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Shirzad F, Shariat SV, Masjedi N, Ghadirivasfi M, Ghalichi L, Fakhrian A, Hadi F. Workshop-based training of pre-hospital emergency technicians for acute psychiatric patients: benefits and drawbacks. BMC MEDICAL EDUCATION 2024; 24:996. [PMID: 39267028 DOI: 10.1186/s12909-024-05856-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 08/01/2024] [Indexed: 09/14/2024]
Abstract
BACKGROUND Pre-hospital emergency technicians are crucial in managing patients with acute psychiatric symptoms. They must quickly assess the condition, make a primary diagnosis, and refer the patient to the appropriate treatment center. Insufficient skills in these situations can cause serious harm. Educating technicians on dealing with these patients may enhance their knowledge and skills; however, we do not know the extent and longevity of this improvement and which areas are affected. This study investigates the impact of training on pre-hospital emergency technicians' knowledge and skills. METHODS This quasi-experimental study involved pre-hospital emergency technicians in Robat Karim and Nasim Shahr counties from December 2022 to January 2022. The technicians received workshops on interacting with psychiatric patients. The training topics included the basic principles of coping with a psychiatric patient. They also covered a step-by-step approach to dealing with an aggressive patient, dealing with a patient threatening suicide, managing agitation, managing a patient suffering from panic attacks, and finally dealing with a delirious patient. A pre-test assessed their baseline knowledge and skills, followed by a post-test after training and another test three months later. The test results were analyzed. RESULTS This study involved forty male participants ranging in age from 25 to 44 and with work experience ranging from five to twenty years. As a result of training in dealing with acute psychiatric patients, technicians developed significant skills and knowledge immediately after training, and these improvements remained significant three months after training. Nevertheless, the correct answers decreased during the three-month follow-up compared to the pre-test. Education was less effective at managing panic, delirium, and agitation. CONCLUSION In conclusion, technicians' knowledge and skills can be effectively enhanced through training; however, the impact diminishes with time. Theories and practical methods, periodic repetition, and real-world internships are the best ways to maximize training effectiveness.
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Grants
- 98-3-8-4868 Vice President of Health, Iran University of Medical Sciences,Tehran,Iran.
- 98-3-8-4868 Vice President of Health, Iran University of Medical Sciences,Tehran,Iran.
- 98-3-8-4868 Vice President of Health, Iran University of Medical Sciences,Tehran,Iran.
- 98-3-8-4868 Vice President of Health, Iran University of Medical Sciences,Tehran,Iran.
- 98-3-8-4868 Vice President of Health, Iran University of Medical Sciences,Tehran,Iran.
- 98-3-8-4868 Vice President of Health, Iran University of Medical Sciences,Tehran,Iran.
- 98-3-8-4868 Vice President of Health, Iran University of Medical Sciences,Tehran,Iran.
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Affiliation(s)
- Fatemeh Shirzad
- Spiritual Health Research Center, Department of Psychiatry, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
| | - Seyed Vahid Shariat
- Mental Health Research Center, School of Behavioral Sciences and Mental Health, Department of Psychiatry, School of Medicine, Tehran Institute of Psychiatry), Tehran, Iran
| | - Neda Masjedi
- Department of psychiatry, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ghadirivasfi
- Medical faculty, Research Center for Addiction and Risky Behaviors (ReCARB), Iran University of Medical Sciences, Tehran, Iran
| | - Leila Ghalichi
- Mental Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Science, Tehran, Iran
| | - Arghavan Fakhrian
- Fellowship of Psychosexual Medicine, Department of Psychosexual Medicine, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Hadi
- Department of Psychiatry, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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2
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Skains RM, Koehl JL, Aldeen A, Carpenter CR, Gettel CJ, Goldberg EM, Hwang U, Kocher KE, Southerland LT, Goyal P, Berdahl CT, Venkatesh AK, Lin MP. Geriatric Emergency Medication Safety Recommendations (GEMS-Rx): Modified Delphi Development of a High-Risk Prescription List for Older Emergency Department Patients. Ann Emerg Med 2024; 84:274-284. [PMID: 38483427 PMCID: PMC11343681 DOI: 10.1016/j.annemergmed.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 04/14/2024]
Abstract
STUDY OBJECTIVE Half of emergency department (ED) patients aged 65 years and older are discharged with new prescriptions. Potentially inappropriate prescriptions contribute to adverse drug events. Our objective was to develop an evidence- and consensus-based list of high-risk prescriptions to avoid among older ED patients. METHODS We performed a modified, 3-round Delphi process that included 10 ED physician experts in geriatrics or quality measurement and 1 pharmacist. Consensus members reviewed all 35 medication categories from the 2019 American Geriatrics Society Beers Criteria and ranked each on a 5-point Likert scale (5=highest) for overall priority for avoidance (Round 1), risk of short-term adverse events and avoidability (Round 2), and reasonable medical indications for high-risk medication use (Round 3). RESULTS For each round, questionnaire response rates were 91%, 82%, and 64%, respectively. After Round 1, benzodiazepines (mean, 4.60 [SD, 0.70]), skeletal muscle relaxants (4.60 [0.70]), barbiturates (4.30 [1.06]), first-generation antipsychotics (4.20 [0.63]) and first-generation antihistamines (3.70 [1.49]) were prioritized for avoidance. In Rounds 2 and 3, hypnotic "Z" drugs (4.29 [1.11]), metoclopramide (3.89 [0.93]), and sulfonylureas (4.14 [1.07]) were prioritized for avoidability, despite lower concern for short-term adverse events. All 8 medication classes were included in the final list. Reasonable indications for prescribing high-risk medications included seizure disorders, benzodiazepine/ethanol withdrawal, end of life, severe generalized anxiety, allergic reactions, gastroparesis, and prescription refill. CONCLUSION We present the first expert consensus-based list of high-risk prescriptions for older ED patients (GEMS-Rx) to improve safety among older ED patients.
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Affiliation(s)
- Rachel M Skains
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL; Geriatric Research, Education and Clinical Center, Birmingham VAMC, Birmingham, AL
| | - Jennifer L Koehl
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA
| | | | | | - Cameron J Gettel
- Department of Emergency Medicine, Yale University, New Haven, CT
| | | | - Ula Hwang
- Department of Emergency Medicine, Yale University, New Haven, CT; Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NY
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | | | - Pawan Goyal
- Quality Division, American College of Emergency Physicians, Irving, TX
| | - Carl T Berdahl
- Department of Emergency Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | | | - Michelle P Lin
- Department of Emergency Medicine, Stanford University, Palo Alto, CA.
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3
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Ranta M, Lönnroos E, Miettinen M, Kouvo A, Lammintakanen J. Emergency nurses' and physicians' perceptions and self-assessed competence in providing care to older patients. Int Emerg Nurs 2024; 74:101443. [PMID: 38677059 DOI: 10.1016/j.ienj.2024.101443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 01/26/2024] [Accepted: 03/23/2024] [Indexed: 04/29/2024]
Abstract
AIM This study examined emergency nurses' and physicians' perceptions and self-assessed competence in caring for older patients. METHODS Data were analyzed using a mixed methods approach and quantitative data were supplemented with qualitative responses. There were 451 nurses and physicians working at the two examined emergency departments, with 125 of them responding to the survey; the response rate was 27.7 %. RESULTS Physicians and nurses felt that acutely ill older patients are a responsibility of emergency services. Nurses were more critical than physicians (p = 0.000) of the failure to recognize older patients as a special group at the emergency department. Over half (51.8 %) of the physicians and 29.0 % of the nurses (p = 0.027) felt that older patients' special needs had been considered during facility planning. Nurses and physicians described the problems related to multimorbidity and aging relatively similarly. Both expressed a need for more knowledge in geriatrics and gerontology. CONCLUSION Future facility planning and care processes at the emergency department should better consider the specific needs of older patients. The results also emphasize a need to more effectively prioritize competence and educational needs of emergency staff and recognize caring for older patients as a specific competence area in the emergency department.
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Affiliation(s)
- Milja Ranta
- University of Eastern Finland, Yliopistonranta 1, Department of Health and Social Management, 70210 Kuopio, Finland.
| | - Eija Lönnroos
- University of Eastern Finland, Yliopistonranta 1, Department of Medicine, Public Health and Clinical Nutrition, 70210 Kuopio, Finland.
| | | | - Antti Kouvo
- University of Eastern Finland, Yliopistonranta 1, Faculty of Social Sciences and Business Studies, Department of Sociology, 70210 Kuopio, Finland.
| | - Johanna Lammintakanen
- University of Eastern Finland, Yliopistonranta 1, Faculty of Social Sciences and Business Studies, Department of Health and Social Management, 70210 Kuopio, Finland.
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4
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Carpenter CR, Lee S, Kennedy M, Arendts G, Schnitker L, Eagles D, Mooijaart S, Fowler S, Doering M, LaMantia MA, Han JH, Liu SW. Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments. Acad Emerg Med 2024. [PMID: 38757369 DOI: 10.1111/acem.14935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening. METHODS We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds. RESULTS Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%. CONCLUSIONS The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.
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Affiliation(s)
| | - Sangil Lee
- University of Iowa, Iowa City, Iowa, USA
| | - Maura Kennedy
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Glenn Arendts
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Linda Schnitker
- Bolton Clarke Research Institute, Bolton Clarke School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | | | - Simon Mooijaart
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, The Netherlands
| | - Susan Fowler
- University of Connecticut Health Sciences, Farmington, Connecticut, USA
| | - Michelle Doering
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | | | - Jin H Han
- Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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5
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Espejo T, Terhalle L, Malinovska A, Riedel HB, Arntz L, Hafner L, Delport-Lehnen K, Zuppinger J, Geigy N, Leuppi J, Somasundaram R, Bingisser R, Nickel CH. Diagnostic and prognostic value of cardiac troponins in emergency department patients presenting after a fall: A prospective, multicenter study. Acad Emerg Med 2024. [PMID: 38532263 DOI: 10.1111/acem.14897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/04/2024] [Accepted: 01/23/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Emergency department (ED) presentations after a ground-level fall (GLF) are common. Falls were suggested to be another possible presenting feature of a myocardial infarction (MI), as unrecognized MIs are common in older adults. Elevated high-sensitivity cardiac troponin (hs-cTn) concentrations could help determine the etiology of a GLF in ED. We investigated the prevalence of both MI and elevated high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI), as well as the diagnostic accuracy of hs-cTnT and hs-cTnI regarding MI, and their prognostic value in older ED patients presenting after a GLF. METHODS This was a prospective, international, multicenter, cohort study with a follow-up of up to 1 year. Patients aged 65 years or older presenting to the ED after a GLF were prospectively enrolled. Two outcome assessors independently reviewed all discharge records to ascertain final gold standard diagnoses. Hs-cTnT and hs-cTnI levels were determined from thawed samples for every patient. RESULTS In total, 558 patients were included. Median (IQR) age was 83 (77-89) years, and 67.7% were female. Elevated hs-cTnT levels were found in 384 (68.8%) patients, and elevated hs-cTnI levels in 86 (15.4%) patients. Three patients (0.5%) were ascertained the gold standard diagnosis MI. Within 30 days, 18 (3.2%) patients had died. Nonsurvivors had higher hs-cTnT and hs-cTnI levels compared with survivors (hs-cTnT 40 [23-85] ng/L in nonsurvivors and 20 [13-33] ng/L in survivors; hs-cTnI 25 [14-54] ng/L in nonsurvivors and 8 [4-16] ng/L in survivors; p < 0.001 for both). CONCLUSIONS A majority of patients (n = 364, 68.8%) presenting to the ED after a fall had elevated hs-cTnT levels and 86 (15.4%) elevated hs-cTnI levels. However, the incidence of MI in these patients was low (n = 3, 0.5%). Our data do not support the opinion that falls may be a common presenting feature of MI. We discourage routine troponin testing in this population. However, hs-cTnT and hs-cTnI were both found to have prognostic properties for mortality prediction up to 1 year.
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Affiliation(s)
- Tanguy Espejo
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Lukas Terhalle
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexandra Malinovska
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Henk B Riedel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Laura Arntz
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Livia Hafner
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Joanna Zuppinger
- Emergency Department, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Nicolas Geigy
- Emergency Department, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Jörg Leuppi
- Medical Faculty University of Basel and Cantonal Hospital Baselland, Liestal, Switzerland
| | - Rajan Somasundaram
- Department of Emergency Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
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6
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Zhou C, Wang H, Wang L, Zhou Y, Wu Q. Diagnostic accuracy of the Family Confusion Assessment Method for delirium detection: A systematic review and meta-analysis. J Am Geriatr Soc 2024; 72:892-902. [PMID: 38018490 DOI: 10.1111/jgs.18692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/03/2023] [Accepted: 10/26/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Delirium is frequently disproportionately under-recognized despite its high prevalence, detrimental impact, and potential lethality. Informant-based delirium detection tools can offer structured assessment and increase the timeliness and frequency of detection. We aimed to examine the diagnostic accuracy of the Family Confusion Assessment Method (FAM-CAM) for delirium detection. METHODS We systematically searched the MEDLINE, EMBASE, PsycINFO, CINAHL, CNKI, WANFANG, and SinoMed databases from January 1988 to December 2022. Two reviewers independently screened studies and evaluated methodological quality using the revised quality assessment of diagnostic accuracy studies (QUADAS-2) tool. A bivariate random effects model was undertaken, and univariable meta-regression was carried out to explore heterogeneity. RESULTS Seven studies with 483 dyads of participants and family caregivers were identified. Pooled sensitivity and specificity were 0.74 (95% CI: 0.59, 0.86) and 0.91 (95% CI: 0.83, 0.95), respectively, with an area under curve (AUC) of 0.91. The positive likelihood ratio was 8.27 (95% CI: 3.97, 17.25), and the negative likelihood ratio was 0.28 (95% CI: 0.16, 0.50). Settings impacted specificity (p = 0.02). CONCLUSIONS Available evidence indicates that FAM-CAM exhibits moderate sensitivity and high specificity for delirium screening in adults. The FAM-CAM is concise and easy to use, making it appropriate for routine clinical practice, which might benefit early delirium detection and potentially foster delirium management. PROSPERO REGISTRATION NUMBER CRD42022378742.
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Affiliation(s)
- Chenxi Zhou
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Wang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lan Wang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanrong Zhou
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiansheng Wu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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7
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Goldberg EM, Dresden SM, Carpenter CR. Clin-STAR corner: Practice changing advances in prescribing for geriatric emergency department patients. J Am Geriatr Soc 2023; 71:3686-3691. [PMID: 37801018 DOI: 10.1111/jgs.18619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 10/07/2023]
Abstract
Reducing adverse drug events among older adults in heterogeneous and often chaotic emergency department (ED) settings requires a multidisciplinary approach. Recent research evaluates the impact of multicomponent protocols designed to reduce ED physician prescribing of potentially inappropriate medications (PIMs), including transdisciplinary training and leveraging electronic health records to provide real-time alternative safer pharmaceuticals while providing personalized feedback to prescribers. Most new research is not randomized trial data. Although this current research does not consistently demonstrate a reduction in the prescribing of PIMs, these studies provide a foundation for emergency medicine healthcare teams, geriatricians, and pharmacists to collaborate with health informatics to continue advancing the frontiers of safer medication prescribing during episodes of acute care.
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Affiliation(s)
- Elizabeth M Goldberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Scott M Dresden
- School of Medicine Department of Emergency Medicine, Northwestern University, Chicago, Illinois, USA
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8
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Bonfichi A, Ceresa IF, Piccioni A, Zanza C, Longhitano Y, Boudi Z, Esposito C, Savioli G. A Lethal Combination of Delirium and Overcrowding in the Emergency Department. J Clin Med 2023; 12:6587. [PMID: 37892725 PMCID: PMC10607343 DOI: 10.3390/jcm12206587] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Delirium is a common public health concern that significantly impacts older patients admitted to the Emergency Department (ED). This condition is linked to adverse outcomes such as reduced long-term functionality, higher mortality rates, extended hospital stays, and increased medical costs. The identification of risk factors is crucial for the early recognition and management of delirium in ED patients. Aging, cognitive decline, polypharmacy, and sensory impairment are some of the most common general risk factors described in the literature. Although validated delirium assessment tools already exist, they are not practical for the fast-paced ED environment because of their extended evaluation period or specialized training request. Moreover, clear guidance is needed to select the most suitable tool for detecting delirium, balancing between the accuracy and the swiftness required in an overcrowded, high-stress, and understaffed healthcare setting. This narrative review aims to analyze the updated literature on delirium risk factors in older ED patients and focuses on the methods for better screening, managing, and treating this condition in the ED.
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Affiliation(s)
- Alessandra Bonfichi
- Department of Internal Medicine, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| | - Iride Francesca Ceresa
- Department of Emergency Medicine, Humanitas University-Research Hospital, 20089 Rozzano, Italy; (I.F.C.); (Y.L.)
| | - Andrea Piccioni
- Department of Emergency, Fondazione Policlinico Universitario A. Gemelli, IRCCS Fondazione Policlinico San Matteo, 00168 Roma, Italy;
| | - Christian Zanza
- Italian Society of Pre-Hospital Emergency Medicine (SIS-118), 74121 Taranto, Italy;
| | - Yaroslava Longhitano
- Department of Emergency Medicine, Humanitas University-Research Hospital, 20089 Rozzano, Italy; (I.F.C.); (Y.L.)
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15260, USA
| | - Zoubir Boudi
- Department of Emergency Medicine, Dr Sulaiman Alhabib Hospital, Dubai 2542, United Arab Emirates;
| | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy;
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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9
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Foucaud A, Gilbert T, Vincent A, Jomard N, Comte B, Porthault S, Comte G, Theurey O, Gueugniaud PY, Bourelly L, Rabilloud M, Boutitie F, Douplat M, Tassa O, Haesebaert J, Termoz A, Schott AM. Evaluation of a training program for emergency medical service physician dispatchers to reduce emergency departments visits. J Am Geriatr Soc 2023; 71:484-495. [PMID: 36317929 DOI: 10.1111/jgs.18101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/08/2022] [Accepted: 09/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Emergency Departments (ED) have seen an increasing number of older patients who are mostly referred following a call to the Emergency Medical Services (EMS). Long waiting times in settings, which are not designed to meet older patients' needs, may increase the risk of hospital-acquired complications. Unnecessary visits should therefore be avoided as much as possible. The objective of the study was to evaluate whether a program to provide geriatric knowledge and tools to the dispatching physicians of the EMS could decrease ED referrals of older patients. METHODS Design: Before-and-after study with two 6-month periods before and after intervention. PARTICIPANTS All calls received by a dispatching physician of the Rhône EMS from 8 am to 6 pm concerning patients aged 75 years or above during the study period. INTERVENTION A program consisting of training dispatching physicians in the specific care of older patients and the developing, with a multidisciplinary team, of specific tools for dispatching physicians. OUTCOME Proportion of ED referrals of patients aged 75 years or above after a call to the EMS. RESULTS A total of 2671 calls to the Rhône EMS were included corresponding to 1307 and 1364 patients in the pre-and post-intervention phases, respectively. There was no significant difference in the proportion of referrals to the ED between the pre-intervention (61.7%) and the post-intervention (62.8%) phases (p = 0.57). Contact of the patients with their General Practitioner (GP) in the month preceding the call was associated with a 22% reduced probability of being referred to an ED. CONCLUSIONS No beneficial effect of the intervention was demonstrated. This strategy of intervention is probably not effective enough in such time-constraint environment. Other strategies with a specific parallel dispatching of geriatric calls by geriatricians should be tested to avoid these unnecessary ED referrals. TRIAL REGISTRATION ClinicalTrials NCT02712450.
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Affiliation(s)
- Amandine Foucaud
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service de Gériatrie, Pierre Bénite, France
| | - Thomas Gilbert
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service de Gériatrie, Pierre Bénite, France.,Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Adélaïde Vincent
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Gériatrie, Lyon, France
| | - Nathalie Jomard
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service de Gériatrie, Pierre Bénite, France
| | - Brigitte Comte
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Gériatrie, Lyon, France
| | - Sylvie Porthault
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Hôpital Edouard Herriot, SAMU, Lyon, France
| | - Gaële Comte
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Hôpital Edouard Herriot, SAMU, Lyon, France
| | - Odile Theurey
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Hôpital Edouard Herriot, SAMU, Lyon, France
| | - Pierre-Yves Gueugniaud
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Hôpital Edouard Herriot, SAMU, Lyon, France
| | - Laura Bourelly
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Gériatrie, Lyon, France
| | - Muriel Rabilloud
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France.,Laboratoire de Biométrie et Biologie Évolutive, CNRS, UMR 5558, Équipe Biostatistique-Santé, Villeurbanne, France
| | - Florent Boutitie
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France
| | - Marion Douplat
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service des Urgences, Pierre Bénite, France
| | - Ouazna Tassa
- Hospices Civils de Lyon, Pôle de Sante Publique, Service Recherche et Épidémiologie Cliniques, Lyon, France
| | - Julie Haesebaert
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France.,Hospices Civils de Lyon, Pôle de Sante Publique, Service Recherche et Épidémiologie Cliniques, Lyon, France
| | - Anne Termoz
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France.,Hospices Civils de Lyon, Pôle de Sante Publique, Service Recherche et Épidémiologie Cliniques, Lyon, France
| | - Anne-Marie Schott
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France.,Hospices Civils de Lyon, Pôle de Sante Publique, Service Recherche et Épidémiologie Cliniques, Lyon, France
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10
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[Four types of old patients in the emergency department : A geriatric medicine qualitative and economic viewpoint]. Z Gerontol Geriatr 2023; 56:53-58. [PMID: 34842961 DOI: 10.1007/s00391-021-01999-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/30/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Lack of clinical management of old patients in the emergency department. QUESTION How can we manage old patients in the emergency department more effectively, medically and economically? METHODS Evaluation of current selection and screening methods and recommendations for old patients in the emergency department. Acute inpatient treatment needs, presence of dysfunction in at least two core areas and assessment of advance care needs are examined. RESULT The identification of old patients in the emergency department as geriatric patients alone shows no control potential. Combining the three test criteria of acute inpatient need for treatment, the presence of dysfunction in at least two core areas and the assessment of advance care needs generates four old patient types that have interesting control potential: the medical traumatology patient, the acute geriatric patient, the rehabilitative geriatric patient, and the ambulatory patient. DISCUSSION in addition to identifying geriatric patients, screening should map acute inpatient treatment needs, assessment of dysfunction, and analysis of advance care needs to define clinically steerable old patients.
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11
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Butcher JD, Smith MC, Roberts L, Ellis B. Utility of head computed tomography for older adults with suspected delirium in the emergency department: A retrospective observational study. Acad Emerg Med 2023; 30:16-22. [PMID: 36478487 DOI: 10.1111/acem.14637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/06/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Delirium in older people is associated with significant morbidity and mortality and has life-threatening etiologies making prompt recognition essential. Computed tomography of the head (CT-head) may have a role in determining the cause of delirium; however, inpatient studies suggest it is overused. There is a paucity of emergency department (ED)-based research surrounding the use of CT-head in delirium. This study aims to describe the utility of CT-head in older patients presenting to the ED with symptoms of delirium. METHODS We conducted a retrospective chart review of patients 65 years and older with symptoms of delirium who visited local EDs over a 3.5-year period (2016-2020). We compared patients who did and did not receive CT-head. Our primary objective was to determine the proportion of acute findings in patients who received CT-head. Our secondary objectives were to describe the proportions of patients who did and did not receive CT-head in terms of their demographics, presenting symptoms, disposition, and indications for and results of CT-head scans. Chi-square tests were utilized for comparisons. RESULTS A total of 630 encounters were identified through database searching; 526 met inclusion criteria. Thirty-four were excluded for presenting directly to consultants, leaving 492 included encounters. Of those who received a CT-head (n = 279), 13 (4.7%) had acute findings. Of the encounters with acute findings, four (30.77%) had focal neurological deficits (FND), and two (15.38%) had Glasgow Coma Scale (GCS) score < 14. Patients without CT-head (n = 213) were more likely to be discharged (p < 0.01) and less likely to have a FND (p < 0.01). CONCLUSIONS CT-head is ordered for over half of older ED patients with symptoms of delirium despite infrequent acute findings. Acute findings typically occur in the context of symptoms suggestive of intracranial abnormalities such as FND or GCS < 14. This suggests physicians should be more selective when ordering CT-heads in patients with symptoms of delirium.
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Affiliation(s)
- Josh D Butcher
- Department of Emergency Medicine, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Mckinley C Smith
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lauren Roberts
- Department of Emergency Medicine, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Brittany Ellis
- Department of Emergency Medicine, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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12
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Lee S, Bobb Swanson M, Fillman A, Carnahan RM, Seaman AT, Reisinger HS. Challenges and opportunities in creating a deprescribing program in the emergency department: A qualitative study. J Am Geriatr Soc 2023; 71:62-76. [PMID: 36258309 PMCID: PMC10092723 DOI: 10.1111/jgs.18047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Morgan Bobb Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Allison Fillman
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ryan M Carnahan
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Aaron T Seaman
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Heather Schacht Reisinger
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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13
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Lee S, Chen H, Hibino S, Miller D, Healy H, Lee JS, Arendts G, Han JH, Kennedy M, Carpenter CR. Can we improve delirium prevention and treatment in the emergency department? A systematic review. J Am Geriatr Soc 2022; 70:1838-1849. [PMID: 35274738 PMCID: PMC9314609 DOI: 10.1111/jgs.17740] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/31/2022] [Accepted: 02/17/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND This systematic review was conducted to evaluate any interventions to prevent incident delirium, or shorten the duration of prevalent delirium, in older adults presenting to the emergency department (ED). METHODS Health sciences librarian designed electronic searches were conducted from database inception through September 2021. Two authors reviewed studies, and included studies that evaluated interventions for the prevention and/or treatment of delirium and excluded non-ED studies. The risk of bias (ROB) was evaluated by the Cochrane ROB tool or the Newcastle-Ottawa (NOS) scale. Meta-analysis was conducted to estimate a pooled effect of multifactorial programs on delirium prevention. RESULTS Our search strategy yielded 11,900 studies of which 10 met study inclusion criteria. Two RCTs evaluated pharmacologic interventions for delirium prevention; three non-RCTs employed a multi-factorial delirium prevention program; three non-RCTs evaluated regional anesthesia for hip fractures; and one study evaluated the use of Foley catheter, medication exposure, and risk of delirium. Only four studies demonstrated a significant impact on delirium incidence or duration of delirium-one RCT of melatonin reduced the incidence of delirium (OR 0.19, 95% CI 0.06 to 0.62), one non-RCT study on a multi-factorial program decreased inpatient delirium prevalence (41% to 19%) and the other reduced incident delirium (RR 0.37, 95% CI 0.22 to 0.61). One case-control study on the use of ED Foley catheters in the ED increased the duration of delirium (proportional OR 3.1, 95% CI 1.3 to 7.4). A pooled odds ratio for three multifactorial programs on delirium prevention was 0.46 (95% CI 0.31-0.68, I2 = 0). CONCLUSION Few interventions initiated in the ED were found to consistently reduce the incidence or duration of delirium. Delirium prevention and treatment trials in the ED are still rare and should be prioritized for future research.
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Affiliation(s)
- Sangil Lee
- Department of Emergency MedicineUniversity of Iowa Roy J and Lucille A Carver College of MedicineIowa CityIowaUSA
| | - Hao Chen
- Department of Emergency MedicineUniversity of Iowa Roy J and Lucille A Carver College of MedicineIowa CityIowaUSA
| | - Seikei Hibino
- Department of Emergency MedicineUniversity of Minnesota Medical CenterMinneapolisMinnesotaUSA
| | - Daniel Miller
- Department of Emergency MedicineUniversity of Iowa Roy J and Lucille A Carver College of MedicineIowa CityIowaUSA
| | - Heather Healy
- Hardin Library for the Health SciencesUniversity of IowaIowa CityIowaUSA
| | - Jacques S. Lee
- Schwartz/Reisman Emergency Medicine InstituteSinai HealthTorontoONCanada
- Department of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Glenn Arendts
- Emergency MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Jin Ho Han
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Geriatric Research, Education, and Clinical CenterTennessee Valley Healthcare SystemNashvilleTennesseeUSA
| | - Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
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14
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Hwang U, Carpenter C, Dresden S, Dussetschleger J, Gifford A, Hoang L, Leggett J, Nowroozpoor A, Taylor Z, Shah M. The Geriatric Emergency Care Applied Research (GEAR) network approach: a protocol to advance stakeholder consensus and research priorities in geriatrics and dementia care in the emergency department. BMJ Open 2022; 12:e060974. [PMID: 35459682 PMCID: PMC9036447 DOI: 10.1136/bmjopen-2022-060974] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/25/2022] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Increasingly, older adults are turning to emergency departments (EDs) to address healthcare needs. To achieve these research demands, infrastructure is needed to both generate evidence of intervention impact and advance the development of implementation science, pragmatic trials evaluation and dissemination of findings from studies addressing the emergency care needs of older adults. The Geriatric Emergency Care Applied Research Network (https://gearnetwork.org) has been created in response to these scientific needs-to build a transdisciplinary infrastructure to support the research that will optimise emergency care for older adults and persons living with dementia. METHODS AND ANALYSIS In this paper, we describe our approach to developing the GEAR Network infrastructure, the scoping reviews to identify research and clinical gaps and its use of consensus-driven research priorities with a transdisciplinary taskforce of stakeholders that includes patients and care partners. We describe how priority topic areas are ascertained, the process of conducting scoping reviews with integrated academic librarians performing standardised searches and providing quality control on reviews, input and support from the taskforce and conducting a large-scale consensus workshop to prioritise future research topics. The GEAR Network approach provides a framework and systematic approach to develop a research agenda and support research in geriatric emergency care. ETHICS AND DISSEMINATION This is a systematic review of previously conducted research; accordingly, it does not constitute human subjects research needing ethics review. These reviews will be prepared as manuscripts and submitted for publication to peer-reviewed journals, and the results will be presented at conferences.Open Science Framework registered DOI: 10.17605/OSF.IO/6QRYX, 10.17605/OSF.IO/AKVZ8, 10.17605/OSF.IO/EPVR5, 10.17605/OSF.IO/VXPRS.
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Affiliation(s)
- Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Geriatric Research, Education and Clinical Center, James J Peters VA Medical Center, Bronx, New York, USA
| | - Christopher Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Scott Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Angela Gifford
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ly Hoang
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jesseca Leggett
- Department of Emergency Medicine and Emergency Care Research Core, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Armin Nowroozpoor
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zachary Taylor
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Manish Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
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15
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Kennedy M, Koehl J, Gao J, Ciampa KA, Hayes BD, Camargo CA. Use of antipsychotic and sedative medications in older patients in the emergency department. J Am Geriatr Soc 2021; 70:731-742. [PMID: 34820831 DOI: 10.1111/jgs.17590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/04/2021] [Accepted: 10/19/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Antipsychotics and sedatives are used to treat agitation in the emergency department (ED) but carry significant risk in older adults. Our objective was to determine factors associated with their administration to older ED patients. METHODS This was an observational study using data from the 2014-2017 National Hospital Ambulatory Medical Care Survey. We identified ED visits for patients aged ≥65 years and determined whether an antipsychotic or sedative was administered. Visits related to substance use/withdrawal, other psychiatric complaints, and intubation were excluded. We performed multivariable logistic regression to identify risk factors for antipsychotic or sedative administration. RESULTS Of the 78.7 million ED visits that met inclusion criteria, 3.5% involved at least one dose of antipsychotic or sedative medication; 13% involved an antipsychotic and 92% a sedative. Factors associated with antipsychotic administration included nursing home residence (adjusted odds ratio [aOR]: 2.67; 95% CI: 1.05-6.80), dementia (aOR: 5.62; 95% CI: 2.44-12.94), and delirium (aOR: 7.33; 95% CI: 2.21-24.32). Sedative administration was positively associated with CT or MR imaging (aOR: 1.86; 95% CI: 1.42-2.43), urbanicity of ED (aOR: 1.46; 95% CI: 1.02-2.08), and female gender (aOR: 1.47; 95% CI: 1.08-1.99) and negatively associated with older age (age: 75-84; aOR: 0.67; 95% CI: 0.49-0.91; age: 85+; aOR: 0.63; 95% CI: 0.45-0.88; reference age: 65-74 years). Antipsychotic and sedative administration were associated with prolonged ED lengths of stay and hospital admission. CONCLUSION We identified patient- and facility-level factors associated with sedative and antipsychotic administration in older ED patients. Antipsychotic and sedative administration were associated with prolonged ED lengths of stay and hospital admission.
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Affiliation(s)
- Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer Koehl
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jingya Gao
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Katherine A Ciampa
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bryan D Hayes
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Division of Toxicology, Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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16
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Hammouda N, Carpenter C, Hung W, Lesser A, Nyamu S, Liu S, Gettel C, Malsch A, Castillo E, Forrester S, Souffront K, Vargas S, Goldberg EM. Moving the needle on fall prevention: A Geriatric Emergency Care Applied Research (GEAR) Network scoping review and consensus statement. Acad Emerg Med 2021; 28:1214-1227. [PMID: 33977589 PMCID: PMC8581064 DOI: 10.1111/acem.14279] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although falls are common, costly, and often preventable, emergency department (ED)-initiated fall screening and prevention efforts are rare. The Geriatric Emergency Medicine Applied Research Falls core (GEAR-Falls) was created to identify existing research gaps and to prioritize future fall research foci. METHODS GEAR's 49 transdisciplinary stakeholders included patients, geriatricians, ED physicians, epidemiologists, health services researchers, and nursing scientists. We derived relevant clinical fall ED questions and summarized the applicable research evidence, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The highest-priority research foci were identified at the GEAR Consensus Conference. RESULTS We identified two clinical questions for our review (1) fall prevention interventions (32 studies) and (2) risk stratification and falls care plan (19 studies). For (1) 21 of 32 (66%) of interventions were a falls risk screening assessment and 15 of 21 (71%) of these were combined with an exercise program or physical therapy. For (2) 11 fall screening tools were identified, but none were feasible and sufficiently accurate for ED patients. For both questions, the most frequently reported study outcome was recurrent falls, but various process and patient/clinician-centered outcomes were used. Outcome ascertainment relied on self-reported falls in 18 of 32 (56%) studies for (1) and nine of 19 (47%) studies for (2). CONCLUSION Harmonizing definitions, research methods, and outcomes is needed for direct comparison of studies. The need to identify ED-appropriate fall risk assessment tools and role of emergency medical services (EMS) personnel persists. Multifactorial interventions, especially involving exercise, are more efficacious in reducing recurrent falls, but more studies are needed to compare appropriate bundle combinations. GEAR prioritizes five research priorities: (1) EMS role in improving fall-related outcomes, (2) identifying optimal ED fall assessment tools, (3) clarifying patient-prioritized fall interventions and outcomes, (4) standardizing uniform fall ascertainment and measured outcomes, and (5) exploring ideal intervention components.
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Affiliation(s)
- Nada Hammouda
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York City, NY
| | | | - William Hung
- Department of Geriatrics and Palliative Care, Mount Sinai School of Medicine, New York City, NY
| | | | - Sylviah Nyamu
- Department of Emergency Medicine, Mount Sinai Hospital, New York City, NY
| | - Shan Liu
- Department of Emergency Medicine, Harvard School of Medicine, Boston, MA
| | - Cameron Gettel
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | | | - Edward Castillo
- Department of Emergency Medicine, University of California San Diego, San Diego, CA
| | - Savannah Forrester
- Department of Emergency Medicine, Queen’s University, Kingston, Ontario, CA
| | - Kimberly Souffront
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York City, NY
| | - Samuel Vargas
- Department of Emergency Medicine, Mount Sinai Hospital, New York City, NY
| | - Elizabeth M. Goldberg
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI
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17
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Abstract
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.
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18
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Harper KJ, Arendts G, Barton AD, Celenza A. Providing fall prevention services in the emergency department: Is it effective? A systematic review and meta-analysis. Australas J Ageing 2021; 40:116-128. [PMID: 33605050 DOI: 10.1111/ajag.12914] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/21/2020] [Accepted: 12/15/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess the effects of fall prevention services initiated in the emergency department (ED) to support patients after discharge. METHODS A systematic review and meta-analysis were conducted. Analysis of pooled data used random-effects modelling with results presented as a risk ratio (RR). RESULTS Eleven studies were identified (n = 4,018). The proportion of older adults who fell did not differ between the intervention and control groups (RR 0.93; 95% CI, 0.82-1.06, I2 68%, P = 0.28). There was a significant (P = 0.01) reduction in the monthly rate of falling (RR 0.69; 95% CI, 0.52-0.91, I2 93%), fall-related injuries (RR 0.72; 95% CI, 0.59-0.88, I2 0%, P = 0.001), and hospital admissions (RR 0.76; 95% CI, 0.64-0.90, I2 0%, P = 0.002). CONCLUSIONS ED fall prevention services did not significantly reduce the proportion of older adults who had future falls. However, multifactorial intervention significantly reduced fall-related injuries and hospital admissions with low heterogeneity.
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Affiliation(s)
- Kristie J Harper
- Occupational Therapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Glenn Arendts
- Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Annette D Barton
- Occupational Therapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Antonio Celenza
- Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
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19
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Carpenter CR, Hammouda N, Linton EA, Doering M, Ohuabunwa UK, Ko KJ, Hung WW, Shah MN, Lindquist LA, Biese K, Wei D, Hoy L, Nerbonne L, Hwang U, Dresden SM. Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement. Acad Emerg Med 2021; 28:19-35. [PMID: 33135274 DOI: 10.1111/acem.14166] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions. METHODS GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci. RESULTS In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research. CONCLUSIONS Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.
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Affiliation(s)
- Christopher R. Carpenter
- From the Department of Emergency Medicine Washington University in St. Louis School of MedicineEmergency Care Research Core St. Louis MIUSA
| | - Nada Hammouda
- the Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
| | - Elizabeth A. Linton
- the Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
- the Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MDUSA
| | - Michelle Doering
- the Becker Medical Library Washington University in St. Louis School of Medicine St. Louis MOUSA
| | - Ugochi K. Ohuabunwa
- the Division of General Medicine and Geriatrics Emory University School of Medicine Atlanta GAUSA
| | - Kelly J. Ko
- Clinical Research West Health Institute La Jolla CAUSA
| | - William W. Hung
- James J. Peters VA Medical Center Bronx NYUSA
- and the Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
| | - Manish N. Shah
- the BerbeeWalsh Department of Emergency Medicine University of Wisconsin–Madison Madison WIUSA
| | - Lee A. Lindquist
- the Department of Medicine Northwestern University Feinberg School of Medicine Chicago ILUSA
| | - Kevin Biese
- the Departments of Emergency Medicine and Internal Medicine University of North Carolina at Chapel Hill Chapel Hill NCUSA
| | - Daniel Wei
- the BerbeeWalsh Department of Emergency Medicine University of Wisconsin–Madison Madison WIUSA
| | | | | | - Ula Hwang
- the Department of Emergency Medicine Yale School of Medicine New Haven CTUSA
| | - Scott M. Dresden
- and the Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL USA
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20
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Gettel CJ, Hayes K, Shield RR, Guthrie KM, Goldberg EM. Care Transition Decisions After a Fall-related Emergency Department Visit: A Qualitative Study of Patients' and Caregivers' Experiences. Acad Emerg Med 2020; 27:876-886. [PMID: 32053283 DOI: 10.1111/acem.13938] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/04/2020] [Accepted: 02/07/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Falls are a leading cause of injury-related emergency department (ED) visits and may serve as a sentinel event for older adults, leading to physical and psychological injury. Our primary objective was to characterize patient- and caregiver-specific perspectives about care transitions after a fall. METHODS Using a semistructured interview guide, we conducted in-depth, qualitative interviews using grounded theory methodology. We included patients enrolled in the Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare) trial aged 65 years and older who had an ED visit for a fall and their caregivers. Patients with cognitive impairment (CI) were interviewed in patient-caregiver dyads. Domains assessed included the postfall recovery period, the skilled nursing facility (SNF) placement decision-making process, and the ease of obtaining outpatient follow-up. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed for a priori and emergent themes. RESULTS A total of 22 interviews were completed with 10 patients, eight caregivers, and four patient-caregiver dyads within the 6-month period after initial ED visits. Patients were on average 83 years old, nine of 14 were female, and two of 14 had CI. Six of 12 caregivers were interviewed in reference to a patient with CI. We identified four overarching themes: 1) the fall as a trigger for psychological and physiological change, 2) SNF placement decision-making process, 3) direct effect of fall on caregivers, and 4) barriers to receipt of recommended follow-up. CONCLUSIONS Older adults presenting to the ED after a fall report physical limitations and a prominent fear of falling after their injury. Caregivers play a vital role in securing the home environment; the SNF placement decision-making process; and navigating the transition of care between the ED, SNF, and outpatient visits after a fall. Clinicians should anticipate and address feelings of isolation, changes in mobility, and fear of falling in older adults seeking ED care after a fall.
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Affiliation(s)
- Cameron J. Gettel
- From the Department of Emergency Medicine Yale University School of Medicine New Haven CT United States
- the Department of Internal Medicine National Clinician Scholars ProgramYale University School of Medicine New Haven CT
| | | | - Renee R. Shield
- the Department of Health Services, Policy and Practice Brown University School of Public Health Providence RI United States
| | - Kate M. Guthrie
- the Department of Psychiatry and Human Behavior Centers for Behavioral and Preventive Medicine Miriam HospitalThe Warren Alpert Medical School of Brown University Providence RI
| | - Elizabeth M. Goldberg
- the Department of Health Services, Policy and Practice Brown University School of Public Health Providence RI United States
- and the Department of Emergency Medicine The Warren Alpert Medical School of Brown University Providence RI
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21
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Schuster S, Singler K, Lim S, Machner M, Döbler K, Dormann H. Quality indicators for a geriatric emergency care (GeriQ-ED) - an evidence-based delphi consensus approach to improve the care of geriatric patients in the emergency department. Scand J Trauma Resusc Emerg Med 2020; 28:68. [PMID: 32678052 PMCID: PMC7364502 DOI: 10.1186/s13049-020-00756-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 06/22/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION In emergency care, geriatric requirements and risks are often not taken sufficiently into account. In addition, there are neither evidence-based recommendations nor scientifically developed quality indicators (QI) for geriatric emergency care in German emergency departments. As part of the GeriQ-ED© research project, quality indicators for geriatric emergency medicine in Germany have been developed using the QUALIFY-instruments. METHODS Using a triangulation methodology, a) clinical experience-based quality aspects were identified and verified, b) research-based quality statements were formulated and assessed for relevance, and c) preliminary quality indicators were operationalized and evaluated in order to recommend a feasible set of final quality indicators. RESULTS Initially, 41 quality statements were identified and assessed as relevant. Sixty-seven QI (33 process, 29 structure and 5 outcome indicators) were extrapolated and operationalised. In order to facilitate implementation into daily practice, the following five quality statements were defined as the GeriQ-ED© TOP 5: screening for delirium, taking a full medications history including an assessment of the indications, education of geriatric knowledge and skills to emergency staff, screening for patients with geriatric needs, and identification of patients with risk of falls/ recurrent falls. DISCUSSION QIs are regarded as gold standard to measure, benchmark and improve emergency care. GeriQ-ED© QI focused on clinical experience- and research-based recommendations and describe for the first time a standard for geriatric emergency care in Germany. GeriQ-ED© TOP 5 should be implemented as a minimum standard in geriatric emergency care.
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Affiliation(s)
- Susanne Schuster
- Faculty of Medicine, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Emergency Department, Klinikum Fürth, Fürth, Germany
- Institute for Nursing Research, Gerontology and Ethics, Lutheran University of Applied Sciences - Evangelische Hochschule Nürnberg, Nuremberg, Germany
| | - Katrin Singler
- Institute for Biomedicine of Ageing, Friedrich-Alexander Universität Erlangen-Nürnberg, Nuremberg, Germany
- Geriatric Department - Medizinische Klinik 2, Geriatrie, Klinikum Nürnberg, Paracelsus Private Medical University, Nuremberg, Germany
| | - Stephen Lim
- Academic Geriatric Medicine, University of Southampton, University Hospital Southampton NHS FT, Southampton, UK
| | - Mareen Machner
- Charité – University of Medicine, Public Health Academy, Berlin, Germany
- Charité – University of Medicine, Lernzentrum, Medical Skills Lab, Berlin, Germany
| | - Klaus Döbler
- Competence Center Quality Management in Health Care, MDK Baden-Württemberg, Stuttgart, Germany
| | - Harald Dormann
- Faculty of Medicine, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Emergency Department, Klinikum Fürth, Fürth, Germany
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22
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Rosen T, Liu SW, Cameron‐Comasco L, Clark S, Mulcare MR, Biese K, Magidson PD, Tyler KR, Melady D, Thatphet P, Wongtangman T, Elder NM, Stern ME. Geriatric Emergency Medicine Fellowships: Current State of Specialized Training for Emergency Physicians in Optimizing Care for Older Adults. AEM EDUCATION AND TRAINING 2020; 4:S122-S129. [PMID: 32072116 PMCID: PMC7011413 DOI: 10.1002/aet2.10428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/30/2019] [Accepted: 12/02/2019] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- Tony Rosen
- Department of Emergency MedicineWeill Cornell Medicine/New York‐Presbyterian HospitalNew YorkNY
| | - Shan W. Liu
- Department of Emergency MedicineMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | | | - Sunday Clark
- Department of Emergency MedicineWeill Cornell Medicine/New York‐Presbyterian HospitalNew YorkNY
| | - Mary R. Mulcare
- Department of Emergency MedicineWeill Cornell Medicine/New York‐Presbyterian HospitalNew YorkNY
| | - Kevin Biese
- Department of Emergency MedicineUniversity of North Carolina School of MedicineChapel HillNC
| | - Phillip D. Magidson
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - Katren R. Tyler
- Department of Emergency MedicineUniversity of California Davis School of MedicineSacramentoCA
| | - Don Melady
- Department of Family and Community MedicineSchwarz/Reisman Emergency Medicine Institute/Mount Sinai Health System/University of TorontoTorontoONCanada
| | - Phraewa Thatphet
- Department of Emergency MedicineMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Thiti Wongtangman
- Department of Emergency MedicineMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Natalie M. Elder
- Department of Emergency MedicineOhio State University School of MedicineColumbusOH
| | - Michael E. Stern
- Department of Emergency MedicineWeill Cornell Medicine/New York‐Presbyterian HospitalNew YorkNY
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23
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Goldberg EM, Marks SJ, Ilegbusi A, Resnik L, Strauss DH, Merchant RC. GAPcare: The Geriatric Acute and Post-Acute Fall Prevention Intervention in the Emergency Department: Preliminary Data. J Am Geriatr Soc 2020; 68:198-206. [PMID: 31621901 PMCID: PMC7001768 DOI: 10.1111/jgs.16210] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/25/2019] [Accepted: 09/07/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVES We aimed to describe a new multidisciplinary team fall prevention intervention for older adults who seek care in the emergency department (ED) after having a fall, assess its feasibility and acceptability, and review lessons learned during its initiation. DESIGN Single-blind randomized controlled pilot study. SETTING Two urban academic EDs PARTICIPANTS: Adults 65 years old or older (n = 110) who presented to the ED within 7 days of a fall. INTERVENTION Participants were randomized to a usual care (UC) and an intervention (INT) arm. Participants in the INT arm received a brief medication therapy management session delivered by a pharmacist and a fall risk assessment and plan by a physical therapist (PT). INT participants received referrals to outpatient services (eg, home safety evaluation, outpatient PT). MEASUREMENTS We used participant, caregiver, and clinician surveys, as well as electronic health record review, to assess the feasibility and acceptability of the intervention. RESULTS Of the 110 participants, the median participant age was 81 years old, 67% were female, 94% were white, and 16.3% had cognitive impairment. Of the 55 in the INT arm, all but one participant received the pharmacy consult (98.2%); the PT consult was delivered to 83.6%. Median consult time was 20 minutes for pharmacy and 20 minutes for PT. ED length of stay was not increased in the INT arm: UC 5.25 hours vs INT 5.0 hours (P < .94). After receiving the Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare), 100% of participants and 97.6% of clinicians recommended the pharmacy consult, and 95% of participants and 95.8% of clinicians recommended the PT consult. CONCLUSION These findings support the feasibility and acceptability of the GAPcare model in the ED. A future larger randomized controlled trial is planned to determine whether GAPcare can reduce recurrent falls and healthcare visits in older adults. J Am Geriatr Soc 68:198-206, 2019.
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Affiliation(s)
- Elizabeth M Goldberg
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Health Services, Practice and Policy, Brown University School of Public Health, Providence, Rhode Island
| | - Sarah J Marks
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Aderonke Ilegbusi
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Linda Resnik
- Department of Health Services, Practice and Policy, Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Daniel H Strauss
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Roland C Merchant
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
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24
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McFadden GP, Hall SE, Gleason LJ, Herrera O, Hogan TM. Identification of Older Adult Fall Occurrence by Brief Emergency Department Triage Screen. J Am Geriatr Soc 2019; 68:442-443. [PMID: 31778217 DOI: 10.1111/jgs.16271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/03/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Glenn P McFadden
- University of Chicago, Department of Medicine, Section of Emergency Medicine, Chicago, Illinois
| | - Stephen E Hall
- University of Chicago, Department of Medicine, Section of Emergency Medicine, Chicago, Illinois
| | - Lauren J Gleason
- University of Chicago Medicine, Department of Medicine, Section of Geriatrics and Palliative Medicine, Chicago, Illinois
| | - Octavio Herrera
- University of Chicago, Department of Medicine, Section of Emergency Medicine, Chicago, Illinois
| | - Teresita M Hogan
- University of Chicago, Department of Medicine, Section of Emergency Medicine, Chicago, Illinois
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25
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Geriatric emergency medicine: Research priorities to respond to "The Silver Boom". CAN J EMERG MED 2019; 20:327-328. [PMID: 29764534 DOI: 10.1017/cem.2018.397] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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26
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Goldberg EM, Resnik L, Marks SJ, Merchant RC. GAPcare: the Geriatric Acute and Post-acute Fall Prevention Intervention-a pilot investigation of an emergency department-based fall prevention program for community-dwelling older adults. Pilot Feasibility Stud 2019; 5:106. [PMID: 31463079 PMCID: PMC6710862 DOI: 10.1186/s40814-019-0491-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 08/14/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Falls are the leading cause of fatal and non-fatal injuries among older adults. Older emergency department (ED) patients who present for evaluations after falls have a 30% higher risk of falling again in the subsequent 6 months than age-matched controls. Although EDs frequently evaluate older adults after their falls, the typical evaluation consists of an injury assessment alone. As such, an opportunity is lost to assess and address the potential causes of falls in this vulnerable population. In this manuscript, we present a multidisciplinary fall prevention protocol for a pilot study of older adult ED patients who recently sustained a fall (GAPcare: the Geriatric Acute and Post-acute Fall Prevention Intervention). METHODS GAPcare is a randomized single-blinded pilot study. Participants in GAPcare are 120 older adults (≥ 65 years old) who present to 1 of 2 academic US EDs after a fall. We randomly assign participants 1:1 to an intervention or a usual care (control) arm. In the intervention arm, the patient's ED physician, a pharmacist, and a physical therapist (PT) collaborate to identify and address any risk factors that may have contributed to the fall. Intervention arm participants and their caregivers return home with a medication-related action plan to taper or stop potentially inappropriate medications and to address polypharmacy and a PT assessment and plan. Participants in the usual care arm receive standard assessments and care in the ED and a home safety brochure. Participants in both study arms complete fall calendars for 6 months to document the number of falls and healthcare visits during follow-up. The primary outcome is feasibility of the GAPcare fall prevention intervention (number and proportion of screened participants who are eligible, recruited, and retained; impact on ED length of stay), while the secondary outcome is to estimate its initial efficacy. DISCUSSION The GAPcare-ED fall prevention intervention has the potential to promote older adult-sensitive care for millions of Americans presenting to EDs after falls and establish a protocol for a future large-scale randomized controlled trial on this topic. TRIAL REGISTRATION ClinicalTrials.gov, NCT03360305. Trial registration date: December 4, 2017. Protocol version: 1.
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Affiliation(s)
- Elizabeth M. Goldberg
- Department of Emergency Medicine, Brown University, 55 Claverick Street, Providence, RI 02903 USA
- Department of Health Services, Practice and Policy, Brown University, 121 S. Main Street, Providence, RI 02912 USA
| | - Linda Resnik
- Department of Health Services, Practice and Policy, Brown University, 121 S. Main Street, Providence, RI 02912 USA
- Providence VA Medical Center, 830 Chalkstone Ave, Providence, RI 02908 USA
| | - Sarah J. Marks
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard University, 75 Francis Street, Boston, MA 02115 USA
| | - Roland C. Merchant
- Department of Emergency Medicine, Brown University, 55 Claverick Street, Providence, RI 02903 USA
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard University, 75 Francis Street, Boston, MA 02115 USA
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27
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Lee JS, Tong T, Tierney MC, Kiss A, Chignell M. Predictive Ability of a Serious Game to Identify Emergency Patients With Unrecognized Delirium. J Am Geriatr Soc 2019; 67:2370-2375. [PMID: 31355442 DOI: 10.1111/jgs.16095] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 06/24/2019] [Accepted: 06/30/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Recognition of delirium in the emergency department (ED) is poor. Our objectives were to assess: (1) the diagnostic accuracy of the Predicting Emergency department Delirium with an Interactive Computer Tablet (PrEDICT) "serious game" to identify older ED patients with delirium compared to clinical recognition and (2) the feasibility of the PrEDICT application compared to existing tests of attention. DESIGN Prospective observational study. SETTING ED of a Canadian tertiary care center. PARTICIPANTS We included ED patients, aged 70 years and older, with a minimum 4-hour stay. We excluded anyone with critical illness, communication barriers, and visual impairment or those unable to use a computer tablet. None had prevalent delirium by ED clinicians' routine clinical assessment. MEASUREMENTS Participants were asked to tap targets on a tablet at four difficulty levels. Time and accuracy were automatically recorded. Other measures included the Confusion Assessment Method, the Delirium Severity Index, the Digit Vigilance Test (DVT), and the Choice Reaction Test (CRT). RESULTS We enrolled 203 patients. Their average age was 80.6 years, 49.8% were female, and their average ED length of stay was 15.9 hours. Sixteen subjects had clinically unrecognized delirium, and 14 of them completed the PrEDICT game (87.5%). We developed a threshold score with 100% sensitivity (95% confidence interval [CI] = 76.8%-100.0%) and 59.7% specificity (95% CI = 52.3%-66.6%) to identify patients with clinically unrecognized delirium. The area under the curve was 0.86 (95% CI = 0.77-0.94). Completion rates were 196/203 (96.6%) for the PrEDICT serious game compared to 128/203 (63.1%) for the CRT and 51/203 (25.1%) for the DVT. CONCLUSION Older ED patients were able to use our serious game, including 87.5% of those with clinically unrecognized delirium. The PrEDICT application has potential to act as a sensitive screening tool to identify older ED patients with clinically unrecognized delirium. J Am Geriatr Soc 67:2370-2375, 2019.
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Affiliation(s)
- Jacques S Lee
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Emergency Services, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Division of Emergency Services, Schwartz-Reisman Emergency Medicine Institute, Toronto, Ontario, Canada
| | - Tiffany Tong
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Mary C Tierney
- Division of Emergency Services, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Primary Care Research Unit, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Alex Kiss
- Division of Emergency Services, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Mark Chignell
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
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28
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Patterson BW, Jacobsohn GC, Shah MN, Song Y, Maru A, Venkatesh AK, Zhong M, Taylor K, Hamedani AG, Mendonça EA. Development and validation of a pragmatic natural language processing approach to identifying falls in older adults in the emergency department. BMC Med Inform Decis Mak 2019; 19:138. [PMID: 31331322 PMCID: PMC6647058 DOI: 10.1186/s12911-019-0843-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 06/20/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Falls among older adults are both a common reason for presentation to the emergency department, and a major source of morbidity and mortality. It is critical to identify fall patients quickly and reliably during, and immediately after, emergency department encounters in order to deliver appropriate care and referrals. Unfortunately, falls are difficult to identify without manual chart review, a time intensive process infeasible for many applications including surveillance and quality reporting. Here we describe a pragmatic NLP approach to automating fall identification. METHODS In this single center retrospective review, 500 emergency department provider notes from older adult patients (age 65 and older) were randomly selected for analysis. A simple, rules-based NLP algorithm for fall identification was developed and evaluated on a development set of 1084 notes, then compared with identification by consensus of trained abstractors blinded to NLP results. RESULTS The NLP pipeline demonstrated a recall (sensitivity) of 95.8%, specificity of 97.4%, precision of 92.0%, and F1 score of 0.939 for identifying fall events within emergency physician visit notes, as compared to gold standard manual abstraction by human coders. CONCLUSIONS Our pragmatic NLP algorithm was able to identify falls in ED notes with excellent precision and recall, comparable to that of more labor-intensive manual abstraction. This finding offers promise not just for improving research methods, but as a potential for identifying patients for targeted interventions, quality measure development and epidemiologic surveillance.
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Affiliation(s)
- Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. .,Health Innovation Program, University of Wisconsin-Madison, Madison, WI, 53705, USA.
| | - Gwen C Jacobsohn
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Department of Medicine, Division of Geriatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Yiqiang Song
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA.,Department of Pediatrics and Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Apoorva Maru
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine and Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, CT, USA
| | - Monica Zhong
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Katherine Taylor
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Azita G Hamedani
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Eneida A Mendonça
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA.,Department of Pediatrics and Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Indianapolis, IN, USA
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29
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Hughes JM, Freiermuth CE, Shepherd-Banigan M, Ragsdale L, Eucker SA, Goldstein K, Hastings SN, Rodriguez RL, Fulton J, Ramos K, Tabriz AA, Gordon AM, Gierisch JM, Kosinski A, Williams JW. Emergency Department Interventions for Older Adults: A Systematic Review. J Am Geriatr Soc 2019; 67:1516-1525. [PMID: 30875098 PMCID: PMC6677239 DOI: 10.1111/jgs.15854] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/21/2019] [Accepted: 02/02/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To evaluate the effect of emergency department (ED) interventions on clinical, utilization, and care experience outcomes for older adults. DESIGN A conceptual model informed, protocol-based systematic review. SETTING Emergency Department (ED). PARTICIPANTS Older adults 65 years of age and older. METHODS AND MEASUREMENT Medline, Embase, CINAHL, and PsycINFO were searched for English-language studies published through December 2017. Studies evaluating the use of one or more eligible intervention strategies (discharge planning, case management, medication safety or management, and geriatric EDs including those that cited the 2014 Geriatric ED Guidelines) with adults 65 years of age and older were included. Studies were classified by the number of intervention strategies used (ie, single strategy or multi-strategy) and key intervention components present (ie, assessment, referral plus follow-up, and contact both before and after ED discharge ["bridge"]). The effect of ED interventions on clinical (functional status, quality of life [QOL]), patient experience, and utilization (hospitalization, ED return visit) outcomes was evaluated. RESULTS A total of 2000 citations were identified; 17 articles describing 15 unique studies (9 randomized and 6 nonrandomized) met eligibility criteria and were included in analyses. ED interventions showed a mixed pattern of effects. Overall, there was a small positive effect of ED interventions on functional status but no effects on QOL, patient experience, hospitalization at or after the initial ED index visit, or ED return visit. CONCLUSION Studies using two or more intervention strategies may be associated with the greatest effects on clinical and utilization outcomes. More comprehensive interventions, defined as those with all three key intervention components present, may be associated with some positive outcomes.
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Affiliation(s)
- Jaime M. Hughes
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina
| | - Caroline E. Freiermuth
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Megan Shepherd-Banigan
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Luna Ragsdale
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Stephanie A. Eucker
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Karen Goldstein
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - S. Nicole Hastings
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina
| | | | - Jessica Fulton
- Psychology Service, Durham VA Health Care System, Durham, North Carolina
| | - Katherine Ramos
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina
| | - Amir Alishahi Tabriz
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Adelaide M. Gordon
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
| | - Jennifer M. Gierisch
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Andrzej Kosinski
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina
| | - John W. Williams
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
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30
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Pua YH, Matchar DB. Physical Performance Predictor Measures in Older Adults With Falls-Related Emergency Department Visits. J Am Med Dir Assoc 2019; 20:780-784. [PMID: 30711461 DOI: 10.1016/j.jamda.2018.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/06/2018] [Accepted: 12/09/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Identifying strong predictors for falls and mobility limitations in older adults with a falls-related emergency department visit is crucial. This study aimed to compare, in this clinical population, the incremental predictive value of the Short Physical Performance Battery (SPPB) component tests for incident falls, injurious falls, and mobility limitations. DESIGN AND MEASURES Prospective cohort study. SETTING AND PARTICIPANTS A total of 323 community-dwelling older adults with a falls-related emergency department visit participated. Baseline physical performance was measured by the SPPB standing balance test, sit-to-stand test, and habitual gait speed test. Six-month prospective fall rate and self-reported mobility limitations at 6 months post baseline assessment were also measured. An injurious fall was defined as a fall for which the participant sought medical attention or that restricted his or her daily activities for at least 48 hours. RESULTS In multivariable proportional odds analyses adjusted for demographics and clinical covariates, higher levels of full-tandem balance and sit-to-stand performance were significantly associated with fewer incident falls (P = .04 and .02, respectively) and lower odds of mobility limitations (P = .05 and .03, respectively) and marginally associated with lower odds of injurious falls (P = .06 and .07, respectively). Habitual gait speed was the weakest predictor of falls but the strongest predictor (odds ratio 0.24, 95% confidence interval 0.08-0.70; P < .001) of mobility limitations. CONCLUSIONS/IMPLICATIONS In high-fall-risk older adults, the SPPB balance and sit-to-stand tests predicted falls whereas the SPPB gait speed test was adept at predicting mobility limitations. No one test is best across all situations, so the choice of test will depend on the goal of the assessment.
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Affiliation(s)
- Yong-Hao Pua
- Department of Physiotherapy, Singapore General Hospital, Singapore.
| | - David B Matchar
- Program in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore; Department of Internal Medicine (General Internal Medicine), Duke University Medical Center, Durham, NC
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Goldberg EM, Gettel CJ, Hayes K, Shield RR, Guthrie KM. GAPcare: The Geriatric Acute and Post-Acute Fall Prevention Intervention for Emergency Department Patients - A Qualitative Evaluation. ACTA ACUST UNITED AC 2019; 3. [PMID: 32352082 PMCID: PMC7189708 DOI: 10.21926/obm.geriatr.1904078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Three million US emergency department (ED) visits occur for falls each year. The mortality of falls is increasing and only one fourth of older adults report their fall to their primary care provider, suggesting that valuable preventative opportunities are missed. A fall prevention intervention initiated in the ED immediately after a fall has the potential to reduce subsequent falls, but ED providers lack the time and resources to complete fall risk assessments on their patients. GAPcare, the Geriatric Acute and Post-Acute Fall Prevention Intervention, was developed to address this need. Methods: GAPcare combines a pharmacist-led medication therapy management intervention with a physical therapist (PT)-administered fall risk assessment and disposition planning. A key objective of this pilot randomized controlled trial (RCT) was to create a patient and caregiver-centric intervention. This manuscript reports on the results of the qualitative companion study in which we conducted in-depth interviews with patients and caregivers to determine their lived experience with the intervention, barriers and perceived impact of the intervention, and to obtain their recommendations for the improvement of GAPcare. We recruited patients and their caregivers from the RCT into 30 minutes interviews in the participants’ home singularly or in dyads (patient and caregiver together). Interviews were audio-recorded, transcribed, and double-coded. We used applied thematic analysis to guide the data analysis. Results: We conducted 20 interviews; patients (n=12), caregivers (n=11). Patients were on average 83 years old, 7/12 were female, and 2/14 had cognitive impairment. 6/11 caregiver interviews were in reference to a patient with dementia. Patients and caregivers reported they embraced the experience of motivational interviewing elements, citing its collaborative and inclusive nature. Caregivers in particular said they felt that PT helped their loved one recognize and overcome functional limitations. Barriers included lack of time, the burden of coordinating multiple service providers once home, and concerns that PT would be ineffective or increase pain. Areas for improvement included better screening for those who would benefit from the individual components (pharmacy vs. PT consultation), improving identification of GAPcare pharmacists and PTs vs. other hospital staff in the ED, and expanding the role of GAPcare personnel to provide culturally competent, comprehensive care to improve adherence and medication education. Conclusions: We found that GAPcare, a new team-based intervention for fall prevention in the ED, was welcomed by patients and their caregivers. Several suggestions to improve the intervention were made that will inform the screening, content, and communication with patients in GAPcare.
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Affiliation(s)
- Elizabeth M Goldberg
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Health Services, Policy and Practice, Brown University School of Public Health, 121 South Main Street, Providence, RI, USA
| | - Cameron J Gettel
- Department of Emergency Medicine, National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, USA
| | - Kelsey Hayes
- College of Our Lady of the Elms, Chicopee, MA, USA
| | - Renee R Shield
- Department of Health Services, Policy and Practice, Brown University School of Public Health, 121 South Main Street, Providence, RI, USA
| | - Kate M Guthrie
- Centers for Behavioral and Preventive Medicine, Miriam Hospital, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Schumacher JG, Hirshon JM, Magidson P, Chrisman M, Hogan T. Tracking the Rise of Geriatric Emergency Departments in the United States. J Appl Gerontol 2018; 39:871-879. [PMID: 30451060 DOI: 10.1177/0733464818813030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The traditional model of emergency care no longer fits the growing needs of the over 20 million older adults annually seeking emergency department care. In 2007 a tailored "geriatric emergency department" model was introduced and rapidly replicated among hospitals, rising steeply over the past 5 years. This survey examined all U.S. emergency departments self-identifying themselves as Geriatric Emergency Departments (GEDs) and providing enhanced geriatric emergency care services. It was guided by the recently adopted Geriatric Emergency Department Guidelines and examined domains including, GED identity, staffing, and administration; education, equipment, and supplies; policies, procedures, and protocols; follow-up and transitions of care; and quality improvement. Results reveal a heterogeneous mix of GED staffing, procedures, physical environments and that GEDs' familiarity with the GED Guidelines is low. Findings will inform emergency departments and gerontologists nationwide about key GED model elements and will help hospitals to improve ED services for their older adult patients.
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Rosen T, Shah M, Lundebjerg NE, Singh C, McMillian M, Sarli CC, Suiter AM, Lee AG, Burton JR, Carpenter CR. Impact of Jahnigen/GEMSSTAR Scholarships on Careers of Recipients in Emergency Medicine and on Development of Geriatric Emergency Medicine. Acad Emerg Med 2018; 25:911-920. [PMID: 29493855 PMCID: PMC6119536 DOI: 10.1111/acem.13396] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/06/2018] [Accepted: 02/13/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Jahnigen Career Development Awards program was launched in 2002 with private funding and transformed into the Grants for Early Medical/Surgical Specialists' Transition to Aging Research (GEMSSTAR) program in 2011 through support from the National Institute on Aging and medical specialty professional societies. The Jahnigen/GEMSSTAR program has provided grants to early career physician-scientists from 10 surgical and related medical specialties to initiate and sustain research careers in the geriatric aspect of their discipline. From 2002 to 2016, there were 20 Jahnigen/GEMSSTAR recipients in emergency medicine (EM). The goal of this investigation was to examine the impact of Jahnigen/GEMSSTAR awards on careers of EM recipients and on development of academic geriatric EM. METHODS We conducted an online survey of the 20 EM recipients from 2002 to 2016 and analyzed their academic productivity, research impact, career trajectory, and contributions to geriatric EM since receiving the award. RESULTS All 20 Jahnigen/GEMSSTAR scholars completed the survey. Scholars have published a median of 33 peer-reviewed articles (interquartile range [IQR] = 10-97) since the award, with median annual publication rates of 4.5 (IQR = 1.6-7.0). All scholars had h-indices of 6 or more, with a median of 18 (IQR = 9-28). Jahnigen/GEMSSTAR scholars have served as principal investigator (PI) or co-PI on 126 grants since their award, with 90% having served as PI on at least one additional grant and 30% having received National Institutes of Health Career Development Awards. All scholars reported believing that the Jahnigen/GEMSSTAR was very helpful or helpful for career progress. Most (85%) reported ongoing contributions to geriatric EM in research, education, or administration. CONCLUSIONS After the Jahnigen/GEMSSTAR award, EM scholars have been highly academically productive and successful, and the award has been instrumental in their career development. Awardees have been critical to the development of geriatric EM.
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Affiliation(s)
- Tony Rosen
- Division of Emergency Medicine, Weill Cornell Medical College, New York, NY 10065, USA
| | - Manish Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA
| | | | - Cynthia Singh
- American College of Emergency Physicians, Irving, TX 75063, USA
| | | | - Cathy C Sarli
- Becker Medical Library, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Amy M. Suiter
- Becker Medical Library, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Andrew G. Lee
- Department of Ophthalmology, Houston Methodist Hospital, Blanton Eye Institute, Houston, TX 77030
| | - John R. Burton
- Division of Geriatric Medicine and Gerontology, School of Medicine, The Johns Hopkins School of Medicine, Baltimore, MD 21224
| | - Christopher R. Carpenter
- The Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
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Patterson BW, Repplinger MD, Pulia MS, Batt RJ, Svenson JE, Trinh A, Mendonça EA, Smith MA, Hamedani AG, Shah MN. Using the Hendrich II Inpatient Fall Risk Screen to Predict Outpatient Falls After Emergency Department Visits. J Am Geriatr Soc 2018; 66:760-765. [PMID: 29509312 PMCID: PMC5937931 DOI: 10.1111/jgs.15299] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the utility of routinely collected Hendrich II fall scores in predicting returns to the emergency department (ED) for falls within 6 months. DESIGN Retrospective electronic record review. SETTING Academic medical center ED. PARTICIPANTS Individuals aged 65 and older seen in the ED from January 1, 2013, through September 30, 2015. MEASUREMENTS We evaluated the utility of routinely collected Hendrich II fall risk scores in predicting ED visits for a fall within 6 months of an all-cause index ED visit. RESULTS For in-network patient visits resulting in discharge with a completed Hendrich II score (N = 4,366), the return rate for a fall within 6 months was 8.3%. When applying the score alone to predict revisit for falls among the study population the resultant receiver operating characteristic (ROC) plot had an area under the curve (AUC) of 0.64. In a univariate model, the odds of returning to the ED for a fall in 6 months were 1.23 times as high for every 1-point increase in Hendrich II score (odds ratio (OR)=1.23 (95% confidence interval (CI)=1.19-1.28). When included in a model with other potential confounders or predictors of falls, the Hendrich II score is a significant predictor of a return ED visit for fall (adjusted OR=1.15, 95% CI=1.10-1.20, AUC=0.75). CONCLUSION Routinely collected Hendrich II scores were correlated with outpatient falls, but it is likely that they would have little utility as a stand-alone fall risk screen. When combined with easily extractable covariates, the screen performs much better. These results highlight the potential for secondary use of electronic health record data for risk stratification of individuals in the ED. Using data already routinely collected, individuals at high risk of falls after discharge could be identified for referral without requiring additional screening resources.
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Affiliation(s)
- Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Health Innovation Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Robert J Batt
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Wisconsin School of Business, University of Wisconsin-Madison, Madison, Wisconsin
| | - James E Svenson
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Alex Trinh
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Eneida A Mendonça
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Maureen A Smith
- Health Innovation Program, University of Wisconsin-Madison, Madison, Wisconsin
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Department of Family Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Azita G Hamedani
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
- Division of Geriatrics, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
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Namboodri BL, Rosen T, Dayaa JA, Bischof JJ, Ramadan N, Patel MD, Grover J, Brice JH, Platts-Mills TF. Elder Abuse Identification in the Prehospital Setting: An Examination of State Emergency Medical Services Protocols. J Am Geriatr Soc 2018; 66:962-968. [PMID: 29566428 DOI: 10.1111/jgs.15329] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe statewide emergency medical service (EMS) protocols relating to identification, management, and reporting of elder abuse in the prehospital setting. DESIGN Cross-sectional analysis. SETTING Statewide EMS protocols in the United States. PARTICIPANTS Publicly available statewide EMS protocols identified from published literature, http://EMSprotocols.org, and each state's public health website. MEASUREMENTS Protocols were reviewed to determine whether elder abuse was mentioned, elder abuse was defined, potential indicators of elder abuse were listed, management of older adults experiencing abuse was described, and instructions regarding reporting were provided. EMS protocols for child abuse were reviewed in the same manner for the purpose of comparison. RESULTS Of the 35 publicly available statewide EMS protocols, only 14 (40.0%) mention elder abuse. Of protocols that mention elder abuse, 6 (42.9%) define elder abuse, 10 (71.4%) describe indicators of elder abuse, 8 (57.1%) provide instruction regarding management, and 12 (85.7%) provide instruction regarding reporting. Almost twice as many states met each of these metrics for child abuse. CONCLUSION Statewide EMS protocols for elder abuse vary in regard to identification, management, and reporting, with the majority of states having no content on this subject. Expansion and standardization of protocols may increase the identification of elder abuse.
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Affiliation(s)
- Brooke L Namboodri
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Tony Rosen
- Division of Emergency Medicine, New York-Presbyterian Hospital / Weill Cornell Medical College, New York, New York
| | - Joseph A Dayaa
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jason J Bischof
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Nadeem Ramadan
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joseph Grover
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jane H Brice
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Taylor A, Broadbent M, Wallis M, Marsden E. The use of functional and cognitive assessment in the emergency department to inform decision making: A scoping review. Australas Emerg Care 2018; 21:13-22. [PMID: 30998859 DOI: 10.1016/j.auec.2017.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/21/2017] [Accepted: 12/14/2017] [Indexed: 10/17/2022]
Abstract
BACKGROUND The use of functional and/or cognitive assessment in the emergency department (ED) to inform decision making in the complex older adult is considered important, yet not routinely administered. METHOD Electronic databases were searched to identify eligible published research studies: older adults >65 years; the administration of a functional and/or cognition assessment instrument whilst the older adult is in any part of the ED; interventions resulting from the administration of the instrument; and a measured outcome post ED visit. A revised scoping review methodology was applied to chart study data and to identify key differences. RESULTS Ten research studies were identified that met the criteria for review. There are a variety of assessments, aimed at different age groups, for several purposes and used at different times in the ED journey. Assessments are not being used in conjunction with routine medical assessment early in the ED patient journey. CONCLUSION This scoping review identified no consistent suite of tools being administered in the ED to influence the disposition decision with measurable outcomes. Further research is required to identify a suite of assessment instruments suitable for use in the ED setting aimed at improving disposition decision making in the complex elderly person.
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Affiliation(s)
- Andrea Taylor
- University of the Sunshine Coast, Australia; Sunshine Coast Hospital and Health Service, Australia.
| | | | | | - Elizabeth Marsden
- University of the Sunshine Coast, Australia; Sunshine Coast Hospital and Health Service, Australia
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Pua YH, Ong PH, Clark RA, Matcher DB, Lim ECW. Falls efficacy, postural balance, and risk for falls in older adults with falls-related emergency department visits: prospective cohort study. BMC Geriatr 2017; 17:291. [PMID: 29268720 PMCID: PMC5740922 DOI: 10.1186/s12877-017-0682-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 12/07/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Risk for falls in older adults has been associated with falls efficacy (self-perceived confidence in performing daily physical activities) and postural balance, but available evidence is limited and mixed. We examined the interaction between falls efficacy and postural balance and its association with future falls. We also investigated the association between falls efficacy and gait decline. METHODS Falls efficacy, measured by the Modified Falls Efficacy Scale (MFES), and standing postural balance, measured using computerized posturography on a balance board, were obtained from 247 older adults with a falls-related emergency department visit. Six-month prospective fall rate and habitual gait speed at 6 months post baseline assessment were also measured. RESULTS In multivariable proportional odds analyses adjusted for potential confounders, falls efficacy modified the association between postural balance and fall risk (interaction P = 0.014): increasing falls efficacy accentuated the increased fall risk related to poor postural balance. Low baseline falls efficacy was strongly predictive of worse gait speed (0.11 m/s [0.06 to 0.16] slower gait speed per IQR decrease in MFES; P < 0.001). CONCLUSION Older adults with high falls efficacy but poor postural balance were at greater risk for falls than those with low falls efficacy; however, low baseline falls efficacy was strongly associated with worse gait function at follow-up. Further research into these subgroups of older adults is warranted. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01713543 .
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Affiliation(s)
- Yong-Hao Pua
- Department of Physiotherapy, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
| | - Peck-Hoon Ong
- Department of Physiotherapy, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Ross Allan Clark
- Research Health Institute, University of the Sunshine Coast, Sunshine Coast, Australia
| | - David B Matcher
- Health Services & Systems Research Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Edwin Choon-Wyn Lim
- Department of Physiotherapy, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
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Goldberg EM, McCreedy EM, Gettel CJ, Merchant RC. Slipping through the cracks: A cross-sectional study examining older adult emergency department patient fall history, post-fall treatment and prevention. RHODE ISLAND MEDICAL JOURNAL (2013) 2017; 100:18-23. [PMID: 29190838 PMCID: PMC5908708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Falls are the leading cause of emergency department (ED) visits for fatal and non-fatal injuries among adults 65 years old and older. We aimed to better understand the fall history, risk for further falls, and actions taken to prevent further falls among this higher fall risk population. This cross-sectional study included older adults without cognitive impairment presenting to the Rhode Island Hospital ED from February to May 2017. Of the 76 participants, 35 self-reported no prior falls, and 41 self-reported at least one prior fall, of whom 20 fell on the day of ED presentation. Participants with vs. without self-reported prior falls were similar in age, gender, race, and substance use. Participants with prior falls scored lower on cognitive testing and had more comorbidities associated with falls. Only one quarter of those with prior falls reported making changes and few were evaluated by professionals to prevent future falls. This study highlights that older adult ED patients who sustain a fall are at higher risk for subsequent falls, and that greater fall prevention efforts are needed to protect this vulnerable group. [Full article available at http://rimed.org/rimedicaljournal-2017-12.asp].
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Affiliation(s)
- Elizabeth M Goldberg
- Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Alpert Medical School of Brown University; Postdoctoral Research Fellow, Center of Gerontology and Healthcare Research,Brown University School of Public Health, Providence, RI
| | - Ellen M McCreedy
- Post-doctoral Research Fellow, Center of Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI
| | - Cameron J Gettel
- PGY-3, Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
| | - Roland C Merchant
- Professor, Departments of Emergency Medicine & Epidemiology, Alpert Medical School of Brown University, Brown University School of Public Health, Providence, RI
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Revised National Estimates of Emergency Department Visits for Sepsis in the United States. Crit Care Med 2017; 45:1443-1449. [PMID: 28817480 DOI: 10.1097/ccm.0000000000002538] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The emergency department is an important venue for initial sepsis recognition and care. We sought to determine contemporary estimates of the epidemiology of U.S. emergency department visits for sepsis. DESIGN Analysis of data from the National Hospital Ambulatory Medical Care Survey. SETTING U.S. emergency department visits, 2009-2011. PATIENTS Adult (age, ≥ 18 yr) emergency department sepsis patients. We defined serious infection as an emergency department diagnosis of a serious infection or a triage temperature greater than 38°C or less than 36°C. We defined three emergency department sepsis classifications: 1) original emergency department sepsis-serious infection plus emergency department diagnosis of organ dysfunction, endotracheal intubation, or systolic blood pressure less than or equal to 90 mm Hg or explicit sepsis emergency department diagnoses; 2) quick Sequential Organ Failure Assessment emergency department sepsis-serious infection plus presence of at least two "quick" Sequential Organ Failure Assessment criteria (Glasgow Coma Scale ≤ 14, respiratory rate ≥ 22 breaths/min, or systolic blood pressure ≤ 100 mm Hg); and 3) revised emergency department sepsis-original or quick Sequential Organ Failure Assessment emergency department sepsis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used survey design and weighting variables to produce national estimates of annual adult emergency department visits using updated sepsis classifications. Over 2009-2011, there were 103,257,516 annual adult emergency department visits. The estimated number of emergency department sepsis visits were as follows: 1) original emergency department sepsis 665,319 (0.64%; 95% CI, 0.57-0.73); 2) quick Sequential Organ Failure Assessment emergency department sepsis 318,832 (0.31%; 95% CI, 0.26-0.37); and 3) revised emergency department sepsis 847,868 (0.82%; 95% CI, 0.74-0.91). CONCLUSIONS Sepsis continues to present a major burden to U.S. emergency departments, affecting up to nearly 850,000 emergency department visits annually. Updated sepsis classifications may impact national estimates of emergency department sepsis epidemiology.
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Patterson BW, Smith MA, Repplinger MD, Pulia MS, Svenson JE, Kim MK, Shah MN. Using Chief Complaint in Addition to Diagnosis Codes to Identify Falls in the Emergency Department. J Am Geriatr Soc 2017; 65:E135-E140. [PMID: 28636072 PMCID: PMC5603381 DOI: 10.1111/jgs.14982] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To compare incidence of falls in an emergency department (ED) cohort using a traditional International Classification of Diseases, Ninth Revision (ICD-9) code-based scheme and an expanded definition that included chief complaint information and to examine the clinical characteristics of visits "missed" in the ICD-9-based scheme. DESIGN Retrospective electronic record review. SETTING Academic medical center ED. PARTICIPANTS Individuals aged 65 and older seen in the ED between January 1, 2013, and September 30, 2015. MEASUREMENTS Two fall definitions were applied (individually and together) to the cohort: an ICD-9-based definition and a chief complaint definition. Admission rates and 30-day mortality (per encounter) were measured for each definition. RESULTS Twenty-three thousand eight hundred eighty older adult visits occurred during the study period. Using the most-inclusive definition (ICD-9 code or chief complaint indicating a fall), 4,363 visits (18%) were fall related. Of these visits, 3,506 (80%) met the ICD-9 definition for a fall-related visit, and 2,664 (61%) met the chief complaint definition. Of visits meeting the chief complaint definition, 857 (19.6%) were missed when applying the ICD-9 definition alone. Encounters missed using the ICD-9 definition were less likely to lead to an admission (42.9%, 95% confidence interval (CI) = 39.7-46.3%) than those identified (54.4%, 95% CI = 52.7-56.0%). CONCLUSION Identifying individuals in the ED who have fallen based on diagnosis codes underestimates the true burden of falls. Individuals missed according to the code-based definition were less likely to have been admitted than those who were captured. These findings call attention to the value of using chief complaint information to identify individuals who have fallen in the ED-for research, clinical care, or policy reasons.
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Affiliation(s)
- Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
- Health Innovation Program, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Maureen A Smith
- Health Innovation Program, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
- Department of Family Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - James E Svenson
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael K Kim
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
- Division of Geriatrics, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
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Duong HV, Herrera LN, Moore JX, Donnelly J, Jacobson KE, Carlson JN, Mann NC, Wang HE. National Characteristics of Emergency Medical Services Responses for Older Adults in the United States. PREHOSP EMERG CARE 2017; 22:7-14. [PMID: 28862480 DOI: 10.1080/10903127.2017.1347223] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Older adults, those aged 65 and older, frequently require emergency care. However, only limited national data describe the Emergency Medical Services (EMS) care provided to older adults. We sought to determine the characteristics of EMS care provided to older adults in the United States. METHODS We used data from the 2014 National Emergency Medical Services Information System (NEMSIS), encompassing EMS response data from 46 States and territories. We excluded EMS responses for children <18 years, interfacility transports, intercepts, non-emergency medical transports, and standby responses. We defined older adults as age ≥65 years. We compared patient demographics (age, sex, race, primary payer), response characteristics (dispatch time, location type, time intervals), and clinical course (clinical impression, injury, procedures, medications) between older and younger adult EMS emergency 9-1-1 responses. RESULTS During the study period there were 20,212,245 EMS emergency responses. Among the 16,116,219 adult EMS responses, there were 6,569,064 (40.76%) older and 9,547,155 (59.24%) younger adults. Older EMS patients were more likely to be white and the EMS incident to be located in healthcare facilities (clinic, hospital, nursing home). Compared with younger patients, older EMS patients were more likely to present with syncope (5.68% vs. 3.40%; OR 1.71; CI: 1.71-1.72), cardiac arrest/rhythm disturbance (3.27% vs. 1.69%; OR 1.97; CI: 1.96-1.98), stroke (2.18% vs. 0.74%; OR 2.99; CI: 2.96-3.02) and shock (0.77% vs. 0.38%; OR 2.02; CI: 2.00-2.04). Common EMS interventions performed on older persons included intravenous access (32.02%), 12-lead ECG (14.37%), CPR (0.87%), and intubation (2.00%). The most common EMS drugs administered to older persons included epinephrine, atropine, furosemide, amiodarone, and albuterol or ipratropium. CONCLUSION One of every three U.S. EMS emergency responses involves older adults. EMS personnel must be prepared to care for the older patient.
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Arendts G, Love J, Nagree Y, Bruce D, Hare M, Dey I. Rates of Delirium Diagnosis Do Not Improve with Emergency Risk Screening: Results of the Emergency Department Delirium Initiative Trial. J Am Geriatr Soc 2017; 65:1810-1815. [DOI: 10.1111/jgs.14904] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Glenn Arendts
- Centre for Clinical Research in Emergency Medicine; Harry Perkins Institute for Medical Research; Fiona Stanley Hospital; Murdoch Western Australia Australia
- University of Western Australia; Nedlands Western Australia Australia
| | - Jennefer Love
- Western Australian Department of Health; Perth Western Australia Australia
| | - Yusuf Nagree
- University of Western Australia; Nedlands Western Australia Australia
| | - David Bruce
- University of Western Australia; Nedlands Western Australia Australia
| | - Malcolm Hare
- Western Australian Department of Health; Perth Western Australia Australia
| | - Ian Dey
- Western Australian Department of Health; Perth Western Australia Australia
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Prusaczyk B, Cherney SM, Carpenter CR, DuBois JM. Informed Consent to Research with Cognitively Impaired Adults: Transdisciplinary Challenges and Opportunities. Clin Gerontol 2017; 40:63-73. [PMID: 28452628 PMCID: PMC5911394 DOI: 10.1080/07317115.2016.1201714] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Due to issues related to informed research consent, older adults with cognitive impairments are often excluded from high-quality studies that are not directly related to cognitive impairment, which has led to a dearth of evidence for this population. The challenges to including cognitively impaired older adults in research and the implications of their exclusion are a transdisciplinary issue. The ethical challenges and logistical barriers to conducting research with cognitively impaired older adults are addressed from the perspectives of three different fields-social work, emergency medicine, and orthopaedic surgery. Issues related to funding, study design, intervention components, and outcomes are discussed through the unique experiences of three different providers. A fourth perspective-medical research ethics-provides alternatives to exclusion when conducting research with cognitively impaired older adults such as timing, corrective feedback and plain language, and capacity assessment and proxy appointments. Given the increasing aging population and the lack of evidence on cognitively impaired older adults, it is critical that researchers, funders, and institutional review boards not be dissuaded from including this population in research studies.
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Affiliation(s)
- Beth Prusaczyk
- a Washington University School of Medicine , St. Louis , Missouri , USA
| | - Steven M Cherney
- a Washington University School of Medicine , St. Louis , Missouri , USA
| | | | - James M DuBois
- a Washington University School of Medicine , St. Louis , Missouri , USA
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Brahmandam S, Holland WC, Mangipudi SA, Braz VA, Medlin RP, Hunold KM, Jones CW, Platts-Mills TF. Willingness and Ability of Older Adults in the Emergency Department to Provide Clinical Information Using a Tablet Computer. J Am Geriatr Soc 2016; 64:2362-2367. [PMID: 27804126 DOI: 10.1111/jgs.14366] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To estimate the proportion of older adults in the emergency department (ED) who are willing and able to use a tablet computer to answer questions. DESIGN Prospective, ED-based cross-sectional study. SETTING Two U.S. academic EDs. PARTICIPANTS Individuals aged 65 and older. MEASUREMENTS As part of screening for another study, potential study participants were asked whether they would be willing to use a tablet computer to answer eight questions instead of answering questions orally. A custom user interface optimized for older adults was used. Trained research assistants observed study participants as they used the tablets. Ability to use the tablet was assessed based on need for assistance and number of questions answered correctly. RESULTS Of 365 individuals approached, 248 (68%) were willing to answer screening questions, 121 of these (49%) were willing to use a tablet computer; of these, 91 (75%) were able to answer at least six questions correctly, and 35 (29%) did not require assistance. Only 14 (12%) were able to answer all eight questions correctly without assistance. Individuals aged 65 to 74 and those reporting use of a touchscreen device at least weekly were more likely to be willing and able to use the tablet computer. Of individuals with no or mild cognitive impairment, the percentage willing to use the tablet was 45%, and the percentage answering all questions correctly was 32%. CONCLUSION Approximately half of this sample of older adults in the ED was willing to provide information using a tablet computer, but only a small minority of these were able to enter all information correctly without assistance. Tablet computers may provide an efficient means of collecting clinical information from some older adults in the ED, but at present, it will be ineffective for a significant portion of this population.
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Affiliation(s)
| | - Wesley C Holland
- Department of Emergency Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Sowmya A Mangipudi
- Department of Emergency Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Valerie A Braz
- Department of Emergency Medicine, Cooper Medical School, Rowan University, Camden, New Jersey
| | - Richard P Medlin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Christopher W Jones
- Department of Emergency Medicine, Cooper Medical School, Rowan University, Camden, New Jersey
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.,Division of Geriatrics, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
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Singler K, Dormann H, Dodt C, Heppner HJ, Püllen R, Burkhardt M, Swoboda W, Roller-Wirnsberger RE, Pinter G, Mrak P, Münzer T. Der geriatrische Patient in der Notaufnahme. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0216-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abrashkin KA, Washko J, Zhang J, Poku A, Kim H, Smith KL. Providing Acute Care at Home: Community Paramedics Enhance an Advanced Illness Management Program-Preliminary Data. J Am Geriatr Soc 2016; 64:2572-2576. [DOI: 10.1111/jgs.14484] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Karen A. Abrashkin
- Department of Internal Medicine; Hoftstra-Northwell School of Medicine; New Hyde Park New York
| | - Jonathan Washko
- Center for Emergency Medical Services; Northwell Health; New Hyde Park New York
| | - Jenny Zhang
- Department of Internal Medicine; Hoftstra-Northwell School of Medicine; New Hyde Park New York
| | - Asantewaa Poku
- Department of Internal Medicine; Hoftstra-Northwell School of Medicine; New Hyde Park New York
| | - Hyun Kim
- Division of Environmental Health Sciences; University of Minnesota; Minneapolis Minnesota
| | - Kristofer L. Smith
- Department of Internal Medicine; Hoftstra-Northwell School of Medicine; New Hyde Park New York
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LaMantia MA, Messina FC, Jhanji S, Nazir A, Maina M, McGuire S, Hobgood CD, Miller DK. Emergency medical service, nursing, and physician providers' perspectives on delirium identification and management. DEMENTIA 2016; 16:329-343. [PMID: 26112165 DOI: 10.1177/1471301215591896] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose of the study The study objective was to understand providers' perceptions regarding identifying and treating older adults with delirium, a common complication of acute illness in persons with dementia, in the pre-hospital and emergency department environments. Design and methods The authors conducted structured focus group interviews with separate groups of emergency medical services staff, emergency nurses, and emergency physicians. Recordings of each session were transcribed, coded, and analyzed for themes with representative supporting quotations identified. Results Providers shared that the busy emergency department environment was the largest challenge to delirium recognition and treatment. When describing delirium, participants frequently detailed hyperactive features of delirium, rather than hypoactive features. Participants shared that they employed no clear diagnostic strategy for identifying the condition and that they used heterogeneous approaches to treat the condition. To improve care for older adults with delirium, emergency nurses identified the need for more training around the management of the condition. Emergency medical services providers identified the need for more support in managing agitated patients when in transport to the hospital and more guidance from emergency physicians on what information to collect from the patient's home environment. Emergency physicians felt that delirium care would be improved if they could have baseline mental status data on their patients and if they had access to a simple, accurate diagnostic tool for the condition. Implications Emergency medical services providers, emergency nurses, and emergency physicians frequently encounter delirious patients, but do not employ clear diagnostic strategies for identifying the condition and have varying levels of comfort in managing the condition. Clear steps should be taken to improve delirium care in the emergency department including the development of mechanisms to communicate patients' baseline mental status, the adoption of a systematized approach to recognizing delirium, and the institution of a standardized method to treat the condition when identified.
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Affiliation(s)
- Michael A LaMantia
- Indiana University Center for Aging Research and Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Frank C Messina
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shola Jhanji
- Indiana University-Purdue University, Indianapolis, IN, USA
| | - Arif Nazir
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mungai Maina
- Indiana University Center for Aging Research and Regenstrief Institute, Inc., Indianapolis, IN
| | - Siobhan McGuire
- Indiana University Center for Aging Research and Regenstrief Institute, Inc., Indianapolis, IN
| | | | - Douglas K Miller
- Indiana University Center for Aging Research and Regenstrief Institute, Inc., Indianapolis, IN
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