Registration Attendants Show Poor Readiness to Handle Advanced Care Planning Discussions.

Background: Emergency departments (ED) and other medical points of care are required to provide patients with advance directive (AD) information. Although many hospitals provide AD information in EDs, the comfort and preparation of the ED staff with this responsibility is unclear. Objective: To determine the attitudes, comfort levels, and prior training of ED staff with AD. Methods: The ED social workers, nurses, registration attendants, residents, and attending physicians at two academic hospitals completed a survey about their attitudes around, preparedness for, and experiences with advance care planning (ACP) discussions in the ED. Results: We received responses from 220 ED staff. Preparedness to discuss ACP with patients varied by profession. Eighty percent of social workers (n = 4/5) and 52% (n = 16/31) of attending physicians reported preparedness to handle ACP discussions. Registration attendants were the least prepared, and only 4% (n = 1/24) reported preparedness to discuss ACP. Attempts at ACP discussions with patients also differed by profession, with attending physicians being the most likely (77%, n = 24/31), whereas registration attendants were the least likely (8%, n = 2/24). Fifty-nine percent of surveyed staff (n = 130/220) believed that ACP was a component of emergency care, although only 13% (n = 29/220) had received training. Conclusion: The ED staff are in favor of ACP in the ED. Preparedness for, and attempts of ACP discussions with patients in the ED vary by profession. Attending physicians and social workers tend to be the most prepared, and they report the most frequent attempts at discussions with patients. Despite the fact that registration attendants are frequently tasked with asking about patient ADs, they show little confidence in asking about and discussing such matters. Our research indicates that registration attendants feel unprepared to guide discussions of ADs and should not do so without additional training.

Social worker assessment of bad news delivery by emergency medicine residents: a novel direct-observation milestone assessment.

The skill of delivering bad news is difficult to teach and evaluate. Residents may practice in simulated settings; however, this may not translate to confidence or competence during real experiences. We investigated the acceptability and feasibility of social workers as evaluators of residents' delivery of bad news during patient encounters, and assessed the attitudes of both groups regarding this process. From August 2013 to June 2014, emergency medicine residents completed self-assessments after delivering bad news. Social workers completed evaluations after observing these conversations. The Assessment tools were designed by modifying the global Breaking Bad News Assessment Scale. Residents and social workers completed post-study surveys. 37 evaluations were received, 20 completed by social workers and 17 resident self-evaluations. Social workers reported discussing plans with residents prior to conversations 90 % of the time (18/20, 95 % CI 64.5, 97.8). Social workers who had previously observed the resident delivering bad news reported that the resident was more skilled on subsequent encounters 90 % of the time (95 % CI 42.2, 99). Both social workers and residents felt that prior training or experience was important. First-year residents valued advice from social workers less than advice from attending physicians, whereas more experienced residents perceived advice from social workers to be equivalent with that of attending physicians (40 versus 2.9 %, p = 0.002). Social worker assessment of residents' abilities to deliver bad news is feasible and acceptable to both groups. This formalized self-assessment and evaluation process highlights the importance of social workers' involvement in delivery of bad news, and the teaching of this skill. This method may also be used as direct-observation for resident milestone assessment.

Predictors of Prolonged Length of Stay and Adverse Events among Older Adults with Behavioral Health-Related Emergency Department Visits: A Systematic Medical Record Review.

BACKGROUND: Behavioral health (BH)-related visits to the emergency department (ED) by older adults are increasing. This population has unique challenges to providing quality, timely care. OBJECTIVE: To characterize older adults with BH-related ED visits and determine risk factors associated with prolonged length of stay (LOS) and adverse events (AEs). METHODS: We performed a retrospective electronic health record review of all patients ≥65 years who presented to our ED from September 2011 to August 2012 for BH-related complaints. Sociodemographic, clinical, and utilization data were tested for association with LOS and AE. RESULTS: The 213 elder BH patients represented 4% of the 5267 total elder visits during the study period. Median age was 75 (interquartile range [IQR] 70-82); largely white (84.5%), female (58.7%), and non-Hispanic (69.5%). There was a median of two comorbidities (IQR 1-3), and 46.9% were cognitively impaired. Most (71.5%) were being evaluated on an involuntary basis. Median LOS was 16.2 h (IQR 9.7-29.7). Increased LOS was associated with involuntary status (12.4 h, 95% confidence interval [95% CI] 6.4-18.4); use of restraints (11.9 h, 95% CI 5.7-18.2); and failed discharge (28.8 h, 95% CI 21.2-36.6). For every 10 additional hours in the ED, the risk for an AEs (p = .002) or potential AEs (p = .01) increased 20%. CONCLUSION: Elderly ED patients with BH complaints had high rates of cognitive impairment and multiple comorbidities. LOS was prolonged, and there were multiple contributing factors including involuntary status, chemical or physical restraint, and failed discharge. Patients with longer LOS were at increased risk of an AE or potentially AEs.

Advance directives for older adults in the emergency department: a systematic review.

BACKGROUND: It has been more than two decades since the passage of the Patient Self-Determination Act (PSDA) of 1991, an act that requires many medical points of care, including emergency departments (EDs), to provide information to patients about advance directives (ADs). OBJECTIVE: The study objective was to determine the prevalence of ADs among ED patients with a focus on older adults and factors associated with rates of completion. METHODS: We searched PubMed, Embase, PsycINFO, CINAHL, Web of Science, Medline, and the Cochrane Library. Articles were selected according to the following criteria: (1) population: adult ED patients; (2) outcome measures: quantitative prevalence data pertaining to ADs and factors associated with completion of an AD; (3) location: EDs in the United States; and (4) date: published 1991 or later. RESULTS: Of the 258 references retrieved as a result of our search, six studies met inclusion criteria. Rates of patient-reported AD completion ranged from 21% to 53%, while ADs were available to ED personnel for 1% to 44% of patients. Patients aged ≥65 years had ADs 21% to 46% of the time. Sociodemographics (e.g., older age, specific religion, white or African American race, being widowed, or having children) and health status related variables (e.g., poor health, institutionalization, and having a primary care provider) were associated with greater likelihood of having an AD. CONCLUSIONS: Published rates of AD completion vary widely among patients presenting to U.S. EDs. Patient sociodemographic and health status factors are associated with increased rates of AD completion, though rates are low for all populations.

When should you test for and treat hypoglycemia in prehospital seizure patients?

OBJECTIVES: Seizure is a frequent reason for activating the Emergency Medical System (EMS). Little is known about the frequency of seizure caused by hypoglycemia, yet many EMS protocols require glucose testing prior to treatment. We hypothesized that hypoglycemia is rare among EMS seizure patients and glucose testing results in delayed administration of benzodiazepines. METHODS: This was a retrospective study of a national ambulance service database encompassing 140 ALS capable EMS systems spanning 40 states and Washington DC. All prehospital calls from August 1, 2010 through December 31, 2012 with a primary or secondary impression of seizure that resulted in patient treatment or transport were included. Median regression with robust and cluster (EMS agency) adjusted standard errors was used to determine if time to benzodiazepine administration was significantly related to blood glucose testing. RESULTS: Of 2,052,534 total calls, 76,584 (3.7%) were for seizure with 53,505 (69.9%) of these having a glucose measurement recorded. Hypoglycemia (blood glucose <60 mg/dL) was present in 638 (1.2%; CI: 1.1, 1.3) patients and 478 (0.9%; CI: 0.8, 1.0) were treated with a glucose product. A benzodiazepine was administered to 73 (11.4%; CI: 9.0, 13.9) of the 638 hypoglycemic patients. Treatment of seizure patients with a benzodiazepine occurred in 6,389 (8.3%; CI: 8.1, 8.5) cases and treatment with a glucose product occurred in 975 (1.3%; CI: 1.2, 1.4) cases. Multivariable median regression showed that obtaining a blood glucose measurement prior to benzodiazepine administration compared to no glucose measurement or glucose measurement after benzodiazepine administration was independently associated with a 2.1 minute (CI: 1.5, 2.8) and 5.9 minute (CI: 5.3, 6.6) delay to benzodiazepine administration by EMS, respectively. CONCLUSIONS: Rates of hypoglycemia were very low in patients treated by EMS for seizure. Glucose testing prior to benzodiazepine administration significantly increased the median time to benzodiazepine administration. Given the importance of rapid treatment of seizure in actively seizing patients, measurement of blood glucose prior to treating a seizure with a benzodiazepine is not supported by our study. EMS seizure protocols should be revisited.

Syndromic surveillance for influenza in the emergency department-A systematic review.

The science of surveillance is rapidly evolving due to changes in public health information and preparedness as national security issues, new information technologies and health reform. As the Emergency Department has become a much more utilized venue for acute care, it has also become a more attractive data source for disease surveillance. In recent years, influenza surveillance from the Emergency Department has increased in scope and breadth and has resulted in innovative and increasingly accepted methods of surveillance for influenza and influenza-like-illness (ILI). We undertook a systematic review of published Emergency Department-based influenza and ILI syndromic surveillance systems. A PubMed search using the keywords "syndromic", "surveillance", "influenza" and "emergency" was performed. Manuscripts were included in the analysis if they described (1) data from an Emergency Department (2) surveillance of influenza or ILI and (3) syndromic or clinical data. Meeting abstracts were excluded. The references of included manuscripts were examined for additional studies. A total of 38 manuscripts met the inclusion criteria, describing 24 discrete syndromic surveillance systems. Emergency Department-based influenza syndromic surveillance has been described worldwide. A wide variety of clinical data was used for surveillance, including chief complaint/presentation, preliminary or discharge diagnosis, free text analysis of the entire medical record, Google flu trends, calls to teletriage and help lines, ambulance dispatch calls, case reports of H1N1 in the media, markers of ED crowding, admission and Left Without Being Seen rates. Syndromes used to capture influenza rates were nearly always related to ILI (i.e. fever +/- a respiratory or constitutional complaint), however, other syndromes used for surveillance included fever alone, "respiratory complaint" and seizure. Two very large surveillance networks, the North American DiSTRIBuTE network and the European Triple S system have collected large-scale Emergency Department-based influenza and ILI syndromic surveillance data. Syndromic surveillance for influenza and ILI from the Emergency Department is becoming more prevalent as a measure of yearly influenza outbreaks.