Prevalence and predictors of elder abuse among older adults attending emergency departments: a prospective cohort study.

INTRODUCTION: Elder abuse is associated with impaired physical and psychological health. It is, however, rarely identified in emergency departments (EDs). The objective was to determine the prevalence and the predictors of elder abuse among older adults visiting EDs. METHODS: This prospective cohort study was conducted in eight Canadian EDs between May and August 2021. Patients were eligible if they were ≥ 65 years old, oriented to time, and with a Canadian Triage and Acuity Scale score 3, 4 or 5. In a private setting, participants were questioned directly about abuse as part of a larger questionnaire exploring ten non-medical problems. We used multivariable logistic regression to identify predictors of elder abuse. RESULTS: A total of 1061 participants were recruited (mean age: 77.1 (SD 7.6) years, female sex: 55.7%, lived alone: 42.5%). Patients mostly attended EDs for pain (19.6%), neurologic (11.3%) or cardiovascular (8.4%) symptoms. The most frequent pre-existing comorbidities were hypertension (67.2%), mental health conditions (33.3%) and cardiac insufficiency (29.6%). Mobility issues outside (41.0%) or inside their home (30.7%) and loneliness (29.4%) were also frequent. Fifty-four (5.1%) participants reported elder abuse, of which 34.3% were aware of available community-based resources. Identified predictors of elder abuse were female sex (OR 2.8 [95%CI 1.4; 5.6]), financial difficulties (OR 3.6 [95%CI 1.8; 7.3]), food insecurity (OR 2.7 [95%CI 1.2; 5.6]), need for a caregiver (OR 2.7 [95%CI 1.5; 5.0]) and at least one pre-existing mental health condition (OR 2.6 [95%CI 1.4; 4.9]). CONCLUSION: When questioned directly, 5.1% of older adults attending EDs reported experiencing abuse. Female sex, functional impairment, social vulnerability, and mental health comorbidities are associated with elder abuse. Given its importance and relatively high prevalence, ED professionals should have a low threshold to ask directly about elder abuse.

RéSUMé: INTRODUCTION: La maltraitance des personnes âgées est associée à une détérioration de la santé physique et psychologique. Elle est cependant rarement identifiée dans les services d'urgence. L'objectif était de déterminer la prévalence et les prédicteurs de l'abus envers les aînés chez les personnes âgées qui consultent dans un service d'urgence. MéTHODES: Cette étude de cohorte prospective a été menée dans huit services d'urgence canadiens entre mai et août 2021. Les patients étaient éligibles s'ils étaient âgés de ≥ 65 ans, s'ils étaient orientés vers le temps et s'ils avaient un score de 3, 4 ou 5 sur l'échelle canadienne de triage et d'acuité. Dans un cadre privé, les participants ont été interrogés directement sur la maltraitance dans le cadre d'un questionnaire plus large explorant 10 problèmes non médicaux. Nous avons utilisé une régression logistique multivariable pour identifier les facteurs prédictifs de la maltraitance envers les personnes âgées. RéSULTATS: Au total, 1 061 participants ont été recrutés (âge moyen : 77,1 (SD 7,6) ans, sexe féminin : 55,7 %, vivant seul : 42,5 %). Les patients se sont surtout rendus aux urgences pour des douleurs (19,6 %), des symptômes neurologiques (11,3 %) ou cardiovasculaires (8,4 %). Les comorbidités préexistantes les plus fréquentes étaient l'hypertension (67,2 %), les problèmes de santé mentale (33,3 %) et l'insuffisance cardiaque (29,6 %). Les problèmes de mobilité à l'extérieur (41,0 %) ou à l'intérieur du domicile (30,7 %) et la solitude (29,4 %) sont également fréquents. Cinquante-quatre (5,1 %) participants ont signalé des cas de maltraitance des personnes âgées, dont 34,3 % connaissaient les ressources communautaires disponibles. Les facteurs prédictifs identifiés de maltraitance envers les personnes âgées étaient le sexe féminin (RC 2,8 [IC 95 % 1,4 ; 5,6]), les difficultés financières (RC 3,6 [IC 95 % 1,8 ; 7,3]), l'insécurité alimentaire (RC 2,7 [IC 95 % 1,2 ; 5,6]), besoin d'un aidant (RC 2,7 [IC 95 % 1,5 ; 5,0]) et au moins un problème de santé mentale préexistant (RC 2,6 [IC 95 % 1,4 ; 4,9]). CONCLUSION: Interrogées directement, 5,1 % des personnes âgées fréquentant les urgences ont déclaré avoir été victimes de maltraitance. Le sexe féminin, les déficits fonctionnels, la vulnérabilité sociale et les problématiques de santé mentale sont associés à la maltraitance des personnes âgées. Compte tenu de son importance et de sa prévalence relativement élevée, les professionnels des urgences ne devraient pas hésiter à poser directement des questions sur la maltraitance aux personnes âgées.

Simulation-based research in emergency medicine in Canada: Priorities and perspectives.

OBJECTIVE: Simulation plays an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High-quality, simulation-based research will ensure its effective use. This study sought to summarize simulation-based research activity and its facilitators and barriers, as well as establish priorities for simulation-based research in Canadian emergency medicine (EM). METHODS: Simulation-leads from Canadian departments or divisions of EM associated with a general FRCP-EM training program surveyed and documented active EM simulation-based research at their institutions and identified the perceived facilitators and barriers. Priorities for simulation-based research were generated by simulation-leads via a second survey; these were grouped into themes and finally endorsed by consensus during an in-person meeting of simulation leads. Priority themes were also reviewed by senior simulation educators. RESULTS: Twenty simulation-leads representing all 14 invited institutions participated in the study between February and May, 2018. Sixty-two active, simulation-based research projects were identified (median per institution = 4.5, IQR 4), as well as six common facilitators and five barriers. Forty-nine priorities for simulation-based research were reported and summarized into eight themes: simulation in competency-based medical education, simulation for inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology. CONCLUSION: This study summarized simulation-based research activity in EM in Canada, identified its perceived facilitators and barriers, and built national consensus on priority research themes. This represents the first step in the development of a simulation-based research agenda specific to Canadian EM.

Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability.

BACKGROUND: Retrospective analyses suggest that pulmonary embolism is ruled out by a d-dimer level of less than 1000 ng per milliliter in patients with a low clinical pretest probability (C-PTP) and by a d-dimer level of less than 500 ng per milliliter in patients with a moderate C-PTP. METHODS: We performed a prospective study in which pulmonary embolism was considered to be ruled out without further testing in outpatients with a low C-PTP and a d-dimer level of less than 1000 ng per milliliter or with a moderate C-PTP and a d-dimer level of less than 500 ng per milliliter. All other patients underwent chest imaging (usually computed tomographic pulmonary angiography). If pulmonary embolism was not diagnosed, patients did not receive anticoagulant therapy. All patients were followed for 3 months to detect venous thromboembolism. RESULTS: A total of 2017 patients were enrolled and evaluated, of whom 7.4% had pulmonary embolism on initial diagnostic testing. Of the 1325 patients who had a low C-PTP (1285 patients) or moderate C-PTP (40 patients) and a negative d-dimer test (i.e., <1000 or <500 ng per milliliter, respectively), none had venous thromboembolism during follow-up (95% confidence interval [CI], 0.00 to 0.29%). These included 315 patients who had a low C-PTP and a d-dimer level of 500 to 999 ng per milliliter (95% CI, 0.00 to 1.20%). Of all 1863 patients who did not receive a diagnosis of pulmonary embolism initially and did not receive anticoagulant therapy, 1 patient (0.05%; 95% CI, 0.01 to 0.30) had venous thromboembolism. Our diagnostic strategy resulted in the use of chest imaging in 34.3% of patients, whereas a strategy in which pulmonary embolism is considered to be ruled out with a low C-PTP and a d-dimer level of less than 500 ng per milliliter would result in the use of chest imaging in 51.9% (difference, -17.6 percentage points; 95% CI, -19.2 to -15.9). CONCLUSIONS: A combination of a low C-PTP and a d-dimer level of less than 1000 ng per milliliter identified a group of patients at low risk for pulmonary embolism during follow-up. (Funded by the Canadian Institutes of Health Research and others; PEGeD ClinicalTrials.gov number, NCT02483442.).

Implementing advanced access to primary care in an academic family medicine network: Participatory action research.

OBJECTIVE: To support the implementation of the advanced access model in a network of family medicine academic settings, and to identify solutions to teaching advanced access to family medicine residents. DESIGN: Participatory action research study using descriptive methods. SETTING: A network of 11 academic family medicine settings, mostly located in the province of Quebec. PARTICIPANTS: Eighteen academic-setting directors and deputy directors and 125 clinical preceptors. METHODS: The study was carried out from August 2015 through January 2017. Settings were represented by a "community of practice" of academic-setting directors and deputy directors. Data were collected via questionnaires, online surveys, and 4, 60-minute focus groups. Data were analyzed using descriptive statistics or thematic analysis. Findings were validated with the community of practice. MAIN FINDINGS: Nearly all of the academic family medicine settings implemented advanced access for their clinical preceptors (90.9%). Four main solutions to teaching advanced access were identified: establishing an optimal panel of patients; ensuring continuity of care during absences and away rotations; optimizing team collaboration; and creating a positive experience of immersion in advanced access. CONCLUSION: An academic-setting community of practice contributed to sharing solutions that were instrumental in broadly implementing the advanced access model and that also paved the way for the integration of advanced access for future family physicians, further supporting timely access to primary care.