電子期刊 |
ISSN:1684-193X
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Updated
Feb 26, 2003
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Contents:
Volume 1, Nomber 2; Jan, 2003 |
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Age-Related
Emergency Department Utilization: A Clue of Patient Demography in
Disaster Medicine |
Chun-Hing Wong, MD, Tzong-Luen Wang, MD, PhD, Hang
Chang, MD, PhD, and Yi-Kung Lee, MD |
From the Department of Emergency Medicine(Wong
CH, Lee YK), Buddish Dalin Tzu Chi General Hospital; Department
of Emergency Medicine(Wang TL), Shin-Kong Wu Ho-Su Memorial Hospital.
Correspondence to Dr. Yi-Kung Lee, Department
of Emergency Medicine, Buddish Dalin Tzu Chi General Hospital,
No. 2, Min-Sheng Road, Dalin Town, Chia-Yi, Taiwan. E-mail lyg1968@titan.seed.net.tw
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Abstract
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The purpose of this study is to
construct a demographic of emergency department (ED) patients and
determine the need of special attention on ED geriatric patients.
We prospectively studied 16,925 patients who visited ED of a community
teaching hospital (Upgraded to medical center in 2001) in Taipei
City from April 9, 1999 to June 27, 1999.. The patients were stratified
into pediatric (age <15 yr), non-elderly adult (age 15-64 yr),
elderly (age 65-74 yr) and extremely old adult (age >75
yr) patients (the later 2 groups were defined as geriatric patients).
Their statistical data in gender, ambulance utilization, disease
severity, revisiting to ED, resources consumed, medical expenditures,
and disease distribution were studied. The geriatric patients occupied
13.9% of the ED visits. According to triage criteria in this study,
more than one third (38.4%) of the geriatric patients’ visits were
rated as “Triage I “or “II “(higher disease acuity) as compared
to16.0% in the pediatric and 24.0% in the non-elderly adult groups.
Extremely old patients were more frequently arrived by ambulance
then the elderly, non-elderly adult and pediatric patients (9.1%
vs 5.5% vs 3.9% vs 0.6%, P<0.001). The geriatric patients occupied
41.7% of the general beds and 45.0% of the ICU beds that used by
ED admission. The rate of revisiting within 48-hr period was similar
among the four groups whereas that within one-month period was highest
in the extremely old aged (13.9% vs 10.9% vs 6.5% vs 6.0%, P<0.001).
The geriatric patients especially the extremely old consumed more
ED resources and works, stayed a longer time in the ED (mean time
of 14.8 hours vs 10.1 hours vs 5.3 hours vs 2.4 hours, P<0.0001),
and also incurred a higher mean expenditure per individual (NTD
4765 vs NTD 4487 vs NTD 1930 vs NTD 627, P<0.0001). The leading
illness of the geriatric patients was related to gastrointestinal
disease as compared to trauma in the non-elderly adult and respiratory
disease in the pediatric patients respectively. Our study provided
the information that highlighted the escalating demand of geriatric
medical service and had the implications on future medical facilities
setup, teaching program, clinical research and financial planning.
Key words---Emergency Department; Geriatric Patients
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Introduction
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Emergency department (ED) utilization
is increasing globally; therefore there is a growing interest in
the characteristics of the ED population. On the other hand, geriatric
population is growing in many developed and developing countries.
In Taiwan, the average life expectancy has increased from 56.3 years
for women in 1952 to 77.8 years in 1998 and from 53.4 to 71.9 years
in men; and elderly population of over 65 years old increased from
5.5% in 1987 to 8.3% in 1998 1. The
impact of this issue to the national expenditures of health cares
especially ED utilization by the geriatric patients will be of special
concern. There were many studies especially concerning care of the
geriatric patients in the ED in United States 2,
5, 7-14. These articles
provided the invaluable information concerning the experiences of
ED in United States. The specialty of emergency medicine is developing
in Taiwan. The development has generally followed the same sequence
of change experienced in the United States. ED utilization by the
geriatric patients in the Taiwan medical community, had been reported
in some studies 4,16-19,
however, still limited in the local literatures. This prospective
consecutive cases study addressed the pattern of ED use of a community
ED in terms of gender, age-group distribution, ambulance use, rate
of revisiting, disease severity and categories, time and resources
consumed, patients disposition and specifically focused on the emergency
services handling for the geriatric population. Our study has the
following purposes: 1) to construct a demographic profile of the
ED patients with according to age distribution; 2) to provide essential
information that emphasizes the growing importance of the aged as
consumers of emergency medical care; 3) to improve patient care,
formation of guidelines concerning future medical facilities setup,
clinical research and financial planning. 4) To highlight the need
of geriatric medical services and knowledge for the emergency physicians
(EP) and other hospital staffs. |
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Methods |
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Study Population |
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This prospective study was conducted
in the ED of Shin-Kong Wu Ho-Su Memorial Hospital (SKH), a 750 beds
community teaching hospital in Taipei, a city of 2,639,939 populations,
in which 9.2 % are >65 years 1.
SKH is one of the 13 qualified hospitals with EP training program
in Taiwan. The 24-hour service ED serves approximately 80,000 patient
visits annually with 750 beds available to handle patients that
mainly came from Taipei City and Taipei County. The study was carried
out from April 9, 1999 through June 27, 1999 in a period of 80 consecutive
days in which 17,446 consecutive cases visiting the ED. We divided
the patients into 4 age groups. Group A was pediatric patients of
age < 15 yr; Group B was non-elderly adult patients of age 15-64
yr; Group C was elderly patients of age 65-74 yr and Group D was
extremely old patients of age >75 yr. |
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Study Items |
A form sheet was designed to record
the data. This form sheet was attached to each of the ED medical
record during arrival and was collected by the counter when patient
discharged. Arrival time, mode of arrival and triage category were
recorded by a triage nurse on the form sheet. Triage category was
also made by the EP when patient was examined. In case of existent
of controversial between the triage nurse and EP, medical chart
were reviewed, final triage category were made by the authors. Information
about revisiting within 48-hrs and recent 1 month (both were regardless
the same hospital or not prior to this visit) were obtained during
history taking by the EP. Disease categories, final disposition
of the patients were also recorded on the form. The time of leaving
the ED was recorded at the counter and hence the length of stay
was known. The application of intravenous catheterization, ancillary
laboratory tests, as well as diagnostic aid utilization were also
recorded on the form during patients’ staying at ED, this was done
by the nurse specialist, any uncompleted form was checked by reviewing
the billing records. The medical expenditure to be refunded from
the National Health Insurance (NHI) by the hospital of each individual
patient was obtained from the computer billing records. The uncompleted
data were checked and completed with reviewing the medical logbooks,
ambulance dispatch records and computer records (arrival and leaving
time records). |
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All the collected forms and hence
the final data were keyed into the data bank by an assistant and
were analyzed by the authors. |
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Triage Classification |
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The triage classification used
in this study ED was listed in Table 1 .
The criteria used for the triage were modified from criteria that
announced by NHI Department, Taiwan, April 1998. |
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Table 1. Guidelines for Triage Classification
in SKH ED |
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Disease Categories |
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The diseases presented to the ED
were classified into the following categories: 1) cardiovascular
diseases; 2) respiratory & pulmonary diseases (including the
URI, tonsillitis); 3) neurological diseases; 4) infection, 5) DOA
(Death on arrival), out of hospital death; 6) gastrointestinal diseases;
7) trauma and injuries; 8) other miscellaneous conditions (genitourinary,
dermatologic, endocrine, intoxications, hematologic etc). All the
patients were coded with at least one ICD-9 (International Code
of Disease) number for the aid of disease identification. |
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Laboratory Test Classification |
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For ancillary laboratory tests,
patients were categorized into those who underwent: 1) no test;
2) 1-3 tests and 3) 34 tests. Tests were grouped under the specific
group or panel regardless of how many items (this was ticked in
the same panel sheet), for example, “one test “of “Blood Chemistry
panel” was considered when Blood glucose, Aspartate amino-transferase,
Sodium, Potassium, Lipase level were checked. Other examples of
specific panel group which were considered as “one test” included:
“Hematology panel “(complete blood count and differential, Prothrombin
time, Activated partial thromboplastin time, etc); “Urine Study”
(routine, pregnancy test etc) and “Cultures” (blood, urine, sputum
etc). |
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Statistic Analysis |
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Statistical procedures and analysis
were performed using the Microsoft Excel, Access version 98 and
SAS 6.12. Proportion variables among the groups were compared by
using Chi-square (X2) analysis. Continuous (length of
stay, medical expenditure) variables among the groups were compared
using and ANOVA (analysis of variance) technique. |
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Results |
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ED Patients Characteristics |
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There were 17,446 patients visited
the ED in the study period. The finally completed forms were 16,925
(97%) cases. Three percent of the form sheets (521 cases) were either
missing during the collection or the main items could not be identified
(no name, birth date, register number and arrival time for the same
individual) and were discarded from the study. The gender ratio
of men to women was 1.03:1 at an overall, but inversely altered
with increasing of age (Table 2 ).
The stratification of patients according to age and their percentage
were shown in Table 3 .
The Group C and Group D had a sum of 13.9% (2,343 visits). Thus,
the geriatric patients in the ED exceeded the expected portion measured
by the distribution of general population when accounted for the
9.2% of aged ( >65 yr) in the city. Our subdivision of
geriatric patients showed that 45.0% of the geriatric patients were
>75 years old. |
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Table 2. Sex and Gender distribution of the age
stratified patients |
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Table 3. Comparison of the clinical characteristics
of the four groups of age stratified patients |
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Severity of Disease |
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The degree of emergency of illness
in these four groups of patients could be seen in Table 3. 38.4%
of the geriatric patients’ visits were rated either as “Category
I” or “ II” according to triage classification in Table 1 . |
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Rate of Ambulance Use |
It is difficult to determine the
inappropriate use of ambulance from the data. Regardless of this
problem, the rate of ambulance use was disproportionately high in
the geriatric patients especially in Group D (9.1%, P<0.001).
(Table 3 ).
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Disposition of the
Patients (Admission and Transferal) |
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Group C and Group D together was
3.3 times more likely to need admission than Group B (23.7% vs 7.3%)
and 21.3 times (23.7% vs 1.1%) to that of Group A patients in this
hospital of the study. Group C and Group D together also had a higher
mean of transferal rate than Group B (1.3% vs 0.5%) and Group A
(1.3% vs 0.1%). (Table 3 ). |
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Rate of ED Revisiting |
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6.3% of Group A revisited within
48-hours, while 6.8% of Group B, 7.7% of Group C and 6.7% of Group
D patients did respectively. For ED revisit within 1 month, 6.0%
of Group A had the experience as compared to 6.5 % of the Group
B, 10.9% of Group C and that of 13.9% of the Group D patients. (Table
3 ). |
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ED Resources Consumed |
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When accounting for hospital admissions
via ED, the geriatric patients occupied 41.7% of the general beds
and 45.0% of the ICU beds used by ED admission (Table 3 ).
The ED resources utilization were significantly high in the geriatric
patients and especially highest in the Group D patients. |
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Length of Stay in the
ED |
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The length of stay (LOS) in the
ED of the four groups of patients was shown in Table 4 .
The geriatric patients stayed a longer time in ED than the younger
counterparts. |
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Table 4. Length of stay and medical expenditure
of the age stratified patients |
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Medical Cost Expenditure |
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Table 4 also indicated the total
medical cost expenditure that was claimed from the NHI by the hospital
in these cases. There were some missing data (of those patients
who paid themselves, overdue bills, escaped without payment or without
the application of NHI), 595 of the16, 925 billing records (3.5%)
were not available during the processing. These missing parts might
confound the data but was assumed to be to a less degree. The remaining
16,330 cases made an expenditure of NT 31,727,747. The average medical
expenditure per individual was significantly higher in the geriatric
patients especially in the Group D (Table 4 ). |
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Disease Distribution |
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The disease distribution in ED patients of the study
hospital can be revealed in Table 5. |
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Table 5.Main diseases distribution of the age
stratified patients |
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Discussion |
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The aging of population had created
a great pressure to the society in many countries. With the rapid
growth of size in the aged, providers, practitioners and administrators
of health care system can expect an increasing medical demands and
health care costs for the geriatric patients. This will meet an
even greater impact during the next several decades. The statistical
data from The Bureau of Census in Taiwan showed that geriatric population
older than 64 years old had accounted for 8.3% of the total population
in 1998, and will continue to increase triple fold to 23.9% in the
next 50 years 1. In the future, a greater
share of emergency physicians’ time and efforts will consist of
treating the elderly, and more of the resources will be encountered
for the special needs of the aged.
In our study, the geriatric patients older than 65 years old occupied
13.9% of all the visits to the ED although they comprised 9.2% of
the population in this city, this is compatible with the results
of previous studies2,3. The rate however was relatively less as
reported by Hu.et al4 in their combine study of eight hospitals
of Taipei City in which 24.3% of ED visits were by geriatric patients.
However, there were some possible confounders in our study. Firstly,
our data was collected in 80 days; this was subjected to seasonal
variations of disease pattern and volume. Secondly, although our
sample size was large, only one community hospital was surveyed,
it might not represent the whole ED use pattern of this city. The
difference between our study and Hu et al 4
also indicated that the range of variation between hospitals was
great in this city. For example, in Taipei Veteran General Hospital,
geriatric patients might be relatively higher in proportion with
comparison to other hospitals. Nevertheless, both of them showed
the disproportion of geriatric patients as mentioned. In the American
population the fastest growing segment was the group over 85 years
of age 2, 5-7. In
our study, group D comprised 45% of the geriatric patients; this
group will definitely deserve special attention in the future since
this segment of population will continue to grow as medical improvement
tends to “extend human’s lives”.
The possible factor that caused the disproportional gender ratio
in this study would be the gender distribution in this community,
but we had no sufficient statistical data to prove it.
38.4% of our geriatric patients had remarkably higher disease acuity
and had life threatening or emergent medical conditions. This was
similar to those in other studies 2,8-12.
Therefore, a relatively high percentage of geriatric patients use
the ED appropriately as compared to the other subgroups. On the
other hand, they have the lowest percentage of non-emergent ED visits
relatively to the younger counterparts.
The decreased mobility of the geriatric patients when sick, and
their higher position in triage classification, made them the frequent
user of ambulance services. This was especially true in the extremely
old aged group (9.1%) as compared to the elderly patients (5.5%),
non-elderly adults (3.9%) and pediatric patients (0.6%). There were
even more remarkable outcomes in Western country studies in which
EMS was highly developed. Strange et al 2
showed that 36.0 % of geriatric patients arrived the ED by ambulance.
Dickinson et al 14 even reported of
39% of total EMS call volume was by the geriatric patients.
The increase in the admission rate of the aged particularly to ICU
also reflected the increase in their disease severity. Our data
indicated that 22.7% of extremely old patients were admitted to
the general beds, compared with 19.0% of the 65-74 yrs patients,
6.7% of the non-elderly adult patients and 0.5% of the pediatric
patients. This was consistent to other studies 2,8,9,15.
In consideration of the need of ICU admission, our data showed that
4.0% of the extremely old patients required critical care, whereas
this was 2.3% for the elderly of age 65-74 yrs, 0.6% for the non-elderly
adults, and 0.1% for the pediatric patients. These data were consistent
with others studies2,4. Our survey also indicated a higher proportion
of transferal in the geriatric population in the ED, which was 1.7%
of the extremely old patients compared to 0.9% of the elderly, 0.5%
of the non-elderly adults and 0.06% of the pediatric patients. The
higher transferal rate also in some degree indicated that the supply
(beds, facilities..) was unable to meet the demand in this group.
Revisiting rate can reflect the severity of the patients’ illness.
Lowenstein et al 9 postulated that the
high rate of revisiting probably reflected multiple factors, including
the number and complexity of older patients’ medical problems and
the difficulties in providing frail elders with episodic and follow-up
care. It was expected that the rate of 48-hr revisiting rate to
the ED (including those visited other ED of other hospital(s) previously)
by the geriatric patients would be much higher than the younger
subjects, our pilot study however, showed less difference of the
rate of returning within 48 hours among the four groups. We postulated
that this was probably due to the escalating ED use of the public
(mostly the younger patients) as a faster route of solving their
medical problems if symptoms did not subsided after their previous
visit(s), therefore there was almost equal rate of return regardless
of the age group. Taiwan had adopted a national health insurance
program that nearly covered all the citizens, this made ED visit
was rather affordable. Many patients utilize ED as the alternative
of OPD follow-up and some were indeed hospital shopping to seek
different opinion. Another possibility that lessen the difference
was the more acuity of illness of the geriatric patients that resulted
in their longer observation in ED or admissions and even transferals
to other higher medical centers, these would make the rate of revisiting
within 48 hours lower in the aged in this community hospital.
When expending the revisiting period to one month, the geriatric
patients showed a higher rate of ED visits. It explained that the
geriatric often suffered from a variety of chronic diseases and
in some part were more likely to return for additional care.
As previously noted, the geriatric patients occupied more admission.
They were also more likely to receive other medical resources in
ED. This was related to their higher likelihood of serious disease
and vaguer of their symptoms. As a result, EPs tended to investigate
them more thoroughly. We agreed with Baum and Rubinstein’s 8
idea that these tests and investigations were not overordered instead
was helpful for the elderly who presented with atypical complaints.
Geriatric cases were much more associated with admission and observation
due to their disease complexity and severity, therefore more time
was spent to gather the laboratory data and more procedures and
diagnostic evaluation were performed before their disposition. As
a result, they had a longer length of stay in ED.
The medical cost expenditure in ED care was strikingly different
between the geriatric and young subjects. This was consistent with
Singal et al’s 10 finding. Our survey
on mean ED expenditure per individual for the different categories
showed that this was NT 627 for the pediatric patients, NT 1,930
for the non-elderly adult patients, NT 4,487 for the elderly patients
and was up to NT 4,765 for the extremely old patients. Due to their
severity of illness and complexity in differential diagnosis, geriatric
patients received a great deal of tests, diagnostic examinations,
procedures, medications, and longer length of stay in ED, therefore
they were, not surprisingly had higher charges during their ED care.
The disease distribution in ED patients was different as well. Respiratory
illness was the leading disease in the pediatric. Due to the physical
activity and the environmental exposure of their daily life, trauma
was the leading cause of ED visit in the non-elderly adult patients.
Whereas for the geriatric patients gastrointestinal disease was
the leading cause of ED visit. The rate of cardiovascular and neurological
diseases also higher in the aged than the younger counterparts.
This is consistent with other studies 4,9.
The high prevalence of gastrointestinal disease in these four groups
also emphasized the growing importance of practicing abdominal ultrasonography
by EPs to handle those present with acute abdomen.
Attention should be paid to the social and care problems of geriatric
patients. Early social service intervention in the ED may be beneficial
to the geriatrics. Social workers might staff EDs and the high-risk
geriatric patients should be followed-up.
Our study had some limitations, as mentioned earlier, our data was
collected in a consecutive 80 days; this was subjected to seasonal
variations of disease pattern and patients’ volume which would confound
the above collected data. Besides only one community hospital was
studied, the administration and management patterns, for example
admission criteria, triage, specific bed availability (e.g. pediatric
ICU) and role of ED among different hospitals are quite varied in
Taiwan and thus this study would not represent the total ED use
pattern of Taiwan.
ED provides a vital service for the health care consumers in the
past and future especially for the geriatric patients. Our prospective
study had constructed a demographic profile of ED population seeking
medical care in a community hospital. It also pointed that the geriatric
patients use the ED differently and uniquely as compared to the
younger counterparts. The high rate of resources used by the aged
also suggested that the health care planning and adequacy of resources
delivery must be evaluated. ED providers, administrators, health
policy analysts and government organizations should prepare to meet
the escalating health care demands of the geriatric patients. The
more severity and urgency and complexity of illness of the aged
patients suggested that attention should be paid. There is also
a need for reassessing the knowledge of ED staffs toward elderly
patients. As suggested by Sanders AB 5,
Geriatrics should be incorporated into the training program of EPs
as well as other ED staffs.
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Acknowledgements |
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We thank the staff of the ED of Shin-Kong Wu Ho-Su Memorial
Hospital for their help in data collection in this study; Eve Chin
and Shin-Ru Sheay for their assistance in data processing and statistical
analysis. |
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References |
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1. |
Statistical data, 1998. Bureau of Census; Department
of Health, Taiwan. |
2. |
Strange GR, Chen EH, Sanders AB: Use of Emergency Departments by
Elderly Patients: Projections From a Multicenter Data Base. Ann Emerg
Med 1992;21:819-24 |
3. |
Strussman BJ: Advance Data: National Hospital Ambulatory Medical
Care Survey: 1993 Emergency Department Summary. National Center for
Health Statistics, US Department of Health and Human Services, Number
271, January 25, 1996. |
4. |
Hu SC, Yen D, Yu YC, Kao WF et al: Elderly use of the ED in an
Asian Metropolis. Am J Emerg Med 1999;17:95-9 |
5. |
Sanders AB: Care of the Elderly in Emergency Departments: Where
Do We Stand? Ann Emerg Med 1992;21:792-4 |
6. |
US Senate Special Committee on Aging: Aging America: Trends and
Projections. Washington, DC, US Department of Health and Human Services,
1988. |
7. |
Eliastam M: Elderly patients in the emergency department. Ann Emerg
Med 1989;18:1222-9 |
8. |
Baum SA, Rubenstein LZ: Old People in the Emergency Room: Age-related
Differences in Emergency Department use and Care. J Am Geriatric Soc
1987; 35:62-8 |
9. |
Loweinstein SR, Crescenzi CA, Kern Dc et al: Care of the Elderly
in the Emergency Department. Ann Emerg Med 1986; 15:528-34 |
10. |
Singal BM, Hedges JR, Sanders AB, et al: Geriatric Patient Emergency
Visits Part I: Comparison of Visits by Geriatric and Younger Patients.
Ann Emerg Med 1992;21:802-7 |
11. |
Hedges JR, Singal BM, Rousseau EW, et al: Geriatric Patient Emergency
Visits Part II: Perceptions of Visits by Geriatric and Younger Patients.
Ann Emerg Med 1992;21:808-12 |
12. |
Gerson LW, Skvarch: Emergency Medical Service Utilization by the
Elderly. Ann Emerg Med 1982;11:610-2 |
13. |
Sanders AB: Care of the elderly in Emergency Departments: Conclusions
and Recommendations. Ann Emerg Med 1992;21:830-4 |
14. |
Dickinson ET, Verdile VP, Kostyun CT et al: Geriatric Use of Emergency
Medical Services. Ann Emerg Med 1996;27:199-203 |
15. |
Gillick M, Steel K: Referral of Patients from Long-term to Acute
Care Facilities. J Am Geriatric Soc 1983;231:74-8 |
16. |
Liao HC, Bullard MJ, Hu PM et al: Clinical Presentations of elderly
patients at emergency departments: a comparison between a medical
center and a community hospital. Changgeng Yi Xue Za Zhi, 2000;23:681-7 |
17. |
Chen JC, Bullard MJ, Hu PM et al: Differences of disease characteristics
between genders in emergency department elderly of a community hospital
in Taiwan. Changgeng Yi Xue Za Zhi, 2000;23:190-6 |
18. |
Liaw SJ, Bullard MJ, Hu PM et al: Rates and causes of emergency
department revisits within 72 hours. J Formos Med Assoc.1999;98:422-5 |
19. |
Bullard MJ, Liaw SJ, Chen JC. Emergency medicine development in
Taiwan. Ann Emerg Med. 1996;28:542-8 |
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