Discharging older patients from the emergency department effectively: a systematic review and meta-analysis.
BACKGROUND
a decline in health state and re-attendance are common in people aged ≥65 years following emergency department (ED) discharge. Diverse care models have been implemented to support safe community transition. This review examined ED community transition strategies (ED-CTS) and evaluated their effectiveness.


METHODS
a systematic review and meta-analysis using multiple databases up to December 2013 was conducted. We assessed eligibility, methodological quality, risk of bias and extracted published data and then conducted random effects meta-analyses. Outcomes were unplanned ED representation or hospitalisation, functional decline, nursing-care home admission and mortality.


RESULTS
five experimental and four observational studies were identified for qualitative synthesis. ED-CTS included geriatric assessment with referral for post-discharge community-based assistance, with differences apparent in components and delivery methods. Four studies were included in meta-analysis. Compared with usual care, the evidence indicates no appreciable benefit for ED-CTS for unplanned ED re-attendance up to 30 days (odds ratio (OR) 1.32, 95% confidence interval (CI) 0.99-1.76; n = 1,389), unplanned hospital admission up to 30 days (OR 0.90, 95% CI 0.70-1.16; n = 1,389) or mortality up to 18 months (OR 1.04, 95% CI 0.83-1.29; n = 1,794). Variability between studies precluded analysis of the impact of ED-CTS on functional decline and nursing-care home admission.


CONCLUSIONS
there is limited high-quality data to guide confident recommendations about optimal ED community transition strategies, highlighting a need to encourage better integration of researchers and clinicians in the design and evaluation process, and increased reporting, including appropriate robust evaluation of efficacy and effectiveness of these innovative models of care.
Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
Judy A
JA
Lowthian
Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
Rosemary A
RA
McGinnes
Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
Caroline A
CA
Brand
Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
Anna L
AL
Barker
Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
Peter A
PA
Cameron
D000367:Age Factors; D000368:Aged; D016009:Chi-Square Distribution; D003153:Community Health Services; D003266:Continuity of Patient Care; D004636:Emergency Service, Hospital; D015577:Geriatric Assessment; D005853:Geriatrics; D006299:Health Services for the Aged; D006707:Homes for the Aged; D017052:Hospital Mortality; D006801:Humans; D009735:Nursing Homes; D016017:Odds Ratio; D010343:Patient Admission; D010351:Patient Discharge; D012307:Risk Factors; D013997:Time Factors
discharge; emergency; meta-analysis; older people