A protocol to determine the acceptability and feasibility of a pilot intervention emergency department virtual observation unit fall prevention program

BACKGROUND

As a third of all community dwellers aged 65+ fall each year, falls are common reasons for older adults to present to an Emergency Department (ED). Although EDs should assess patients' multifactorial fall risks to prevent future fall-related injuries, this frequently does not occur. We describe our protocol to determine the feasibility, acceptability, and safety of a pilot ED Virtual Observation Unit (VOU) Falls program.

METHODS

To ensure standardized conduct and reporting, the Standard Protocol Items for Intervention Trials (SPIRIT) guidelines will be used. The VOU is a program where patients are sent home from the ED but are part of a virtual observation unit in that they can call on-call ED physicians while they are being treated for conditions such as cellulitis, congestive heart failure, or pneumonia. A paramedic conducts daily visits with the patient and facilitates a telemedicine consult with an ED physician. VOU nursing staff conduct daily assessments of patients via telemedicine. The ED VOU Falls program is one of the VOU pathways and is a multi-component fall prevention program for fall patients who present after an ED visit. The paramedic conducts a home safety evaluation, a Timed Up and Go Test (TUG). During the VOU visit, the ED physician conducts a telemedicine visit, while the paramedic is visiting the home, to review patients' fall-risk-increasing drugs and their TUG test. We will determine feasibility by calculating rates of patient enrollment refusal, and adherence to fall-risk prevention recommendations using information from 3-month follow-up telephone calls, as well as qualitative interviews with the paramedics. We will determine the acceptability of the ED VOU Falls program based on patient and provider surveys using a Likert scale. We will ask VOU nursing staff to report any safety issues encountered while the patient is in the ED VOU Falls program (e.g., tripping hazards). We will use the chi-square test or Fisher's exact test for categorical variables, Student's t-test for continuous variables, and Mann-Whitney for nonparametric data. We will review interview transcripts and generate codes. Codes will then be extracted and organized into concepts to generate an overall theme following grounded theory methods. This is a pilot study; hence, results cannot be extrapolated. However, a definite trial would be the next step in the future to determine if such a program could be implemented as part of fall prevention interventions.

DISCUSSION

This study will provide insights into the feasibility and acceptability of a novel ED VOU Falls program with the aim of ultimately decreasing falls. In the future, such a program could be implemented as part of fall prevention interventions.

Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments

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.

Emergency Palliative Care: Early Assessment of an Older Adult With a Fall and Hip Fracture

In this segment of the emergency department (ED) palliative care case series, we present a patient who arrives to the ED after a fall resulting in a hip fracture. He is also found to have hypernatremia and an acute kidney injury and develops delirium while in the ED awaiting an inpatient bed. The ED-based integrated geriatric palliative care program is consulted and performs a multidimensional assessment. The geriatric palliative care clinician facilitates discussion with his daughter about surgical intervention based on the patient's goals and values, diagnoses delirium, and worsening depression, creates a plan for delirium and pain management, and accelerates postdischarge planning.

Predicting methane emissions of individual grazing dairy cows from spectral analyses of their milk samples

Data on the enteric methane emissions of individual cows are useful not just in assisting management decisions and calculating herd inventories but also as inputs for animal genetic evaluations. Data generation for many animal characteristics, including enteric methane emissions, can be expensive and time consuming, so being able to extract as much information as possible from available samples or data sources is worthy of investigation. The objective of the present study was to attempt to predict individual cow methane emissions from the information contained within milk samples, specifically the spectrum of light transmittance across different wavelengths of the mid-infrared (MIR) region of the electromagnetic spectrum. A total of 93,888 individual spot measures of methane (i.e., individual samples of an animal's breath when using the GreenFeed technology) from 384 lactations on 277 grazing dairy cows were collapsed into weekly averages expressed as grams per day; each weekly average coincided with a MIR spectral analysis of a morning or evening individual cow milk sample. Associations between the spectra and enteric methane measures were performed separately using partial least squares regression or neural networks with different tuning parameters evaluated. Several alternative definitions of the enteric methane phenotype (i.e., average enteric methane in the 6 d preceding or 6 d following taking the milk sample or the average of the 6 d before and after the milk sample, all of which also included the enteric methane emitted on the day of milk sampling), the candidate model features (e.g., milk yield, milk composition, and milk MIR) as well as validation strategy (i.e., cross-validation or leave-one-experimental treatment-out) were evaluated. Irrespective of the validation method, the prediction accuracy was best when the average of the milk MIR from the morning and evening milk sample was used and the prediction model was developed using neural networks; concurrently including milk yield and days in milk in the prediction model generated superior predictions relative to just the spectral information alone. Furthermore, prediction accuracy was best when the enteric methane phenotype was the average of at least 20 methane spot measures across a 6-d period flanking each side of the milk sample with associated spectral data. Based on the strategy that achieved the best accuracy of prediction, the correlation between the actual and predicted daily methane emissions when based on 4-fold cross-validation varied per validation stratum from 0.68 to 0.75; the corresponding range when validated on each of the 8 different experimental treatments focusing on alternative pasture grazing systems represented in the dataset varied from 0.55 to 0.71. The root mean square error of prediction across the 4-folds of cross-validation was 37.46 g/d, whereas the root mean square error averaged across all folds of leave-one-treatment-out was 37.50 g/d. Results suggest that even with the likely measurement errors contained within the MIR spectrum and gold standard enteric methane phenotype, enteric methane can be reasonably well predicted from the infrared spectrum of milk samples. What is yet to be established, however, is whether (a) genetic variation exists in this predicted enteric methane phenotype and (b) selection on estimates of genetic merit for this phenotype translate to actual phenotypic differences in enteric methane emissions.

Preparing Preclinical Medical Students for Routine Code Status Discussions: A Mixed-Methods Study

CONTEXT

Medical students are expected to gain competency in inquiring about patients' goals of care, per the Association of American Medical Colleges' Entrustable Professional Activities. While students may be part of teams that conduct routine code status discussions (CSDs), formal training in this skill prior to clinical clerkships is lacking.

OBJECTIVES

We aimed to address this training gap by designing a curriculum to teach preclinical medical students about routine CSDs.

METHODS

We designed and conducted an interactive workshop for preclinical medical students to learn about routine CSDs and practice this skill, using Kern's Six Steps to Curriculum Design. A qualitative and quantitative pre- and postsurvey was administered. A convergent, parallel, mixed methods analysis was performed.

RESULTS

Students (n = 135) named more options for code status following the workshop (presurvey 1.3 vs. postsurvey 4.3, P < 0.01). There was an increase in the proportion of students reporting that they felt "somewhat comfortable" or "extremely comfortable" conducting a CSD (presurvey 19% vs. postsurvey 64%, P < 0.01), and a decrease in those reporting that they felt "extremely uncomfortable" or "somewhat uncomfortable" (presurvey 53% vs. postsurvey 18%, P < 0.01). Thematic analysis revealed that students were concerned about knowledge gaps, communication tools, personal discomfort, and upsetting patients or family.

CONCLUSION

A workshop to train medical students to conduct routine CSDs can be included as part of a preclinical medical education curriculum. Students reported that the workshop increased their confidence in conducting CSDs and demonstrated an increase in corresponding knowledge, preparing them to deliver person-centered care on their clerkships.

Perceptions of Acute Care Telemedicine Among Caregivers for Persons Living with Dementia: A Qualitative Study

Persons living with dementia (PLWD) have high emergency department (ED) utilization. Little is known about using telemedicine with PLWD and caregivers as an alternative to ED visits for minor acute health problems. This qualitative interview-based study elicited caregivers' perspectives about the acceptability of telemedicine for acute complaints. We performed telephone interviews with 28 caregivers of PLWD from two academic EDs, one in the Northeast and another in the South. Using a combined deductive-inductive approach, we coded interview transcripts and elucidated common themes by consensus. All caregivers reported they would need to participate in the telemedicine visit to help overcome communication and digital literacy challenges. People from racial/ethnic minority groups reported lower comfort with the virtual format. In both sites, participants expressed uncertainty about illness severity that could preclude using telemedicine for acute complaints. Overall, respondents deemed acute care telemedicine acceptable, but caregivers describe specific roles as crucial intermediaries to facilitate virtual care.

The differences in code status conversation approaches reported by emergency medicine and palliative care clinicians: A mixed-method study

BACKGROUND

During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different.

METHODS

We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians' self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale ("very unlikely" to "very likely") was used to assess the likelihood of asking about medical procedures (procedure based) and patients' values (value based) during code status conversations, followed by semistructured interviews.

RESULTS

Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patient's acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients' goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies.

CONCLUSIONS

Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.

Race and Ethnicity and Primary Language in Emergency Department Triage

Importance

Emergency department (ED) triage substantially affects how long patients wait for care but triage scoring relies on few objective criteria. Prior studies suggest that Black and Hispanic patients receive unequal triage scores, paralleled by disparities in the depth of physician evaluations.

Objectives

To examine whether racial disparities in triage scores and physician evaluations are present across a multicenter network of academic and community hospitals and evaluate whether patients who do not speak English face similar disparities.

Design, Setting, and Participants

This was a cross-sectional, multicenter study examining adults presenting between February 28, 2019, and January 1, 2023, across the Mass General Brigham Integrated Health Care System, encompassing 7 EDs: 2 urban academic hospitals and 5 community hospitals. Analysis included all patients presenting with 1 of 5 common chief symptoms.

Exposures

Emergency department nurse-led triage and physician evaluation.

Main Outcomes and Measures

Average Triage Emergency Severity Index [ESI] score and average visit work relative value units [wRVUs] were compared across symptoms and between individual minority racial and ethnic groups and White patients.

Results

There were 249 829 visits (149 861 female [60%], American Indian or Alaska Native 0.2%, Asian 3.3%, Black 11.8%, Hispanic 18.8%, Native Hawaiian or Other Pacific Islander <0.1%, White 60.8%, and patients identifying as Other race or ethnicity 5.1%). Median age was 48 (IQR, 29-66) years. White patients had more acute ESI scores than Hispanic or Other patients across all symptoms (eg, chest pain: Hispanic, 2.68 [95% CI, 2.67-2.69]; White, 2.55 [95% CI, 2.55-2.56]; Other, 2.66 [95% CI, 2.64-2.68]; P < .001) and Black patients across most symptoms (nausea/vomiting: Black, 2.97 [95% CI, 2.96-2.99]; White: 2.90 [95% CI, 2.89-2.91]; P < .001). These differences were reversed for wRVUs (chest pain: Black, 4.32 [95% CI, 4.25-4.39]; Hispanic, 4.13 [95% CI, 4.08-4.18]; White 3.55 [95% CI, 3.52-3.58]; Other 3.96 [95% CI, 3.84-4.08]; P < .001). Similar patterns were seen for patients whose primary language was not English.

Conclusions and Relevance

In this cross-sectional study, patients who identified as Black, Hispanic, and Other race and ethnicity were assigned less acute ESI scores than their White peers despite having received more involved physician workups, suggesting some degree of mistriage. Clinical decision support systems might reduce these disparities but would require careful calibration to avoid replicating bias.

Extra-mandibular Osteoradionecrosis after the Treatment of Head and Neck Cancer

AIMS

Osteoradionecrosis (ORN) is a serious toxicity of head and neck radiotherapy. It predominantly affects the mandible. Extra-mandibular ORN is rare. The aim of this study was to report the incidence and outcomes of extra-mandibular ORNs from a large institutional database.

MATERIALS AND METHODS

In total, 2303 head and neck cancer patients were treated with radical or adjuvant radiotherapy. Of these, extra-mandibular ORN developed in 13 patients (0.5%).

RESULTS

Maxillary ORNs (n = 8) were a consequence of the treatment of various primaries (oropharynx = 3, sinonasal = 2, maxilla = 2, parotid = 1). The median interval from the end of radiotherapy to the development of ORN was 7.5 months (range 3-42 months). The median radiotherapy dose in the centre of the ORN was 48.5 Gy (range 22-66.5 Gy). Four patients (50%) healed in 7, 14, 20 and 41 months. All temporal bone ORNs (n = 5) developed after treatment to the parotid gland (of a total of 115 patients who received radiotherapy for parotid gland malignancy). The median interval from the end of radiotherapy to the development of ORN was 41 months (range 20-68 months). The median total dose in the centre of the ORN was 63.5 Gy (range 60.2-65.3 Gy). ORN healed in only one patient after 32 months of treatment with repeated debridement and topical betamethasone cream.

CONCLUSION

Extra-mandibular ORN is a rare late toxicity and this current study provides useful information on its incidence and outcome. The risk of temporal bone ORN should be considered in the treatment of parotid malignancies and patients should be counselled. More research is required to determine the optimal management of extra-mandibular ORN, particularly on the role of the PENTOCLO regimen.

Using the Electronic Health Record to Support Implementation of Emergency Department Delirium Screening: A Qualitative Study

Objective To understand how emergency departments (EDs) use health information technology (HIT), and specifically the electronic health record (EHR), to support implementation of delirium screening. Materials and Methods We conducted semi-structured interviews with 23 ED clinician-administrators, representing 20 EDs, about how they used HIT resources to implement delirium screening. Interviews focused on challenges participants experienced when implementing ED delirium screening and EHR-based strategies they used to overcome them. We coded interview transcripts using dimensions from the Singh and Sittig socio-technical model, which addresses use of HIT in complex adaptive healthcare systems. Subsequently, we analyzed data for common themes across dimensions of the socio-technical model. Results Three themes emerged about how the EHR could be used to address challenges in implementation of delirium screening: (1) staff adherence to screening, (2) communication among ED team members about a positive screen, and (3) linking positive screening to delirium management. Participants described several HIT-based strategies including visual nudges, icons, hard stop alerts, order sets, and automated communications that facilitated implementation of delirium screening. An additional theme emerged about challenges related to the availability of HIT resources. Discussion Building delirium screening tools and reminders to perform screening into the EHR may prompt adherence to screening. Automating related workflows, team communication, and management of patients who screen positive for delirium may help save staff members' time. Staff education, engagement, and access to HIT resources may support successful screening implementation. Conclusion Our findings provide practical HIT-based strategies for healthcare institutions planning to adopt geriatric screenings.

Assessing the Acceptability and Feasibility of Leveraging Emergency Department Social Workers' Advanced Communication Skills to Assess Elderly Patients' Goals and Values

Background: The Emergency Department (ED) has increasingly been recognized as an important site of care for older adults with unmet palliative care needs. Despite this, no clear model of care delivery has emerged. Aim: To assess the acceptability and feasibility of a scripted palliative care communication intervention in the ED directed by social workers. We hypothesized that the intervention would be feasible, acceptable to patients and ED social workers, and that the collection of patient outcomes would be possible. Design: A prospective, unblinded, pilot randomized clinical trial of older adults with serious illness presenting to the ED. Patients were randomized to either receive a social worker-directed palliative care intervention (n-65), which consisted of a conversation focused on patients' goals, values, hopes and worries, or to usual care (n-52). The intervention was evaluated for feasibility and acceptability. Results: Of patients randomized to the intervention arm, 66% (43/65) completed a conversation with the social worker. Focus group feedback with the social workers further demonstrated the feasibility of these conversations. There was minimal (12%) loss to follow-up. Of the patients who received the intervention, the majority reported that they appreciated the social workers bringing up their goals for the future (77%), their social workers asking about their fears and worries (72%), and they liked the way the conversation was set up (81%). Social workers administered 95% of the conversation components. Conclusions: This pilot trial demonstrated the feasibility and acceptability of a social worker-directed, scripted palliative care communication intervention in a single urban, academic ED.

Physical therapy consultation in the emergency department for older adults with falls: A qualitative study

Objectives

Little is known about current practices in consulting physical therapy (PT) in the emergency department (ED) for older adults with falls, a practice that can reduce fall-related ED revisits. This qualitative study aimed to understand perspectives of ED staff about ED PT consultation for older adults with falls and fall-related complaints, specifically regarding perceived value and associated challenges and strategies.

Methods

We performed focus groups and key informant interviews with emergency physicians, advanced practice clinicians, nurses, physical therapists, occupational therapists, and technicians who perform ED geriatric screenings. We used rapid qualitative analysis to identify common themes related to decisions to consult PT from the ED, perceived value of PT, and common challenges and strategies in ED PT consultation.

Results

Twenty-five participants in 4 focus groups and 3 interviews represented 22 distinct institutions with ED PT consultation available for older adults with falls. About two thirds of EDs represented relied on clinician gestalt to request PT consultation (n = 15, 68%), whereas one third used formal consultation pathways (n = 7, 32%). Participants valued physical therapists' expertise, time, and facilitation of hospital throughput by developing safe discharge plans and contact with patients to improve outpatient follow-up. Common challenges included limited ED PT staffing and space for PT evaluations; strategies to promote ED PT consultation included advocating for leadership buy-in and using ED observation units to monitor patients and avoid admission until PT consultation was available.

Conclusion

ED PT consultation for older adults with falls may benefit patients, ED staff, and hospital throughput. Uncertainty remains over whether geriatric screening-triggered consultation versus emergency clinician gestalt successfully identifies patients likeliest to benefit from ED PT evaluation. Leadership buy-in, designated consultation space, and formalized consultation pathways are strategies to address current challenges in ED PT consultation.

Examination of geriatric care processes implemented in level 1 and level 2 geriatric emergency departments

Introduction

Older adults constitute a large and growing proportion of the population and have unique care needs in the emergency department (ED) setting. The geriatric ED accreditation program aims to improve emergency care provided to older adults by standardizing care provided across accredited geriatric EDs (GED) and through implementation of geriatric-specific care processes. The purpose of this study was to evaluate select care processes at accredited level 1 and level 2 GEDs.

Methods

This was a cross-sectional analysis of a cohort of level 1 and level 2 GEDs that received accreditation between May 7, 2018 and March 1, 2021. We a priori selected five GED care processes for analysis: initiatives related to delirium, screening for dementia, assessment of function and functional decline, geriatric falls, and minimizing medication-related adverse events. For all protocols, a trained research assistant abstracted information on the tool used or care process, which patients received the interventions, and staff members were involved in the care process; additional information was abstracted specific to individual care processes.

Results

A total of 35 level 1 and 2 GEDs were included in this analysis. Among care processes studied, geriatric falls were the most common (31 GEDs, 89%) followed by geriatric pain management (25 GEDs, 71%), minimizing the use of potentially inappropriate medications (24 EDs, 69%), delirium (22 GEDs, 63%), medication reconciliation (21 GEDs, 60%), functional assessment (20 GEDs, 57%), and dementia screening (17 GEDs, 49%). For protocols related to delirium, dementia, function, and geriatric falls, sites used an array of different screening tools and there was heterogeneity in who performed the screening and which patients were assessed. Medication reconciliation protocols leveraged pharmacists, pharmacy technicians and/or nurses. Protocols on avoiding potentially inappropriate medication administration generally focused on ED administration of medications and used the BEERs criteria, and few sites indicated whether pain medications protocols had dosing modifications for age and/or renal function.

Conclusion

This study provides a snapshot of care processes implemented in level 1 and level 2 accredited GEDs and demonstrates significant heterogeny in how these care processes are implemented.

Reply to: Expanding options to include language barriers for predicting postoperative delirium in geriatric patients

This letter comments on the letter by Streetman et al.

Communication Training and Code Status Conversation Patterns Reported by Emergency Clinicians

CONTEXT

During acute health decompensations for seriously ill patients, emergency clinicians often determine the intensity end-of-life care. Little is known about how emergency clinicians conduct these conversations, especially among those who have received serious illness communication training.

OBJECTIVES

To determine the self-reported practice patterns of code status conversations by emergency clinicians with and without serious illness communication training.

METHODS

A cross-sectional survey was conducted among emergency clinicians with and without a recent evidence-based, serious illness communication training tailored for emergency clinicians. Emergency clinicians were included from two academic medical centers. A five-point Likert scale ("very unlikely" to "very likely" to ask) was used to assess the self-reported likelihood of asking about patients' preferences for medical procedures and patients' values and goals.

RESULTS

Among 161 respondents (71% response rate), 77 (48%) received the training. A total of 70% of emergency clinicians reported asking about procedure-based questions, and only 38% reported asking about patient's values regarding end-of-life care. For value-based questions, statistically significant differences were observed between emergency clinicians who underwent the training and those who did not in four of the seven questions asked (e.g., the higher odds of exploring the patient's life priorities [adjusted OR = 4.34, 95% CI = 1.95-9.65, P-value < 0.001]). No difference was observed in the self-reported rates of all procedure-based questions between the two groups.

CONCLUSION

Most emergency clinicians reported asking about procedure-based questions, and some asked about patient's value-based questions. Clinicians with recent serious illness communication training may ask more about some values and priorities.

Developing a novel integrated geriatric palliative care consultation program for the emergency department

With the aging of our population, older adults are living longer with multiple chronic conditions, frailty, and life‐limiting illnesses, which creates specific challenges for emergency departments (EDs). Older adults and those with serious illnesses have high rates of ED use and hospitalization, and the emergency care they receive may be discordant with their goals and values. In response, new models of care delivery have begun to emerge to address both geriatric and palliative care needs in the ED. However, these programs are typically siloed from one another despite significant overlap. To develop a new combined model, we assembled stakeholders and thought leaders at the intersection of emergency medicine, palliative care, and geriatrics and used a consensus process to define elements of an ideal model of a combined palliative care and geriatric intervention in the ED. This article provides a brief history of geriatric and palliative care integration in EDs and presents the integrated geriatric and palliative care model developed.

Association of Race and Ethnicity With Triage Emergency Severity Index Scores and Total Visit Work Relative Value Units for Emergency Department Patients

This cross-sectional study evaluates the association of race and ethnicity with triage Emergency Severity Index scores and total work relative value units for emergency department (ED) patients.

Optimal Emergency Department Care Practices for Persons Living With Dementia: A Scoping Review

OBJECTIVES

To summarize research on optimal emergency department (ED) care practices for persons living with dementia (PLWDs) and develop research priorities.

DESIGN

Systematic scoping review.

SETTINGS AND PARTICIPANTS

PLWDs in the ED.

METHODS

The following Patient-Intervention-Comparison-Outcome (PICO) questions were developed: PICO 1, What components of emergency department care improve patient-centered outcomes for persons with dementia? PICO 2, How do emergency care needs for persons with dementia differ from other patients in the emergency department? A scoping review was conducted following PRISMA-ScR guidelines and presented to the Geriatric Emergency care Applied Research 2.0 Advancing Dementia Care network to inform research priorities.

RESULTS

From the 6348 publications identified, 23 were abstracted for PICO 1 and 26 were abstracted for PICO 2. Emergency care considerations for PLWDs included functional dependence, behavioral and psychological symptoms of dementia, and identification of and management of pain. Concerns regarding ED care processes, the ED environment, and meeting a PWLD's basic needs were described. A comprehensive geriatric assessment and dedicated ED unit, a home hospital program, and a low-stimulation bed shade and contact-free monitor all showed improvement in patient-centered or health care use outcomes. However, all were single-site studies evaluating different outcomes. These results informed the following research priorities: (1) training and dementia care competencies; (2) patient-centric and care partner-centric evaluation interventions; (3) the impact of community- and identity-based factors on ED care for PLWDs; (4) economic or other implementation science measures to address viability; and (5) environmental, operational, personnel, system, or policy changes to improve ED care for PLWDs.

CONCLUSIONS AND IMPLICATIONS

A wide range of components of both ED care practices and ED care needs for PLWDs have been studied. Although many interventions show positive results, the lack of depth and reproducible results prevent specific recommendations on best practices in ED care for PLWDs.

Can we improve delirium prevention and treatment in the emergency department? A systematic review

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.

Reach and Adoption of a Geriatric Emergency Department Accreditation Program in the United States

STUDY OBJECTIVE

The objectives of this study were to describe the reach and adoption of Geriatric Emergency Department Accreditation (GEDA) program and care processes instituted at accredited geriatric emergency departments (EDs).

METHODS

We analyzed a cross-section of a cohort of US EDs that received GEDA from May 2018 to March 2021. We obtained data from the American College of Emergency Physicians and publicly available sources. Data included GEDA level, geographic location, urban/rural designation, and care processes instituted. Frequencies and proportions and median and interquartile ranges were used to summarize categorical and continuous data, respectively.

RESULTS

Over the study period, 225 US geriatric ED accreditations were issued and included in our analysis-14 Level 1, 21 Level 2, and 190 Level 3 geriatric EDs; 5 geriatric EDs reapplied and received higher-level accreditation after initial accreditation at a lower level. Only 9 geriatric EDs were in rural regions. There was significant heterogeneity in protocols enacted at geriatric EDs; minimizing urinary catheter use and fall prevention were the most common.

CONCLUSION

There has been rapid growth in geriatric EDs, driven by Level 3 accreditation. Most geriatric EDs are in urban areas, indicating the potential need for expansion beyond these areas. Future research evaluating the impact of GEDA on health care utilization and patient-oriented outcomes is needed.

COVID-19 hospital and emergency department visitor policies in the United States: Impact on persons with cognitive or physical impairment or receiving end-of-life care

OBJECTIVE

To characterize the national distribution of COVID-19 hospital and emergency department visitor restriction policies across the United States, focusing on patients with cognitive or physical impairment or receiving end-of-life care.

METHODS

Cross-sectional study of visitor policies and exceptions, using a nationally representative random sample of EDs and hospitals during the first wave of the COVID-19 pandemic, by trained study investigators using standardized instrument.

RESULTS

Of the 352 hospitals studied, 326 (93%) had a COVID-19 hospital-wide visitor restriction policy and 164 (47%) also had an ED-specific policy. Hospital-wide policies were more prevalent at academic than non-academic (96% vs 90%; P < 0.05) and at urban than rural sites (95% vs 84%; P < 0.001); however, the prevalence of ED-specific policies did not significantly differ across these site characteristics. Geographic region was not associated with the prevalence of any visitor policies. Among all study sites, only 58% of hospitals reported exceptions for patients receiving end-of-life care, 39% for persons with cognitive impairment, and 33% for persons with physical impairment, and only 12% provided policies in non-English languages. Sites with ED-specific policies reported even fewer exceptions for patients with cognitive impairment (29%), with physical impairments (24%), or receiving end-of-life care (26%).

CONCLUSION

Although the benefits of visitor policies towards curbing COVID-19 transmission had not been firmly established, such policies were widespread among US hospitals. Exceptions that permitted family or other caregivers for patients with cognitive or physical impairments or receiving end-of-life care were predominantly lacking, as were policies in non-English languages.

Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement

OBJECTIVES

Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions.

METHODS

GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research.

RESULTS

Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research.

CONCLUSIONS

ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.

Use of antipsychotic and sedative medications in older patients in the emergency department

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.

Evaluating older adults with cognitive dysfunction: A qualitative study with emergency clinicians

BACKGROUND

Evaluating older adults with cognitive dysfunction in emergency departments (EDs) requires obtaining collateral information from sources other than the patient. Understanding the challenges emergency clinicians face in obtaining collateral information can inform development of interventions to improve geriatric emergency care and, more specifically, detection of ED delirium. The objective was to understand emergency clinicians' experiences obtaining collateral information on older adults with cognitive dysfunction, both before and during the COVID-19 pandemic.

METHODS

From February to May 2021, we conducted semi-structured interviews with a purposive sample of 22 emergency physicians and advanced practice providers from two urban academic hospitals and one community hospital in the Northeast United States. Interviews lasted 10-20 min and were digitally recorded and transcribed. Interview transcripts were analyzed for dominant themes using a combined deductive-inductive approach. Responses regarding experiences before and during the pandemic were compared.

RESULTS

Five major challenges emerged regarding (1) availability of caregivers, (2) reliability of sources, (3) language barriers, (4) time constraints, and (5) incomplete transfer documentation. Participants perceived all challenges, but those relating to transfer documentation were amplified by the COVID-19 pandemic.

CONCLUSION

Emergency clinicians' perspectives can inform efforts to support caregiver presence at bedside and develop standardized communication tools to improve recognition of delirium and, more broadly, geriatric emergency care.

Real world radiation exposure in left atrial appendage occlusion device implantation performed in a high volume center

 

Left atrial appendage occlusion (LAAO) is an established and effective treatment to reduce the risk of thromboembolic stroke derived from the LAA in patient with non valvular atrial fibrillation. Per-cutaneous closure of the LAA is typically guided by fluoroscopic and echocardiographic guidance.

The purpose of our study is to ascertain real world radiation exposure during the LAAO performed in our institution and the interplay of different variables and patient characteristics.

Our study retrospectively analyzed all consecutive LAAO procedures performed at our Tertiary level Teaching Hospital. Data was collected using Hospital electronic records and cardiac catherization laboratory records.

A total of 261 patients who underwent LAAO were identified, 28% were female. Average age at the time of procedure was 77 years (range 54–93 years). Mean fluoroscopy time was 10.2 minutes (±7.0), average Radiation dose was 67 gy/cm2 (±73). Interestingly, gy/cm2 per minute of fluoroscopy averaged at 6.69 (±5.0).

Subgroup analysis focused on the effect of Body mass index (BMI) on radiation dose. Since the recent introduction of a partial electronic health record system, BMI data was only available on 161 patients. The cohort with BMI &lt;30 had a mean radiation dose of 57±62 gy/cm2, whereas for BMI &gt;30 mean dose was 96.8±68, p=0.0025 (95% CI (65 to 14)).

Analysis by the four different device types (Watchman, Watchman Flx, Wavecrest and ACP) were used for LAAO, with highest number been watchman (n=189). Upon comparing the radiation exposure in our study cohort watchman device had the least Dose adjusted Product (DAP) at 62gy/cm2 but the newer watchman flx (n=25) had slightly lower gy/cm2 per minute of fluoroscopy time 6.58±3.41 versus 6.83±5.56.

In addition, operator volume between our two implanters was assessed. Our highest volume operator implanted the majority of devices (n=235) whilst the Watchman Flx was predominantly implanted by our newer implanter (n=26). Despite the relatively modest numbers of the Watchman Flx, there was minimal difference in exposure time in favor of the more senior interventionist.

In conclusion, LAAO in our center has encouraging radiation safety data, which is comparable to previously published data in internationally recognized high volume centers. Normal BMI patients had the least radiation exposure, with the dose increasing with rising BMI.

Funding Acknowledgement

Type of funding sources: None. Bar Graph, radiation dose vs BMIScatter Plot, radiation dose vs BMI

1312 Characteristics of Those Who Present with Self-Inflicted Burns: A Burns Unit Service Evaluation Which Challenges Stereotypes

Introduction

Self-harm rates in the UK are increasing. Healthcare professionals’ beliefs regarding repeat attendance; attention-seeking; and poor treatment compliance may contribute to patients’ stigma. Self-inflicted burns (SIB) constitute a minority of burns cases, but require disproportionate healthcare input, yet little is known about these patients. Our aim was to evaluate presentations, compliance and outcomes in this patient group.

Method

A retrospective audit of outpatients with SIBs attending a UK Burns Unit over four years (Jan 2016-Dec 2019).

Results

Over the study period, 58 patients presented with 94 burn wounds. Incidence doubled over one year (2018-2019). Most patients were female (85%) with a median age of 29 years (range 19-62). The most commonly associated psychiatric diagnosis was personality disorder. On presentation 22% (n = 21) were admitted under the Mental Health Act. For 83% (n = 48) it was their first presentation with a SIB, although 74% had previously presented with non-burn self-harm. Median burn size was 0.5% TBSA, the most common mechanism was contact (48%) and 77% were deep (n = 77). 92% were compliant with treatment and did not tamper with their wounds or dressings.

Conclusions

The majority, 70% (n = 41), of patients only presented once to the Burns Department during the study period. This challenges the commonly held stereotype that those who self-harm will also seek attention through repeat presentation. Ongoing education among health professionals may dispel some myths regarding these individuals. Further, larger investigations, may permit rigorous comparison of treatment outcomes with non-SIB patients.

Lessons Learned From Emergency Department Fall Assessment and Prevention Programs

Objectives

This research describes the experiences of emergency departments (EDs) with geriatric fall programs and qualitatively synthesizes lessons learned to inform other EDs planning new fall program implementation.

Methods

By using grounded theory, we conducted semi-structured, open-ended telephone/skype interviews of emergency physicians and geriatric providers recruited from a purposeful sampling technique. The interviews were transcribed and reviewed by two investigators. The codes were generated and listed, and common concepts emerged. Lastly, the final codes were organized into concepts and themes with the aim to create a strong coding structure.

Result

The main lessons learned are: (1) understand the hospital’s existing local environment and resources, (2) utilize champions and interdisciplinary teams, (3) acknowledge that specific fall assessment tools and interventions vary widely between institutions, (4) engage in routine plan-do-study-act (PDSA) cycles to improve the quality of fall initiatives, and (5) operate under the principle that falls are a syndrome, which must be incorporated within the multifactorial medical needs of geriatric fall patients.

Conclusion

Based on the lessons learned from our ED fall implementation pioneers, implementing an effective geriatric fall protocol in an ED setting is complicated. Understanding a hospital’s resources, assigning champions, working as an interdisciplinary team, choosing proper fall assessment tools/interventions, and completing regular PDSA cycles are important lessons for ED programs planning to implement their own ED fall programs.

Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities

The $1 trillion industry of acute hospital care in the United States is shifting from inside the walls of the hospital to patient homes. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services announced that the acute hospital care at home waiver would reimburse for "home hospital" services. A "home hospital" is the home-based provision of acute services usually associated with the traditional inpatient hospital setting. Prior work suggests that home hospital care can reduce costs, maintain quality and safety, and improve patient experiences for select acutely ill adults who require hospital-level care. However, most emergency physicians are unfamiliar with the evidence of benefits demonstrated by home hospital services, especially for older adults. Therefore, the lead author solicited narrative inputs on this topic from selected experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then we sought to identify information most relevant to the practice of emergency medicine. We outline the proven and potential benefits of home hospital services specific to older adults compared to traditional acute care hospitalization with a focus on the emergency department.

Hospital complications among older adults: Better processes could reduce the risk of delirium

Using observational data and variation in hospital admissions across days of the week, we examined the association between ED boarding time and development of delirium within 72 hours of admission among patients aged 65+ years admitted to an inpatient neurology ward. We exploited a natural experiment created by potentially exogenous variation in boarding time across days of the week because of competition for the neurology floor beds. Using proportional hazard models adjusting for socio-demographic and clinical characteristics in a propensity score, we examined the time to delirium onset among 858 patients: 2/3 were admitted for stroke, with the remaining admitted for another acute neurologic event. Among all patients, 81.2% had at least one delirium risk factor in addition to age. All eligible patients received delirium prevention protocols upon admission to the floor and received at least one delirium screening event. While the clinical and social-demographic characteristics of admitted patients were comparable across days of the week, patients with ED arrival on Sunday or Tuesday were more likely to have had delayed floor admission (waiting time greater than 13 hours) and delirium (adjusted HR = 1.54, 95%CI:1.37-1.75). Delayed initiation of delirium prevention protocol appeared to be associated with greater risk of delirium within the initial 72 hours of a hospital admission.

406 Bioabsorbable Screws in Scaphoid Fractures; a systematic review

Background

Scaphoid fractures account for 90% carpal injury. Due to the limited vascular supply achieving adequate reduction and healing is important to avoid complications including avascular necrosis. Recent technological advances have led to renewed vigour in bioabsorbable material research to develop devices which could be used without the need for removal and complications including stress shielding and suboptimal imaging.

Method

A systematic review was made using PubMed, Ovid Medline, and Google Scholar databases according to PRISMA guidelines.

Results

Initial search results yielded 852 studies. 124 studies were screened, resulting in 7 studies which were included in this review. The level of evidence of studies ranged between III-IV of low power. Analysis demonstrated mixed findings with generally comparable outcomes to traditionally used screws. Heterogeneity of studies prevented a meta-analysis.

Conclusions

Development in bioabsorbable materials has yielded promising results in orthopaedic studies, however there is a dearth in research using these devices in the scaphoid. Further robust research is needed to establish the efficacy and applicability of bioabsorbable devices in the scaphoid bone.