Core requirements of frailty screening in the emergency department: an international Delphi consensus study.

INTRODUCTION: Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study. METHODS: A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August-September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors. RESULTS: In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include. CONCLUSIONS: Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen.

BACKGROUND: Ground-level falls are common among older adults and are the most frequent cause of traumatic intracranial bleeding. The aim of this study was to derive a clinical decision rule that safely excludes clinically important intracranial bleeding in older adults who present to the emergency department after a fall, without the need for a computed tomography (CT) scan of the head. METHODS: This prospective cohort study in 11 emergency departments in Canada and the United States enrolled patients aged 65 years or older who presented after falling from standing on level ground, off a chair or toilet seat, or out of bed. We collected data on 17 potential predictor variables. The primary outcome was the diagnosis of clinically important intracranial bleeding within 42 days of the index emergency department visit. An independent adjudication committee, blinded to baseline data, determined the primary outcome. We derived a clinical decision rule using logistic regression. RESULTS: The cohort included 4308 participants, with a median age of 83 years; 2770 (64%) were female, 1119 (26%) took anticoagulant medication and 1567 (36%) took antiplatelet medication. Of the participants, 139 (3.2%) received a diagnosis of clinically important intracranial bleeding. We developed a decision rule indicating that no head CT is required if there is no history of head injury on falling; no amnesia of the fall; no new abnormality on neurologic examination; and the Clinical Frailty Scale score is less than 5. Rule sensitivity was 98.6% (95% confidence interval [CI] 94.9%-99.6%), specificity was 20.3% (95% CI 19.1%-21.5%) and negative predictive value was 99.8% (95% CI 99.2%-99.9%). INTERPRETATION: We derived a Falls Decision Rule, which requires external validation, followed by clinical impact assessment. Trial registration: ClinicalTrials. gov, no. NCT03745755.

How Emergency Medicine Residents Have Conversations About Life-Sustaining Treatments in Critical Illness: A Qualitative Study Using Inductive Thematic Analysis.

STUDY OBJECTIVE: The inherent pressures of high-acuity, critical illness in the emergency department create a unique environment whereby acute goals-of-care discussions must be had with patients or substitute decision makers to rapidly decide between divergent treatment paths. Among university-affiliated hospitals, resident physicians are often conducting these highly consequential discussions. This study aimed to use qualitative methods to explore how emergency medicine residents make recommendations regarding life-sustaining treatments during acute goals-of-care discussions in critical illness. METHODS: Using qualitative methods, semistructured interviews were conducted with a purposive sample of emergency medicine residents in Canada from August to December 2021. Inductive thematic analysis of the interview transcripts was conducted using line-by-line coding, and key themes were identified through comparative analysis. Data collection continued until thematic saturation was reached. RESULTS: Seventeen emergency medicine residents from 9 Canadian universities were interviewed. Two factors guided residents' treatment recommendations (a duty to provide a recommendation and the balance between disease prognosis and patient values). Three factors influenced residents' comfort when making recommendations (time constraints, uncertainty, and moral distress). CONCLUSION: While conducting acute goals-of-care discussions with critically ill patients or their substitute decision makers in the emergency department, residents felt a sense of duty to provide a recommendation informed by an intersection between the patient's disease prognosis and the patient's values. Their comfort in making these recommendations was limited by time constraints, uncertainty, and moral distress. These factors are important for informing future educational strategies.

A systematic review of sufentanil for the management of adults with acute pain in the emergency department and pre-hospital setting.

BACKGROUND: Pain is commonly encountered in the Emergency Department (ED) and pre-hospital setting and often requires opioid analgesia. We sought to synthesize the available evidence on the effectiveness of sufentanil for acute pain relief for adult patients in the pre-hospital or ED setting. METHODS: This systematic review was conducted in accordance with PRISMA guidelines. Medline, Embase, Cochrane CENTRAL, and CINAHL were searched from inception to February 1, 2022. The grey literature was also searched. We included randomized controlled trials of adult patients with acute pain who were treated with sufentanil. Two reviewers independently completed screening, full text review, and data extraction. Primary outcome was reduction in pain. Secondary outcomes included adverse events, need for rescue analgesia, and patient and provider satisfaction. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. A meta-analysis was not performed due to heterogeneity. RESULTS: Of 1120 unique citations, four studies (3 ED and 1 pre-hospital) met full inclusion criteria (n = 467 participants). The overall quality of the included studies was high. Intranasal (IN) sufentanil was superior to placebo for pain relief at 30 min (difference 20.8%, 95% CI 4.0-36.2%, p = 0.01). Both IN (two studies) and IV sufentanil (one study) were comparable to IV morphine. Mild adverse events were common and there was a higher propensity for minor sedation in patients receiving sufentanil. There were no serious adverse events requiring advanced interventions. CONCLUSION: Sufentanil was comparable to IV morphine and was superior to placebo for rapid relief of acute pain in the ED setting. The safety profile of sufentanil is similar to IV morphine in this setting, with minimal concern for serious adverse events. The intranasal formulation may provide an alternative, rapid, non-parenteral route that could benefit our unique emergency department and pre-hospital patient population. Due to the overall small sample size of this review, larger studies are required to confirm safety.

Cervical spine injuries in adults ≥ 65 years after low-level falls - A systematic review and meta-analysis.

BACKGROUND: Adults ≥ 65 are at risk of cervical spine (C-spine) injury, even after low-level falls. The objectives of this systematic review were to determine the prevalence of C-spine injury in this population and explore the association of unreliable clinical exam with C-spine injury. METHODS: We conducted this systematic review according to PRISMA guidelines. We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic reviews to include studies reporting on C-spine injury in adults ≥ 65 years after low-level falls. Two reviewers independently screened articles, abstracted data, and assessed bias. Discrepancies were resolved by a third reviewer. A meta-analysis was performed to estimate overall prevalence and the pooled odds ratio for the association between C-spine injury and an unreliable clinical exam. RESULTS: The search identified 2044citations, 138 full texts were screened, and 21 studies were included in the systematic review. C-spine injury prevalence in adults ≥ 65 years after low-level falls was 3.8% (95% CI: 2.8-5.3). The odds of c-spine injury in those with altered level of consciousness (aLOC) v/s not aLOC was 1.21 (0.90-1.63) and in those with GCS < 15 v/s GCS 15 was 1.62 (0.37-6.98). Studies were at a low-risk of bias, although some had low recruitment and significant loss to follow-up. CONCLUSIONS: Adults ≥ 65 years are at risk of cervical spine injury after low-level falls. More research is needed to determine whether there is an association between cervical spine injury and GCS < 15 or altered level of consciousness.

Assessment of frailty by paramedics using the clinical frailty scale - an inter-rater reliability and accuracy study.

BACKGROUND: Frailty assessment by paramedics in the prehospital setting is understudied. The goals of this study were to assess the inter-rater reliability and accuracy of frailty assessment by paramedics using the Clinical Frailty Scale (CFS). METHODS: This was a cross-sectional study with paramedics exposed to 30 clinical vignettes created from real-life situations. There was no teaching intervention prior to the study and paramedics were only provided with the French version of the CFS (definitions and pictograms). The primary outcome was the inter-rater reliability of the assessment. The secondary outcome was the accuracy, compared with the expert-based assessment. Reliability was determined by calculating an intraclass correlation coefficient (ICC). Accuracy was assessed through a mixed effects logistic regression model. A sensitivity analysis was carried out by considering that an assessment was still accurate if the score differed from no more than 1 level. RESULTS: A total of 56 paramedics completed the assessment. The overall assessment was found to have good inter-rater reliability (ICC = 0.87 [95%CI 0.81-0.93]). The overall accuracy was moderate at 60.6% (95%CI 54.9-66.1) when considering the full scale. It was however much higher (94.8% [95%CI 92.0-96.7] when close assessments were considered as accurate. The only factor associated with accurate assessment was field experience. CONCLUSION: The assessment of frailty by paramedics was reliable in this vignette-based study. However, the accuracy deserved to be improved. Future research should focus on the clinical impact of these results and on the association of prehospital frailty assessment with patient outcomes. REGISTRATION: This study was registered on the Open Science Framework registries ( https://doi.org/10.17605/OSF.IO/VDUZY ).

Functional Decline After Nonhospitalized Injuries in Older Patients: Results From the Canadian Emergency Team Initiative Cohort in Elders.

STUDY OBJECTIVE: To estimate the cumulative incidence of functional decline over 6 months following emergency department (ED) assessments of nonhospitalized injuries and to identify its main determinants. METHODS: We conducted a prospective multicenter cohort of older adults discharged home following assessment for injuries in 8 Canadian EDs. Participants were assessed at 3 time points: baseline in the ED, 3 months, and 6 months. The primary outcome, functional decline, was defined as a 2-points loss from baseline on the Older American Resources Scale (OARS). Other measures included demographics, comorbidities, injury characteristics, frailty, cognition, mobility status, etc. Cumulative incidences were estimated using proportions with 95% confidence intervals. Log-binomial regressions and the "least absolute shrinkage and selection operator" (LASSO) were used to identify significant functional decline determinants. RESULTS: Among 2,919 participants, 403 (13.8%) were lost to follow-up. Mean age was 76.2±7.6 years, 65.3% were women, 9% were frail, and 40.0% prefrail. Main injury mechanisms were falls (65.5%) and motor vehicle accidents (18.6%). The cumulative incidence of functional decline over 6 months was 17.0% (95% confidence interval 12.5% to 23.0%). Occasional use of walking devices, less than 5 outings/week, frailty, and older age were significant baseline determinants of functional decline. CONCLUSION: A significant 17% of older adults with "minor" injuries experience a persistent functional decline over 6 months following their ED visit. Four frailty-related determinants were identified: occasional use of a walking device, less than 5 outings/week, frailty, and older age. Further work is needed to assess if these can help ED clinicians screen seniors at risk and initiate interventions at discharge.

Barriers and facilitators to nursing delirium screening in older emergency patients: a qualitative study using the theoretical domains framework.

BACKGROUND: delirium is common in older emergency department (ED) patients, but vastly under-recognised, in part due to lack of standardised screening processes. Understanding local context and barriers to delirium screening are integral for successful implementation of a delirium screening protocol. OBJECTIVES: we sought to identify barriers and facilitators to delirium screening by nurses in older ED patients. METHODS: we conducted 15 semi-structured, face-to-face interviews based on the Theoretical Domains Framework with bedside nurses, nurse educators and managers at two academic EDs in 2017. Two research assistants independently coded transcripts. Relevant domains and themes were identified. RESULTS: a total of 717 utterances were coded into 14 domains. Three dominant themes emerged: (i) lack of clinical prioritisation because of competing demands, lack of time and heavy workload; (ii) discordance between perceived capabilities and knowledge and (iii) hospital culture. CONCLUSION: this qualitative study explored nursing barriers and facilitators to delirium screening in older ED patients. We found that delirium was recognised as an important clinical problem; however, it was not clinically prioritised; there was a false self-perception of knowledge and ability to recognise delirium and hospital culture was a strong influencer of behaviour. Successful adoption of a delirium screening protocol will only be realised if these issues are addressed.

Prevalence, management and outcomes of unrecognized delirium in a National Sample of 1,493 older emergency department patients: how many were sent home and what happened to them?

BACKGROUND: Retrospective studies estimate Emergency Department (ED) delirium recognition at <20%; few prospective studies have assessed delirium recognition and outcomes for patients with unrecognized delirium. OBJECTIVES: To prospectively measure delirium recognition by ED nurses and physicians, document their confidence in diagnosis and disposition, actual dispositions, and patient outcomes. METHODS: Prospective observational study of people ≥65 years. We assessed delirium using the Confusion Assessment Method, then asked ED staff if the patient had delirium, confidence in their assessment, if the patient could be discharged, and contacted patients 1 week postdischarge. We report proportions and 95% confidence intervals (Cls). RESULTS: We enrolled 1,493 participants; mean age was 77.9 years; 49.2% were female, 79 (5.3%, 95% CI 4.2-6.5%) had delirium. ED nurses missed delirium in 43/78 cases (55.1%, 95% CI 43.4-66.4%). Nurses considered 12/43 (27.9%) patients with unrecognized delirium safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 7.0/10. Physicians missed delirium in 10/20 (50.0%, 95% CI 27.2-72.8) cases and considered 2/10 (20.0%) safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 8.0/10. Fifteen patients with unrecognized delirium were sent home: 6.7% died at 1 week follow-up vs. none in those with recognized delirium and 1.1% in the rest of the cohort. CONCLUSION: Delirium recognition by nurses and physicians was sub-optimal at ~50% and may be associated with increased mortality. Research should explore root causes of unrecognized delirium, and novel strategies to systematically improve delirium recognition and patient outcomes.

Effect of inpatient antibiotic treatment among older adults with delirium found with a positive urinalysis: a health record review.

BACKGROUND: Among older adults with delirium and positive urinalysis, antibiotic treatment for urinary tract infection is common practice, but unsupported by literature or guidelines. We sought to: i) determine the rate of antibiotic treatment and the proportion of asymptomatic patients (other than delirium) in this patient population, and ii) examine the effect of antibiotic treatment on delirium resolution and adverse outcomes. METHODS: A health record review was conducted at a tertiary academic centre from January to December 2020. Inclusion criteria were age ≥ 65, positive delirium screening assessment, positive urinalysis, and admission to general medical units. Outcomes included rates of antibiotic treatment, delirium on day 7 of admission, and 30-day adverse outcomes. We compared delirium and adverse outcome rates in antibiotic-treated vs. non-treated groups. We conducted subgroup analyses among asymptomatic patients. RESULTS: We included 150 patients (57% female, mean age 85.4 years). Antibiotics were given to 86%. The asymptomatic subgroup (delirium without urinary symptoms or fever) comprised 38% and antibiotic treatment rate in this subgroup was 68%. There was no significant difference in delirium rate on day 7 between antibiotic-treated vs. non-treated groups, (entire cohort RR 0.94 [0.41-2.16] and asymptomatic subgroup RR 0.69 [0.22-2.15]) or in 30-day adverse outcomes. CONCLUSIONS: Older adults with delirium and positive urinalysis in general medical inpatient units were frequently treated with antibiotics - often despite the absence of urinary or other infectious symptoms. We failed to find evidence that antibiotic treatment in this population is associated with delirium resolution on day 7 of admission.

Physician choices in pulmonary embolism testing.

BACKGROUND: Evidence-based guidelines advise excluding pulmonary embolism (PE) diagnosis using d-dimer in patients with a lower probability of PE. Emergency physicians frequently order computed tomography (CT) pulmonary angiography without d-dimer testing or when d-dimer is negative, which exposes patients to more risk than benefit. Our objective was to develop a conceptual framework explaining emergency physicians' test choices for PE. METHODS: We conducted a qualitative study using in-depth interviews of emergency physicians in Canada. A nonmedical researcher conducted in-person interviews. Participants described how they would test simulated patients with symptoms of possible PE, answered a knowledge test and were interviewed on barriers to using evidence-based PE tests. RESULTS: We interviewed 63 emergency physicians from 9 hospitals in 5 cities, across 3 provinces. We identified 8 domains: anxiety with PE, barriers to using the evidence (time, knowledge and patient), divergent views on evidence-based PE testing, inherent Wells score problems, the drive to obtain CT rather than to diagnose PE, gestalt estimation artificially inflating PE probability, subjective reasoning and cognitive biases supporting deviation from evidence-based tests and use of evidence-based testing to rule out PE in patients who are very unlikely to have PE. Choices for PE testing were influenced by the disease, environment, test qualities, physician and probability of PE. INTERPRETATION: Analysis of structured interviews with emergency physicians provided a conceptual framework to explain how these physicians use tests for suspected PE. The data suggest 8 domains to address when implementing an evidence-based protocol to investigate PE.

Adverse Events Among Emergency Department Patients With Cardiovascular Conditions: A Multicenter Study.

STUDY OBJECTIVE: We aim to determine incidence and type of adverse events (adverse outcomes related to emergency care) among emergency department (ED) patients discharged with recent-onset atrial fibrillation, acute heart failure, and syncope. METHODS: This 5-year prospective cohort study included high-acuity adult patients discharged with the 3 sentinel diagnoses from 6 tertiary care Canadian EDs. We screened all ED visits for eligibility and performed telephone interviews 14 days postdischarge to identify flagged outcomes: death, hospital admission, return ED visit, health care provider visit, and new or worsening symptoms. We created case summaries describing index ED visit and flagged outcomes, and trained emergency physicians reviewed case summaries to identify adverse events. We reported adverse event incidence and rates with 95% confidence intervals and contributing factor themes. RESULTS: Among 4,741 subjects (mean age 70.2 years; 51.2% men), we observed 170 adverse events (3.6 per 100 patients; 95% confidence interval 3.1 to 4.2). Patients discharged with acute heart failure were most likely to experience adverse events (5.3%), followed by those with atrial fibrillation (2.0%) and syncope (0.8%). We noted variation in absolute adverse event rates across sites from 0.7 to 6.0 per 100 patients. The most common adverse event types were management issues, diagnostic issues, and unsafe disposition decisions. Frequent contributing factor themes included failure to recognize underlying causes and inappropriate management of dual diagnoses. CONCLUSION: Among adverse events after ED discharge for patients with these 3 sentinel cardiovascular diagnoses, we identified quality improvement opportunities such as strengthening dual diagnosis detection and evidence-based clinical practice guideline adherence.

Treatment failure definitions for non-purulent skin and soft tissue infections: a systematic review.

OBJECTIVE: There is currently no uniform definition for antimicrobial treatment failure for adults with non-purulent skin and soft tissue infections (SSTIs). The objective of this systematic review was to identify treatment failure definitions and their common components in the literature. METHODS: Five electronic databases were searched from inception to March 2019. Two independent reviewers identified studies involving adults (age ≥ 18 years) with non-purulent SSTIs in which antimicrobial treatment failure was a defined outcome. There were no language restrictions. Only randomized trials or observational studies were included. RESULTS: After screening 4953 abstracts, 26 studies (N = 6629 patients) met full inclusion criteria. Reported treatment failure ranged from 0 to 29.5%. The most common definition components were hospital admission (78.9%), change in antibiotics (65.4%), and persistent or worsening signs and symptoms of infection (34.6%). Only one study listed specific criteria for persistent or worsening signs and symptoms of infection. CONCLUSIONS: For studies involving non-purulent SSTIs, the outcome of treatment failure is inconsistently defined and reported failure rates are highly variable. This systematic review has highlighted the need for more robust treatment failure definitions for non-purulent SSTIs. Research should focus on the development of a uniform treatment failure definition that should be used in future studies.

Evaluation of the Ottawa 3DY as a screening tool for cognitive impairment in older emergency department patients.

OBJECTIVE: This study sought to evaluate the implementation of the Ottawa 3DY Tool, a simple screening instrument for cognitive impairment, by front-line ED clinicians. METHODS: We conducted a prospective cohort study in an academic ED. Patients ≥75 years underwent cognitive screening with the Ottawa 3DY by front-line nurses and physicians. Descriptive statistics were used to describe level of implementation and acceptability of the tool. Sensitivity and specificity was calculated using an Mini-Mental State Exam <25 as the cut-off for cognitive impairment. A weighted kappa was calculated to establish inter-rater agreement. RESULTS: Cognitive screening was completed in 260/332 eligible patients (78.3%), who were 60% female and had a mean age of 83.7 years. Facilitators to screening: perceived importance and ownership of screening and feasibility of Ottawa 3DY. Barriers to screening were: over confidence in clinical judgement and perceived lack of patient benefit. Ottawa 3DY had a sensitivity of 84.6% (64.3-95.0) and specificity of 54.2% (39.3-68.4) when completed by nurses. When completed by emergency physicians, sensitivity was 78.9% (53.9-93.0) and specificity was 70.0% (45.7-87.2). Inter-rater agreement kappa score was 0.67. DISCUSSION: This study demonstrated that incorporating the Ottawa 3DY tool into the routine evaluation of older ED patients by front-line ED clinicians is both feasible and effective. With its demonstrated good inter-rater reliability and moderate level of sensitivity and specificity when compared with the much longer MMSE, the routine adoption of this tool may help lead to improved recognition of cognitive impairment and ultimately patient and system outcomes.

Serial Ottawa 3DY assessments to detect delirium in older emergency department community dwellers.

BACKGROUND: delirium is associated with increased morbidity and mortality among older emergency department (ED) patients. When using physician gestalt, delirium is missed in the majority of patients. The Ottawa 3DY (O3DY) has been validated to detect cognitive dysfunction among older ED patients. OBJECTIVES: to determine the sensitivity and specificity of serial O3DY assessments to detect delirium in older ED patients. DESIGN: a prospective observational multicenter cohort study. SETTING: four Quebec EDs. PARTICIPANTS: independent or semi-independent older patients (age ≥ 65 years) with an ED stay of at least 8 hours that required hospitalisation. MEASUREMENTS: eligible patients were evaluated using serial O3DY assessments at least 6 hours apart. The primary outcome was delirium after at least 8 hours in the ED. The reference standard for delirium assessment was the confusion assessment method (CAM). The sensitivity and specificity of the serial O3DY to detect delirium were calculated. RESULTS: we enrolled 301 patients (mean age 77 years, 49.5% male, 3.0% with a history of mild dementia). Thirty patients (10.0%) were CAM positive for delirium. Patients had a median of three O3DY assessments. Serial O3DY evaluations to detect delirium among patients with at least one abnormal O3DY had a sensitivity of 86.7% (95% confidence interval-CI 69.3-96.2%) and a specificity of 44.3% (95%; CI 38.3-50.4%). CONCLUSION: serial O3DY testing demonstrates good sensitivity as a screening tool to detect delirium among older adult patients with prolonged ED lengths of stay. Emergency physicians should consider the use of the serial O3DY over clinician gestalt to improve delirium detection.

Evaluation of an emergency department to outpatient parenteral antibiotic therapy program for cellulitis.

OBJECTIVE: Emergency department (ED) patients with non-purulent skin and soft tissue infections (SSTIs) requiring intravenous antibiotics may be managed via outpatient parenteral antibiotic therapy (OPAT). Prospective studies describing the performance of an ED-to-OPAT clinic program are lacking. The primary objective was to determine the OPAT treatment failure rate for ED patients with non-purulent SSTIs. METHODS: We conducted a prospective observational cohort study of adults with non-purulent SSTIs managed via an ED-to-OPAT clinic program. OPAT treatment failure was defined as hospitalization after a minimum of 48 h of OPAT for: worsening infection; intravenous line complications; or adverse antibiotic effects. Secondary outcomes were to describe OPAT clinic processes, patient satisfaction, and physician rationale for selecting intravenous antibiotics. RESULTS: We enrolled a consecutive sample of 153 patients [mean age 60.5 years, 82 male (53.6%)]; 137 patients (89.5%) attended their clinic appointment. OPAT treatment failure was 4.4%. None of the adverse intravenous line (10.9%) and adverse antibiotic (8.0%) events required hospitalization. Patients reported high satisfaction with timeliness of referral (median score 9 out of 10) and overall care received (median score of 10). The top five reasons given by physicians for selecting intravenous therapy were: clinical impression (52.9%); failed oral therapy (41.8%); diabetes (17.6%); severe pain (7.8%); and peripheral vascular disease (7.8%). CONCLUSIONS: This prospective study demonstrates that an ED-to-OPAT clinic program for non-purulent SSTIs is safe, has a low rate of treatment failures and results in high patient satisfaction. The rationale for selecting intravenous antibiotics showed significant variability among ED physicians.

Validation of the O3DY French Version (O3DY-F) for the Screening of Cognitive Impairment in Community Seniors in the Emergency Department.

BACKGROUND: It is recommended that older patients undergo systematic mental status screening when presenting to the emergency department (ED). However, the tools available are not necessarily adapted to the ED environment, therefore, quicker and easier tools are needed. OBJECTIVES: The purpose of this study is to validate the Ottawa 3DY-French (O3DY-F) Scale as a screening tool for delirium and cognitive impairment in a French-speaking cohort. METHOD: This multicenter prospective study was conducted in four hospitals across the province of Quebec. Inclusion criteria were: age ≥ 65 years, ED stay ≥ 8 h, awaiting admission to a care unit, and independent or semi-independent in their daily living activities. Cognitive status was assessed during the initial interview using the Telephone Interview for Cognitive Screening-modified (TICS-m) and the O3DY-F scale. Comparisons were made between the O3DY-F and the TICS-m and Confusion Assessment Method (CAM) to assess the sensitivity and specificity of the O3DY-F for the detection of cognitive impairment and delirium. RESULTS: A total of 313 patients were included in this study, 139 of which had a positive O3DY-F. When compared with the CAM, the O3DY-F had a sensitivity of 84.2% (95% confidence interval [CI] 60.4-96.6) and a specificity of 58.2% (95% CI 52.3-63.9) for the detection of prevalent delirium. The O3DY-F had a sensitivity of 76.2% (95% CI 66.7-84.8) and a specificity of 67.6% (95% CI 61.0-73.6) for cognitive impairment (defined as a TICS-m < 27). CONCLUSION: The O3DY-F is a useful and effective tool to screen for delirium and undetected cognitive impairment among a French-speaking cohort in the ED.

Barriers and enablers that influence guideline-based care of geriatric fall patients presenting to the emergency department.

BACKGROUND: Geriatric patients commonly present to the ED after a fall. Recent evidence suggests that ED physicians are poorly adherent to published ED-specific geriatric fall guidelines. This study applied a theoretical domains framework (TDF) approach to systematically investigate barriers and enablers in the provision of guideline-based care to ED geriatric fall patients. METHODS: From June to September 2017, semistructured interviews of staff ED physicians practising in Ontario, Canada, were conducted and analysed. An interview guide based on the TDF was used to capture 14 domains influencing provision of guideline-based care. Relevant domains were identified based on frequencies of beliefs, existence of conflicting beliefs and evidence of strong beliefs that would influence provision of guideline-based care. RESULTS: Eleven interviews were conducted with practising ED physicians. Thirty belief statements were identified across 13 relevant TDF domains (all except Optimism). Prominent themes included lack of knowledge, paucity of evidence, heterogeneous self-perceived skills, perceived increased time and workload, importance of allied health support, inconsistently available allied health workers, lack of positive reinforcement, emotions negatively impacting these clinical encounters and support for memory aids. Overall, ED physicians were supportive of guideline implementation, and believe it will lead to better outcomes for geriatric fall patients. CONCLUSION: This study identified important barriers and enablers to provision of guideline-based care in geriatric ED fall patients. Based on these findings, future implementation of guidelines nationally and internationally should focus on improving knowledge and training on guidelines, improving positive reinforcement for guideline-appropriate management, greater allied health support and further research to support guidelines.

Outcomes of Older Hospitalized Patients Requiring Rapid Response Team Activation for Acute Deterioration.

OBJECTIVES: Rapid response teams are groups of healthcare providers that have been implemented by many hospitals to respond to acutely deteriorating patients admitted to the hospital wards. Hospitalized older patients are at particular risk of deterioration. We sought to examine outcomes of older patients requiring rapid response team activation. DESIGN: Analysis of a prospectively collected registry. SETTING: Two hospitals within a single tertiary care level hospital system between 2012 and 2016. PATIENTS: Five-thousand nine-hundred ninety-five patients were analyzed. Comparisons were made between older patients (defined as ≥ 75 yr old) and younger patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All patient information, outcomes, and rapid response team activation information were gathered at the time of rapid response team activation and assessment. The primary outcome was in-hospital mortality, analyzed using multivariate logistic regression. Two-thousand three-hundred nine were older patients (38.5%). Of these, 835 (36.2%) died in-hospital, compared with 998 younger patients (27.1%) (adjusted odds ratio, 1.83 [1.54-2.18]; p < 0.001). Among patients admitted from home, surviving older patients were more likely to be discharged to a long-term care facility (adjusted odds ratio, 2.38 [95% CI, 1.89-3.33]; p < 0.001). Older patients were more likely to have prolonged delay to rapid response team activation (adjusted odds ratio, 1.79 [1.59-2.94]; p < 0.001). Among patients with goals of care allowing for ICU admission, older patients were less likely to be admitted to the ICU (adjusted odds ratio, 0.66 [0.36-0.79]), and less likely to have rapid response team activation during daytime hours (adjusted odds ratio, 0.73 [0.62-0.98]; p < 0.001). CONCLUSIONS: Older patients with in-hospital deterioration requiring rapid response team activation had increased odds of death and long-term care disposition. Rapid response team activation for older patients was more likely to be delayed, and occur during nighttime hours. These findings highlight the worse outcomes seen among older patients with in-hospital deterioration, identifying areas for future quality improvement.

Heart failure and palliative care in the emergency department.

OBJECTIVES: Heart failure is a common ED presentation that is underserved by palliative care services and is associated with significant morbidity and mortality. We sought to evaluate use of palliative care services in patients with heart failure presenting to the ED. The primary outcome studied was palliative care involvement. Secondary outcomes of the study were: (1) 1-year mortality, (2) ED visits, (3) hospital admissions and (4) heart failure clinic involvement. METHODS: We conducted a health records review of 500 patients with heart failure who presented to two Canadian academic hospital EDs from January to August 2013. RESULTS: Patients were of mean age 80.7 years, women (53.2%) and had significant comorbidities. Only 41% of all deceased patients at 1 year had any palliative care involvement. Of those with palliative care, 44 (76%) patients had less than 2 weeks of palliative care involvement prior to death. Compared with those with no palliative care, the 79 (15.8%) patients with palliative care involvement had a higher 1-year mortality rate (70.9% vs 18.8%) and more hospital admissions/year (1.4 vs 0.85) for heart failure. CONCLUSIONS: We found that few patients with heart failure had palliative care services. Additionally, the majority of those who have palliative care involvement do not meet current recommendations for early palliative care involvement in heart failure. This study suggests that the ED may be an appropriate setting to identify and refer high-risk patients with heart failure who could benefit from earlier palliative care involvement.