The decision to admit or discharge a given patient may be complex. Obviously any patients with sepsis, dehydration, hypoxemia, or an inability to take oral medications should be admitted. In addition, frail patients or those with significant underlying disease also may benefit from hospitalization.

The patient's living situation, functional status, and the availability of home and community resources also affect this decision. In many cases, the pendulum swings to admission?a decision well-supported in the literature. Several studies propose that 76-90% of febrile patients over the age of 60 have an illness serious enough to warrant admission! ^4,5 Other studies demonstrate that the febrile elderly patient has an 18-35% likelihood of bacteremia or a focal bacterial infection.^5,117,118 Community- acquired bacteremia in the elderly patient carries a sobering 38% mortality rate.¹¹⁹ These statistics justify a liberal admission policy for the elderly. The threshold for admission should also be lowered for the febrile elderly patient with an unclear diagnosis.

An alternate perspective is that the hospital may be a dangerous place for the elderly. As Samuel Goldwyn pronounced, "A hospital is no place to be sick." Nosocomial infection is a significant possibility, and the unfamiliar environment may lead to confusion and injury. Immobilization in the hospital bed may promote pneumonia, decubitus ulcers, and pulmonary embolus.

Several safeguards should be in place for the discharged patient. If the patient is being returned to a nursing home, write specific orders including monitoring parameters, antibiotic delivery, and follow-up. Specify under what conditions a physician should be called. When possible, discuss the outpatient plan and follow-up with the patient's primary physician. Patients being discharged home should receive explicit discharge instructions and close follow-up. One study of elderly patients discharged from the ED demonstrated that 20% of patients were actually worse at follow-up.¹²⁰ The services of a social worker in the ED may be invaluable. The worker may assess the patients' functional status and social supports and help arrange home health visits.