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Lee M, Briggs W, Gordon D, Hauser E, Hebbard C, Hunold KM, Southerland LT. Incorporation of geriatric screening into clinical practice: A quality improvement study in a geriatric emergency department. Am J Emerg Med 2024:S0735-6757(24)00186-4. [PMID: 38677909 DOI: 10.1016/j.ajem.2024.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/15/2024] [Accepted: 04/15/2024] [Indexed: 04/29/2024] Open
Affiliation(s)
- Michelle Lee
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Whitney Briggs
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Darnell Gordon
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Eric Hauser
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Carleigh Hebbard
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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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:S0196-0644(24)00071-4. [PMID: 38483427 DOI: 10.1016/j.annemergmed.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [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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Southerland LT, Pasadyn CL, Alnemer O, Foy C, Vaswani S, Chughtai S, Young HW, Brownlowe KB. Involuntary sedation of patients in the emergency department for mental health: A retrospective cohort study. Am J Emerg Med 2024; 77:53-59. [PMID: 38101227 DOI: 10.1016/j.ajem.2023.11.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/14/2023] [Accepted: 11/28/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Involuntary sedation of agitated mental health patients in the Emergency Department (ED) is standard practice to obtain accurate medical assessments and maintain safety. However, the rate of this practice and what factors are associated with the use of involuntary sedation is unknown. The purpose of this study was to obtain baseline data on involuntary sedation in our EDs. METHODS Retrospective chart review of patients with ED visits for mental health care in 2020-2021. Patients >12 years old who received both a psychiatry consultation and involuntary sedation were included. Data variables included demographics, medical and mental health diagnoses, sedatives given, substance use, ED length of stay, and disposition. The primary outcome was repeated involuntary sedation. RESULTS Involuntary sedation was used in 18.8% of the mental health patients screened for study inclusion. 334 patients were included in the study cohort and 31.6% (n = 106) required repeated involuntary sedation. Their average age was 35.5 ± 13.5 years with 58.4% men, 40.1% women, and 1.2% transgender persons. Most (90.0%, n = 299) had prior mental health diagnoses with the most common being substance use disorder (38.9%, n = 130), bipolar disorder (34.1%, n = 114), depressive disorder (29.0%, n = 97), and schizophrenia (24.3%, n = 81). Two-thirds (65.9%, n = 220) had current substance use and 41.9% (n = 142) reported current use with a chemical associated with aggression. Hospital security was called for 73.1% (n = 244). Current cocaine, methamphetamines, or alcohol use was associated with decreased odds of repeated sedation (0.52 OR, 95% CI 0.32-0.85). Prior mental health diagnosis and non-white race were associated with increased odds of repeated sedation. In the multivariable regression, the effect of race was more significant. CONCLUSIONS Involuntary sedation was used in 18.8% of ED patients for mental health care and almost a third were repeatedly sedated, with race being a potential risk factor for repeated sedation. ED care could benefit from evidence-based interventions to reduce the need for involuntary sedation.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | | | - Omar Alnemer
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Chase Foy
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sheela Vaswani
- Department of Psychiatry, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sana Chughtai
- Department of Psychiatry, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Henry W Young
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Katherine B Brownlowe
- Department of Psychiatry, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Goett R, Lyou J, Willoughby LR, Markwalter DW, Gorgas DL, Southerland LT. Integrating Hospice and Palliative Medicine Education Within the American Board of Emergency Medicine Model. West J Emerg Med 2024; 25:213-220. [PMID: 38596921 PMCID: PMC11000566 DOI: 10.5811/westjem.18448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/20/2023] [Accepted: 01/12/2023] [Indexed: 04/11/2024] Open
Abstract
Background Hospice and palliative medicine (HPM) is a board-certified subspecialty within emergency medicine (EM), but prior studies have shown that EM residents do not receive sufficient training in HPM. Experts in HPM-EM created a consensus list of competencies for HPM training in EM residency. We evaluated how the HPM competencies integrate within the American Board of Emergency Medicine Milestones, which include the Model of the Clinical Practice of Emergency Medicine (EM Model) and the knowledge, skills, and abilities (KSA) list. Methods Three emergency physicians independently mapped the HPM-EM competencies onto the 2019 EM Model items and the 2021 KSAs. Discrepancies were resolved by a fourth independent reviewer, and the final mapping was reviewed by all team members. Results The EM Model included 78% (18/23) of the HPM competencies as a direct match, and we identified recommended areas for incorporating the other five. The KSAs included 43% (10/23). Most HPM competencies included in the KSAs mapped onto at least one level B (minimal necessary for competency) KSA. Three HPM competencies were not clearly included in the EM Model or in the KSAs (treating end-of-life symptoms, caring for the imminently dying, and caring for patients under hospice care). Conclusion The majority of HPM-EM competencies are included in the current EM Model and KSAs and correspond to knowledge needed to be competent in EM. Programs relying on the EM Milestones to plan their curriculums may miss training in symptom management and care for patients at the end of life or who are on hospice.
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Affiliation(s)
- Rebecca Goett
- Rutgers New Jersey Medical School, Department of Emergency Medicine, Newark, New Jersey
| | - Jason Lyou
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
| | - Lauren R. Willoughby
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
| | - Daniel W. Markwalter
- University of North Carolina School of Medicine, Department of Emergency Medicine, Chapel Hill, North Carolina
- University of North Carolina School of Medicine, UNC Palliative Care Program, Chapel Hill, North Carolina
| | - Diane L. Gorgas
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
| | - Lauren T. Southerland
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
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Hunold KM, Schwaderer AL, Exline M, Hebert C, Lampert BC, Southerland LT, Stephens JA, Boyer EW, Gure TR, Mion LC, Hill M, Chu CMB, Lee G, Caterino JM. Functional decline in older adults with suspected pneumonia at emergency department presentation. J Am Geriatr Soc 2024. [PMID: 38366347 DOI: 10.1111/jgs.18798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/03/2024] [Accepted: 01/09/2024] [Indexed: 02/18/2024]
Affiliation(s)
- Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Andrew L Schwaderer
- Section of Pediatric Nephrology, Indiana University, Indianapolis, Indiana, USA
| | - Matthew Exline
- Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Courtney Hebert
- Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA
- Division of Infectious Disease, The Ohio State University, Columbus, Ohio, USA
| | - Brent C Lampert
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Julie A Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA
| | - Edward W Boyer
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Tanya R Gure
- Division of General Internal Medicine & Geriatrics, The Ohio State University, Columbus, Ohio, USA
| | - Lorraine C Mion
- College of Nursing, The Ohio State University, Columbus, Ohio, USA
| | - Michael Hill
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Ching-Min B Chu
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Gabriel Lee
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
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Haimovich AD, Shah MN, Southerland LT, Hwang U, Patterson BW. Automating risk stratification for geriatric syndromes in the emergency department. J Am Geriatr Soc 2024; 72:258-267. [PMID: 37811698 PMCID: PMC10866303 DOI: 10.1111/jgs.18594] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/11/2023] [Accepted: 08/19/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Geriatric emergency department (GED) guidelines endorse screening older patients for geriatric syndromes in the ED, but there have been significant barriers to widespread implementation. The majority of screening programs require engagement of a clinician, nurse, or social worker, adding to already significant workloads at a time of record-breaking ED patient volumes, staff shortages, and hospital boarding crises. Automated, electronic health record (EHR)-embedded risk stratification approaches may be an alternate solution for extending the reach of the GED mission by directing human actions to a smaller subset of higher risk patients. METHODS We define the concept of automated risk stratification and screening using existing EHR data. We discuss progress made in three potential use cases in the ED: falls, cognitive impairment, and end-of-life and palliative care, emphasizing the importance of linking automated screening with systems of healthcare delivery. RESULTS Research progress and operational deployment vary by use case, ranging from deployed solutions in falls screening to algorithmic validation in cognitive impairment and end-of-life care. CONCLUSIONS Automated risk stratification offers a potential solution to one of the most pressing problems in geriatric emergency care: identifying high-risk populations of older adults most appropriate for specific GED care. Future work is needed to realize the promise of improved care with less provider burden by creating tools suitable for widespread deployment as well as best practices for their implementation and governance.
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Affiliation(s)
- Adrian D Haimovich
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ula Hwang
- Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Industrial and Systems Engineering, Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Southerland LT, Willoughby LR, Lyou J, Goett RR, Markwalter DW, Gorgas DL. Integration of Geriatric Education Within the American Board of Emergency Medicine Model. West J Emerg Med 2024; 25:51-60. [PMID: 38205985 PMCID: PMC10777174 DOI: 10.5811/westjem.60842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/30/2023] [Accepted: 11/03/2023] [Indexed: 01/12/2024] Open
Abstract
Background Emergency medicine (EM) resident training is guided by the American Board of Emergency Medicine Model of the Clinical Practice of Emergency Medicine (EM Model) and the EM Milestones as developed based on the knowledge, skills, and abilities (KSA) list. These are consensus documents developed by a collaborative working group of seven national EM organizations. External experts in geriatric EM also developed competency recommendations for EM residency education in geriatrics, but these are not being taught in many residency programs. Our objective was to evaluate how the geriatric EM competencies integrate/overlap with the EM Model and KSAs to help residency programs include them in their educational curricula. Methods Trained emergency physicians independently mapped the geriatric resident competencies onto the 2019 EM Model items and the 2021 KSAs using Excel spreadsheets. Discrepancies were resolved by an independent reviewer with experience with the EM Model development and resident education, and the final mapping was reviewed by all team members. Results The EM Model included 77% (20/26) of the geriatric competencies. The KSAs included most of the geriatric competencies (81%, 21/26). All but one of the geriatric competencies mapped onto either the EM Model or the KSAs. Within the KSAs, most of the geriatric competencies mapped onto necessary level skills (ranked B, C, D, or E) with only five (8%) also mapping onto advanced skills (ranked A). Conclusion All but one of the geriatric EM competencies mapped to the current EM Model and KSAs. The geriatric competencies correspond to knowledge at all levels of training within the KSAs, from beginner to expert in EM. Educators in EM can use this mapping to integrate the geriatric competencies within their curriculums.
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Affiliation(s)
- Lauren T. Southerland
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
| | - Lauren R. Willoughby
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
| | - Jason Lyou
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
| | - Rebecca R. Goett
- Rutgers New Jersey Medical School, Department of Emergency Medicine, Newark, New Jersey
| | - Daniel W. Markwalter
- University of North Carolina School of Medicine, Department of Emergency Medicine, Chapel Hill, North Carolina
- University of North Carolina School of Medicine, UNC Palliative Care Program, Chapel Hill, North Carolina
| | - Diane L. Gorgas
- The Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
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Hunold KM, Schwaderer AL, Exline M, Hebert C, Lampert BC, Southerland LT, Stephens JA, Boyer EW, Gure TR, Mion LC, Hill M, Chu CMB, Ernie E, Caterino JM. Emergency department patient and physician survey accuracy compared to chart abstraction in patients with acute respiratory illness. Acad Emerg Med 2023; 30:1246-1252. [PMID: 37767732 PMCID: PMC11034752 DOI: 10.1111/acem.14810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/07/2023] [Accepted: 09/23/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND High-quality research studies in older adults are needed. Unfortunately, the accuracy of chart review data in older adult patients has been called into question by previous studies. Little is known on this topic in patients with suspected pneumonia, a disease with 500,000 annual older adult U.S. emergency department (ED) visits that presents a diagnostic challenge to ED physicians. The study objective was to compare direct interview and chart abstraction as data sources. METHODS We present a preplanned secondary analysis of a prospective, observational cohort of ED patients ≥65 years of age with suspected pneumonia in two Midwest EDs. We describe the agreement between chart review and a criterion standard of prospective direct patient survey (symptoms) or direct physician survey (examination findings). Data were collected by chart review and from the patient and treating physician by survey. RESULTS The larger study enrolled 135 older adults; 134 with complete symptom data and 129 with complete examination data were included in this analysis. Pneumonia symptoms (confusion, malaise, rapid breathing, any cough, new/worse cough, any sputum production, change to sputum) had agreement between patient/legally authorized representative survey and chart review ranging from 47.8% (malaise) to 80.6% (confusion). All examination findings (rales, rhonchi, wheeze) had percent agreement between physician survey and chart review of ≥80%. However, all kappas except wheezing were less than 0.60, indicating weak agreement. CONCLUSIONS Both patient symptoms and examination findings demonstrated discrepancies between chart review and direct survey with larger discrepancies in symptoms reported. Researchers should consider these potential discrepancies during study design and data interpretation.
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Affiliation(s)
- Katherine M. Hunold
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | | | - Matthew Exline
- Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Courtney Hebert
- Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA
- Division of Infectious Disease, The Ohio State University, Columbus, Ohio, USA
| | - Brent C. Lampert
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | | | - Julie A. Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA
| | - Edward W. Boyer
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Tanya R. Gure
- Division of General Internal Medicine & Geriatrics, The Ohio State University, Columbus, Ohio, USA
| | - Lorraine C. Mion
- College of Nursing, The Ohio State University, Columbus, Ohio, USA
| | - Michael Hill
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Ching-Min B. Chu
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Edriane Ernie
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
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Punches BE, Osuji E, Bischof JJ, Li-Sauerwine S, Young H, Lyons MS, Southerland LT. Patient perceptions of microaggressions and discrimination toward patients during emergency department care. Acad Emerg Med 2023; 30:1192-1200. [PMID: 37335980 PMCID: PMC11075179 DOI: 10.1111/acem.14767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/13/2023] [Accepted: 06/13/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Disparities in emergency department (ED) care based on race and ethnicity have been demonstrated. Patient perceptions of emergency care can have broad impacts, including poor health outcomes. Our objective was to measure and explore patient experiences of microaggressions and discrimination during ED care. METHODS This mixed-methods study of adult patients from two urban academic EDs integrates quantitative discrimination measures and semistructured interviews of discrimination experiences during ED care. Participants completed demographic questionnaires and the Discrimination in Medical Settings (DMS) scale and were invited for a follow-up interview. Transcripts of recorded interviews were analyzed leveraging conventional content analysis with line-by-line coding for thematic descriptions. RESULTS The cohort included 52 participants, with 30 completing the interview. Nearly half the participants were Black (n = 24, 46.1%) and half were male (n = 26, 50%). "No" or "rare" experiences of discrimination during the ED visit were reported by 22/48 (46%), some/moderate discrimination by 19/48 (39%), and significant discrimination in 7/48 (15%). Five main themes were found: (1) clinician behaviors-communication and empathy, (2) emotional response to health care team actions, (3) perceived reasons for discrimination, (4) environmental pressures in the ED, and (5) patients are hesitant to complain. We found an emergent concept where persons with moderate/high DMS scores, in discussing instances of discrimination, frequently reflected on previous health care experiences rather than on their current ED visit. CONCLUSIONS Patients attributed microaggressions to many factors beyond race and gender, including age, socioeconomic status, and environmental pressures in the ED. Of those who endorsed moderate to significant discrimination via survey response during their recent ED visit, most described historical experiences of discrimination during their interview. Previous experiences of discrimination may have lasting effects on patient perceptions of current health care. System and clinician investment in patient rapport and satisfaction is important to prevent negative expectations for future encounters and counteract those already in place.
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Affiliation(s)
- Brittany E. Punches
- The Ohio State University College of Nursing, Columbus, Ohio, USA
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Evans Osuji
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Simiao Li-Sauerwine
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Henry Young
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael S. Lyons
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Lauren T. Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Southerland LT, Gulker P, Van Fossen J, Rine-Haghiri L, Caterino JM, Mion LC, Carpenter CR, Cardone MS, Hill M, Hunold KM. Implementation of geriatric screening in the emergency department using the Consolidated Framework for Implementation Research. Acad Emerg Med 2023; 30:1117-1128. [PMID: 37449967 DOI: 10.1111/acem.14776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 07/03/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Implementation of evidence-based care processes (EBP) into the emergency department (ED) is challenging and there are only a few studies of real-world use of theory-based implementation frameworks. We report final implementation results and sustainability of an EBP geriatric screening program in the ED using the Consolidated Framework for Implementation Research (CFIR). METHODS The EBP involved nurses screening older patients for delirium (Delirium Triage Screen), fall risk (4-Stage Balance Test), and vulnerability (Identification of Seniors at Risk score) with subsequent appropriate referrals to physicians, therapy specialists, or social workers. The proportions of screened adults ≥65 years old were tracked monthly. Outcomes are reported January 2021-December 2022. Barriers encountered were classified according to CFIR. Implementation strategies were classified according to the CFIR-Expert Recommendations for Implementing Change (ERIC). RESULTS Implementation strategies increased geriatric screening from 5% to 68%. This did not meet our prespecified goal of 80%. Change was sustained through several COVID-19 waves. Inner setting barriers included culture and implementation climate. Initially, the ED was treated as a single inner setting, but we found different cultures and uptake between ED units, including night versus day shifts. Characteristics of individuals barriers included high levels of staff turnover in both clinical and administrative roles and very low self-efficacy from stress and staff turnover. Initial attempts with individualized audit and feedback were not successful in improving self-efficacy and may have caused moral injury. Adjusting feedback to a team/unit level approach with unitwide stretch goals worked better. Identifying early adopters and conducting on-shift education increased uptake. Lessons learned regarding ED culture, implementation in interconnected health systems, and rapid cycle process improvement are reported. CONCLUSIONS The pandemic exacerbated barriers to implementation in the ED. Cognizance of a large ED as a sum of smaller units and using the CFIR model resulted in improvements.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Peg Gulker
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jenifer Van Fossen
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Lorri Rine-Haghiri
- The Ohio State University James Cancer Hospital & Solove Research Center, Columbus, Ohio, USA
| | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Lorraine C Mion
- College of Nursing, The Ohio State University, Columbus, Ohio, USA
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Michael S Cardone
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Michael Hill
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
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Caterino JM, Stephens JA, Wexler R, Camargo CA, Hunold KM, Wei L, Hains D, Southerland LT, Bischof JJ, Schwaderer A. Establishment of baseline urinary antimicrobial peptide levels by age: a prospective observational study. J Gerontol A Biol Sci Med Sci 2023:glad223. [PMID: 37708314 DOI: 10.1093/gerona/glad223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Antimicrobial peptides (AMPs) are key effectors of urinary tract innate immunity. Identifying differences in urinary AMP levels between younger and older adults is important in understanding older adults' susceptibility and response to urinary tract infections (UTI) and AMP use as diagnostic biomarkers. We hypothesized that uninfected older adults have higher urinary human neutrophil peptides 1-3 (HNP 1-3), human alpha-defensin-5 (HD-5), and human beta-defensin-2 (hBD-2), but lower urinary cathelicidin (LL-37) than younger adults. METHODS We conducted a cross-sectional study of patients age ≥18 years completing a family medicine clinic non-acute visit. Enzyme-linked immunosorbent assays (ELISA) were performed for AMPs. We identified associations between age and AMPs using unadjusted and multivariable linear regression models. RESULTS Of the 308 subjects, 144 (46.8%) were ≥65 years of age. Comparing age ≥65 versus <65 years, there were no significant differences in HNP 1-3 (p=0.371), HD5 (p=0.834) or LL-37 (p=0.348) levels. Values for hBD-2 were lower in older adults versus younger (p <0.001). In multivariable analyses, older males and females had significantly lower hBD-2 levels (p<0.001 and p=0.004). Models also showed urine leukocyte esterase was associated with increased levels of HNP 1-3 and HD5; hematuria with increased hBD-2; and urine cultures with contamination with increased HNP 1-3 and hBD-2. CONCLUSIONS Baseline urinary HNP 1-3, HD5, and LL-37 did not vary with age. Older adults had lower baseline hBD-2. This finding has implications for the potential use of urinary AMPs as diagnostic markers and will facilitate further investigation into the role of innate immunity in UTI susceptibility in older adults.
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Affiliation(s)
- Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University College of Medicine. 790 Prior Hall, 376 W. 10th Ave, Columbus, OH, USA
| | - Julie A Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine. 1800 Cannon Dr., Columbus, OH 43210, USA
| | - Randell Wexler
- Department of Family and Community Medicine, The Ohio State University College of Medicine. 920 North Hamilton Rd., Gahanna, OH, 43230, USA
| | - Carlos A Camargo
- Massachusetts General Hospital Department of Emergency Medicine, 125 Nashua St, Suite 920, Boston, MA 02114, USA
| | - Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University College of Medicine. 790 Prior Hall, 376 W. 10th Ave, Columbus, OH, USA
| | - Lai Wei
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine. 1800 Cannon Dr., Columbus, OH 43210, USA
| | - David Hains
- Division of Nephrology, Department of Pediatrics, Indiana University School of Medicine. 699 Riley Hospital Drive, Indianapolis
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University College of Medicine. 790 Prior Hall, 376 W. 10th Ave, Columbus, OH, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University College of Medicine. 790 Prior Hall, 376 W. 10th Ave, Columbus, OH, USA
| | - Andrew Schwaderer
- Division of Nephrology, Department of Pediatrics, Indiana University School of Medicine. 699 Riley Hospital Drive, Indianapolis
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Southerland LT, Biese K, Hwang U. Geriatric assessment in the emergency department reduces healthcare costs-So when will CMS pay for it? J Am Geriatr Soc 2023; 71:2698-2700. [PMID: 37435831 DOI: 10.1111/jgs.18473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/20/2023] [Indexed: 07/13/2023]
Abstract
This editorial comments on the article by Haynesworth et al. in this issue.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Kevin Biese
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
- Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
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Delamare Fauvel A, Southerland LT, Panchal AR, Camargo CA, Hansen ML, Wang HE. Emergency department course of patients with asthma receiving initial emergency medical services care-Perspectives From the National Hospital Ambulatory Medical Care Survey. J Am Coll Emerg Physicians Open 2023; 4:e13026. [PMID: 37600901 PMCID: PMC10436788 DOI: 10.1002/emp2.13026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/22/2023] Open
Abstract
Objective Although 911 calls for acute shortness of breath are common, the role of emergency medical services (EMS) in acute asthma care is unclear. We sought to characterize the demographics, course, and outcomes of adult emergency department (ED) patients with asthma in the United States receiving initial EMS care. Methods We analyzed data from the 2016-2019 National Hospital Ambulatory Medical Care Survey (NHAMCS). We included patients aged ≥18 years with an ED visit diagnosis of asthma, stratifying the cases according to initial EMS care. Accounting for the survey design of NHAMCS, we generated nationalized estimates of the number of EMS and non-EMS asthma visits. Using logistic regression, we determined the associations between initial EMS care and patient demographics (age, sex, race, and insurance type), ED course (initial vital signs, triage category, testing, medications), and outcomes (hospital admission, ED length of stay). Results Of 435 million adult ED visits during 2016-2019, there were ≈5.3 million related to asthma (1.3 million annually, 1.2%; 95% confidence interval [CI], 1.1%-1.4%). A total of 602,569 (150,642 annually, 11.3%; 95% CI, 8.6%-14.8%) ED patients with asthma received initial EMS care. Compared with non-EMS asthma patients, EMS asthma patients were more likely to present with an "urgent" ED triage category (odds ratio [OR], 22.2; 95% CI, 6.6-74.9) and to undergo laboratory (OR, 2.78; 95% CI, 1.41-5.46) or imaging tests (OR, 2.42; 95% CI, 1.21-4.83). ED patients with asthma receiving initial EMS care were almost 3 times more likely to be admitted to the hospital (OR, 2.81; 95% CI, 1.27-6.25). There were no differences in demographics, ED use of β-agonists or corticosteroids, or ED length of stay between EMS and non-EMS asthma patients. Conclusions Approximately 1 in 10 adult ED patients with asthma receive initial care by EMS. EMS asthma patients present to the ED with higher acuity, undergo more diagnostic testing in the ED, and are more likely to be admitted. Although limited in information regarding the prehospital course, these findings highlight the more severe illness of asthma patients transported by EMS and underscore the importance of EMS in emergency asthma care.
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Affiliation(s)
- Alix Delamare Fauvel
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
- Emergency DepartmentRouen University HospitalRouenFrance
| | | | - Ashish R. Panchal
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Carlos A. Camargo
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Matthew L. Hansen
- Department of Emergency MedicineOregon Health and Science UniversityPortlandOregonUSA
| | - Henry E. Wang
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
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Southerland LT, Presley CJ, Hunold KM, Caterino JM, Collins CE, Walker DM. Barriers to and recommendations for integrating the age-friendly 4-Ms framework into electronic health records. J Am Geriatr Soc 2023; 71:1573-1579. [PMID: 36455548 PMCID: PMC10175090 DOI: 10.1111/jgs.18156] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/04/2022] [Accepted: 11/10/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND The Institute for Healthcare Improvement's 4-Ms framework of care for older adults recommends a multidisciplinary assessment of a patient's Medications, Mentation, Mobility, and What Matters Most. Electronic health record (EHR) systems were developed prior to this emphasis on the 4-Ms. We sought to understand how healthcare providers across the healthcare system perceive their EHRs and to identify any current best practices and ideas for improvement regarding integration of the 4-Ms. METHODS Anonymous survey of healthcare providers who care for older adults. The survey aimed to evaluate efficiency, error tolerance, and satisfaction (usefulness and likeability). The survey was distributed through organizational list serves that focus on the care of older adults and through social media. RESULTS Sixty-six respondents from all geographic segments of the U.S. (n = 62) and non-U.S. practices (n = 4) responded. Most (82%) were physicians. Respondents used a range of EHRs and 82% had >5 years of experience with their current EHR. Over half of respondents agreed that their EHR had easy to find contact information (56%) and advance directives. Finding a patient's prior cognitive status (26% agreement), goals of care (24%), functional status (14%), and multidisciplinary geriatric assessments (27%) was more difficult. Only 3% were satisfied with how their EHR handles geriatric syndromes. In free text responses, respondents (79%) described three areas that the EHR assists in the care of older adults: screening tied to actions or orders; advance care planning, and medication alerts or review. Common suggestions on how to improve the EHR included incorporating geriatric assessments in notes, establishing a unified place to review the 4-Ms, and creating age-specific best practice alerts. CONCLUSIONS The majority of healthcare providers were not satisfied with how their EHR handles multidisciplinary geriatric assessment and geriatric care. EHR modifications would aide in reporting, communicating, and tracking the 4-Ms in EHRs.
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Affiliation(s)
| | - Carolyn J. Presley
- Department of Internal Medicine, Division of Medical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus OH USA
| | - Katherine M. Hunold
- Department of Emergency Medicine, The Ohio State University, Columbus OH USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus OH USA
| | | | - Daniel M. Walker
- Department of Family and Community Medicine, The Ohio State University, Columbus OH USA
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Chary A, Brickhouse E, Torres B, Cameron‐Comasco L, Lee S, Punches B, Skains RM, Naik AD, Quatman‐Yates CC, Kennedy M, Southerland LT, Liu S. Physical therapy consultation in the emergency department for older adults with falls: A qualitative study. J Am Coll Emerg Physicians Open 2023; 4:e12941. [PMID: 37090953 PMCID: PMC10114865 DOI: 10.1002/emp2.12941] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/02/2023] [Accepted: 03/15/2023] [Indexed: 04/25/2023] Open
Abstract
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.
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Affiliation(s)
- Anita Chary
- Department of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
- Department of MedicineBaylor College of MedicineHoustonTexasUSA
- Center for Innovations in Quality, Effectiveness and SafetyMichael E. DeBakey VA Medical CenterHoustonTexasUSA
| | | | - Beatrice Torres
- UT Health Science CenterUniversity of Texas School of Public HealthHoustonTexasUSA
| | - Lauren Cameron‐Comasco
- Beaumont HospitalRoyal OakMichiganUSA
- School of MedicineOakland University William Beaumont School of MedicineRochesterMichiganUSA
| | - Sangil Lee
- College of MedicineUniversity of Iowa CarverIowa CityIowaUSA
| | - Brittany Punches
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
- College of NursingThe Ohio State UniversityColumbusOhioUSA
| | - Rachel M. Skains
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness and SafetyMichael E. DeBakey VA Medical CenterHoustonTexasUSA
- UT Health Science CenterUniversity of Texas School of Public HealthHoustonTexasUSA
- Consortium on AgingUniversity of Texas Health Science CenterHoustonTexasUSA
| | | | - Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Shan Liu
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
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Pyles O, Richards R, Galligher A, Du J, Brooks J, Southerland LT. Impact of a trauma recovery center on emergency department utilization for victims of violence. Am J Emerg Med 2023; 65:125-129. [PMID: 36610175 DOI: 10.1016/j.ajem.2022.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 11/01/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Victims of violence are at high risk for unmet mental and physical health care needs which can translate into increased Emergency Department (ED) visits. We investigated the effectiveness of participation in a psychosocial, case management-based trauma recovery program on ED utilization. METHODS A retrospective cohort study of ED utilization before and after referral to a Trauma Recovery Center (TRC). Charts of TRC participants from 6/2017-5/2019 who consented in clinic to their medical records being used for research were reviewed. The primary outcome was the change in ED utilization 6 months pre- and post-referral to a TRC. The secondary outcomes were factors associated with ED visits after TRC referral, including victimization or mental health issues. RESULTS The study group contained 143 patients, of which 82% identified as female and 62% identified as white. Many (39%, n = 56) were part of one or more vulnerable populations and type of victimization varied extensively. Intervention uptake was high as almost all (92%, n = 132) had at least one TRC encounter [median of 6 encounters (IQR 2-13)] and an average of 2.7 services used. Most participants (67.1%, n = 96) had no change in ED use. Forty (28.0%) had at least 1 ED visit 6 months before, 38 (26.8%) had at least 1 ED visit 6 months afterwards, and 81 (56.6%) had no ED visits during either timeframe. ED visits per person in the 6 months prior to referral were not different from visits per person in the 6 months after referral (0.52 vs 0.49, p = 0.76, paired t-test). Negative binomial regression indicated number of ED visits before referral (IRR 1.5, 95% confidence interval [1.27-1.79]) and pre-existing mental health conditions (IRR 2.2, 95% confidence interval [0.98-5.02]) were most associated with an increase in the incidence rate ratio of ED visits in the 6 months after referral. CONCLUSION Despite high engagement, a multidisciplinary Trauma Recovery Center did not reduce ED utilization. ED utilization prior to TRC was the most predictive factor of ED utilization afterwards.
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Affiliation(s)
- Olivia Pyles
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Rebekah Richards
- The Ohio State University Wexner Medical Center Department of Emergency Medicine, Columbus, OH, USA
| | - Arianna Galligher
- The Ohio State University Wexner Medical Center Department of Psychiatry, Columbus, OH, USA
| | - Joanne Du
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jacob Brooks
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Lauren T Southerland
- The Ohio State University Wexner Medical Center Department of Emergency Medicine, Columbus, OH, USA.
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Santangelo I, Ahmad S, Liu S, Southerland LT, Carpenter C, Hwang U, Lesser A, Tidwell N, Biese K, Kennedy M. Examination of geriatric care processes implemented in level 1 and level 2 geriatric emergency departments. J Geriatr Emerg Med 2023; 3:10.17294/2694-4715.1041. [PMID: 36970655 PMCID: PMC10035774 DOI: 10.17294/2694-4715.1041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
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.
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Affiliation(s)
- Ilianna Santangelo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Surriya Ahmad
- SUNY Downstate Medical Center / Kings County Hospital Center
| | - Shan Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | | | - Christopher Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT; Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NY
| | | | | | - Kevin Biese
- West Health Institute, La Jolla, CA; Division of Geriatric Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
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Carpenter CR, Southerland LT, Lucey BP, Prusaczyk B. Around the EQUATOR with clinician-scientists transdisciplinary aging research (Clin-STAR) principles: Implementation science challenges and opportunities. J Am Geriatr Soc 2022; 70:3620-3630. [PMID: 36005482 PMCID: PMC10538952 DOI: 10.1111/jgs.17993] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/25/2022] [Accepted: 07/04/2022] [Indexed: 12/24/2022]
Abstract
The Institute of Medicine and the National Institute on Aging increasingly understand that knowledge alone is necessary but insufficient to improve healthcare outcomes. Adapting the behaviors of clinicians, patients, and stakeholders to new standards of evidence-based clinical practice is often significantly delayed. In response, over the past twenty years, Implementation Science has developed as the study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners and policymakers. One important advance in Implementation Science research was the development of Standards for Reporting Implementation Studies (StaRI), which provided a 27-item checklist for researchers to consistently report essential elements of the implementation and intervention strategies. Using StaRI as a framework, this review discusses specific Implementation Science challenges for research with older adults, provides solutions for those obstacles, and opportunities to improve the value of this evolving approach to reduce the knowledge translation losses that exist between published research and clinical practice.
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Affiliation(s)
- Christopher R Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Brendan P Lucey
- Department of Neurology, Washington University in St Louis School of Medicine, St. Louis, Missouri, USA
| | - Beth Prusaczyk
- Department of Medicine Institute for Informatics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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Grudzen CR, Barker PC, Bischof JJ, Cuthel AM, Isaacs ED, Southerland LT, Yamarik RL. Palliative care models for patients living with advanced cancer: a narrative review for the emergency department clinician. Emerg Cancer Care 2022; 1:10. [PMID: 35966217 PMCID: PMC9362452 DOI: 10.1186/s44201-022-00010-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/18/2022] [Indexed: 11/19/2022]
Abstract
Eighty-one percent of persons living with cancer have an emergency department (ED) visit within the last 6 months of life. Many cancer patients in the ED are at an advanced stage with high symptom burden and complex needs, and over half is admitted to an inpatient setting. Innovative models of care have been developed to provide high quality, ambulatory, and home-based care to persons living with serious, life-limiting illness, such as advanced cancer. New care models can be divided into a number of categories based on either prognosis (e.g., greater than or less than 6 months), or level of care (e.g., lower versus higher intensity needs, such as intravenous pain/nausea medication or frequent monitoring), and goals of care (e.g., cancer-directed treatment versus symptom-focused care only). We performed a narrative review to (1) compare models of care for seriously ill cancer patients in the ED and (2) examine factors that may hasten or impede wider dissemination of these models.
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Southerland LT, Benson KK, Schoeffler AJ, Lashutka MA, Borson S, Bischof JJ. Inclusion of older adults and reporting of consent processes in randomized controlled trials in the emergency department: A scoping review. J Am Coll Emerg Physicians Open 2022; 3:e12774. [PMID: 35919513 PMCID: PMC9337842 DOI: 10.1002/emp2.12774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 01/07/2023] Open
Abstract
Objective Conducting research in the emergency department (ED) is often complicated by patients' acute and chronic illnesses, which can adversely affect cognition and subsequently capacity to consent for research, especially in older adults. Validated screening tools to assess capacity to consent for research exist, but neither the frequency of use nor which ones are used for ED research are known. Methods We conducted a scoping review using standard review techniques. Inclusion criteria included (1) randomized controlled trials (RCTs) from publication years 2014-2019 that (2) enrolled participants only in the ED, (3) included patients aged 65+ years, and (4) were fully published in English. Articles were sourced from Embase and screened using Covidence. Results From 3130 search results, 269 studies passed title/abstract and full text screening. Average of the mean or median ages was 55.7 years (SD 14.2). The mean number of study participants was 311.9 [range 8-10,807 participants]. A few (n = 13, 4.8%) waived or had exception from informed consent. Of the 256 studies requiring consent, a fourth (26.5%, n = 68) specifically excluded patients due to impaired capacity to consent. Only 11 (4.3%) documented a formal capacity screening tool and only 13 (5.1%) reported consent by legally authorized representative (LAR). Conclusions Most RCTs enrolling older adults in EDs did not report assessment of capacity to consent or use of LARs. This snapshot of informed consent procedures is potentially concerning and suggests that either research consent processes for older patients and/or reporting of consent processes require improvement.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | | | | | - Margaret A. Lashutka
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Soo Borson
- Department of Family MedicineKeck School of Medicine University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Jason J. Bischof
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
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Goldberg EM, Southerland LT, Meltzer AC, Pagenhardt J, Hoopes R, Camargo CA, Kline JA. Age-related differences in symptoms in older emergency department patients with COVID-19: Prevalence and outcomes in a multicenter cohort. J Am Geriatr Soc 2022; 70:1918-1930. [PMID: 35460268 PMCID: PMC9115070 DOI: 10.1111/jgs.17816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/24/2022] [Accepted: 04/02/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Older adults represent a disproportionate share of severe COVID-19 presentations and fatalities, but we have limited understanding of the differences in presentation by age and the association between less typical emergency department (ED) presentations and clinical outcomes. METHODS This retrospective cohort study used the RECOVER Network registry, a research collaboration of 86 EDs in 27 U.S. states. We focused on encounters with a positive nasopharyngeal swab for SARS-CoV-2, and described their demographics, clinical presentation, and outcomes. Sequential multivariable logistic regressions examined the strength of association between age cohort and outcomes. RESULTS Of 4536 encounters, median patient age was 55 years, 49% were women, and 34% were non-Hispanic Black persons. Cough was the most common presenting complaint across age groups (18-64, 65-74, and 75+): 71%, 67%, and 59%, respectively (p < 0.001). Neurological symptoms, particularly altered mental status, were more common in older adults (2%, 11%, 26%; p < 0.001). Patients 75+ had the greatest odds of ED index visit admission of all age groups (adjusted odds ratio [aOR] 6.66; 95% CI 5.23-8.56), 30-day hospitalization (aOR 7.44; 95% CI 5.63-9.99), and severe COVID-19 (aOR 4.26; 95% CI 3.45-5.27). Compared to individuals with alternate presentations and adjusting for age, patients with typical symptoms (fever, cough and/or shortness of breath) had similar odds of ED index visit admission (aOR 1.01; 95% CI 0.81-1.24), potentially higher odds of 30-day hospitalization (aOR 1.23; 95% CI 1.00-1.53), and greater odds of severe COVID-19 (aOR 1.46; 95% CI 1.12-1.90). CONCLUSIONS Older patients with COVID-19 are more likely to have presentations without the most common symptoms. However, alternate presentations of COVID-19 in older ED patients are not associated with greater odds of mechanical ventilation and/or death. Our data highlights the importance of a liberal COVID-19 testing strategy among older ED patients to facilitate accurate diagnoses and timely treatment and prophylaxis.
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Affiliation(s)
| | | | - Andrew C. Meltzer
- Department of Emergency MedicineGeorge Washington School of Medicine & Health ServicesWashingtonDistrict of ColumbiaUSA
| | - Justine Pagenhardt
- Department of Emergency MedicineWest Virginia UniversityMorgantownWest VirginiaUSA
| | - Ryan Hoopes
- Warren Alpert School of MedicineBrown UniversityProvidenceRhode IslandUSA
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Jeffrey A. Kline
- Department of Emergency MedicineWayne State UniversityDetroitMichiganUSA
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22
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Pyles O, Hritz CM, Gulker P, Straveler JD, Grudzen CR, Briggs C, Southerland LT. Locating Advance Care Planning Documents in the Electronic Health Record during Emergency Care. J Pain Symptom Manage 2022; 63:e489-e494. [PMID: 34896277 PMCID: PMC9199955 DOI: 10.1016/j.jpainsymman.2021.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/30/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022]
Abstract
CONTEXT Emergency Departments (EDs) care for people at critical junctures in their illness trajectories, but Advanced Care Planning (ACP) seldom happens during ED visits. One barrier to incorporating patient goals into ED care may be locating ACP documents in the electronic health record (EHR). OBJECTIVES To determine the ease and accuracy of locating ACP documentation in the EHR during an ED visit. METHODS Academic ED with 82,000 visits per year. The EHR system includes a Storyboard with the patient's code status and a link to ACP documents. A real-time chart audit study was performed of ED patients who were either ≥65 years old or had a cancer diagnosis. Data elements included age, Emergency Severity Index, ACP document location(s) in the EHR, Storyboard accuracy, ED code status orders, and discussions of ACP or code status. RESULTS Of the 160 audited charts, 51 (32%) were for adults <65 years old with a cancer diagnosis. Code status was discussed and updated during the ED visit in 68% (n=108). ACP documents were found in 3 different EHR places. Only 30% (n=48) had ACP documents in the EHR, and of these (22%, n=13) were found in only one of the three EHR locations. The Storyboard was inaccurate for 5% (n=8). ED case managers frequently discussed APC documentation (78%, 43/55 charts). CONCLUSIONS Even under optimal conditions with social work availability, ACP documents are lacking for ED patients. Multiple potential locations of ACP documents and inaccurate linkage to the Storyboard are potentially addressable barriers to ACP conversations.
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Affiliation(s)
- Olivia Pyles
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Christopher M Hritz
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Peg Gulker
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Jansi D Straveler
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Corita R Grudzen
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Cole Briggs
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA
| | - Lauren T Southerland
- The Ohio State University College of Medicine (O.P.), Columbus, Ohio, USA; Division of Palliative Medicine, Department of Internal Medicine (C.M.H.), The Ohio State University, Columbus, Ohio, USA; Department of Emergency Medicine (P.G., L.T.S.), The Ohio State University, Columbus, Ohio USA; Clinical Analytics (J.D.S.), The Ohio State University Wexner Medical Center, Columbus, Ohio USA; Ronald O. Perelman Department of Emergency Medicine (C.R.G.), New York University School of Medicine, Department of Population Health, New York, New York, USA.
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23
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Kennedy M, Lesser A, Israni J, Liu SW, Santangelo I, Tidwell N, Southerland LT, Carpenter CR, Biese K, Ahmad S, Hwang U. Reach and Adoption of a Geriatric Emergency Department Accreditation Program in the United States. Ann Emerg Med 2022; 79:367-373. [PMID: 34389196 PMCID: PMC10015385 DOI: 10.1016/j.annemergmed.2021.06.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA.
| | | | | | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Ilianna Santangelo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | | | | | - Christopher R Carpenter
- Department of Emergency Medicine and Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Kevin Biese
- West Health Institute, La Jolla, CA; Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Surriya Ahmad
- Department of Emergency Medicine, SUNY Downstate, Kings County Hospital Center, Brooklyn, NY
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT; Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY
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24
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Kizziah MA, Miller KN, Bischof JJ, Emerson G, Khandelwal S, Mitzman J, Southerland LT, Way DP, Hunold KM. Emergency medicine resident clinical experience vs. in-training examination content: A national database study. AEM Educ Train 2022; 6:e10729. [PMID: 35368501 PMCID: PMC8908307 DOI: 10.1002/aet2.10729] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/12/2022] [Accepted: 01/25/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Emergency medicine (EM) residents take the In-Training Examination (ITE) annually to assess medical knowledge. Question content is derived from the Model of Clinical Practice of Emergency Medicine (EM Model), but it is unknown how well clinical encounters reflect the EM Model. The objective of this study was to compare the content of resident patient encounters from 2016-2018 to the content of the EM Model represented by the ITE Blueprint. METHODS This was a retrospective cross-sectional study utilizing the National Hospital Ambulatory Medical Care Survey (NHAMCS). Reason for visit (RFV) codes were matched to the 20 categories of the American Board of Emergency Medicine (ABEM) ITE Blueprint. All analyses were done with weighted methodology. The proportion of visits in each of the 20 content categories and 5 acuity levels were compared to the proportion in the ITE Blueprint using 95% confidence intervals (CIs). RESULTS Both resident and nonresident patient visits demonstrated content differences from the ITE Blueprint. The most common EM Model category were visits with only RFV codes related to signs, symptoms, and presentations regardless of resident involvement. Musculoskeletal disorders (nontraumatic), psychobehavioral disorders, and traumatic disorders categories were overrepresented in resident encounters. Cardiovascular disorders and systemic infectious diseases were underrepresented. When residents were involved with patient care, visits had a higher proportion of RFV codes in the emergent and urgent acuity categories compared to those without a resident. CONCLUSIONS Resident physicians see higher acuity patients with varied patient presentations, but the distribution of encounters differ in content category than those represented by the ITE Blueprint.
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Affiliation(s)
- Melinda A. Kizziah
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Krystin N. Miller
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Jason J. Bischof
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Geremiha Emerson
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Sorabh Khandelwal
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Jennifer Mitzman
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | | | - David P. Way
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
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25
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Rege RM, Peyton K, Pajka SE, Grudzen CR, Conroy MJ, Southerland LT. Arranging Hospice Care from the Emergency Department: A Single Center Retrospective Study. J Pain Symptom Manage 2022; 63:e281-e286. [PMID: 34411660 PMCID: PMC9069289 DOI: 10.1016/j.jpainsymman.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Arranging hospice services from the Emergency Department (ED) can be difficult due to physician discomfort, time constraints, and the intensity of care coordination needed. We report patient and visit characteristics associated with successful transition from the ED directly to hospice. METHODS Setting: Academic ED with 82,000 annual visits. POPULATION ED patients with a referral to hospice order placed during the ED visit from January 2014-December 2018. Charts were abstracted by trained, non-blinded personnel. Primary goal was to evaluate patient and visit factors associated with requiring admission for hospice transition. RESULTS Electronic Health Record inquiry yielded 113 patients, 93 of which met inclusion criteria. Patients were aged 65.8 years (range 32-92), 54% were female, and 78% were white, non-hispanic. The majority had cancer (78%, n = d72) and were on public insurance (60%, n = 56). Half (55%, n = 51) were full code upon arrival. Average ED length of stay was 4.6 ± 2.6 hours. Discharge from the ED to hospice was successful for 38% (n = 35), a few (n = 5) were dispositioned to an ED observation unit, and 57% (n = 53) were admitted. Only 10 (11%) required an inpatient length of stay longer than an observation visit (2 days). Case management and social work team arranged for transportation (54.8%, n = 51), hospital beds (16.1%, n = 16), respiratory equipment (18.3%, n = 17), facility placement (33.3%, n = 31), and home health aides (29.0%, n = 27). CONCLUSION Transitioning patients to hospice care from the ED is possible within a typical ED length of stay with assistance from a case manager/social work team.
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Affiliation(s)
- Rahul M Rege
- Department of Emergency Medicine, The Ohio State University, (R.M.R., K.P., M.J.C., L.T.S.) Columbus OH.
| | - Kelee Peyton
- Department of Emergency Medicine, The Ohio State University, (R.M.R., K.P., M.J.C., L.T.S.) Columbus OH
| | - Sarah E Pajka
- The Ohio State University College of Medicine, (S.E.P.) Columbus OH
| | - Corita R Grudzen
- Department of Population Health, (C.R.G.) NYU Grossman School of Medicine, New York, NY
| | - Mark J Conroy
- Department of Emergency Medicine, The Ohio State University, (R.M.R., K.P., M.J.C., L.T.S.) Columbus OH
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, (R.M.R., K.P., M.J.C., L.T.S.) Columbus OH
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26
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Southerland LT, Hunold KM, Van Fossen J, Caterino JM, Gulker P, Stephens JA, Bischof JJ, Farrell E, Carpenter CR, Mion LC. An implementation science approach to geriatric screening in an emergency department. J Am Geriatr Soc 2022; 70:178-187. [PMID: 34580860 PMCID: PMC8742753 DOI: 10.1111/jgs.17481] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The Geriatric Emergency Department (ED) Guidelines recommend screening older adults during their ED visit for delirium, fall risk/safe mobility, and home safety needs. We used the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementation Change (ERIC) tool for preimplementation planning. METHODS The cross-sectional survey was conducted among ED nurses at an academic medical center. The survey was adapted from the CFIR Interview Guide Tool and consisted of 21 Likert scale questions based on four CFIR domains. Potential barriers identified by the survey were mapped to identify recommended implementation strategies using ERIC. RESULTS Forty-six of 160 potential participants (29%) responded. Intervention Characteristics: Nurses felt geriatric screening should be standard practice for all EDs (76.1% agreed some/very much) and that there was good evidence (67.4% agreed some/very much). Outer setting: The national and regional practices such as the existence of guidelines or similar practices in other hospitals were unknown to many (20.0%). Nurses did agree some/very much (64.4%) that the intervention was good for the hospital/health system. Inner Setting: 67.4% felt more staff or infrastructure and 63.0% felt more equipment were needed for the intervention. When asked to pick from a list of potential barriers, the most commonly chosen were motivational (I often do not remember (n = 27, 58.7%) and It is not a priority (n = 14, 30.4%)). The identified barriers were mapped using the ERIC tool to rate potential implementation strategies. Strategies to target culture change were identifying champions, improve adaptability, facilitate the nurses performing the intervention, and increase demand for the intervention. CONCLUSION CFIR domains and ERIC tools are applicable to an ED intervention for older adults. This preimplementation process could be replicated in other EDs considering implementing geriatric screening.
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Affiliation(s)
| | | | - Jenifer Van Fossen
- Department of Emergency Medicine, The Ohio State University, Columbus OH
| | | | - Peg Gulker
- Department of Emergency Medicine, The Ohio State University, Columbus OH
| | - Julie A. Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State College of Medicine, Columbus, OH, USA
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus OH
| | - Erin Farrell
- Department of Emergency Medicine, The Ohio State University, Columbus OH
| | | | - Lorraine C. Mion
- College of Nursing, The Ohio State Wexner Medical Center, Columbus, OH, USA
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27
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Southerland LT, Frey JA, Williams R. We'll Deal With That Later. Narrat Inq Bioeth 2021; 11:20-22. [PMID: 34334459 DOI: 10.1353/nib.2021.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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28
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Fareed N, Southerland LT, Rao BM, Sieck CJ. Geriatric assistive devices improve older patient engagement and clinical care in an emergency department. Am J Emerg Med 2021; 46:656-658. [PMID: 32828596 PMCID: PMC9933906 DOI: 10.1016/j.ajem.2020.07.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/26/2020] [Accepted: 07/29/2020] [Indexed: 10/23/2022] Open
Affiliation(s)
- Naleef Fareed
- CATALYST - The Center for the Advancement of Team Science, Analytics, and Systems Thinking, College of Medicine, The Ohio State University, Institute for Behavioral Medicine Research, 460 Medical Center Drive, Columbus, OH 43210, United States of America; Department of Biomedical Informatics, College of Medicine, The Ohio State University, 1585 Neil Ave., Columbus, OH 43210, United States of America.
| | - Lauren T. Southerland
- Department of Emergency Medicine, College of Medicine, The Ohio State University, 410 W 10th Ave., Columbus, OH 43210, United States of America
| | - Brian M. Rao
- Department of Emergency Medicine, College of Medicine, The Ohio State University, 410 W 10th Ave., Columbus, OH 43210, United States of America
| | - Cynthia J. Sieck
- CATALYST – The Center for the Advancement of Team Science, Analytics, and Systems Thinking, College of Medicine, The Ohio State University, Institute for Behavioral Medicine Research, 460 Medical Center Drive, Columbus, OH 43210, United States of America,Department of Family Medicine, College of Medicine, The Ohio State University, 2231 N High St., Columbus, OH 43210, United States of America
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29
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Hunold KM, Schwaderer AL, Exline M, Hebert C, Lampert BC, Southerland LT, Stephens JA, Bischof JJ, Caterino JM. Diagnosing Dyspneic Older Adult Emergency Department Patients: A Pilot Study. Acad Emerg Med 2021; 28:675-678. [PMID: 33249675 PMCID: PMC10561323 DOI: 10.1111/acem.14183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/29/2020] [Accepted: 11/23/2020] [Indexed: 11/29/2022]
Abstract
Study Objectives: Pneumonia, chronic obstructive pulmonary disease (COPD), and heart failure (HF) exacerbations can present similarly in the older adult in the Emergency Department (ED), leading to sub-optimal treatment from over- and under-diagnosis. There may be a role for antimicrobial peptides (AMPs) in improving the accurate diagnosis of pneumonia in these patients. Methods: This pilot was a prospective, observational cohort study of older adults (aged ≥65 years of age) who presented to the ED with dyspnea or elevated respiratory rate. To identify biomarkers of pneumonia, serum levels of white blood cell count, procalcitonin (PCT), and antimicrobial peptides (human beta defensin 1 and 2 [HBD-1, -2], human neutrophil peptides 1–3 [HNP1–3] and cathelididin [LL-37]) were compared between those with and without pneumonia. Criterion standard reviewers retrospectively determined the diagnoses present in the ED. Results: Three hundred ninety-one patients were screened, 140 were eligible, and 79 were enrolled. Based on criterion standard review, pneumonia was present in 10 (12.7%), COPD in 9 (11.4%) and HF in 31 (39.2%) with a co-diagnosis rate of 10.1% by criterion standard review. Comparatively, emergency medicine attending physicians diagnosed pneumonia in 16 (20.3%), COPD in 12 (15.2%), and HF in 30 (38.0%) with co-diagnosis rate of 15.2%. Emergency physicians agreed with criterion standard diagnoses in 90% of pneumonia, 75% of COPD and 65% of HF diagnoses. Differences in leukocyte count (p<0.01) and two novel AMPs (DEFA5 (p=0.08) and DEFB2 (p=0.09)) showed promise for diagnosing pneumonia. Conclusions: Emergency physicians continue to have poor diagnostic accuracy in dyspneic older adult patients. Serum AMP levels are one potential tool to improve diagnostic accuracy and outcomes for this important population and require further study.
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Affiliation(s)
| | | | - Matthew Exline
- The Ohio State University, Department of Internal Medicine
| | - Courtney Hebert
- The Ohio State University, Department of Biomedical Informatics
- The Ohio State University, Division of Infectious Disease
| | | | | | - Julie A. Stephens
- The Ohio State University, Center for Biostatistics, Department of Biomedical Informatics
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30
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Hyder A, Lee J, Dundon A, Southerland LT, All D, Hammond G, Miller HJ. Opioid Treatment Deserts: Concept development and application in a US Midwestern urban county. PLoS One 2021; 16:e0250324. [PMID: 33979342 PMCID: PMC8115812 DOI: 10.1371/journal.pone.0250324] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 04/05/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives An Opioid Treatment Desert is an area with limited accessibility to medication-assisted treatment and recovery facilities for Opioid Use Disorder. We explored the concept of Opioid Treatment Deserts including racial differences in potential spatial accessibility and applied it to one Midwestern urban county using high resolution spatiotemporal data. Methods We obtained individual-level data from one Emergency Medical Services (EMS) agency (Columbus Fire Department) in Franklin County, Ohio. Opioid overdose events were based on EMS runs where naloxone was administered from 1/1/2013 to 12/31/2017. Potential spatial accessibility was measured as the time (in minutes) it would take an individual, who may decide to seek treatment after an opioid overdose, to travel from where they had the overdose event, which was a proxy measure of their residential location, to the nearest opioid use disorder (OUD) treatment provider that provided medically-assisted treatment (MAT). We estimated accessibility measures overall, by race and by four types of treatment providers (any type of MAT for OUD, Buprenorphine, Methadone, or Naltrexone). Areas were classified as an Opioid Treatment Desert if the estimate travel time to treatment provider (any type of MAT for OUD) was greater than a given threshold. We performed sensitivity analysis using a range of threshold values based on multiple modes of transportation (car and public transit) and using only EMS runs to home/residential location types. Results A total of 6,929 geocoded opioid overdose events based on data from EMS agencies were used in the final analysis. Most events occurred among 26–35 years old (34%), identified as White adults (56%) and male (62%). Median travel times and interquartile range (IQR) to closest treatment provider by car and public transit was 2 minutes (IQR: 3 minutes) and 17 minutes (IQR: 17 minutes), respectively. Several neighborhoods in the study area had limited accessibility to OUD treatment facilities and were classified as Opioid Treatment Deserts. Travel time by public transit for most treatment provider types and by car for Methadone-based treatment was significantly different between individuals who were identified as Black adults and White adults based on their race. Conclusions Disparities in access to opioid treatment exist at the sub-county level in specific neighborhoods and across racial groups in Columbus, Ohio and can be quantified and visualized using local public safety data (e.g., EMS runs). Identification of Opioid Treatment Deserts can aid multiple stakeholders better plan and allocate resources for more equitable access to MAT for OUD and, therefore, reduce the burden of the opioid epidemic while making better use of real-time public safety data to address a public health epidemic that has turned into a public safety crisis.
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Affiliation(s)
- Ayaz Hyder
- Division of Environmental Health, College of Public Health, The Ohio State University, Columbus, OH, United States of America
- Translational Data Analytics Institute, The Ohio State University, Columbus, OH, United States of America
- * E-mail:
| | - Jinhyung Lee
- Department of Geography and Environment, Faculty of Social Science, Western University, Social Science Centre, London, ON, Canada
| | - Ashley Dundon
- Division of Environmental Health, College of Public Health, The Ohio State University, Columbus, OH, United States of America
| | - Lauren T. Southerland
- Department of Emergency Medicine, College of Medicine, The Ohio State University, Columbus, OH, United States of America
| | - David All
- Founder and CEO, Mount Ethos, Seattle, WA, United States of America
| | - Gretchen Hammond
- College of Social Work, The Ohio State University, Columbus, OH, United States of America
| | - Harvey J. Miller
- Center for Urban Regional Analysis, The Ohio State University, Columbus, OH, United States of America
- Department of Geography, The Ohio State University, Columbus, OH, United States of America
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Abstract
Each emergency department (ED) visit represents a crucial transition of care for older adults. Systems, provider, and patient factors are barriers to safe transitions and can contribute to morbidity and mortality in older adults. Safe transitions from ED to inpatient, ED to skilled nursing facility, or ED back to the community require a holistic approach, such as the 4-Ms model-what matters (patient goals of care), medication, mentation, and mobility-along with safety and social support. Clear written and verbal communication with patients, caregivers, and other members of the interdisciplinary team is paramount in ensuring successful care transitions.
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Affiliation(s)
- Kimberly Bambach
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, 376 West 10th Avenue, Columbus, OH 43210, USA. https://twitter.com/kimbambach
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, 376 West 10th Avenue, Columbus, OH 43210, USA.
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Kline JA, Camargo CA, Courtney DM, Kabrhel C, Nordenholz KE, Aufderheide T, Baugh JJ, Beiser DG, Bennett CL, Bledsoe J, Castillo E, Chisolm-Straker M, Goldberg EM, House H, House S, Jang T, Lim SC, Madsen TE, McCarthy DM, Meltzer A, Moore S, Newgard C, Pagenhardt J, Pettit KL, Pulia MS, Puskarich MA, Southerland LT, Sparks S, Turner-Lawrence D, Vrablik M, Wang A, Weekes AJ, Westafer L, Wilburn J. Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021. PLoS One 2021; 16:e0248438. [PMID: 33690722 PMCID: PMC7946184 DOI: 10.1371/journal.pone.0248438] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/25/2021] [Indexed: 12/11/2022] Open
Abstract
Objectives Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care. Methods Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables. Results Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79–0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8–96.3%), specificity of 20.0% (19.0–21.0%), negative likelihood ratio of 0.22 (0.19–0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points). Conclusion Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.
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Affiliation(s)
- Jeffrey A. Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
- * E-mail:
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - D. Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, United States of America
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kristen E. Nordenholz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Thomas Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Joshua J. Baugh
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - David G. Beiser
- Section of Emergency Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Christopher L. Bennett
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Joseph Bledsoe
- Department of Emergency Medicine, Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, Utah, United States of America
| | - Edward Castillo
- Department of Emergency Medicine, University of California, San Diego, California, United States of America
| | - Makini Chisolm-Straker
- Department of Emergency Medicine, Mt. Sinai School of Medicine, New York, New York, United States of America
| | - Elizabeth M. Goldberg
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Hans House
- Department of Emergency Medicine, University of Iowa School of Medicine, Iowa City, Iowa, United States of America
| | - Stacey House
- Department of Emergency Medicine, Washington University School of Medicine, St. Louise, Missouri, United States of America
| | - Timothy Jang
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Stephen C. Lim
- University Medical Center New Orleans, Louisiana State University School of Medicine, New Orleans, Louisiana, United States of America
| | - Troy E. Madsen
- Division of Emergency Medicine, Department Surgery, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Danielle M. McCarthy
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Andrew Meltzer
- Department of Emergency Medicine, George Washington University School of Medicine, Washington D.C., DC, United States of America
| | - Stephen Moore
- Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States of America
| | - Craig Newgard
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Justine Pagenhardt
- Department of Emergency Medicine, West Virginia University School of Medicine, Morgantown, West Virginia, United States of America
| | - Katherine L. Pettit
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Michael S. Pulia
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Michael A. Puskarich
- Department of Emergency Medicine, Hennepin County Medical Center and the University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Lauren T. Southerland
- Department of Emergency Medicine, Ohio State University Medical Center, Columbus, Ohio, United States of America
| | - Scott Sparks
- Department of Emergency Medicine, Riverside Regional Medical Center, Newport News, Virginia, United States of America
| | - Danielle Turner-Lawrence
- Department of Emergency Medicine, Beaumont Health, Royal Oak, Michigan, United States of America
| | - Marie Vrablik
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Alfred Wang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Anthony J. Weekes
- Department of Emergency Medicine, Carolinas Medical Center at Atrium Health, Charlotte, North Carolina, United States of America
| | - Lauren Westafer
- Department of Emergency Medicine, Baystate Health, Springfield, Massachusetts, United States of America
| | - John Wilburn
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
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Caterino JM, Stephens JA, Camargo CA, Wexler R, Hebert C, Southerland LT, Hunold KM, Hains DS, Bischof JJ, Wei L, Wolfe AJ, Schwaderer A. Asymptomatic Bacteriuria versus Symptom Underreporting in Older Emergency Department Patients with Suspected Urinary Tract Infection. J Am Geriatr Soc 2021; 68:2696-2699. [PMID: 33460062 DOI: 10.1111/jgs.16775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 07/18/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Julie A Stephens
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Randell Wexler
- Department of Family Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Courtney Hebert
- Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA.,Division of Infectious Diseases, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA
| | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - David S Hains
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Lai Wei
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Alan J Wolfe
- Department of Microbiology and Immunology, Loyola University Chicago, Chicago, Illinois, USA
| | - Andrew Schwaderer
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Li Y, Hyder A, Southerland LT, Hammond G, Porr A, Miller HJ. 311 service requests as indicators of neighborhood distress and opioid use disorder. Sci Rep 2020; 10:19579. [PMID: 33177583 PMCID: PMC7658248 DOI: 10.1038/s41598-020-76685-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/30/2020] [Indexed: 01/19/2023] Open
Abstract
Opioid use disorder and overdose deaths is a public health crisis in the United States, and there is increasing recognition that its etiology is rooted in part by social determinants such as poverty, isolation and social upheaval. Limiting research and policy interventions is the low temporal and spatial resolution of publicly available administrative data such as census data. We explore the use of municipal service requests (also known as "311" requests) as high resolution spatial and temporal indicators of neighborhood social distress and opioid misuse. We analyze the spatial associations between georeferenced opioid overdose event (OOE) data from emergency medical service responders and 311 service request data from the City of Columbus, OH, USA for the time period 2008-2017. We find 10 out of 21 types of 311 requests spatially associate with OOEs and also characterize neighborhoods with lower socio-economic status in the city, both consistently over time. We also demonstrate that the 311 indicators are capable of predicting OOE hotspots at the neighborhood-level: our results show code violation, public health, and street lighting were the top three accurate predictors with predictive accuracy as 0.92, 0.89 and 0.83, respectively. Since 311 requests are publicly available with high spatial and temporal resolution, they can be effective as opioid overdose surveillance indicators for basic research and applied policy.
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Affiliation(s)
- Yuchen Li
- Department of Geography, The Ohio State University, Columbus, OH, USA
- Center for Urban and Regional Analysis, The Ohio State University, Columbus, OH, USA
| | - Ayaz Hyder
- College of Public Health, The Ohio State University, Columbus, OH, USA
| | | | | | - Adam Porr
- Center for Urban and Regional Analysis, The Ohio State University, Columbus, OH, USA
| | - Harvey J Miller
- Department of Geography, The Ohio State University, Columbus, OH, USA.
- Center for Urban and Regional Analysis, The Ohio State University, Columbus, OH, USA.
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Southerland LT, Savage EL, Muska Duff K, Caterino JM, Bergados TR, Hunold KM, Finnegan GI, Archual G. Hospital Costs and Reimbursement Model for a Geriatric Emergency Department. Acad Emerg Med 2020; 27:1051-1058. [PMID: 32338422 DOI: 10.1111/acem.13998] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/07/2020] [Accepted: 02/14/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVES The American College of Emergency Physicians' geriatric emergency department (GED) guidelines recommend additional staff and geriatric equipment, which may not be financially feasible for every ED. Data from an accredited Level 1 GED was used to report equipment costs and to develop a business model for financial sustainability of a GED. METHODS Staff salaries including the cost of fringe benefits were obtained from a Midwestern hospital with an academic ED of 80,000 annual visits. Reimbursement assumptions included 100% Medicare/Medicaid insurance payor and 8-hour workdays with 4.5 weeks of leave annually. Equipment costs from hospital invoices were collated. Operational and patient safety metrics were compared before and after the GED. RESULTS A geriatric nurse practitioner in the ED is financially self-sustaining at 7.1 consultations, a pharmacist is self-sustaining at 7.7 medication reconciliation consultations, and physical and occupational therapist evaluations are self-sustaining at 5.7 and 4.6 consults per workday, respectively. Total annual equipment costs for mobility aids, delirium aids, sensory aids, and personal care items for the GED was $4,513. Comparing the 2 years before and after, in regard to operational metrics the proportions of patients with lengths of stay > 8 hours and patients placed in observation did not change. In regard to patient safety, the rate of falls decreased from 0.60/1,000 patient visits to 0.42/1,000 in the ED observation unit and 0.42/1,000 to 0.36/1,000 in the ED. ED recidivism at 7 and 30 days did not change. Estimated cost savings from the reduction in falls was $80,328. CONCLUSION The additional equipment and personnel costs for comprehensive geriatric assessment in the ED are potentially financially justified by revenue generation and improvements in patient safety measures. A geriatric ED was associated with a decrease in patient falls in the ED but did not decrease admissions or ED recidivism.
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Affiliation(s)
- Lauren T. Southerland
- From the Department of Emergency Medicine The Ohio State University Wexner Medical Center Columbus OH USA
| | - Elizabeth L. Savage
- From the Department of Emergency Medicine The Ohio State University Wexner Medical Center Columbus OH USA
| | - Katrina Muska Duff
- Human Resources College of Medicine The Ohio State University Wexner Medical Center Columbus OH USA
| | - Jeffrey M. Caterino
- From the Department of Emergency Medicine The Ohio State University Wexner Medical Center Columbus OH USA
| | - Tina R. Bergados
- and the James Cancer Hospital and Solove Research Institute Columbus OH USA
| | - Katherine M. Hunold
- From the Department of Emergency Medicine The Ohio State University Wexner Medical Center Columbus OH USA
| | | | - Gregory Archual
- From the Department of Emergency Medicine The Ohio State University Wexner Medical Center Columbus OH USA
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Southerland LT, Stephens JA, Carpenter CR, Mion LC, Moffatt-Bruce SD, Zachman A, Hill M, Caterino JM. Study protocol for IMAGE: implementing multidisciplinary assessments for geriatric patients in an emergency department observation unit, a hybrid effectiveness/implementation study using the Consolidated Framework for Implementation Research. Implement Sci Commun 2020; 1:28. [PMID: 32885187 PMCID: PMC7427917 DOI: 10.1186/s43058-020-00015-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 01/27/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Older adults in the emergency department (ED) are at high risk for functional decline, unrecognized delirium, falls, and medication interactions. Holistic assessment by a multidisciplinary team in the ED decreases these adverse outcomes and decreases admissions, but there are many barriers to incorporating this type of care during the ED visit. METHODS This is a hybrid type II effectiveness-implementation study using a pre-/post-cohort design (n = 380) at a tertiary care academic ED with an ED observation unit (Obs Unit). The intervention is a two-step protocol of (step 1) ED nurses screening adult patients ≥ 65 years old for geriatric needs using the Delirium Triage Screen, 4-Stage Balance Test, and the Identifying Seniors at Risk score. Patients who have geriatric needs identified by this screening but who do not meet hospital admission criteria will (step 2) be placed in the Obs Unit for multidisciplinary geriatric assessment by the hospital's geriatric consultation team, physical therapists, occupational therapists, pharmacists, and/or case managers. Not all patients may require all elements of the multidisciplinary geriatric assessment. The Consolidated Framework for Implementation Research: Care Transitions Framework was used to identify barriers to implementation. Lean Six Sigma processes will be used to overcome these identified barriers with the goal of achieving geriatric screening rates of > 80%. Implementation success and associated factors will be reported. For the effectiveness aim, pre-/post-cohorts of adults ≥ 65 years old cared for in the Obs Unit will be followed for 90 days post-ED visit (n = 150 pre and 230 post). The primary outcome is the prevention of functional decline. Secondary outcomes include health-related quality of life, new geriatric syndromes identified, new services provided, and Obs Unit metrics such as length of stay and admission rates. DISCUSSION A protocol for implementing integrated multidisciplinary geriatric assessment into the ED setting has the potential to improve patient functional status by identifying and addressing geriatric issues and needs prior to discharge from the ED. Using validated frameworks and implementation strategies will increase our understanding of how to improve the quality of ED care for older adults in the acute care setting. TRIAL REGISTRATION ClinicalTrials.gov Identifier, NCT04068311, registered 28 August 2019.
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Affiliation(s)
- Lauren T. Southerland
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
| | - Julie A. Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State College of Medicine, Columbus, OH USA
| | | | - Lorraine C. Mion
- College of Nursing, The Ohio State Wexner Medical Center, Columbus, OH USA
| | | | - Angela Zachman
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
| | - Michael Hill
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, 750 Prior Hall, 376 W 10th Ave, Columbus, OH 43210 USA
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Southerland LT, Lo AX, Biese K, Arendts G, Banerjee J, Hwang U, Dresden S, Argento V, Kennedy M, Shenvi CL, Carpenter CR. Concepts in Practice: Geriatric Emergency Departments. Ann Emerg Med 2019; 75:162-170. [PMID: 31732374 DOI: 10.1016/j.annemergmed.2019.08.430] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 01/02/2023]
Abstract
In 2018, the American College of Emergency Physicians (ACEP) began accrediting facilities as "geriatric emergency departments" (EDs) according to adherence to the multiorganizational guidelines published in 2014. The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-effective manner and within the capabilities of their facilities and staff. Because all innovation is at heart local and must function within the constraints of local resources, different hospital systems have developed implementation processes for the geriatric ED guidelines according to their differing institutional capabilities and resources. This article describes 4 geriatric ED models of care to provide practical examples and guidance for institutions considering developing geriatric EDs: a geriatric ED-specific unit, geriatrics practitioner models, geriatric champions, and geriatric-focused observation units. The advantages and limitations of each model are compared and examples of specific institutions and their operational metrics are provided.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Alexander X Lo
- Department of Emergency Medicine, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kevin Biese
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Glenn Arendts
- Emergency Medicine, School of Medicine, University of Western Australia, Perth, Australia
| | - Jay Banerjee
- College of Life Sciences, University of Leicester and Department of Emergency Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Ula Hwang
- Department of Emergency Medicine, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NY
| | - Scott Dresden
- Department of Emergency Medicine, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Vivian Argento
- Geriatric Services, Bridgeport Hospital, Yale University School of Medicine, New Haven, CT
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Christina L Shenvi
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Bischof JJ, Emerson G, Mitzman J, Khandelwal S, Way DP, Southerland LT. Does the Emergency Medicine In-training Examination Accurately Reflect Residents' Clinical Experiences? AEM Educ Train 2019; 3:317-322. [PMID: 31637348 PMCID: PMC6795359 DOI: 10.1002/aet2.10381] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/19/2019] [Accepted: 07/20/2019] [Indexed: 05/21/2023]
Abstract
OBJECTIVE The American Board of Emergency Medicine Model of the Clinical Practice of Emergency Medicine (ABEM Model) serves as a guide for resident education and the basis for the resident In-training Examination (ITE) and the Emergency Medicine Board Qualification Examinations. The purpose of this study was to determine how closely resident-patient encounters in our emergency departments (EDs) matched the ABEM Model as presented in the specifications of the content outline for the ITE. METHODS This single-site study of an academic residency program analyzed all documented resident-patient encounters in the ED during a 2.5-year period recorded in the electronic medical record. The chief complaints from these encounters were matched to the 20 categories of the ABEM Model. Chi-square goodness-of-fit tests were performed to compare the proportions of categorized encounters and proportions of patient acuity levels to the proportions of categories as outlined in the content blueprint of the ITE. RESULTS After the exclusion of encounters with missing data and those not involving EM residents, 125,405 encounters were analyzed. We found a significant difference between the clinical experience of EM residents and the ABEM Model as reflected in the ITE for both case categories (p < 0.01) and patient acuity (p < 0.01). The following categories were the most overrepresented in clinical care: signs, symptoms, and presentations; psychobehavioral disorders; and abdominal and gastrointestinal disorders. The most underrepresented were procedures and skills, systemic infectious disorders, and thoracic-respiratory disorders. CONCLUSION The clinical experience of EM residents differs significantly from the ITE Content Blueprint, which reflects the ABEM Model. This type of inquiry may help to provide custom education reports to residents about their clinical encounters to help identify clinical knowledge gaps that may require supplemental nonclinical training.
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Affiliation(s)
- Jason J. Bischof
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
| | - Geremiha Emerson
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
| | - Jennifer Mitzman
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
| | - Sorabh Khandelwal
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
| | - David P. Way
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
| | - Lauren T. Southerland
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
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Southerland LT, Pearson S, Hullick C, Carpenter CR, Arendts G. Safe to send home? Discharge risk assessment in the emergency department. Emerg Med Australas 2019; 31:266-270. [DOI: 10.1111/1742-6723.13250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/20/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Lauren T Southerland
- Department of Emergency MedicineThe Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Scott Pearson
- Department of Emergency MedicineChristchurch Hospital Christchurch New Zealand
| | - Carolyn Hullick
- Faculty of HealthThe University of Newcastle Newcastle New South Wales Australia
- Hunter Medical Research Institute Newcastle New South Wales Australia
| | | | - Glenn Arendts
- School of MedicineThe University of Western Australia Perth Western Australia Australia
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Southerland LT, Simerlink SR, Vargas AJ, Krebs M, Nagaraj L, Miller KN, Adkins EJ, Barrie MG. Beyond observation: Protocols and capabilities of an Emergency Department Observation Unit. Am J Emerg Med 2018; 37:1864-1870. [PMID: 30639128 DOI: 10.1016/j.ajem.2018.12.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/04/2018] [Accepted: 12/25/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Emergency Department Observation Units (Obs Units) provide a setting and a mechanism for further care of Emergency Department (ED) patients. Our hospital has a protocol-driven, type 1, complex 20 bed Obs Unit with 36 different protocols. We wanted to understand how the different protocols performed and what types of care were provided. METHODS This was an IRB-approved, retrospective chart review study. A random 10% of ED patient charts with a "transfer to observation" order were selected monthly from October 2015 through June 2017. This database was designed to identify high and low functioning protocols based on length of stays (LOS) and admission rates. RESULTS Over 20 months, a total of 984 patients qualified for the study. The average age was 49.5 ± 17.2 years, 57.3% were women, and 32.3% were non-Caucasian. The admission rate was 23.5% with an average LOS in observation of 13.7 h [95% CI 13.3-14.1]. Thirty day return rate was 16.8% with 5.3% of the patients returning to the ED within the first 72 h. Thirty six different protocols were used, with the most common being chest pain (13.9%) and general (13.2%). Almost 70% received a consultation from another service, and 7.2% required a procedure while in observation. Procedures included fluoroscopic-guided lumbar punctures, endoscopies, dental extractions, and catheter replacements (nephrostomy, gastrostomy, and biliary tubes). CONCLUSIONS An Obs Unit can care for a wide variety of patients who require multiple consultations, procedures, and care coordination while maintaining an acceptable length of stay and admission rate.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA. https://twitter.com/LSGeriatricEM
| | | | - Anthony J Vargas
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Margaret Krebs
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lalitha Nagaraj
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Krystin N Miller
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Eric J Adkins
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Michael G Barrie
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Southerland LT, Hunold KM, Carpenter CR, Caterino JM, Mion LC. A National Dataset Analysis of older adults in emergency department observation units. Am J Emerg Med 2018; 37:1686-1690. [PMID: 30563716 DOI: 10.1016/j.ajem.2018.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/03/2018] [Accepted: 12/06/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Emergency Department (ED) Observation Units (Obs Units) are prevalent in the US, but little is known regarding older adults in observation. Our objective was to describe the Obs Units nationally and observation patients with specific attention to differences in care with increasing age. DESIGN This is an analysis of 2010-2013 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national observational cohort study including ED patients. Weighted means are presented for continuous data and weighted percent for categorical data. Multivariable logistic regression was used to identify variables associated with placement in and admission from observation. RESULTS The number of adult ED visits varied from 100 million to 107 million per year and 2.3% of patients were placed in observation. Adults ≥65 years old made up a disproportionate number of Obs Unit patients, 30.6%, compared to only 19.7% of total ED visits (odds ratio 1.5 (95% CI 1.5-1.6), adjusting for sex, race, month, day of week, payer source, and hospital region). The overall admission rate from observation was 35.6%, ranging from 31.3% for ages 18-64 years to 47.5% for adults ≥85 years old (p < 0.001). General symptoms (e.g., nausea, dizziness) and hypertensive disease were the most common diagnoses overall. Older adults varied from younger adults in that they were frequently observed for diseases of the urinary system (ICD-9 590-599) and metabolic disorders (ICD-9 270-279). CONCLUSIONS Older adults are more likely to be cared for in Obs Units. Older adults are treated for different medical conditions than younger adults.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lorraine C Mion
- College of Nursing, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Ringer T, Dougherty M, McQuown C, Melady D, Ouchi K, Southerland LT, Hogan TM. White Paper-Geriatric Emergency Medicine Education: Current State, Challenges, and Recommendations to Enhance the Emergency Care of Older Adults. AEM Educ Train 2018; 2:S5-S16. [PMID: 30607374 PMCID: PMC6304282 DOI: 10.1002/aet2.10205] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 10/02/2018] [Indexed: 05/21/2023]
Abstract
Older adults account for 25% of all emergency department (ED) patient encounters. One in five Americans will be 65 or older by 2030. In response to this need, geriatric emergency medicine (GEM) has developed into a robust area of academic and clinical interest, with extensive evidence-based research and guidelines, including clear undergraduate and postgraduate GEM competencies. Despite these developments, GEM content remains underrepresented in curricula and licensing examinations. The complex reasons for these deficits include a perception that care of older adults is not a core emergency medicine (EM) competency, a disjunction between traditional definitions of expertise and the GEM perspective, and lack of curricular capacity. This White Paper, prepared on behalf of the Academy of Geriatric Emergency Medicine, describes the state of GEM education, identifies the challenges it faces, and reviews innovations, including research presented at the 2018 Society for Academic Emergency Medicine (SAEM) Annual Scientific Meeting. The authors propose a number of recommendations. These include recognizing GEM as a core educational priority in EM, enhancing academic support for GEM clinician-educators, using social learning and practical problem solving to teach GEM concepts, emphasizing a whole-person multisystem approach to care of older adults, and identifying ageist attitudes as a hurdle to safe and effective GEM care.
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Affiliation(s)
- Thom Ringer
- Mount Sinai Academic Family Health TeamTorontoOntarioCanada
| | | | - Colleen McQuown
- Northeast Ohio Medical UniversityRootstownOH
- Academic & Community Emergency SpecialistsLLCUniontownOH
| | - Don Melady
- Schwarz/Reisman Emergency Medicine InstituteDepartment of Family and Community MedicineSinai Health SystemUniversity of TorontoTorontoOntarioCanada
| | - Kei Ouchi
- Brigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - Lauren T. Southerland
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
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Caterino JM, Kline DM, Leininger R, Southerland LT, Carpenter CR, Baugh CW, Pallin DJ, Hunold KM, Stevenson KB. Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department. J Am Geriatr Soc 2018; 67:484-492. [PMID: 30467825 DOI: 10.1111/jgs.15679] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/05/2018] [Accepted: 10/06/2018] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED). DESIGN Preplanned, secondary analysis of a prospective observational study. SETTING Tertiary care, academic ED. PARTICIPANTS A total of 424 patients in the ED, 65 years or older, including all chief complaints. MEASUREMENTS We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection. RESULTS Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40-2.53) or malaise/lethargy (PLR range, 1.25-1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15-18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79-0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms. CONCLUSIONS The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484-492, 2019.
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Affiliation(s)
- Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - David M Kline
- Department of Biomedical Informatics Center for Biostatistics, The Ohio State University, Columbus, Ohio
| | | | - Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Christopher R Carpenter
- Division of Emergency Medicine and Emergency Care Research Core, Washington University in St Louis, St Louis, Missouri
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katherine M Hunold
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kurt B Stevenson
- Department of Epidemiology and Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Southerland LT, Porter BL, Newman NW, Payne K, Hoyt C, Rodis JL. The feasibility of an inter-professional transitions of care service in an older adult population. Am J Emerg Med 2018; 37:553-556. [PMID: 30131205 DOI: 10.1016/j.ajem.2018.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 07/24/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Older adults discharged from the Emergency Department (ED) are at high risk for medication interactions and side effects; examples of practice models addressing this transition of care are lacking. METHODS This was a prospective cohort study for adults in one of two urban community EDs. Patients ≥50 years of age discharged with at least one new, non-schedule II prescription medication were included. Patients had the option of three transitions of care services: 1) pharmacist-only with home delivery of discharge medications and full medication reconciliation, 2) pharmacist and home health care, including home delivery, medication reconciliation, and a visit from a home health nurse, or 3) either of the above without home delivery. RESULTS Over seven months, 440 ED patients were screened. Of those, 43 patients were eligible, and three patients elected to join the study. All three patients selected pharmacy-only. Identified barriers to enrollment include the rate of schedule II prescriptions from the ED (53% of potential patients) and high patient loyalty to their community pharmacist. CONCLUSIONS A pharmacy and home health care transitions of care program was not feasible at an urban community ED. While the pharmacist team identified and managed multiple medication issues, most patients did not qualify due to prescriptions ineligible for delivery. Patients did not want pharmacist or home health nurse involvement in their post ED visit care, many due to loyalty to their community pharmacy. Multiple barriers must be addressed to create a successful inter-professional transition of care model.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State Wexner Medical Center, Columbus, OH, United States of America.
| | - Brianne L Porter
- Division of Pharmacy Practice and Science, The Ohio State University, College of Pharmacy, United States of America
| | - Nicholas W Newman
- The Ohio State University, College of Pharmacy, United States of America
| | - Kimberly Payne
- Home Care by BlackStone, Columbus, OH, United States of America.
| | - Cara Hoyt
- Uptown Pharmacy, Westerville, OH, United States of America
| | - Jennifer L Rodis
- Division of Pharmacy Practice and Science, The Ohio State University, College of Pharmacy, United States of America.
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Southerland LT, Vargas AJ, Nagaraj L, Gure TR, Caterino JM. An Emergency Department Observation Unit Is a Feasible Setting for Multidisciplinary Geriatric Assessments in Compliance With the Geriatric Emergency Department Guidelines. Acad Emerg Med 2018; 25:76-82. [PMID: 28975679 DOI: 10.1111/acem.13328] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/22/2017] [Accepted: 09/24/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Geriatric Emergency Department (ED) Guidelines recommend providing multidisciplinary geriatric assessment in the ED, but these assessments can be difficult to coordinate and may prolong length of stay. Patients who need longer than a typical ED stay can be placed in an ED observation unit (Obs Unit). We investigated the effects of offering multidisciplinary assessments for ED patients in an Obs Unit. METHODS Evaluation by a geriatric hospital consultation team, physical therapist, case manager, and/or pharmacist was made available to all Obs Unit patients. Use of any or all of these ancillary consult services could be requested by the Obs Unit physician. A retrospective chart review of random older adult Obs Unit patients was done to assess rates of consult use and interventions by these consulting teams. All patients ≥ 65 years old in our institutional review board-approved, monthly Obs Unit quality database from October 2015 through March 2017 were included. RESULTS Our quality database included 221 older patients over 18 months. The mean (±SD) age was 73.3 (±6.8) years (range = 65-96 years) and 55.2% were women. The mean (±SD) observation length of stay was 14.7 (±6.5) hours. The majority (74.3%) were discharged from the Obs Unit and 72-hour ED recidivism was 3.6%. Overall, at least one of the multidisciplinary consultant services were requested in 40.3% of patients (n = 89). Additional interventions or services were recommended in 80.0% of patients evaluated by physical therapy (32 of 40 patients), 100% of those evaluated by a pharmacist (five of five patients), 38% of those evaluated by case management (27 of 71 patients), and 100% of those evaluated by a geriatrician (eight of eight patients). Only 5.4% (n = 12) of patients were placed in observation specifically for multidisciplinary assessment; these patients had a mean (±SD) length of stay of 12.2 (±5) hours and an admission rate of 41.7%. CONCLUSIONS Incorporating elements of multidisciplinary geriatric assessment for older patients is feasible within an observation time frame and resulted in targeted interventions. An Obs Unit is a reasonable setting to offer services in compliance with the Geriatric ED Guidelines.
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Affiliation(s)
| | | | - Lalitha Nagaraj
- Department of Emergency Medicine The Ohio State University Columbus OH
| | - Tanya R. Gure
- Department of Internal Medicine Division of General Internal Medicine and Geriatrics The Ohio State University Columbus OH
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Caterino JM, Leininger R, Kline DM, Southerland LT, Khaliqdina S, Baugh CW, Pallin DJ, Stevenson KB. Accuracy of Current Diagnostic Criteria for Acute Bacterial Infection in Older Adults in the Emergency Department. J Am Geriatr Soc 2017; 65:1802-1809. [PMID: 28440855 DOI: 10.1111/jgs.14912] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To compare the accuracy of the Loeb criteria, emergency department (ED) physicians' diagnoses, and Centers for Disease Control and Prevention (CDC) guidelines for acute bacterial infection in older adults with a criterion standard expert review. DESIGN Prospective, observational study. SETTING Urban, tertiary-care ED. PARTICIPANTS Individuals aged 65 and older in the ED, excluding those who were incarcerated, underwent a trauma, did not speak English, or were unable to consent. MEASUREMENTS Two physician experts identified bacterial infections using clinical judgement, participant surveys, and medical records; a third adjudicated in cases of disagreement. Agreement and test characteristics were measured for ED physician diagnosis, Loeb criteria, and CDC surveillance guidelines. RESULTS Criterion-standard review identified bacterial infection in 77 of 424 participants (18%) (18 (4.2%) lower respiratory, 19 (4.5%) urinary tract (UTI), 22 (5.2%) gastrointestinal, 15 (3.5%) skin and soft tissue). ED physicians diagnosed infection in 71 (17%), but there were 33 with under- and 27 with overdiagnosis. Physician agreement with the criterion standard was moderate for infection overall and each infection type (κ = 0.48-0.59), but sensitivity was low (<67%), and the negative likelihood ratio (LR(-)) was greater than 0.30 for all infections. The Loeb criteria had poor sensitivity, agreement, and LR(-) for lower respiratory (50%, κ = 0.55; 0.51) and urinary tract infection (26%, κ = 0.34; 0.74), but 87% sensitivity (κ = 0.78; LR(-) 0.14) for skin and soft tissue infections. CDC guidelines had moderate agreement but poor sensitivity and LR(-). CONCLUSION Emergency physicians often under- and overdiagnose infections in older adults. The Loeb criteria are useful only for diagnosing skin and soft tissue infections. CDC guidelines are inadequate in the ED. New criteria are needed to aid ED physicians in accurately diagnosing infection in older adults.
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Affiliation(s)
- Jeffrey M Caterino
- Department of Emergency Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Robert Leininger
- Division of Infectious Diseases, Wexner Medical Center, The Ohio State University, Columbus, OH, The Ohio State University, Columbus, Ohio
| | - David M Kline
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio
| | - Lauren T Southerland
- Department of Emergency Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Salman Khaliqdina
- Department of Emergency Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kurt B Stevenson
- Division of Infectious Diseases, Wexner Medical Center, The Ohio State University, Columbus, OH, The Ohio State University, Columbus, Ohio.,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
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Southerland LT, Gure TR, Ruter DI, Li MM, Evans DC. Early geriatric consultation increases adherence to TQIP Geriatric Trauma Management Guidelines. J Surg Res 2017; 216:56-64. [PMID: 28807214 DOI: 10.1016/j.jss.2017.03.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/31/2017] [Accepted: 03/23/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The American College of Surgeons' Trauma Quality Improvement Program (TQIP) Geriatric Trauma Management Guidelines recommend geriatric consultation for injured older adults. However it is not known how or whether geriatric consultation improves compliance to these quality measures. METHODS This study is a retrospective chart review of our institutional trauma databank. Adherence to quality measures was compared before and after implementation of specific triggers for geriatric consultation. Secondary analyses evaluated adherence by service: trauma service (Trauma) or a trauma service with early geriatric consultation (GeriTrauma). RESULTS The average age of the 245 patients was 76.7 years, 47% were women, and mean Injury Severity Score was 9.5 (SD ±8.1). Implementation of the GeriTrauma collaborative increased geriatric consultation rates from 2% to 48% but had minimal effect on overall adherence to TQIP quality measures. A secondary analysis comparing those in the post implementation group who received geriatric consultation (n = 94) to those who did not (n = 103) demonstrated higher rates of delirium diagnosis (36.2% vs 14.6%, P < 0.01) and better documentation of initial living situation, code status, and medication list in the GeriTrauma group. Physical therapy was consulted more frequently for GeriTrauma patients (95.7% vs 68.0%, P < 0.01) Documented goals of care discussions were rare and difficult to abstract. A subgroup analysis of only patients with fall-related injuries demonstrated similar outcomes. CONCLUSIONS Early geriatric consultation increases adherence to TQIP guidelines. Further research into the long term significance and validity of these geriatric trauma quality indicators is needed.
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Affiliation(s)
| | - Tanya R Gure
- Department of Internal Medicine, Division of General Internal Medicine and Geriatrics, The Ohio State University, Columbus, OH
| | - Daniel I Ruter
- The Ohio State University College of Medicine, Columbus, OH
| | - Michael M Li
- The Ohio State University College of Medicine, Columbus, OH
| | - David C Evans
- Department of Surgery, The Ohio State University, Columbus, OH
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Southerland LT, Slattery L, Rosenthal JA, Kegelmeyer D, Kloos A. Are triage questions sufficient to assign fall risk precautions in the ED? Am J Emerg Med 2016; 35:329-332. [PMID: 27823938 DOI: 10.1016/j.ajem.2016.10.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 10/13/2016] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES The American College of Emergency Physicians Geriatric Emergency Department (ED) Guidelines and the Center for Disease Control recommend that older adults be assessed for risk of falls. The standard ED assessment is a verbal query of fall risk factors, which may be inadequate. We hypothesized that the addition of a functional balance test endorsed by the Center for Disease Control Stop Elderly Accidents, Deaths, and Injuries Falls Prevention Guidelines, the 4-Stage Balance Test (4SBT), would improve the detection of patients at risk for falls. METHODS Prospective pilot study of a convenience sample of ambulatory adults 65 years and older in the ED. All participants received the standard nursing triage fall risk assessment. After patients were stabilized in their ED room, the 4SBT was administered. RESULTS The 58 participants had an average age of 74.1 years (range, 65-94), 40.0% were women, and 98% were community dwelling. Five (8.6%) presented to the ED for a fall-related chief complaint. The nursing triage screen identified 39.7% (n=23) as at risk for falls, whereas the 4SBT identified 43% (n=25). Combining triage questions with the 4SBT identified 60.3% (n=35) as at high risk for falls, as compared with 39.7% (n=23) with triage questions alone (P<.01). Ten (17%) of the patients at high risk by 4SBT and missed by triage questions were inpatients unaware that they were at risk for falls (new diagnoses). CONCLUSIONS Incorporating a quick functional test of balance into the ED assessment for fall risk is feasible and significantly increases the detection of older adults at risk for falls.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Lauren Slattery
- Ohio State University School of Health and Rehabilitation Sciences, Columbus, OH
| | - Joseph A Rosenthal
- Department of Physical Medicine & Rehabilitation, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Deborah Kegelmeyer
- Department of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Anne Kloos
- Department of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus, OH
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Ruter D, Southerland LT, Gure TR, Li MM, Evans DC. Geriatric Consultation for Older Trauma Patients Improves Adherence to Geriatric Trauma Management Guidelines. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Southerland LT, Stephens JA, Robinson S, Falk J, Phieffer L, Rosenthal JA, Caterino JM. Head Trauma from Falling Increases Subsequent Emergency Department Visits More Than Other Fall-Related Injuries in Older Adults. J Am Geriatr Soc 2016; 64:870-4. [PMID: 27100582 DOI: 10.1111/jgs.14041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To determine whether fall-related injuries affect return to the ED after the initial visit. DESIGN Retrospective chart review. SETTING Academic Level 1 trauma center ED. PARTICIPANTS Individuals aged 65 and older evaluated for a fall from standing height or less and discharged (N = 263, average age 77, 70% female). MEASUREMENTS After institutional review board approval, electronic medical record data were queried. Univariate and multivariable logistic regression models were used to determine factors associated with risk of returning to the ED within 90 days. RESULTS Injuries included fractures (45%, n = 117); head trauma (22%, n = 58); abrasions, lacerations, or contusions (34%, n = 88); and none (22%, n = 57). Emergency care was frequently required, with 13 (5%, 95% confidence interval (CI) = 2.3-7.6%) returning within 72 hours, 35 (13%, 95% CI = 9.2-17%] within 30 days, and 57 (22%, 95% CI = 17-27%) within 90 days. Univariately, the odds of returning to the ED within 90 days was more than two times as high for those with head trauma as for those without (odds ratio = 2.66). This remained significant in the multivariable model, which controlled for Charlson Comorbidity Index, fractures, soft tissue injuries, and ED observation unit use. CONCLUSION More than one-third of older adults with minor head trauma from a fall will need to return to the ED in the following 90 days. These individuals should receive close attention from primary care providers. The link between minor head trauma and ED recidivism is a new finding.
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Affiliation(s)
| | - Julie A Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio
| | - Shari Robinson
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio
| | - James Falk
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio
| | - Laura Phieffer
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio
| | - Joseph A Rosenthal
- Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, Ohio
| | - Jeffrey M Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio
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