the hospital authority. CDARS
has been in operation since 2002, and analysis of ED
attendances has been possible since 2005. Data on patient
age, gender, laboratory and radiological investigations,
emergency ward and inpatient hospital admissions and
lengths of stay were all retrieved for each patient and
categorized by hospital and by age group (young adults
and elderly). A retrospective analysis was undertaken.
Statistics
The chi-square test was used to compare categorical or
dichotomous variables. The Mann-Whitney test was used to
compare total length of stay in EDs and in the emergency
ward as data were not normally distributed. P<0.05 was
considered statistically significant. Data were analyzed
using SPSS version 13.0 (SPSS Inc., Chicago, Ill.).
Results
Younger adults constituted 61% of the total ED attendance,
while elderly patients constituted 24%. Table 1 shows the
ED attendances by age and hospital for 2006. Of the
patients, 14.8% (33,262/224,921) in the younger adult
Table 1 Emergency department attendances, admissions to inpatient
ward and number of ambulance admissions to ED, by age group and
hospital
Hospital Age
15-64
Patients and definitions
All adult patients (aged 15 or above) who attended any of
the three hospitals’ EDs within the calendar year 2006
were included in the study. Patients aged 15 to 64 years
on admission were defined as younger adults, and patients
aged 65 years or above were defined as elderly for the
purposes of the study. The emergency ward is a short-term
care facility adjacent to the ED where patients with
selected conditions (mild respiratory disease, mild heart
failure, poor mobility, etc.) are admitted for monitoring
and treatment. A designated specialist emergency physician is responsible for taking care of patients in the
emergency ward at all times. Inpatient admission is defined
as admission to a hospital ward (other than the emergency
ward) under the care of a specialist who is not an emergency
physician.
ED attendances
AHNH
NDH
PWH
Total
ED attendances brought by
AHNH
ambulance
NDH
PWH
Total
ED patients who were admitted AHNH
to inpatient wards
NDH
PWH
Total
71,952
65,572
87,397
224,921
6,625
12,570
14,067
33,262
8,159
9,199
17,621
34,979
ED: Emergency department
AHNH: Alice Ho Mui Ling Nethersole Hospital
NDH: North District Hospital
PWH: Prince of Wales Hospital
Age
≥65
Total
23,232
26,670
37,721
87,623
9,077
13,401
15,066
37,544
11,089
12,855
15,511
39,455
115,044
111,627
143,852
370,523
Int J Emerg Med (2009) 2:19–24
21
100%
Proportion of patients
80%
Younger adults
Elderly
100%
Younger adults
80%
Proportion of patient within
age group
group were brought to the ED by ambulance compared to
42.8% (37,544/87,623) of the elderly group (p<0.0001,
χ2 test).
Figure 1 shows the proportion of elderly and younger
adult patients in different triage categories. Elderly patients
presented to EDs with more serious conditions than younger
adults. Of the elderly patients, 44.4% (38,872/87,623) were
triaged to the critical, emergency or urgent categories
compared to 18.2% of younger adults (40,975/224,921)
(p<0.0001, χ2 test).
Elderly patients utilize more resources during the ED
care process. Figure 2 shows the proportion of patients with
investigations performed in ED. More diagnostic tests were
performed on elderly patients compared to younger adults.
The differences in the two groups are statistically significant for plain radiography, laboratory tests and CT scanning
(p<0.0001, χ2 test).
The difference in the process of care for elderly and
younger adults is further demonstrated in their difference in
the total length of stay in the ED. Table 2 shows the median
length of ED stay for patients in the two groups by different
triage category. Elderly patients in the critical and emergency categories stayed in EDs for a significantly shorter
period of time when compared to younger adults in the
same triage categories. In contrast, elderly patients in
triage categories 3, 4 and 5 spend more time in the ED
consultation process than younger adults.
Elderly patients presented to EDs with a different
spectrum of disease when compared to younger adults.
Figure 3 shows the ten most common diagnoses made by
emergency physicians in the two groups. Elderly patients
most commonly presented to EDs with neurological symptoms. These included loss of consciousness, syncope or
dizziness. Chest pain was the second most common reason
for the elderly to come to EDs for consultation. ‘Decreased
Elderly
69%
60%
40.6%
40%
22.8%
20%
11.4%
1%
2.6%
0%
Plain
Xrays
Blood
tests
CT
scan
Fig. 2 Proportion of patients with investigations performed in the ED
general condition,’ acute exacerbation of chronic obstructive
pulmonary disease and congestive heart failure were
common conditions presenting to EDs in the elderly, but
not in the younger adult group.
Of the patients in the younger adult group, 15.5%
(34,979/224,921) were admitted to the hospital, while 45.0%
in the elderly group (39,455/87,623) were admitted (p<
0.0001, χ2 test).
Of the younger adult patients, 5.1% (11,427/224,921)
attending the ED were admitted to the emergency ward
compared to 12.5% (10,947/87,623) in the elderly group
(p<0.0001, χ2 test). Apart from being admitted to the
emergency ward more frequently than younger adults,
elderly patients stayed in the emergency ward for a longer
duration. Table 3 shows the difference in length of stay in the
emergency ward in different hospitals, with elderly patients
staying in the emergency ward for a longer period of time
than younger adults.
There was also a significant difference in patients’ length
of stay in the emergency ward among the three hospitals,
both in the elderly group and the younger adult group. (1.6
h in AHNH vs. 10.5 h in NDH vs. 11.4 h in PWH for the
younger adult group, p<0.001, Mann-Whitney test; 2.1 h in
AHNH vs. 15.4 h in NHD vs. 19.5 h in PWH for the
elderly group, p<0.001, Mann-Whitney test).
60%
40%
Table 2 Median length of ED stay by triage category, in minutes
20%
Triage category
Elderly
Younger adults
P value
Critical [1]
Emergency [2]
Urgent [3]
Semi-urgent [4]
Non-urgent [5]
38 (60)
49 (99)
103 (254)
133 (274)
94 (149)
50
56
93
97
73
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
Not
recorded
Non-urgent
Semi-
urgent
Urgent
Emergency
Critical
0%
Triage category
Fig. 1 Proportion of younger adult and elderly patients in different
triage categories
Mann-Whitney test
ED: Emergency department
(95)
(137)
(192)
(169)
(130)
22
Int J Emerg Med (2009) 2:19–24
39.4% (27,846/70,745) from the community were admitted
(p<0.0001, χ2 test).
Younger adults
Elderly
8
6
Discussion
4
COPD
Congestive Heart Failure
Decreased General Condition
Headache
Urinary Tract Infection
Joint Symptoms
Low Back Pain
Injury
Chest Pain
Gastroenteritis
Neurological Symptoms
0
Abdominal pain
2
Respiratory Tract Infection
Proportion of patient in each age group
10
Fig. 3 Ten most common diagnoses in ED patients
Table 4 shows the patterns of ED utilization of elderly
patients from old age homes and those living in the
community; 80.7% (70,745/87,623) of the elderly attending
the ED were from the community, and the remainder [19.3%
(16,878/87,623)] came from old age homes.
Elderly patients from old age homes utilized the
ambulance service significantly more frequently than those
from the community, with 80.6% (13,600/16,878) transferred to the ED by ambulance compared to 33.8% (23,944/
70,745) of those living in the community (p<0.0001, χ2
test).
Of the elderly ED patients from old age homes, 68.8%
(11,609/16,878) were admitted to the hospital, whereas
Table 3 Emergency ward admissions and lengths of stay by age
group and hospital
Admissions to
emergency ward
Median length of
stay in emergency
ward in hours (mean)
Hospital
Age
15-64
Age ≥65
AHNH
NDH
PWH
Total
AHNH
NDH
PWH
Overall
4,086
4,279
3,062
11,427
1.6 (2.6)
10.5 (13.0)
11.4 (15.8)
6.6 (10.0)
4,388
3,128
3,431
10,947
2.1 (3.3)
15.4 (18.0)
19.5 (26.7)
8.4 (14.9)
*All P < 0.0001, Mann-Whitney test
ED: Emergency department
AHNH: Alice Ho Mui Ling Nethersole Hospital
NDH: North District Hospital
PWH: Prince of Wales Hospital
*
*
*
*
Emergency departments are important means of access to
health-care service for the elderly, as indicated by the
disproportionate representation of elderly patients in the
ED population. Elderly patients constitute 25% of ED
attendances, whereas the elderly represent only 12% of the
general population. As the population ages, this overrepresentation of elderly ED patients may have serious impacts
on health-care resources in the future.
We found that emergency care for the elderly utilizes
more resources than for younger patients. Elderly patients
were significantly more likely to use ambulances to get to
hospital and to require hospital admission than younger
adult patients. However, the elderly presented to EDs with
more serious conditions than younger adults. A significantly higher proportion of elderly patients were triaged as
being in the critical, emergency or urgent category when
compared to younger adults. This pattern of a higher degree
of urgency in the elderly patients is consistent with that
reported by the Society for Academic Emergency Medicine
Geriatric Task Force [3]. The admission rates in our hospital
cluster are similar to those reported in the literature in the
United States [2–5].
The elderly are a unique population of patients. They
differ from younger adults not only in the pattern of ED
use, but also in the presenting spectrum of disease. They
present to the ED with more complex and acute medical
problems. This results in a significant difference in the
process of care in the two groups. Neurological symptoms,
chest pain and ‘decreased general condition’ were the most
common presenting symptoms in the elderly. These presenting complaints may signify underlying serious acute conditions and therefore utilize more resources in the ED
diagnostic and consultation process.
Also, the elderly differ from younger adults physiologically; common diseases may present with atypical symptoms or non-specific ‘deterioration in general condition.’
More time and resources are required in making an accurate
diagnosis for those with non-specific complaints. This may
explain the more frequent laboratory and radiological
investigations in the elderly group compared to younger
adults.
The higher complexity of medical problems in the
elderly results in a higher hospital admission rate, emergency ward admission rate and an increased ED length of
stay in the elderly compared to younger adults. Length of
ED stay in the two groups varies with triage category.
Elderly patients in the critical or emergency categories
Int J Emerg Med (2009) 2:19–24
23
Table 4 Emergency department attendances, admissions to inpatient ward and number of ambulance admissions to ED, by domicile and hospital
Patients from elderly home
AHNH
NDH
PWH
Total
Patients living in the community
ED attendances
Ambulance attendances
IP ward admissions
ED attendances
Ambulance attendances
IP ward admissions
5,094
6,396
5,388
16,878
4,333
5,324
3,943
13,600
3,712
4,508
3,389
11,609
18,138
20,274
32,333
70,745
4,744
8,077
11,123
23,944
7,377
8,347
12,122
27,846
ED: Emergency department
IP: Inpatient
AHNH: Alice Ho Mui Ling Nethersole Hospital
NDH: North District Hospital
PWH: Prince of Wales Hospital
stayed in EDs for a significantly shorter period of time than
younger adults. This may be explained by the fact that
around 39% of the elderly in the critical category were in
cardiac arrest on arrival to ED. These patients generally had
brief resuscitation attempts due to advanced pre-morbid
illness or clear failure of resuscitation in the prehospital
arena, and these patients were certified dead shortly after
ED arrival. In contrast, only 17% of patients in the younger
adult group presented to the ED in cardiac arrest.
Furthermore, 16% of younger adult patients in the
critical and emergency categories were victims of severe
trauma compared to 2.5% in the elderly group. These
severely injured patients undergo resuscitation and radiological investigations, including CT scans if indicated,
before they are admitted for definitive treatment. Therefore,
it takes longer to manage a patient with severe trauma
compared to cardiac arrest. This contributes to the longer
average staying time in the ED in younger adult patients in
the critical and emergency triage categories.
However, elderly patients in the urgent, semi-urgent or
non-urgent categories stayed in EDs for a significantly
longer duration than younger adults. This reflects the more
complex medical conditions that elderly patients present
with to EDs and is directly related to the fact that more
investigations are performed on elderly ED patients than
younger adults.
Apart from the length of stay in the ED, elderly and
younger adults also differ in their average length of stay in
the emergency ward. The special health-care needs and
more complex conditions in elderly patients result in a
significantly longer length of stay in the emergency ward.
All three hospitals in this study showed the same pattern of
a longer median length of stay in the emergency ward in the
elderly group, but the duration of stay varies in different
hospitals. This is because the different hospitals use different
criteria for admitting patients to emergency wards, and
the spectrum of conditions managed in different hospitals
depends on the resources available.
The health-care needs of the elderly living in old age
homes require special attention. About 10% of the elderly
in Hong Kong live in old age homes [6]. In our hospital
cluster, 19.3% of elderly ED patients were from old age
homes. Patients from old age homes utilized more healthcare resources than other elderly. They used the ambulance
service and in-patient care more frequently than those from
the community. There are a number of reasons behind these
findings. The old age home residents are often wheelchair
bound or bed bound, and the ambulance service is often the
only way to transfer them to EDs for consultation. Patients
from old age homes are generally in a poorer pre-morbid state
compared to those who live in the community. The level of
nursing and medical care provided in the old age home may
not be able to cope with the additional strains of acute illness
in the elderly patient. Thus, staff in old age homes are more
prone to send these acutely ill patients to EDs. In addition, the
condition of the elderly may deteriorate very rapidly with
acute illnesses, resulting in a higher rate of hospital admission.
The high utilization rates of the ED and ambulance
service in old age home residents reflect to a degree the
inadequacy in health-care services for this vulnerable
group. The Hospital Authority has introduced a number of
measures in order to reduce hospital utilization in this group
of patients. Multidisciplinary outreach teams (comprising
a geriatrician, nurse, physiotherapist and occupational
therapist) provide community health-care services to old
age home residents, including follow-up of chronic conditions and treatment of acute illnesses. Exploring further
collaborations between ED service and this multidisciplinary team may reduce hospital admissions and ED
attendances in this group of frail patients.
Conclusion
The unique health-care needs of the elderly ED patients
require special attention. The elderly require significantly
24
more emergency care resources compared to younger
adults. Anticipation of greater demand on resources with
the aging population in Hong Kong suggests the need for
proactive planning, service delivery, education and research
in geriatric emergency medicine.
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