A national survey of Canadian emergency medicine residents' comfort with geriatric emergency medicine

Geriatric screening in the emergency department increases consultations to geriatric medicine and physical and occupational therapy: A pre/post cohort study

BACKGROUND

The Geriatric Emergency Department (ED) Guidelines recommend screening older patients for need for evaluation by geriatric medicine, physical therapy (PT), and occupational therapy (OT), but explicit evidence that geriatric screening changes care compared to physician gestalt is lacking. We assessed changes in multidisciplinary consultation after implementation of standardized geriatric screening in the ED.

METHODS

Retrospective single-site observational cohort of older adult ED patients from 2019 to 2023 with three time periods: (1) preimplementation, (2) implementation of geriatric screening, and (3) postimplementation. Geriatric, PT, and OT consultations/referrals were available during all time periods. Descriptive analysis was stratified by disposition: discharged, observation and discharged, observation and hospital admission, and hospital admission. The independent variable was completion of three geriatric screening tools by ED nurses. The dependent variable was consultation and/or referral to geriatrics, PT, and OT. Secondary outcomes were disposition, ED revisits, and 30-day rehospitalizations.

RESULTS

There were 57,775 qualifying ED visits of patients age ≥ 65 years during the time periods: implementation increased geriatric screening from 0.5% to 63.2%; postimplementation, discharge patients who received screening had more consultations/referrals to geriatrics (1.5% vs. 0.4%), PT (7.9% vs. 1.9%), and OT (6.5% vs. 1.2%) compared to unscreened patients. Patients observed and then discharged had more consultations/referrals to geriatrics (15.1% vs. 11.3%), PT (74.1% vs. 64.5%), and OT (65.7% vs. 56.5%). Admitted patients had no change in consultation rates. Geriatric screening was not associated with a change in 7-day ED revisits for discharged patients but was associated with decreased revisits for patients discharged from observation (11.6% vs. 42.9%, p < 0.001).

CONCLUSION

Geriatric screening was associated with increased consultations/referrals to geriatrics, PT, and OT in the ED and ED observation unit. This suggests that geriatric screening changes ED care for older adults.

Risk of falls is associated with 30-day mortality among older adults in the emergency department

OBJECTIVE

Falls in older adults correlate with heightened morbidity and mortality. Assessing fall risk in the emergency department (ED) not only aids in identifying candidates for prevention interventions but may also offer insights into overall mortality risk. We sought to examine the link between fall risk and 30-day mortality in older ED adults.

METHODS

Observational cohort study of adults aged ≥ 75years who presented to an academic ED and who were assessed for fall risk using the Memorial Emergency Department Fall Risk Assessment Tool (MEDFRAT), a validated, ED-specific screening tool. The fall risk was classified as low (0-2 points), moderate (3-4 points), or high (≥5) risk. The primary outcome was 30-day mortality. Hazard ratios (HR) with 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 941 patients whose fall risk was assessed in the ED were included in the study. Median age was 83.7 years; 45.6% were male, 75.6% lived in private residences, and 62.7% were admitted. Mortality at 30 days among the high fall risk group was four times that of the low fall risk group (11.8% vs 3.1%; HR 4.00, 95% CI 2.18 to 7.34, p < 0.001). Moderate fall risk individuals had nearly double the mortality rate of the low-risk group (6.0% vs 3.1%), but the difference was not statistically significant (HR 1.98, 95% CI 0.91 to 4.32, p = 0.087).

CONCLUSION

ED fall risk assessments are linked to 30-day mortality. Screening may facilitate the stratification of older adults at risk for health deterioration.

Clinical decision-making and adaptive expertise in residency: a think-aloud study

Clinical decision-making (CDM) is the ability to make clinical choices based on the knowledge and information available to the physician. It often refers to individual cognitive processes that becomes more dependent with the acquisition of experience and knowledge. Previous research has used dual-process theory to explain the cognitive processes involved in how physicians acquire experiences that help them develop CDM. However, less is known about how CDM is shaped by the physicians' situated cognition in the clinical environment. This is especially challenging for novice physicians, as they need to be adaptive to compensate for the lack of experience. The adaptive expert framework has been used to explain how novice physicians learn, but it has not yet been explored, how adaptive expertise is linked to clinical decision-making amongst novice physicians.This study aimed to analyse how residents utilize and develop adaptive expert cognition in a natural setting. By describing cognitive processes through verbalization of thought processes, we sought to explore their CDM strategies considering the adaptive expert framework.We used concurrent and retrospective think-aloud interviews in a natural setting of an emergency department (ED) at a university hospital, to query residents about their reasoning during a patient encounter. We analysed data using protocol analysis to map cognitive strategies from these verbalizations. Subsequently in a narrative analysis, we compared these strategies with the literature on adaptive expertise.Fourteen interviews were audio recorded over the course for 17 h of observation. We coded 78 informational concepts and 46 cognitive processes. The narrative analysis demonstrated how epistemic distance was prevalent in the initial CDM process and self-regulating processes occurred during hypothesis testing. However, residents who too quickly moved on to hypothesis testing tended to have to redirect their hypothesis more often, and thus be more laborious in their CDM. Uncertainty affected physicians' CDM when they did not reconcile their professional role with being allowed to be uncertain. This allowance is an important feature of orientation to new knowledge as it facilitates the evaluation of what the physician does not know.For the resident to learn to act as an adaptive decision-maker, she relied on contextual support. The professional role was crucial in decisional competency. This supports current literature, which argues that role clarification helps decisional competency. This study adds that promoting professional development by tolerating uncertainty may improve adaptive decisional competency.

Challenges and opportunities in creating a deprescribing program in the emergency department: A qualitative study

BACKGROUND

As the population of older adults increases, appropriate deprescribing becomes increasingly important for emergency geriatric care. Older adults represent the sickest patients with chronic medical conditions, and they are often exposed to high-risk medications. We need to provide an evidence-based, standardized deprescribing program in the acute care setting, yet the evidence base is lacking and standardized medication programs are needed.

METHODS

We conducted a qualitative study with the goal to understand the perspective of healthcare workers, patients, and caregivers on deprescribing high-risk medications in the context of emergency care practices, provider preferences, and practice variability, along with the facilitators and barriers to an effective deprescribing program in the emergency department (ED). To ensure rich, contextual data, the study utilized two qualitative methods: (1) a focus group with physicians, advanced practice providers, nurses, pharmacists, and geriatricians involved in care of older adults and their prescriptions in the acute care setting; (2) semi-structured interviews with patients and caregivers involved in treatment and emergency care. Transcriptions were coded using thematic content analysis, and the principal investigator (S.L.) and trained research staff categorized each code into themes.

RESULTS

Data collection from a focus group with healthcare workers (n = 8) and semi-structured interviews with patients and caregivers (n = 20) provided evidence of a potentially promising ED medication program, aligned with the vision of comprehensive care of older adults, that can be used to evaluate practices and develop interventions. We identified four themes: (1) Challenges in medication history taking, (2) missed opportunities in identifying high-risk medications, (3) facilitators and barriers to deprescribing recommendations, and (4) how to coordinate deprescribing recommendations.

CONCLUSIONS

Our focus group and semi-structured interviews resulted in a framework for an ED medication program to screen, identify, and deprescribe high-risk medications for older adults and coordinate their care with primary care providers.

Epidemiology and Clinical Characteristics of Older Patients Transferred from Long-Term-Care Hospitals (LTCHs) to Emergency Departments by a Comparison with Non-LTCHs in South Korea: A Cross-Sectional Observational Study

The South Korean population is rapidly aging, and the number of older patients in long-term-care hospitals (LTCHs) continues to increase. This study aims to investigate the epidemiologic data, characteristics, and clinical outcomes of patients aged 65 years and older transferred from LTCHs to emergency departments (EDs). This is a retrospective study based on National Emergency Department Information System data from 2014 to 2019. Of the 6,209,695 older patients visiting EDs for disease treatment, 211,141 (3.4%) were transferred from LTCHs. Among patients from LTCHs (211,141), 24.2% were discharged from EDs, 43.0% were admitted to general wards, 20.7% were hospitalized in intensive care units, 3.1% were transferred to another hospital, 6.1% returned to LTCHs, and 2.1% died in EDs. ED stays were the longest for those returning to LTCHs (710.49 ± 1127.43 min). Foley catheterization (40.3%) was most frequently performed in preventable ED visits. In South Korea, older patients being discharged from the ED or returning to LTCHs, after being transferred from LTCHs to EDs, increased. ED stays among older LTCH patients were longer than among non-LTCH older patients, contributing to congestion. To reduce avoidable transfer to EDs from LTCHs, it is necessary to discuss policies, such as expanding appropriate medical personnel and transitional treatment.

Dutch emergency physicians insufficiently educated in geriatric emergency medicine: results of a nationwide survey

Background

Emergency physicians (EPs) provide care to older adults with complex health problems. Treating these patients is challenging for many EPs, which might originate from modest geriatric education.

Objective

Our aim was to assess EPs’ self-perceived needs regarding geriatric emergency medicine (GEM) education, factors determining these needs and the utilization of this education. Our secondary aim was to assess emergency department (ED) managers’ view and support for GEM education.

Methods

All EPs and ED managers in the Netherlands received a survey by e-mail. The questionnaires focused on EPs’ needs in GEM education, EPs’ utilization of GEM education and managerial support for GEM education. We used descriptive statistics to analyse needs, utilization of- and support for GEM education. Regression analyses were used to identify factors associated with EPs’ need for GEM education.

Results

EPs reported to need better training in diagnosing, treating and communicating with older adults. Seventy percent of EPs reported no GEM education program in their hospital, and 83% reported no utilization of GEM education outside their hospital. EPs working in EDs with a possibility for geriatric consultation, and EPs aware of actual GEM education programs, had lower educational needs. Of responding managers, 86.2% reported the care for older adults as an important topic; lack of finances and time were obstacles to provide GEM education for EPs.

Conclusion

EPs in the Netherlands feel insufficiently educated to treat older adults. ED managers largely recognize this educational challenge. This nationwide survey underlines the need to prioritize GEM education for EPs.

Impact of Geriatric Emergency Fellowship Training on the careers of Emergency Physicians

Introduction

The geriatric population continues to increase and will impact the emergency department (ED). Older adult patients require different care from other groups of patients. Hence, it is essential to create a workforce that specializes in geriatric emergency medicine (GEM). Geriatric emergency medicine fellowships were developed to serve this need. However, despite 20 years since the creation of GEM fellowships, it is not known how GEM fellowships have impacted the career of graduates of GEM fellowships. The goal of this study is to examine the impact of these geriatric emergency fellowship training programs on the career of geriatric emergency fellows.

Methods

We surveyed the emergency physicians who had graduated from GEM fellowship programs in the US and Canada by using a 36-question, web-based questionnaire. The survey was pilot-tested on five GEM experts, fellowship graduates, and a GEM fellowship director.

Result

We had a 68% survey completion rate, two partially answered the study. All participants reported that they continue to have GEM as a part of his/her career. More than half either received grants, published papers, helped establish GEM divisions or caring in their hospital, and worked beyond clinical work in the ED, including academic and administrative fields. More than 80% reported that their fellowship helped obtain their current positions and was helpful in career progression. Approximately two-thirds were satisfied with their current work/life balance.

Conclusion

The GEM fellowship training has been impactful in the careers of former GEM fellows and has contributed to many becoming leaders in GEM clinical service, administration, education, and research. It can serve as a stepping stone to a leadership position in a GEM career. Furthermore, our study demonstrates that GEM graduates report high levels of career and clinical satisfaction.

Trends in Geriatric Emergency Medicine

Geriatric emergency medicine has emerged as a subspecialty of emergency medicine over the past 25 years. This emergence has seen the development of increases in training opportunities, care delivery strategies, collaborative best practice guidelines, and formal geriatric emergency department accreditation. This multidisciplinary field remains ripe for continued development in the coming decades as the aging US population parallels a call from patients, health care providers, and health systems to improve the delivery of high-value care. This article educates emergency medicine practitioners and highlights high-value care practice trends to inform and prioritize decision-making for this unique patient population.

Assessing Family Medicine Residents' Preparedness for the Practice of Geriatric Care

Introduction

Family physicians provide care to a growing and often complex group of older adults. Family medicine residencies are expected to prepare trainees to manage the medical and social needs of these seniors, but whether they feel prepared to do so is unknown. This study aimed to assess family medicine residents' sense of preparedness to address geriatric-related issues, and to identify factors that might affect this self-evaluation.

Methods

As an exploratory cross-sectional study, a 28-item questionnaire was circulated among 180 McGill University family medicine residents for voluntary completion. The survey assessed residents' demographics, attitudes toward, and perceptions of their training in geriatrics.

Results

One hundred residents (55.5% response rate) completed the questionnaire. Residents perceived their level of preparedness increasing as they progressed in their training; however, they felt least comfortable managing behavioral problems and engaging community resources. Positive perceptions about their training for geriatric care was proportionate to the number of positive role models they had during training. Sense of preparedness was most strongly and significantly associated with the duration of exposure residents had to long-term care.

Conclusion

The aging population requires physicians who are interested in care of the elderly and who are adequately prepared through comprehensive training to care for the complex medical and social issues that affect this large segment of society. This study, through its survey of family medicine residents, provides insights about potential curriculum changes and recommendations for updating the approach to care of the elderly.

Predicting hospital admission for older emergency department patients: Insights from machine learning

BACKGROUND

Emergency departments (ED) are a portal of entry into the hospital and are uniquely positioned to influence the health care trajectories of older adults seeking medical attention. Older adults present to the ED with distinct needs and complex medical histories, which can make disposition planning more challenging. Machine learning (ML) approaches have been previously used to inform decision-making surrounding ED disposition in the general population. However, little is known about the performance and utility of ML methods in predicting hospital admission among older ED patients. We applied a series of ML algorithms to predict ED admission in older adults and discuss their clinical and policy implications.

MATERIALS AND METHODS

We analyzed the Canadian data from the interRAI multinational ED study, the largest prospective cohort study of older ED patients to date. The data included 2274 ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Data were extracted from the interRAI ED Contact Assessment, with predictors including a series of geriatric syndromes, functional assessments, and baseline care needs. We applied a total of five ML algorithms. Models were trained, assessed, and analyzed using 10-fold cross-validation. The performance of predictive models was measured using the area under the receiver operating characteristic curve (AUC). We also report the accuracy, sensitivity, and specificity of each model to supplement performance interpretation.

RESULTS

Gradient boosted trees was the most accurate model to predict older ED patients who would require hospitalization (AUC = 0.80). The five most informative features include home intravenous therapy, time of ED presentation, a requirement for formal support services, independence in walking, and the presence of an unstable medical condition.

CONCLUSION

To the best of our knowledge, this is the first study to predict hospital admission in older ED patients using a series of geriatric syndromes and functional assessments. We were able to predict hospital admission in older ED patients with good accuracy using the items available in the interRAI ED Contact Assessment. This information can be used to inform decision-making about ED disposition and may expedite admission processes and proactive discharge planning.

Geriatric Emergency Medicine Fellowships: Current State of Specialized Training for Emergency Physicians in Optimizing Care for Older Adults

Improving emergency department (ED) care for older adults is a critical issue in emergency medicine. Institutions throughout the United States and Canada have recognized the growing need for a workforce of emergency physician (EP) leaders focused on clinical innovation, education, and research and have developed specialized fellowship training in geriatric emergency medicine (GEM). We describe here the overview, structure, and curricula of these fellowships as well as successes and challenges they have encountered. Seven GEM fellowships are active in the United States and Canada, with five offering postresidency training only, one offering fellowship training during residency only, and one offering both. The backbone of the curriculum for all fellowships is the achievement of core competencies in various aspects of GEM, and each includes clinical rotations, teaching, and a research project. Evaluation strategies and feedback have allowed for significant curricular changes as well as customization of the fellowship experience for individual fellows. Key successes include an improved collaborative relationship with geriatrics faculty that has led to additional initiatives and projects and former fellows already becoming regional and national leaders in GEM. The most critical challenges have been ensuring adequate funding and recruiting new fellows each year who are interested in this clinical area. We believe that interest in GEM fellowships will grow and that opportunities exist to combine GEM fellowship training with a focus in research, administration, or health policy to create unique new types of highly impactful specialized training. Future research may include exploring former fellows' postfellowship experiences, careers, accomplishments, and contributions to GEM to better understand the impact of GEM fellowships.

Effectiveness of interventions to alleviate emergency department crowding by older adults: a systematic review

BACKGROUND

The growing demand for elderly care often exceeds the ability of emergency department (ED) services to provide quality of care within reasonable time. The purpose of this systematic review is to assess the effectiveness of interventions on reducing ED crowding by older patients, and to identify core characteristics shared by successful interventions.

METHODS

Six major biomedical databases were searched for (quasi)experimental studies published between January 1990 and March 2017 and assessing the effect of interventions for older patients on ED crowding related outcomes. Two independent reviewers screened and selected studies, assessed risk of bias and extracted data into a standardized form. Data were synthesized around the study setting, design, quality, intervention content, type of outcome and observed effects.

RESULTS

Of the 16 included studies, eight (50%) were randomized controlled trials (RCTs), two (13%) were non-RCTs and six (34%) were controlled before-after (CBA) studies. Thirteen studies (81%) evaluated effects on ED revisits and four studies (25%) evaluated effects on ED throughput time. Thirteen studies (81%) described multicomponent interventions. The rapid assessment and streaming of care for older adults based on time-efficiency goals by dedicated staff in a specific ED unit lead to a statistically significant decrease of ED length of stay (LOS). An ED-based consultant geriatrician showed significant time reduction between patient admission and geriatric review compared to an in-reaching geriatrician.

CONCLUSION

Inter-study heterogeneity and poor methodological quality hinder drawing firm conclusions on the intervention's effectiveness in reducing ED crowding by older adults. More evidence-based research is needed using uniform and valid effect measures.

TRIAL REGISTRATION

The protocol is registered with the PROSPERO International register of systematic reviews: ID = CRD42017075575).

Evaluation of the geriatric curriculum implemented at Shiraz University of Medical Sciences, Iran, since 2017: A qualitative study

Background: Recently, there has been an increase in life expectancy due to improvements in nutrition, health, and sanitation. The aim of this study was to evaluate the geriatric curriculum in the field of general medicine at Shiraz University of Medical Sciences (SUMS), Iran to improve the quality of services provided to this population in the community. Methods: This was a qualitative study­­. Six educational hospitals and ambulatory centers of Shiraz University of Medical Sciences participated in this study. Within these centers, 15 medical education faculty members and educational experts, 6 medical students, 6 elderly patients and 6 nurses working in the university related to the geriatric field were selected using purposive sampling. Data were gathered through semi-structured interviews, focus group discussion and field observations in the teaching hospital and ambulatory setting of SUMS from June 2017 to May 2018.  Based on the qualitative research, the data underwent conventional content analysis and the main themes were developed from this. Results: Three main themes were extracted from the data: effective clinical education, geriatrics curriculum challenges and promotion strategies for geriatric medicine. Subcategories that emerged were a competent curriculum teacher, a challenging program, management of resources, promotion of the program, and the revision required in the curriculum, which were related to other concepts and described in the real-world situation of the geriatric curriculum in the university, as observed in field observations. Conclusions: This study identified three concepts as main themes that can be used to explain how to implement a geriatric curriculum in a medical university. The main contributing factor to different views of the participants was identified as the revision required to the curriculum for integrative care in a geriatric patient. This should be taken into consideration while planning any programs and decisions aimed at education of medical students on this topic.

Geriatric Education Programs for Emergency Department Professionals: A Systematic Review

OBJECTIVES

To evaluate geriatric education programs for emergency department (ED) professionals based on: content and teaching methods and learning outcome effects and factors promoting or hindering program implementation.

DESIGN

Systematic review.

SETTING

ED.

PARTICIPANTS

Physicians, nurses, and medical residents working in the ED.

METHODS AND MEASUREMENT

Five major biomedical databases were searched for (quasi) experimental studies, published between 1990 and April 2018, evaluating geriatric education programs for ED professionals. Data were synthesized around study quality, learning participants, teaching content and methods, and Kirkpatrick learning outcomes.

RESULTS

Nine before‐after studies were included. Learners were mostly ED residents and, to a smaller extent, ED nurses and physicians. Study quality was moderate, with the lowest scores on sampling and instrument validity. Programs varied from a 1‐day workshop to a 2‐year curriculum, mostly combining didactic lectures with active and experiential learning formats. Topics commonly addressed included managing: geriatric syndromes, trauma and falls, medication, atypical presentations, and care transitions. Statistically significant improvements were mostly found in learners' knowledge acquisition (six studies). Significant improvements were also found in single studies on: self‐reported geriatric screening, documentation of geriatric care, and appropriate urinary catheter placement. Factors promoting program implementation included: solving competing educational demands and busy work schedules, embedding the program in preexisting curricula, and close collaboration between emergency and geriatric medicine faculties.

CONCLUSIONS

Various geriatric education programs improve the geriatric knowledge of ED professionals and seem to positively impact their clinical practice. However, more program evaluations with larger study samples, and use of valid and reliable outcome measures, are needed to provide robust evidence on the effectiveness of such programs. J Am Geriatr Soc, 1–8, 2019. J Am Geriatr Soc 67:2402–2409, 2019

Resuscitating the Critically Ill Geriatric Emergency Department Patient

The emergency department resuscitation of the critically ill geriatric patient is challenging and can be fraught with peril. The anatomic and physiologic changes that occur with aging can significantly influence the recognition of critical illness and the logistics of resuscitation itself. This article discusses the relevant physiologic changes with aging, the effect of these changes on clinical manifestations of critical illness in older adults, and the core principles of resuscitation in this population, with specific attention to sepsis and trauma care. In addition, end-of-life care is also discussed.

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.

Ten Best Practices for the Older Patient in the Emergency Department

This article reviews 10 best practices that integrate geriatric principles into emergency department processes of care. These best practices are grouped around ten words: complexity; clinician education; geriatric-specific; atypical; medication; variability; cognitive impairment; psychosocial issues; end-of-life care; and interdisciplinary.