Emergency medicine resident clinical experience vs. in-training examination content: A national database study

OBJECTIVES

Emergency medicine (EM) residents take the In-Training Examination (ITE) annually to assess medical knowledge. Question content is derived from the Model of Clinical Practice of Emergency Medicine (EM Model), but it is unknown how well clinical encounters reflect the EM Model. The objective of this study was to compare the content of resident patient encounters from 2016-2018 to the content of the EM Model represented by the ITE Blueprint.

METHODS

This was a retrospective cross-sectional study utilizing the National Hospital Ambulatory Medical Care Survey (NHAMCS). Reason for visit (RFV) codes were matched to the 20 categories of the American Board of Emergency Medicine (ABEM) ITE Blueprint. All analyses were done with weighted methodology. The proportion of visits in each of the 20 content categories and 5 acuity levels were compared to the proportion in the ITE Blueprint using 95% confidence intervals (CIs).

RESULTS

Both resident and nonresident patient visits demonstrated content differences from the ITE Blueprint. The most common EM Model category were visits with only RFV codes related to signs, symptoms, and presentations regardless of resident involvement. Musculoskeletal disorders (nontraumatic), psychobehavioral disorders, and traumatic disorders categories were overrepresented in resident encounters. Cardiovascular disorders and systemic infectious diseases were underrepresented. When residents were involved with patient care, visits had a higher proportion of RFV codes in the emergent and urgent acuity categories compared to those without a resident.

CONCLUSIONS

Resident physicians see higher acuity patients with varied patient presentations, but the distribution of encounters differ in content category than those represented by the ITE Blueprint.

Arranging Hospice Care from the Emergency Department: A Single Center Retrospective Study

BACKGROUND

Arranging hospice services from the Emergency Department (ED) can be difficult due to physician discomfort, time constraints, and the intensity of care coordination needed. We report patient and visit characteristics associated with successful transition from the ED directly to hospice.

METHODS

Setting: Academic ED with 82,000 annual visits.

POPULATION

ED patients with a referral to hospice order placed during the ED visit from January 2014-December 2018. Charts were abstracted by trained, non-blinded personnel. Primary goal was to evaluate patient and visit factors associated with requiring admission for hospice transition.

RESULTS

Electronic Health Record inquiry yielded 113 patients, 93 of which met inclusion criteria. Patients were aged 65.8 years (range 32-92), 54% were female, and 78% were white, non-hispanic. The majority had cancer (78%, n = d72) and were on public insurance (60%, n = 56). Half (55%, n = 51) were full code upon arrival. Average ED length of stay was 4.6 ± 2.6 hours. Discharge from the ED to hospice was successful for 38% (n = 35), a few (n = 5) were dispositioned to an ED observation unit, and 57% (n = 53) were admitted. Only 10 (11%) required an inpatient length of stay longer than an observation visit (2 days). Case management and social work team arranged for transportation (54.8%, n = 51), hospital beds (16.1%, n = 16), respiratory equipment (18.3%, n = 17), facility placement (33.3%, n = 31), and home health aides (29.0%, n = 27).

CONCLUSION

Transitioning patients to hospice care from the ED is possible within a typical ED length of stay with assistance from a case manager/social work team.

An implementation science approach to geriatric screening in an emergency department

BACKGROUND

The Geriatric Emergency Department (ED) Guidelines recommend screening older adults during their ED visit for delirium, fall risk/safe mobility, and home safety needs. We used the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementation Change (ERIC) tool for preimplementation planning.

METHODS

The cross-sectional survey was conducted among ED nurses at an academic medical center. The survey was adapted from the CFIR Interview Guide Tool and consisted of 21 Likert scale questions based on four CFIR domains. Potential barriers identified by the survey were mapped to identify recommended implementation strategies using ERIC.

RESULTS

Forty-six of 160 potential participants (29%) responded. Intervention Characteristics: Nurses felt geriatric screening should be standard practice for all EDs (76.1% agreed some/very much) and that there was good evidence (67.4% agreed some/very much). Outer setting: The national and regional practices such as the existence of guidelines or similar practices in other hospitals were unknown to many (20.0%). Nurses did agree some/very much (64.4%) that the intervention was good for the hospital/health system. Inner Setting: 67.4% felt more staff or infrastructure and 63.0% felt more equipment were needed for the intervention. When asked to pick from a list of potential barriers, the most commonly chosen were motivational (I often do not remember (n = 27, 58.7%) and It is not a priority (n = 14, 30.4%)). The identified barriers were mapped using the ERIC tool to rate potential implementation strategies. Strategies to target culture change were identifying champions, improve adaptability, facilitate the nurses performing the intervention, and increase demand for the intervention.

CONCLUSION

CFIR domains and ERIC tools are applicable to an ED intervention for older adults. This preimplementation process could be replicated in other EDs considering implementing geriatric screening.

Diagnosing Dyspneic Older Adult Emergency Department Patients: A Pilot Study

Study Objectives:

Pneumonia, chronic obstructive pulmonary disease (COPD), and heart failure (HF) exacerbations can present similarly in the older adult in the Emergency Department (ED), leading to sub-optimal treatment from over- and under-diagnosis. There may be a role for antimicrobial peptides (AMPs) in improving the accurate diagnosis of pneumonia in these patients.

Methods:

This pilot was a prospective, observational cohort study of older adults (aged ≥65 years of age) who presented to the ED with dyspnea or elevated respiratory rate. To identify biomarkers of pneumonia, serum levels of white blood cell count, procalcitonin (PCT), and antimicrobial peptides (human beta defensin 1 and 2 [HBD-1, -2], human neutrophil peptides 1–3 [HNP1–3] and cathelididin [LL-37]) were compared between those with and without pneumonia. Criterion standard reviewers retrospectively determined the diagnoses present in the ED.

Results:

Three hundred ninety-one patients were screened, 140 were eligible, and 79 were enrolled. Based on criterion standard review, pneumonia was present in 10 (12.7%), COPD in 9 (11.4%) and HF in 31 (39.2%) with a co-diagnosis rate of 10.1% by criterion standard review. Comparatively, emergency medicine attending physicians diagnosed pneumonia in 16 (20.3%), COPD in 12 (15.2%), and HF in 30 (38.0%) with co-diagnosis rate of 15.2%. Emergency physicians agreed with criterion standard diagnoses in 90% of pneumonia, 75% of COPD and 65% of HF diagnoses. Differences in leukocyte count (p<0.01) and two novel AMPs (DEFA5 (p=0.08) and DEFB2 (p=0.09)) showed promise for diagnosing pneumonia.

Conclusions:

Emergency physicians continue to have poor diagnostic accuracy in dyspneic older adult patients. Serum AMP levels are one potential tool to improve diagnostic accuracy and outcomes for this important population and require further study.

Opioid Treatment Deserts: Concept development and application in a US Midwestern urban county

Objectives

An Opioid Treatment Desert is an area with limited accessibility to medication-assisted treatment and recovery facilities for Opioid Use Disorder. We explored the concept of Opioid Treatment Deserts including racial differences in potential spatial accessibility and applied it to one Midwestern urban county using high resolution spatiotemporal data.

Methods

We obtained individual-level data from one Emergency Medical Services (EMS) agency (Columbus Fire Department) in Franklin County, Ohio. Opioid overdose events were based on EMS runs where naloxone was administered from 1/1/2013 to 12/31/2017. Potential spatial accessibility was measured as the time (in minutes) it would take an individual, who may decide to seek treatment after an opioid overdose, to travel from where they had the overdose event, which was a proxy measure of their residential location, to the nearest opioid use disorder (OUD) treatment provider that provided medically-assisted treatment (MAT). We estimated accessibility measures overall, by race and by four types of treatment providers (any type of MAT for OUD, Buprenorphine, Methadone, or Naltrexone). Areas were classified as an Opioid Treatment Desert if the estimate travel time to treatment provider (any type of MAT for OUD) was greater than a given threshold. We performed sensitivity analysis using a range of threshold values based on multiple modes of transportation (car and public transit) and using only EMS runs to home/residential location types.

Results

A total of 6,929 geocoded opioid overdose events based on data from EMS agencies were used in the final analysis. Most events occurred among 26–35 years old (34%), identified as White adults (56%) and male (62%). Median travel times and interquartile range (IQR) to closest treatment provider by car and public transit was 2 minutes (IQR: 3 minutes) and 17 minutes (IQR: 17 minutes), respectively. Several neighborhoods in the study area had limited accessibility to OUD treatment facilities and were classified as Opioid Treatment Deserts. Travel time by public transit for most treatment provider types and by car for Methadone-based treatment was significantly different between individuals who were identified as Black adults and White adults based on their race.

Conclusions

Disparities in access to opioid treatment exist at the sub-county level in specific neighborhoods and across racial groups in Columbus, Ohio and can be quantified and visualized using local public safety data (e.g., EMS runs). Identification of Opioid Treatment Deserts can aid multiple stakeholders better plan and allocate resources for more equitable access to MAT for OUD and, therefore, reduce the burden of the opioid epidemic while making better use of real-time public safety data to address a public health epidemic that has turned into a public safety crisis.

Applying Geriatric Principles to Transitions of Care in the Emergency Department

Each emergency department (ED) visit represents a crucial transition of care for older adults. Systems, provider, and patient factors are barriers to safe transitions and can contribute to morbidity and mortality in older adults. Safe transitions from ED to inpatient, ED to skilled nursing facility, or ED back to the community require a holistic approach, such as the 4-Ms model-what matters (patient goals of care), medication, mentation, and mobility-along with safety and social support. Clear written and verbal communication with patients, caregivers, and other members of the interdisciplinary team is paramount in ensuring successful care transitions.

Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021

Objectives

Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care.

Methods

Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables.

Results

Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79–0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8–96.3%), specificity of 20.0% (19.0–21.0%), negative likelihood ratio of 0.22 (0.19–0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points).

Conclusion

Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.

311 service requests as indicators of neighborhood distress and opioid use disorder

Opioid use disorder and overdose deaths is a public health crisis in the United States, and there is increasing recognition that its etiology is rooted in part by social determinants such as poverty, isolation and social upheaval. Limiting research and policy interventions is the low temporal and spatial resolution of publicly available administrative data such as census data. We explore the use of municipal service requests (also known as "311" requests) as high resolution spatial and temporal indicators of neighborhood social distress and opioid misuse. We analyze the spatial associations between georeferenced opioid overdose event (OOE) data from emergency medical service responders and 311 service request data from the City of Columbus, OH, USA for the time period 2008-2017. We find 10 out of 21 types of 311 requests spatially associate with OOEs and also characterize neighborhoods with lower socio-economic status in the city, both consistently over time. We also demonstrate that the 311 indicators are capable of predicting OOE hotspots at the neighborhood-level: our results show code violation, public health, and street lighting were the top three accurate predictors with predictive accuracy as 0.92, 0.89 and 0.83, respectively. Since 311 requests are publicly available with high spatial and temporal resolution, they can be effective as opioid overdose surveillance indicators for basic research and applied policy.

Hospital Costs and Reimbursement Model for a Geriatric Emergency Department

OBJECTIVES

The American College of Emergency Physicians' geriatric emergency department (GED) guidelines recommend additional staff and geriatric equipment, which may not be financially feasible for every ED. Data from an accredited Level 1 GED was used to report equipment costs and to develop a business model for financial sustainability of a GED.

METHODS

Staff salaries including the cost of fringe benefits were obtained from a Midwestern hospital with an academic ED of 80,000 annual visits. Reimbursement assumptions included 100% Medicare/Medicaid insurance payor and 8-hour workdays with 4.5 weeks of leave annually. Equipment costs from hospital invoices were collated. Operational and patient safety metrics were compared before and after the GED.

RESULTS

A geriatric nurse practitioner in the ED is financially self-sustaining at 7.1 consultations, a pharmacist is self-sustaining at 7.7 medication reconciliation consultations, and physical and occupational therapist evaluations are self-sustaining at 5.7 and 4.6 consults per workday, respectively. Total annual equipment costs for mobility aids, delirium aids, sensory aids, and personal care items for the GED was $4,513. Comparing the 2 years before and after, in regard to operational metrics the proportions of patients with lengths of stay > 8 hours and patients placed in observation did not change. In regard to patient safety, the rate of falls decreased from 0.60/1,000 patient visits to 0.42/1,000 in the ED observation unit and 0.42/1,000 to 0.36/1,000 in the ED. ED recidivism at 7 and 30 days did not change. Estimated cost savings from the reduction in falls was $80,328.

CONCLUSION

The additional equipment and personnel costs for comprehensive geriatric assessment in the ED are potentially financially justified by revenue generation and improvements in patient safety measures. A geriatric ED was associated with a decrease in patient falls in the ED but did not decrease admissions or ED recidivism.

Study protocol for IMAGE: implementing multidisciplinary assessments for geriatric patients in an emergency department observation unit, a hybrid effectiveness/implementation study using the Consolidated Framework for Implementation Research

BACKGROUND

Older adults in the emergency department (ED) are at high risk for functional decline, unrecognized delirium, falls, and medication interactions. Holistic assessment by a multidisciplinary team in the ED decreases these adverse outcomes and decreases admissions, but there are many barriers to incorporating this type of care during the ED visit.

METHODS

This is a hybrid type II effectiveness-implementation study using a pre-/post-cohort design (n = 380) at a tertiary care academic ED with an ED observation unit (Obs Unit). The intervention is a two-step protocol of (step 1) ED nurses screening adult patients ≥ 65 years old for geriatric needs using the Delirium Triage Screen, 4-Stage Balance Test, and the Identifying Seniors at Risk score. Patients who have geriatric needs identified by this screening but who do not meet hospital admission criteria will (step 2) be placed in the Obs Unit for multidisciplinary geriatric assessment by the hospital's geriatric consultation team, physical therapists, occupational therapists, pharmacists, and/or case managers. Not all patients may require all elements of the multidisciplinary geriatric assessment. The Consolidated Framework for Implementation Research: Care Transitions Framework was used to identify barriers to implementation. Lean Six Sigma processes will be used to overcome these identified barriers with the goal of achieving geriatric screening rates of > 80%. Implementation success and associated factors will be reported. For the effectiveness aim, pre-/post-cohorts of adults ≥ 65 years old cared for in the Obs Unit will be followed for 90 days post-ED visit (n = 150 pre and 230 post). The primary outcome is the prevention of functional decline. Secondary outcomes include health-related quality of life, new geriatric syndromes identified, new services provided, and Obs Unit metrics such as length of stay and admission rates.

DISCUSSION

A protocol for implementing integrated multidisciplinary geriatric assessment into the ED setting has the potential to improve patient functional status by identifying and addressing geriatric issues and needs prior to discharge from the ED. Using validated frameworks and implementation strategies will increase our understanding of how to improve the quality of ED care for older adults in the acute care setting.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier, NCT04068311, registered 28 August 2019.

Concepts in Practice: Geriatric Emergency Departments

In 2018, the American College of Emergency Physicians (ACEP) began accrediting facilities as "geriatric emergency departments" (EDs) according to adherence to the multiorganizational guidelines published in 2014. The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-effective manner and within the capabilities of their facilities and staff. Because all innovation is at heart local and must function within the constraints of local resources, different hospital systems have developed implementation processes for the geriatric ED guidelines according to their differing institutional capabilities and resources. This article describes 4 geriatric ED models of care to provide practical examples and guidance for institutions considering developing geriatric EDs: a geriatric ED-specific unit, geriatrics practitioner models, geriatric champions, and geriatric-focused observation units. The advantages and limitations of each model are compared and examples of specific institutions and their operational metrics are provided.

Does the Emergency Medicine In-training Examination Accurately Reflect Residents' Clinical Experiences?

OBJECTIVE

The American Board of Emergency Medicine Model of the Clinical Practice of Emergency Medicine (ABEM Model) serves as a guide for resident education and the basis for the resident In-training Examination (ITE) and the Emergency Medicine Board Qualification Examinations. The purpose of this study was to determine how closely resident-patient encounters in our emergency departments (EDs) matched the ABEM Model as presented in the specifications of the content outline for the ITE.

METHODS

This single-site study of an academic residency program analyzed all documented resident-patient encounters in the ED during a 2.5-year period recorded in the electronic medical record. The chief complaints from these encounters were matched to the 20 categories of the ABEM Model. Chi-square goodness-of-fit tests were performed to compare the proportions of categorized encounters and proportions of patient acuity levels to the proportions of categories as outlined in the content blueprint of the ITE.

RESULTS

After the exclusion of encounters with missing data and those not involving EM residents, 125,405 encounters were analyzed. We found a significant difference between the clinical experience of EM residents and the ABEM Model as reflected in the ITE for both case categories (p < 0.01) and patient acuity (p < 0.01). The following categories were the most overrepresented in clinical care: signs, symptoms, and presentations; psychobehavioral disorders; and abdominal and gastrointestinal disorders. The most underrepresented were procedures and skills, systemic infectious disorders, and thoracic-respiratory disorders.

CONCLUSION

The clinical experience of EM residents differs significantly from the ITE Content Blueprint, which reflects the ABEM Model. This type of inquiry may help to provide custom education reports to residents about their clinical encounters to help identify clinical knowledge gaps that may require supplemental nonclinical training.

Beyond observation: Protocols and capabilities of an Emergency Department Observation Unit

OBJECTIVE

Emergency Department Observation Units (Obs Units) provide a setting and a mechanism for further care of Emergency Department (ED) patients. Our hospital has a protocol-driven, type 1, complex 20 bed Obs Unit with 36 different protocols. We wanted to understand how the different protocols performed and what types of care were provided.

METHODS

This was an IRB-approved, retrospective chart review study. A random 10% of ED patient charts with a "transfer to observation" order were selected monthly from October 2015 through June 2017. This database was designed to identify high and low functioning protocols based on length of stays (LOS) and admission rates.

RESULTS

Over 20 months, a total of 984 patients qualified for the study. The average age was 49.5 ± 17.2 years, 57.3% were women, and 32.3% were non-Caucasian. The admission rate was 23.5% with an average LOS in observation of 13.7 h [95% CI 13.3-14.1]. Thirty day return rate was 16.8% with 5.3% of the patients returning to the ED within the first 72 h. Thirty six different protocols were used, with the most common being chest pain (13.9%) and general (13.2%). Almost 70% received a consultation from another service, and 7.2% required a procedure while in observation. Procedures included fluoroscopic-guided lumbar punctures, endoscopies, dental extractions, and catheter replacements (nephrostomy, gastrostomy, and biliary tubes).

CONCLUSIONS

An Obs Unit can care for a wide variety of patients who require multiple consultations, procedures, and care coordination while maintaining an acceptable length of stay and admission rate.

A National Dataset Analysis of older adults in emergency department observation units

BACKGROUND

Emergency Department (ED) Observation Units (Obs Units) are prevalent in the US, but little is known regarding older adults in observation. Our objective was to describe the Obs Units nationally and observation patients with specific attention to differences in care with increasing age.

DESIGN

This is an analysis of 2010-2013 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national observational cohort study including ED patients. Weighted means are presented for continuous data and weighted percent for categorical data. Multivariable logistic regression was used to identify variables associated with placement in and admission from observation.

RESULTS

The number of adult ED visits varied from 100 million to 107 million per year and 2.3% of patients were placed in observation. Adults ≥65 years old made up a disproportionate number of Obs Unit patients, 30.6%, compared to only 19.7% of total ED visits (odds ratio 1.5 (95% CI 1.5-1.6), adjusting for sex, race, month, day of week, payer source, and hospital region). The overall admission rate from observation was 35.6%, ranging from 31.3% for ages 18-64 years to 47.5% for adults ≥85 years old (p < 0.001). General symptoms (e.g., nausea, dizziness) and hypertensive disease were the most common diagnoses overall. Older adults varied from younger adults in that they were frequently observed for diseases of the urinary system (ICD-9 590-599) and metabolic disorders (ICD-9 270-279).

CONCLUSIONS

Older adults are more likely to be cared for in Obs Units. Older adults are treated for different medical conditions than younger adults.

White Paper-Geriatric Emergency Medicine Education: Current State, Challenges, and Recommendations to Enhance the Emergency Care of Older Adults

Older adults account for 25% of all emergency department (ED) patient encounters. One in five Americans will be 65 or older by 2030. In response to this need, geriatric emergency medicine (GEM) has developed into a robust area of academic and clinical interest, with extensive evidence-based research and guidelines, including clear undergraduate and postgraduate GEM competencies. Despite these developments, GEM content remains underrepresented in curricula and licensing examinations. The complex reasons for these deficits include a perception that care of older adults is not a core emergency medicine (EM) competency, a disjunction between traditional definitions of expertise and the GEM perspective, and lack of curricular capacity. This White Paper, prepared on behalf of the Academy of Geriatric Emergency Medicine, describes the state of GEM education, identifies the challenges it faces, and reviews innovations, including research presented at the 2018 Society for Academic Emergency Medicine (SAEM) Annual Scientific Meeting. The authors propose a number of recommendations. These include recognizing GEM as a core educational priority in EM, enhancing academic support for GEM clinician-educators, using social learning and practical problem solving to teach GEM concepts, emphasizing a whole-person multisystem approach to care of older adults, and identifying ageist attitudes as a hurdle to safe and effective GEM care.

Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department

OBJECTIVES

To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED).

DESIGN

Preplanned, secondary analysis of a prospective observational study.

SETTING

Tertiary care, academic ED.

PARTICIPANTS

A total of 424 patients in the ED, 65 years or older, including all chief complaints.

MEASUREMENTS

We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection.

RESULTS

Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40-2.53) or malaise/lethargy (PLR range, 1.25-1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15-18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79-0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms.

CONCLUSIONS

The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484-492, 2019.

The feasibility of an inter-professional transitions of care service in an older adult population

BACKGROUND

Older adults discharged from the Emergency Department (ED) are at high risk for medication interactions and side effects; examples of practice models addressing this transition of care are lacking.

METHODS

This was a prospective cohort study for adults in one of two urban community EDs. Patients ≥50 years of age discharged with at least one new, non-schedule II prescription medication were included. Patients had the option of three transitions of care services: 1) pharmacist-only with home delivery of discharge medications and full medication reconciliation, 2) pharmacist and home health care, including home delivery, medication reconciliation, and a visit from a home health nurse, or 3) either of the above without home delivery.

RESULTS

Over seven months, 440 ED patients were screened. Of those, 43 patients were eligible, and three patients elected to join the study. All three patients selected pharmacy-only. Identified barriers to enrollment include the rate of schedule II prescriptions from the ED (53% of potential patients) and high patient loyalty to their community pharmacist.

CONCLUSIONS

A pharmacy and home health care transitions of care program was not feasible at an urban community ED. While the pharmacist team identified and managed multiple medication issues, most patients did not qualify due to prescriptions ineligible for delivery. Patients did not want pharmacist or home health nurse involvement in their post ED visit care, many due to loyalty to their community pharmacy. Multiple barriers must be addressed to create a successful inter-professional transition of care model.

An Emergency Department Observation Unit Is a Feasible Setting for Multidisciplinary Geriatric Assessments in Compliance With the Geriatric Emergency Department Guidelines

BACKGROUND

The Geriatric Emergency Department (ED) Guidelines recommend providing multidisciplinary geriatric assessment in the ED, but these assessments can be difficult to coordinate and may prolong length of stay. Patients who need longer than a typical ED stay can be placed in an ED observation unit (Obs Unit). We investigated the effects of offering multidisciplinary assessments for ED patients in an Obs Unit.

METHODS

Evaluation by a geriatric hospital consultation team, physical therapist, case manager, and/or pharmacist was made available to all Obs Unit patients. Use of any or all of these ancillary consult services could be requested by the Obs Unit physician. A retrospective chart review of random older adult Obs Unit patients was done to assess rates of consult use and interventions by these consulting teams. All patients ≥ 65 years old in our institutional review board-approved, monthly Obs Unit quality database from October 2015 through March 2017 were included.

RESULTS

Our quality database included 221 older patients over 18 months. The mean (±SD) age was 73.3 (±6.8) years (range = 65-96 years) and 55.2% were women. The mean (±SD) observation length of stay was 14.7 (±6.5) hours. The majority (74.3%) were discharged from the Obs Unit and 72-hour ED recidivism was 3.6%. Overall, at least one of the multidisciplinary consultant services were requested in 40.3% of patients (n = 89). Additional interventions or services were recommended in 80.0% of patients evaluated by physical therapy (32 of 40 patients), 100% of those evaluated by a pharmacist (five of five patients), 38% of those evaluated by case management (27 of 71 patients), and 100% of those evaluated by a geriatrician (eight of eight patients). Only 5.4% (n = 12) of patients were placed in observation specifically for multidisciplinary assessment; these patients had a mean (±SD) length of stay of 12.2 (±5) hours and an admission rate of 41.7%.

CONCLUSIONS

Incorporating elements of multidisciplinary geriatric assessment for older patients is feasible within an observation time frame and resulted in targeted interventions. An Obs Unit is a reasonable setting to offer services in compliance with the Geriatric ED Guidelines.

Accuracy of Current Diagnostic Criteria for Acute Bacterial Infection in Older Adults in the Emergency Department

OBJECTIVES

To compare the accuracy of the Loeb criteria, emergency department (ED) physicians' diagnoses, and Centers for Disease Control and Prevention (CDC) guidelines for acute bacterial infection in older adults with a criterion standard expert review.

DESIGN

Prospective, observational study.

SETTING

Urban, tertiary-care ED.

PARTICIPANTS

Individuals aged 65 and older in the ED, excluding those who were incarcerated, underwent a trauma, did not speak English, or were unable to consent.

MEASUREMENTS

Two physician experts identified bacterial infections using clinical judgement, participant surveys, and medical records; a third adjudicated in cases of disagreement. Agreement and test characteristics were measured for ED physician diagnosis, Loeb criteria, and CDC surveillance guidelines.

RESULTS

Criterion-standard review identified bacterial infection in 77 of 424 participants (18%) (18 (4.2%) lower respiratory, 19 (4.5%) urinary tract (UTI), 22 (5.2%) gastrointestinal, 15 (3.5%) skin and soft tissue). ED physicians diagnosed infection in 71 (17%), but there were 33 with under- and 27 with overdiagnosis. Physician agreement with the criterion standard was moderate for infection overall and each infection type (κ = 0.48-0.59), but sensitivity was low (<67%), and the negative likelihood ratio (LR(-)) was greater than 0.30 for all infections. The Loeb criteria had poor sensitivity, agreement, and LR(-) for lower respiratory (50%, κ = 0.55; 0.51) and urinary tract infection (26%, κ = 0.34; 0.74), but 87% sensitivity (κ = 0.78; LR(-) 0.14) for skin and soft tissue infections. CDC guidelines had moderate agreement but poor sensitivity and LR(-).

CONCLUSION

Emergency physicians often under- and overdiagnose infections in older adults. The Loeb criteria are useful only for diagnosing skin and soft tissue infections. CDC guidelines are inadequate in the ED. New criteria are needed to aid ED physicians in accurately diagnosing infection in older adults.

Early geriatric consultation increases adherence to TQIP Geriatric Trauma Management Guidelines

BACKGROUND

The American College of Surgeons' Trauma Quality Improvement Program (TQIP) Geriatric Trauma Management Guidelines recommend geriatric consultation for injured older adults. However it is not known how or whether geriatric consultation improves compliance to these quality measures.

METHODS

This study is a retrospective chart review of our institutional trauma databank. Adherence to quality measures was compared before and after implementation of specific triggers for geriatric consultation. Secondary analyses evaluated adherence by service: trauma service (Trauma) or a trauma service with early geriatric consultation (GeriTrauma).

RESULTS

The average age of the 245 patients was 76.7 years, 47% were women, and mean Injury Severity Score was 9.5 (SD ±8.1). Implementation of the GeriTrauma collaborative increased geriatric consultation rates from 2% to 48% but had minimal effect on overall adherence to TQIP quality measures. A secondary analysis comparing those in the post implementation group who received geriatric consultation (n = 94) to those who did not (n = 103) demonstrated higher rates of delirium diagnosis (36.2% vs 14.6%, P < 0.01) and better documentation of initial living situation, code status, and medication list in the GeriTrauma group. Physical therapy was consulted more frequently for GeriTrauma patients (95.7% vs 68.0%, P < 0.01) Documented goals of care discussions were rare and difficult to abstract. A subgroup analysis of only patients with fall-related injuries demonstrated similar outcomes.

CONCLUSIONS

Early geriatric consultation increases adherence to TQIP guidelines. Further research into the long term significance and validity of these geriatric trauma quality indicators is needed.

Are triage questions sufficient to assign fall risk precautions in the ED?

OBJECTIVES

The American College of Emergency Physicians Geriatric Emergency Department (ED) Guidelines and the Center for Disease Control recommend that older adults be assessed for risk of falls. The standard ED assessment is a verbal query of fall risk factors, which may be inadequate. We hypothesized that the addition of a functional balance test endorsed by the Center for Disease Control Stop Elderly Accidents, Deaths, and Injuries Falls Prevention Guidelines, the 4-Stage Balance Test (4SBT), would improve the detection of patients at risk for falls.

METHODS

Prospective pilot study of a convenience sample of ambulatory adults 65 years and older in the ED. All participants received the standard nursing triage fall risk assessment. After patients were stabilized in their ED room, the 4SBT was administered.

RESULTS

The 58 participants had an average age of 74.1 years (range, 65-94), 40.0% were women, and 98% were community dwelling. Five (8.6%) presented to the ED for a fall-related chief complaint. The nursing triage screen identified 39.7% (n=23) as at risk for falls, whereas the 4SBT identified 43% (n=25). Combining triage questions with the 4SBT identified 60.3% (n=35) as at high risk for falls, as compared with 39.7% (n=23) with triage questions alone (P<.01). Ten (17%) of the patients at high risk by 4SBT and missed by triage questions were inpatients unaware that they were at risk for falls (new diagnoses).

CONCLUSIONS

Incorporating a quick functional test of balance into the ED assessment for fall risk is feasible and significantly increases the detection of older adults at risk for falls.