Evaluation of an Emergency Department-based Palliative Care Extender Program on Hospital and Patient Outcomes.

BACKGROUND: Boston Medical Center (BMC), a safety-net hospital, treated a substantial portion of the Boston cohort that was sick with COVID-19. Unfortunately, these patients experienced high rates of morbidity and mortality given the significant health disparities that many of BMC's patients face. Boston Medical Center launched a palliative care extender program to help address the needs of critically ill ED patients under crisis conditions. In this program evaluation our goal was to assess outcomes between those who received palliative care in the emergency department (ED) vs those who received palliative care as an inpatient or were admitted to an intensive care unit (ICU). METHODS: We used a matched retrospective cohort study design to assess the difference in outcomes between the two groups. RESULTS: A total of 82 patients received palliative care services in the ED, and 317 patients received palliative care services as an inpatient. After controlling for demographics, patients who received palliative care services in the ED were less likely to have a change in level of care (P<0.001) or be admitted to an ICU (P<0.001). Cases had an average length of stay of 5.2 days compared to controls who stayed 9.9 days (P<0.001). CONCLUSION: Within a busy ED environment, initiating palliative care discussions by ED staff can be challenging. This study demonstrates that consulting palliative care specialists early in the course of the patient's ED stay can benefit patients and families and improve resource utilization.

Social Determinants of Health Screening at an Urban Emergency Department Urgent Care During COVID-19.

INTRODUCTION: Social determinants of health (SDoH) impact patients' health outcomes, yet screening methods in emergency departments (ED) are not consistent or standardized. The SDoH-related health disparities may have widened during the coronavirus 2019 (COVID-19) pandemic, especially among patients who primarily receive their medical care in EDs. We sought to identify SDoH among ED urgent care patients during the COVID-19 pandemic at an urban safety-net hospital, assess the impact of the pandemic on their SDoH, study the feasibility of SDoH screening and resource referrals, and identify preferred methods of resource referrals and barriers to accessing resources. METHODS: Research assistants screened ED urgent care patients using a validated SDoH screener, inquiring about the impact of COVID-19 on their SDoH. A printed resource guide was provided. Two weeks later, a follow-up telephone survey assessed for barriers to resource connection and patients' preferred methods for resource referrals. This study was deemed exempt by our institutional review board. RESULTS: Of the 418 patients presented with a screener, 414 (99.0%) patients completed the screening. Of those screened, 296 (71.5%) reported at least one adverse SDoH, most commonly education (38.7%), food insecurity (35.3%), and employment (31.0%). Housing insecurity was reported by 21.0%. Over half of patients (57.0%) endorsed COVID-19 affecting their SDoH. During follow-up, 156 of 234 (67%) attempted calls were successful and 36/156 (23.1%) reported attempting to connect with a resource, with most attempts made for stable housing (11.0%) and food (7.7%). Reasons for not contacting the provided resources included lack of time (37.8%) and forgetting to do so (26.3%). Patients preferred resource guides to be printed (34.0%) and sent via text message to their mobile devices (25.6%). CONCLUSION: Many urgent care patients of this urban ED reported at least one adverse SDoH, the majority of which were exacerbated by the COVID-19 pandemic. This finding further emphasizes the need to allocate more resources to standardize and expand SDoH screening in EDs. Additionally, hospitals should increase availability of printed or electronic SDoH resource guides, resource navigators, and interpreters both during and after ED visits.

Evaluating a social risk screening and referral program in an urban safety-net hospital emergency department.

Objective: The emergency department (ED) is an opportune venue to screen for unmet social needs and connect patients with social services. This quality improvement study incorporates both qualitative and quantitative data to examine unmet social needs among ED patients and program implementation. Methods: From September 2020 to December 2021, an urban safety-net hospital adult ED implemented a social needs screening and referral program. Trained emergency staff screened eligible patients for 5 social needs (housing, food, transportation, utilities, employment), giving resource guides to patients who screened positive (THRIVE+). We collected screening data from the electronic health record, conducted semi-structured interviews with THRIVE+ patients and clinical staff, and directly observed discharge interactions. Results: Emergency staff screened 58.5% of eligible patients for social risk. Of the screened patients, 27.0% reported at least 1 unmet social need. Of those, 74.8% requested assistance. Screened patients reported housing insecurity (16.3%) as the most prevalent unmet social need followed by food insecurity (13.3%) and unemployment (8.7%). Among interviewed patients, 57.1% recalled being screened, but only 24.5% recalled receiving resource guides. Patients who received guides reported little success connecting with resources and supported universal guide dissemination. Staff expressed preference for warm handoff to social services. Of 13 observed discharge interactions, clinical staff only discussed guides with 2 patients, with no positive endorsement of the guides in any observed interactions. Conclusions: An ED social needs screening program can be moderately feasible and accepted. We identified housing as the most prevalent need. Significant gaps exist between screening and referral, with few patients receiving resources. Further training and workflow optimization are underway.

A High-yield Fall Risk and Adverse Events Screening Questions From the Stopping Elderly Accidents, Death, and Injuries (STEADI) Guideline for Older Emergency Department Fall Patients.

OBJECTIVES: The objectives were to examine whether responses to the Stopping Elderly Accidents, Death, and Injuries (STEADI) questions responses predicted adverse events after an older adult emergency department (ED) fall visits and to identify factors associated with such recurrent fall. METHODS: We conducted a prospective study at two urban, teaching hospitals. We included patients aged ≥ 65 years who presented to the ED for an accidental fall. Data were gathered for fall-relevant comorbidities, high-risk medications for falls, and the responses to 12 questions from the STEADI guideline recommendation. Our outcomes were the number of 6-month adverse events that were defined as mortality, ED revisit, subsequent hospitalization, recurrent falls, and a composite outcome. RESULTS: There were 548 (86.3%) patients who completed follow-up and 243 (44.3%) patients experienced an adverse event after a fall within 6 months. In multivariate analysis, seven questions from the STEADI guideline predicted various outcomes. The question "Had previous fall" predicted recurrent falls (odds ratio [OR] = 2.45, 95% confidence interval [CI] = 1.52 to 3.97), the question "Feels unsteady when walking sometimes" (OR = 2.34, 95% CI = 1.44 to 3.81), and "Lost some feeling in their feet" predicted recurrent falls. In addition to recurrent falls risk, the supplemental questions "Use or have been advised to use a cane or walker," "Take medication that sometimes makes them feel light-headed or more tired than usual," "Take medication to help sleep or improve mood," and "Have to rush to a toilet" predicted other outcomes. CONCLUSION: A STEADI score of ≥4 did not predict adverse outcomes although seven individual questions from the STEADI guidelines were associated with increased adverse outcomes within 6 months. These may be organized into three categories (previous falls, physical activity, and high-risk medications) and may assist emergency physicians to evaluate and refer high-risk fall patients for a comprehensive falls evaluation.

Older adult falls prevention behaviors 60 days post-discharge from an urban emergency department after treatment for a fall.

BACKGROUND: Falls are a common and debilitating health problem for older adults. Older adults are often treated and discharged home by emergency department (ED)-based providers with the hope they will receive falls prevention resources and referrals from their primary care provider. This descriptive study investigated falls prevention activities, including interactions with primary care providers, among community-dwelling older adults who were discharged home after presenting to an ED with a fall-related injury. METHODS: We enrolled English speaking patients, aged ≥ 65 years, who presented to the ED of an urban level one trauma center with a fall or fall related injury and discharged home. During subjects' initial visits to the ED, we screened and enrolled patients, gathered patient demographics and provided them with a flyer for a Matter of Balance course. Sixty-days post enrollment, we conducted a phone follow-up interview to collect information on post-fall behaviors including information regarding the efforts to engage family and the primary care provider, enroll in a falls prevention program, assess patients' attitudes towards falling and experiences with any subsequent falls. RESULTS: Eighty-seven community-dwelling people between the ages of 65 and 90 were recruited, the majority (76%) being women. Seventy-one percent of subjects reported talking to their provider regarding the fall; 37% reported engaging in falls prevention activities. No subjects reported enrolling in a fall prevention program although two reported contacting falls program staff. Fourteen percent of subjects (n=12) reported a recurrent fall and 8% (7) reported returning to the ED after a recurrent fall. CONCLUSIONS: Findings indicate a low rate of initiating fall prevention behaviors following an ED visit for a fall-related injury among community-dwelling older adults, and highlight the ED visit as an important, but underutilized, opportunity to mobilize health care resources for people at high risk for subsequent falls.

Savings in acute care costs if all older adults treated for fall-related injuries completed matter of balance.

BACKGROUND: Falls among older adults are a common and serious public health problem. Evidence-based fall prevention programs delivered in community settings and targeting older adults living independently are increasingly deployed throughout the nation. These programs tend to be offered by public and private organizations that serve older adults, and recruitment usually occurs through direct marketing to the target population, rather than through referrals from healthcare providers. Matter of Balance, a program developed to reduce fear of falling and associated activity restriction in community-dwelling older adults, is currently being delivered in 38 of the 50 United States. In this study, we estimate the one-year medical care cost savings if older adults treated at Massachusetts hospitals for fall-related injuries were referred by healthcare providers to participate in Matter of Balance. METHODS: Data from several sources were used for this study. We estimated annual cost savings in older adult falls recidivism for a hypothetical 100 patients presenting at an emergency department for a fall-related injury, assuming that all were referred to, and 50 % completed, Matter of Balance. This cost-saving estimate was subsequently expanded based on the actual number (43,931) of older adult patients presenting at, and discharged from Massachusetts emergency departments for all fall-related injuries in 2012. Cost savings were calculated for two additional participation rates: 25 % and 75 %. The return on investment (ROI), was calculated based on the percentage of return per each dollar invested. RESULTS: The calculated ROI for Matter of Balance was 144 %. Statewide savings ranged from $2.79 million assuming a 25 % participation rate to $8.37 million, assuming a 75 % participation rate. CONCLUSIONS: Referral to evidence-based falls prevention programs of older adult patients presenting at EDs with a fall-related injury could reduce subsequent falls and associated treatment costs.