Weakness and fatigue in older ED patients in the United States.

BACKGROUND: The objectives of this study are to estimate the prevalence of weakness and fatigue visits in older emergency department (ED) patients, to compare demographics and resource use in these patients with those without these complaints, and to determine their ED diagnoses and disposition. METHODS: We performed a cross-sectional cohort analysis of ED visits in patients aged older than 65 years from the 2003 to 2007 National Hospital Ambulatory Medical Care Surveys. Weakness and fatigue visits had a reason for visit code of generalized weakness (1020.0) or tiredness and exhaustion (1015.0); the comparison cohort lacked these codes. Descriptive data are presented as totals, means, and proportions with 95% confidence intervals (CIs). Comparisons between cohorts used χ(2) for proportions and the adjusted Wald test for means. RESULTS: There were an estimated 575 million ED visits, those aged 65 years and older made 14.7% (95% CI, 14.2-15.3) of visits. Overall, 6.0% (95% CI, 5.6-6.4) of these visits had weakness and fatigue; this was the fifth most common primary reason for visit. Weakness and fatigue visits increased with age. Weakness and fatigue visits had longer ED lengths of stay (300 vs 249 minutes, P < .001), more diagnostic tests (7.7 vs 5.0, P < .001), procedures (5.7 vs 4.7, P < .001), and hospital admissions (55% vs 35%, P < .001). The most common primary diagnoses for the weakness and fatigue cohort were "other malaise and fatigue," pneumonia, and urinary tract infection. CONCLUSION: Weakness and fatigue are common in older ED patients. These patients undergo more tests and procedures, and most are admitted.

A 12 week, open label, phase I/IIa study using apatone for the treatment of prostate cancer patients who have failed standard therapy.

PURPOSE: To evaluate the safety and efficacy of oral Apatone (Vitamin C and Vitamin K3) administration in the treatment of prostate cancer in patients who failed standard therapy. MATERIALS AND METHODS: Seventeen patients with 2 successive rises in PSA after failure of standard local therapy were treated with (5,000 mg of VC and 50 mg of VK3 each day) for a period of 12 weeks. Prostate Specific Antigen (PSA) levels, PSA velocity (PSAV) and PSA doubling times (PSADT) were calculated before and during treatment at 6 week intervals. Following the initial 12 week trial, 15 of 17 patients opted to continue treatment for an additional period ranging from 6 to 24 months. PSA values were followed for these patients. RESULTS: At the conclusion of the 12 week treatment period, PSAV decreased and PSADT increased in 13 of 17 patients (p < or = 0.05). There were no dose-limiting adverse effects. Of the 15 patients who continued on Apatone after 12 weeks, only 1 death occurred after 14 months of treatment. CONCLUSION: Apatone showed promise in delaying biochemical progression in this group of end stage prostate cancer patients.

Health promotion and disease prevention in the emergency department.

This article provides an overview of health promotion and disease and injury prevention concepts. It provides an emergency medicine perspective and reviews approaches that can be used in the emergency department. It discusses examples of innovative emergency medicine-based preventive activities including prevention in the prehospital setting. This article ends with a discussion of the importance of a system approach to prevention and suggests a role for a preventionist as a new member of the emergency medicine team.

Etiology and clinical course of abdominal pain in senior patients: a prospective, multicenter study.

BACKGROUND: The authors describe the epidemiology and clinical course of older persons examined in emergency departments (EDs) for abdominal pain. METHODS: This was a prospective, multicenter, observational study of older persons (>or=60 years) examined in participating EDs for nontraumatic abdominal pain. Medical records were reviewed for demographics, ED diagnoses, findings of radiographic imaging, disposition, operative procedures, length of hospitalization, and final diagnoses. Patients were interviewed at 2 weeks to determine clinical course, final diagnoses, and mortality status. The authors compared ED diagnoses with final diagnoses, reporting the percentage change in aggregate and for the 12 most common diagnoses. RESULTS: Of 360 patients (mean age, 73.2+/- 8.8 years; 66% women; 51% white) who met selection criteria, 209 (58%) were admitted to the hospital and 63 (18%) required surgery or an invasive procedure. For patients with complete follow-up information (n=337), 37 (11%) had repeated ED visits and 23 (7%) were readmitted to the hospital. The case-fatality rate was 5%. Leading causes of abdominal pain were nonspecific (14.8%), urinary tract infection (8.6%), bowel obstruction (8%), gastroenteritis (6.8%), and diverticulitis (6.5%). The ED and final diagnoses matched 82% of the time. Older patients had higher mortality rates (odds ratio, 4.4; 95% confidence interval, 1.4--14) and lower diagnostic concordance rates (76% vs 87%; p=.01). Study limitations include inability to enroll all eligible persons and possible inaccuracies in participant-reported follow-up interviews. CONCLUSIONS: Abdominal pain in older patients should be investigated thoroughly as, in this study, nearly 60% of patients were hospitalized, 20% underwent operative or invasive procedures, 10% had return ED visits, and 5% died within a 2-week follow-up period.

A research agenda for geriatric emergency medicine.

OBJECTIVES: The Research Agenda Setting Process (RASP), part of the American Geriatric Society's (AGS's) project "Increasing Geriatric Expertise in Surgical and Related Medical Specialties," was designed to define a research agenda for the geriatrics aspects of participating specialties. This paper presents a summary of the research agenda for emergency medicine. METHODS: The RASP was developed by the AGS in conjunction with experts from the participating specialty organizations. A "content expert" (CE) for each specialty developed a Medline search strategy in conjunction with RAND Health librarians. The CE reviewed the search to identify papers that were germane to research in the emergency care of older patients. The CE and a senior writing group member drafted a paper that synthesized the current literature and suggested areas for further research. A panel consisting of AGS members and emergency physicians with geriatrics expertise reviewed this paper. The research agenda was further refined at a two-day retreat. Two senior geriatricians reviewed the resulting paper. RESULTS: The Medline search for emergency medicine resulted in a list of 3,348 articles; 299 articles were pertinent and reviewed. The search for trauma resulted in a list of 1,838 articles; 133 were reviewed. Research agenda items were defined for multiple topics within geriatric emergency medicine and trauma. CONCLUSION: A research agenda for geriatric emergency medicine has been developed, using a combination of review of current literature and expert opinion.

Assessment of emergency medicine residents' computer knowledge and computer skills: time for an upgrade?

OBJECTIVE: To describe emergency medicine residents' (EMRs') personal computer (PC) use and educational needs and to compare their perceived and actual PC skills. METHODS: This was a prospective, cross-sectional study. Subjects were all EMRs at seven midwestern Accreditation Council for Graduate Medical Education (ACGME) residency programs. The EMRs completed a questionnaire about their PC use and ability to perform 23 tasks derived from two national retail-training programs. The tasks covered word processing, slide making, and Internet use. The EMRs then took a three-part test performing the skills in the questionnaire. Two independent raters scored the tests. Frequencies with 95% confidence intervals (95% CIs) were calculated for categorical data. Positive and negative predictive values were used to report information comparing residents' performance with their self-assessment of skills. Cohen's kappa was used to test agreement between raters. RESULTS: One hundred twenty-four of 158 (79%) eligible EMRs participated. Since not all participants engaged in all parts of the study, the sample size varies between 121 and 124. One hundred one of 122 (83%; 95% CI = 75 to 89) owned a PC. The EMRs use home PCs a mean of 3.8 hours/week for physician duties and use residency PCs 1.9 hours/week (range 0-20). Ninety-six of 122 (79%; 95% CI = 70 to 86) EMRs reported no formal PC training during residency. Thirty-five percent (43/122; 95% CI = 27 to 44) passed the word-processing test and 50% (62/123; 95% CI = 41 to 60) passed the slide-making test. Reasons for failure were because of errors and not having a presentable product. Thirty-eight of 122 (31%; 95% CI = 23 to 40) failed the literature search, including 33 who said they could perform it. One hundred fifteen of 123 (94%; 95% CI = 88 to 98) EMRs were able to find an Internet address, including ten who stated they could not. Twenty-one percent of the residents who attempted any test (26/124; 95% CI = 14 to 29) passed all three tests. There was no association between year of training and success on the tests (p = 0.374). Thirty-seven of 115 (32%; 95% CI = 24 to 42) EMRs said they had insufficient PC training to meet their physician needs. CONCLUSIONS: Emergency medicine residents have much access to computer technology and possess some computer skills; however, many are unable to produce a usable product or conduct a literature search. Emergency medicine residents have not had sufficient computer training prior to residency. The computer skills of EMRs should be assessed through skills testing rather than self-assessment, and computer training during residency should be improved.

US emergency department visits for hip fracture, 1992-2000.

BACKGROUND: Hip fracture is a significant injury for older persons. Little has been reported about emergency department (ED) care of these patients. OBJECTIVE: To characterize the management of older patients treated in the ED for hip fracture with specific attention to the use of analgesia. METHODS: This study analysed data from the National Hospital Ambulatory Medical Care Survey ( approximately 400 hospitals report each year) for the years 1992-2000. We included records of patients who were at least 50 years old and had a diagnosis of hip fracture (International Classification of Disease, 9th revision, clinical modification 820-820.9) in any of the three fields allowed for recording diagnosis. RESULTS: There were 1,935,000 ED visits ( approximately 215,000 a year), predominantly among older white women. The rate in those over 80 years old was 25 times that of the youngest group. Fifty-six per cent of patients received analgesia (44% narcotics). There were no ethnic or racial distinctions in the use of analgesia. CONCLUSIONS: The ED visit presents a largely untapped opportunity for focused efforts in fall and hip fracture prevention, especially in countries with comprehensive geriatric services and well integrated healthcare delivery systems. Despite the high likelihood of pain, the administration of analgesics appears to be low and may be a worthy focus for practice improvement.

Temporal artery temperature measurements in healthy infants, children, and adolescents.

A noninvasive temporal artery thermometer that uses arterial heat balance technology has been compared to rectal and ear thermometry and is available in the marketplace. This study was undertaken to establish mean temperatures and temperatures 2 standard deviations above the mean for healthy infants, children, and adolescents. Temperatures were measured in healthy patients 0 to 18 years of age using a noninvasive temporal artery thermometer. Temperatures were measured in 2,346 patients. Mean temperatures and temperatures 2 standard deviations above the mean were: 37.1 degrees C (38.1 degrees C) for 383 infants 0 to 2 months; 36.9 degrees C (37.9 degrees C) for 860 children 3 to 47 months; 36.8 degrees C (37.8 degrees C) for 680 children 4 to 9 years; and 36.7 degrees C (37.8 degrees C) for 423 adolescents 10 to 18 years. There were no significant differences in temperatures in white compared to African-American children, children with or without perspiration on their forehead, or between measurements taken on the left compared to the right side of the forehead. This study provides information about temporal artery temperatures in healthy infants and children that can serve as a basis for interpreting temperature measurements in ill children when the same instrument is used.

Optimal older adult emergency care: introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine.

In the United States and around the world, effective, efficient, and reliable strategies to provide emergency care to aging adults is challenging crowded emergency departments (EDs) and strained healthcare systems. In response, geriatric emergency medicine clinicians, educators, and researchers collaborated with the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine to develop guidelines intended to improve ED geriatric care by enhancing expertise, educational, and quality improvement expectations, equipment, policies, and protocols. These Geriatric Emergency Department Guidelines represent the first formal society-led attempt to characterize the essential attributes of the geriatric ED and received formal approval from the boards of directors of each of the four societies in 2013 and 2014. This article is intended to introduce emergency medicine and geriatric healthcare providers to the guidelines while providing recommendations for continued refinement of these proposals through educational dissemination, formal effectiveness evaluations, cost-effectiveness studies, and eventually institutional credentialing.

Optimal older adult emergency care: introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine.

In the United States and around the world, effective, efficient, and reliable strategies to provide emergency care to aging adults is challenging crowded emergency departments (EDs) and a strained health care system. In response, geriatric emergency medicine (EM) clinicians, educators, and researchers collaborated with the American College of Emergency Physicians (ACEP), American Geriatrics Society (AGS), Emergency Nurses Association (ENA), and the Society for Academic Emergency Medicine (SAEM) to develop guidelines intended to improve ED geriatric care by enhancing expertise, educational, and quality improvement expectations; equipment; policies; and protocols. These "Geriatric Emergency Department Guidelines" represent the first formal society-led attempt to characterize the essential attribute of the geriatric ED and received formal approval from the boards of directors for each of the four societies in 2013 and 2014. This article is intended to introduce EM and geriatric health care providers to the guidelines, while providing proposals for educational dissemination, refinement via formal effectiveness evaluations and cost-effectiveness studies, and institutional credentialing.

High yield research opportunities in geriatric emergency medicine: prehospital care, delirium, adverse drug events, and falls.

Emergency services constitute crucial and frequently used safety nets for older persons, an emergency visit by a senior very often indicates high vulnerability for functional decline and death, and interventions via the emergency system have significant opportunities to change the clinical course of older patients who require its services. However, the evidence base for widespread employment of emergency system-based interventions is lacking. In this article, we review the evidence and offer crucial research questions to capitalize on the opportunity to optimize health trajectories of older persons seeking emergency care in four areas: prehospital care, delirium, adverse drug events, and falls.

Research priorities for high-quality geriatric emergency care: medication management, screening, and prevention and functional assessment.

BACKGROUND: Geriatric adults represent an increasing proportion of emergency department (ED) users and can be particularly vulnerable to acute illnesses. Health care providers have recently begun to focus on the development of quality indicators (QIs) to define a minimal standard of care. OBJECTIVES: The original objective of this project was to develop additional ED-specific QIs for older patients within the domains of medication management, screening and prevention, and functional assessment, but the quantity and quality of evidence were insufficient to justify unequivocal minimal standards of care for these three domains. Accordingly, the authors modified the project objectives to identify key research opportunities within these three domains that can be used to develop QIs in the future. METHODS: Each domain was assigned one or two content experts who created potential QIs based on a systematic review of the literature, supplemented by expert opinion. Candidate QIs were then reviewed by four groups: the Society for Academic Emergency Medicine (SAEM) Geriatric Task Force, the SAEM Geriatric Interest Group, and audiences at the 2008 SAEM Annual Meeting and the 2009 American Geriatrics Society Annual Meeting, using anonymous audience response system technology as well as verbal and written feedback. RESULTS: High-quality evidence based on patient-oriented outcomes was insufficient or nonexistent for all three domains. The participatory audiences did not reach a consensus on any of the proposed QIs. Key research questions for medication management (three), screening and prevention (two), and functional assessment (three) are presented based on proposed QIs that the majority of participants accepted. CONCLUSIONS: In assessing a minimal standard of care by which to systematically derive geriatric QIs for medication management, screening and prevention, and functional assessment, compelling clinical research evidence is lacking. Patient-oriented research questions that are essential to justify and characterize future QIs within these domains are described.

Technology-assisted education in graduate medical education: a review of the literature.

UNLABELLED: Studies on computer-aided instruction and web-based learning have left many questions unanswered about the most effective use of technology-assisted education in graduate medical education. OBJECTIVE: We conducted a review of the current medical literature to report the techniques, methods, frequency and effectiveness of technology-assisted education in graduate medical education. METHODS: A structured review of MEDLINE articles dealing with "Computer-Assisted Instruction," "Internet or World Wide Web," "Education" and "Medical" limited to articles published between 2002-2007 in the English language was performed. RESULTS: The two literature searches returned 679 articles; 184 met our inclusion and exclusion criteria. In 87 articles, effectiveness was measured primarily using self-reported results from a survey of subjects. Technology-assisted education was superior to traditional methods in 42 of the 64 direct comparison articles (66%, 95% CI 53-77%). Traditional teaching methods were superior to technology-assisted education in only 3/64 (5%, 95% CI 1-13%). The remaining 19 direct comparison articles showed no difference. A detailed review of the 64 comparative studies (technology-assisted education versus traditional teaching methods) also failed to identify a best method or best uses for technology-assisted education. CONCLUSIONS: Technology-assisted education is used in graduate medical education across a variety of content areas and participant types. Knowledge gain was the predominant outcome measured. The majority of studies that directly compared knowledge gains in technology-assisted education to traditional teaching methods found technology-assisted education equal or superior to traditional teaching methods, though no "best methods" or "best use" was found within those studies. Only three articles were specific to Emergency Medicine, suggesting further research in our specialty is warranted.

Short-term functional decline and service use in older emergency department patients with blunt injuries.

BACKGROUND: Injuries are a common reason for emergency department (ED) visits by older patients. Although injuries in older patients can be serious, 75% of these patients are discharged home after their ED visit. These patients may be at risk for short-term functional decline related to their injuries or treatment. OBJECTIVES: The objectives were to determine the incidence of functional decline in older ED patients with blunt injuries not requiring hospital admission for treatment, to describe their care needs, and to determine the predictors of short-term functional decline in these patients. METHODS: This institutional review board-approved, prospective, longitudinal study was conducted in two community teaching hospital EDs with a combined census of 97,000 adult visits. Eligible patients were > or = 65 years old, with blunt injuries <48 hours old, who could answer questions or had a proxy. We excluded those too ill to participate; skilled nursing home patients; those admitted for surgery, major trauma, or acute medical conditions; patients with poor baseline function; and previously enrolled patients. Interviewers collected baseline data and the used the Older Americans Resources and Services (OARS) questionnaire to assess function and service use. Potential predictors of functional decline were derived from prior studies of functional decline after an ED visit and clinical experience. Follow-up occurred at 1 and 4 weeks, when the OARS questions were repeated. A three-point drop in activities of the daily living (ADL) score defined functional decline. Data are presented as means and proportions with 95% confidence intervals (CIs). Logistic regression was used to model potential predictors with functional decline at 1 week as the dependent variable. RESULTS: A total of 1,186 patients were evaluated for eligibility, 814 were excluded, 129 refused, and 13 were missed, leaving 230 enrolled patients. The mean (+/-SD) age was 77 (+/-7.5) years, and 70% were female. In the first week, 92 of 230 patients (40%, 95% CI = 34% to 47%) had functional decline, 114 of 230 (49%, 95% CI = 43% to 56%) had new services initiated, and 76 of 230 had an unscheduled medical contact (33%, 95% CI = 27% to 39%). At 4 weeks, 77 of 219 had functional decline (35%, 95% CI = 29% to 42%), 141 of 219 had new services (65%, 95% CI = 58% to 71%), and 123 of 219 had an unscheduled medical contact (56%, 95% CI = 49% to 63%), including 15% with a repeated ED visit and 11% with a hospital admission. Family members provided the majority of new services at both time periods. Significant predictors of functional decline at 1 week were female sex (odds ratio [OR] = 2.2, 95% CI = 1.1 to 4.5), instrumental ADL dependence (IADL; OR = 2.5, 95% CI = 1.3 to 4.8), upper extremity fracture or dislocation (OR = 5.5, 95% CI = 2.5 to 11.8), lower extremity fracture or dislocation (OR = 4.6, 95% CI = 1.4 to 15.4), trunk injury (OR = 2.4, 95% CI = 1.1 to 5.3), and head injury (OR = 0.48, 95% CI = 0.23 to 1.0). CONCLUSIONS: Older patients have a significant risk of short-term functional decline and other adverse outcomes after ED visits for injuries not requiring hospitalization for treatment. The most significant predictors of functional decline are upper and lower extremity fractures.

Quality indicators for geriatric emergency care.

OBJECTIVES: Emergency departments (EDs), similar to other health care environments, are concerned with improving the quality of patient care. Older patients comprise a large, growing, and particularly vulnerable subset of ED users. The project objective was to develop ED-specific quality indicators for older patients to help practitioners identify quality gaps and focus quality improvement efforts. METHODS: The Society for Academic Emergency Medicine (SAEM) Geriatric Task Force, including members representing the American College of Emergency Physicians (ACEP), selected three conditions where there are quality gaps in the care of older patients: cognitive assessment, pain management, and transitional care in both directions between nursing homes and EDs. For each condition, a content expert created potential quality indicators based on a systematic review of the literature, supplemented with expert opinion when necessary. The original candidate quality indicators were modified in response to evaluation by four groups: the Task Force, the SAEM Geriatric Interest Group, and audiences at the 2007 SAEM Annual Meeting and the 2008 American Geriatrics Society Annual Meeting. RESULTS: The authors offer 6 quality indicators for cognitive assessment, 6 for pain management, and 11 for transitions between nursing homes and EDs. CONCLUSIONS: These quality indicators will help researchers and clinicians target quality improvement efforts. The next steps will be to test the feasibility of capturing the quality indicators in existing medical records and to measure the extent to which each quality indicator is successfully met in current emergency practice.