Nonspecific Complaints in Older Emergency Department Patients.

Nonspecific complaints such as generalized weakness and fatigue are common in older adults presenting to an emergency department. These complaints may be caused by acute or chronic medical problems, or they may be exacerbated or caused by socioeconomic risks factors. Acute causes may be related to serious medical conditions requiring prompt treatment. A thorough history and physical examination in conjunction with an interdisciplinary approach allows emergency departments to identify acute conditions as well as geriatric syndromes and unmet home needs, such as food insecurity and caregiver burden. A whole-health system approach should be used for safe transitions of care.

Dissemination and implementation of age-friendly care and geriatric emergency department accreditation at Veterans Affairs hospitals.

OBJECTIVES: In 2018, the U.S. Department of Veterans Affairs (VA) National Office of Geriatrics and Extended Care (GEC) and the National Emergency Medicine (EM) Program partnered to improve emergency care for older Veterans. A core team disseminated age-friendly models of care via education and standardization of practice with the goal of multisite geriatric emergency department (GED) accreditation. We compare rates of GED screening at VAs with GED implementation to those without. METHODS: Observational evaluation of GED screening of older Veterans (≥65 years) at VA Emergency Departments (ED) from January 2018 to March 2022, during peak pandemic years. Data were extracted from the VA Corporate Data Warehouse of Veteran ED visit encounters to track documented GED screens and Veteran demographic data. Generalized estimating equation models were used to compare screening completion across different levels of GED accreditation, adjusting for potential confounding. RESULTS: During this period, over 1.07 million Veterans ≥ 65 years of age made 4.07 million VA ED visits. Mean (±SD) age was 73.4 (±7.2) years, 96.5% were male, 68% were White, and 89.9% made their index ED visit at a non-GED VA ED. As of early 2022, a total of 50 of 111 VA EDs have achieved or applied for GED accreditation. During early 2022, 8.3% of all visits by older Veterans had at least one GED screen documented; 15% were screened at Levels 1-3 GED versus 2.2% at non-GED facilities. Screens identifying older adults at risk for poor outcomes, for delirium, and for falls had the highest usage rates within VA GEDs. Veterans seen at Level 1 GEDs had a 76-fold greater odds of having a GED screen than at Level 3 GEDs (odds ratio 75.8, 95% confidence interval 72.8-79.0). CONCLUSIONS: Through VA National Office of GEC and EM Program partnership, the VA has created, standardized, and disseminated a GED Model of Care, despite the pandemic. GED accreditation was associated with GED screen implementation, with Level 1 having the highest screening prevalence.

Leveraging VA geriatric emergency department accreditation to improve elder abuse detection in older Veterans using a standardized tool.

Elder abuse (EA) is common and has devastating health impacts, yet most cases go undetected limiting opportunities to intervene. Older Veterans receiving care in the Veterans Health Administration (VHA) represent a high-risk population for EA. VHA emergency department (ED) visits provide a unique opportunity to identify EA, as assessment for acute injury or illness may be the only time isolated older Veterans leave their home, but most VHA EDs do not have standardized EA assessment protocols. To address this, we assembled an interdisciplinary team of VHA social workers, physicians, nurses, intermediate care technicians (ICTs; former military medics and corpsmen who often conduct screenings in VHA EDs) and both VHA and non-VHA EA subject matter experts to adapt the Elder Mistreatment Screening and Response Tool (EM-SART) to pilot in the Louis Stokes Cleveland VA Medical Center geriatric ED (GED) program. The cornerstone of their approach is an interdisciplinary GED consultation led by ICTs and nurses who screen high-risk older Veterans for geriatric syndromes and unmet needs. The adapted EM-SART was integrated into the electronic health record and GED workflow in December 2020. By July 2022, a total of 251 Veterans were screened with nine (3.6%) positive on the prescreen and five (2%) positive on the comprehensive screen. Based on the first-year pilot experience, the interdisciplinary team was expanded and convened regularly to further adapt the EM-SART for wider use in VHA, including embedding flexibility for both licensed and nonlicensed clinicians to complete the screening tool and tailoring response options to be specific to VHA policy and resources. The national momentum for VHA EDs to improve care for older Veterans and secure GED accreditation offers unique opportunities to embed this evidence-based approach to EA assessment in the largest integrated health system in the United States.

Telehealth for geriatric post-emergency department visits to promote age-friendly care.

OBJECTIVE: To describe a feasibility pilot study for older adults that addresses the digital divide, unmet health care needs, and the 4Ms of Age-Friendly Health Systems via the emergency department (ED) follow-up home visits supported by telehealth. DATA SOURCES AND STUDY SETTING: Data sources were a pre-implementation site survey and pilot phase individual-level patient data from six US Department of Veterans Affairs (VA) EDs. STUDY DESIGN: A pre-implementation survey assessed existing geriatric ED processes. In the pilot called SCOUTS (Supporting Community Outpatient, Urgent care & Telehealth Services), sites identified high-risk patients during an ED visit. After ED discharge, Intermediate Care Technicians (ICTs, former military medics), performed follow-up telephone, or home visits. During the follow-up visit, ICTs identified "what matters," performed geriatric screens aligned with Age-Friendly Health Systems, observed home safety risks, assisted with video telehealth check-ins with ED providers, and provided care coordination. SCOUTS visit data were recorded in the patient's electronic medical record using a standardized template. DATA COLLECTION/EXTRACTION METHODS: Sites were surveyed via electronic form. Administrative pilot data extracted from VA Corporate Data Warehouse, May-October 2021. PRINCIPLE FINDINGS: Site surveys showed none of the EDs had a formalized way of identifying the 4 M "what matters." During the pilot, ICT performed 56 telephone and 247 home visits. All home visits included a telehealth visit with an ED provider (n = 244) or geriatrician (n = 3). ICTs identified 44 modifiable home fall risks and 99 unmet care needs, recommended 80 pieces of medical equipment, placed 36 specialty care consults, and connected 180 patients to a Patient Aligned Care Team member for follow-up. CONCLUSIONS: A post-ED follow-up program in which former military medics perform geriatric screens and care coordination is feasible. Combining telehealth and home visits allows providers to address what matters and unmet care needs.

Association of a geriatric emergency department program with healthcare outcomes among veterans.

BACKGROUND: We aim to describe the outcomes of Geriatric Emergency Room Innovations for Veterans (GERI-VET), the first comprehensive Veterans Affairs Geriatric ED program. METHODS: In this prospective observational cohort study at an urban Veterans Affairs Medical Center ED, participants included Veterans aged 65 years and older treated in the ED from January 7, 2017 to February 29, 2020. Veterans with an Identification of Seniors At Risk (ISAR) score >2 were considered eligible for GERI-VET, receiving geriatric screens and care coordination in addition to standard ED treatment. The control group included GERI-VET eligible Veterans who did not receive GERI-VET care. Propensity score matching was used to compare outcomes in the GERI-VET group (N = 725) and a matched control group (n = 725). Key measures included ED resource utilization, outpatient referrals, ED admission, and 30-day admission. RESULTS: In the ED, the GERI-VET group received more consults to pharmacy (315 [43.4%] vs. 195 [26.9%], p < 0.001) and social work (399 [55.0%] vs. 132 [18.2%], p < 0.001). The GERI-VET group had higher referral rates to Geriatrics (64 [17.7%] vs. 18 [5.8%], p < 0.001) and Home Based Primary Care (110 [30.4%] vs. 24 [7.8%], p < 0.001). Key outcome measures included lower rates of ED admission (363 [50.1%] vs. 417 [n = 57.5%], p = 0.003) and 30-day hospital admission (412 [56.8%] vs. 464 [64.0%], p = 0.004) without increasing ED length of stay (5.4 ± 2.2 vs. 5.4 ± 2.6 h, p = 0.85) or 72-h ED revisits (23 [3.2%] vs. 16 [2.2%], p = 0.25) in the GERI-VET group. CONCLUSIONS: A program designed to screen for geriatric syndromes and coordinate care among at-risk older Veterans was associated with increased multidisciplinary resource utilization and reduced ED and 30-day admissions without increasing ED length of stay or re-visitation.

Impact of Geriatric Emergency Fellowship Training on the careers of Emergency Physicians.

Introduction The geriatric population continues to increase and will impact the emergency department (ED). Older adult patients require different care from other groups of patients. Hence, it is essential to create a workforce that specializes in geriatric emergency medicine (GEM). Geriatric emergency medicine fellowships were developed to serve this need. However, despite 20 years since the creation of GEM fellowships, it is not known how GEM fellowships have impacted the career of graduates of GEM fellowships. The goal of this study is to examine the impact of these geriatric emergency fellowship training programs on the career of geriatric emergency fellows. Methods We surveyed the emergency physicians who had graduated from GEM fellowship programs in the US and Canada by using a 36-question, web-based questionnaire. The survey was pilot-tested on five GEM experts, fellowship graduates, and a GEM fellowship director. Result We had a 68% survey completion rate, two partially answered the study. All participants reported that they continue to have GEM as a part of his/her career. More than half either received grants, published papers, helped establish GEM divisions or caring in their hospital, and worked beyond clinical work in the ED, including academic and administrative fields. More than 80% reported that their fellowship helped obtain their current positions and was helpful in career progression. Approximately two-thirds were satisfied with their current work/life balance. Conclusion The GEM fellowship training has been impactful in the careers of former GEM fellows and has contributed to many becoming leaders in GEM clinical service, administration, education, and research. It can serve as a stepping stone to a leadership position in a GEM career. Furthermore, our study demonstrates that GEM graduates report high levels of career and clinical satisfaction.

Creation and Implementation of a Large-Scale Geriatric Interprofessional Education Experience.

The care of the older adult requires an interprofessional approach to solve complex medical and social problems, but this approach is difficult to teach in our educational silos. We developed an interprofessional educational session in response to national requests for innovative practice models that use collaborative interprofessional teams. We chose geriatric fall prevention as our area of focus as our development of the educational session coincided with the development of an interprofessional Fall Risk Reduction Clinic. Our aim of this study was to evaluate the number and type of students who attended a pilot and 10 subsequent educational sessions. We also documented the changes that occurred due to a Plan-Do-Study-Act (PDSA) rapid-cycle improvement model to modify our educational session. The educational session evolved into an online presession self-study didactic and in-person educational session with a poster/skill section, an interprofessional team simulation, and simulated patient experience. The simulated patient experience included an interprofessional fall evaluation, team meeting, and presentation to an expert panel. The pilot session had 83 students from the three sponsoring institutions (hospital system, university, and medical university). Students were from undergraduate nursing, nurse practitioner graduate program, pharmacy, medicine, social work, physical therapy, nutrition, and pastoral care. Since the pilot, 719 students have participated in various manifestations of the online didactic plus in-person training sessions. Ten separate educational sessions have been given at three different institutions. Survey data with demographic information were available on 524 participants. Students came from ten different schools and represented thirteen different health care disciplines. A large-scale interprofessional educational session is possible with rapid-cycle improvement, inclusion of educators from a variety of learning institutions, and flexibility with curriculum to accommodate learners in various stages of training.

Interprofessional education model for geriatric falls risk assessment and prevention.

BACKGROUND: One in three people over the age of 65 fall every year, with 1/3 sustaining at least moderate injury. Falls risk reduction requires an interprofessional health team approach. The literature is lacking in effective models to teach students how to work collaboratively in interprofessional teams for geriatric falls prevention. The purpose of this paper is to describe the development, administration and outcome measures of an education programme to teach principles of interprofessional care for older adults in the context of falls prevention. METHODS: Students from three academic institutions representing 12 health disciplines took part in the education programme over 18 months (n=237). A mixed method one-group pretest and post-test experimental design was implemented to measure the impact of a multistep education model on progression in interprofessional collaboration competencies and satisfaction. RESULTS: Paired t-tests of pre-education to posteducation measures of Interprofessional Socialization and Valuing Scale scores (n=136) demonstrated statistically significant increase in subscales and total scores (p<0.001). Qualitative satisfaction results were strongly positive. DISCUSSION: Results of this study indicate that active interprofessional education can result in positive student attitude regarding interprofessional team-based care, and satisfaction with learning. Lessons learnt in a rapid cycle plan-do-study-act approach are shared to guide replication efforts for other educators. CONCLUSION: Effective models to teach falls prevention interventions and interprofessional practice are not yet established. This education model is easily replicable and can be used to teach interprofessional teamwork competency skills in falls and other geriatric syndromes.

Iatrogenic emergency medicine procedure complications and associated trouble-shooting strategies.

PURPOSE: The purpose of this paper is to provide a consolidated reference for the acute management of selected iatrogenic procedural injuries occurring in the emergency department (ED). DESIGN/METHODOLOGY/APPROACH: A literature search was performed utilizing PubMed, Scopus, Web of Science and Google Scholar for studies through March of 2017 investigating search terms "iatrogenic procedure complications," "error management" and "procedure complications," in addition to the search terms reflecting case reports involving the eight below listed procedure complications. FINDINGS: This may be particularly helpful to academic faculty who supervise physicians in training who present a higher risk to cause such injuries. ORIGINALITY/VALUE: Emergent procedures performed in the ED present a higher risk for iatrogenic injury than in more controlled settings. Many physicians are taught error-avoidance rather than how to handle errors when learning procedures. There is currently very limited literature on the error management of iatrogenic procedure complications in the ED.

White Paper-Geriatric Emergency Medicine Education: Current State, Challenges, and Recommendations to Enhance the Emergency Care of Older Adults.

Older adults account for 25% of all emergency department (ED) patient encounters. One in five Americans will be 65 or older by 2030. In response to this need, geriatric emergency medicine (GEM) has developed into a robust area of academic and clinical interest, with extensive evidence-based research and guidelines, including clear undergraduate and postgraduate GEM competencies. Despite these developments, GEM content remains underrepresented in curricula and licensing examinations. The complex reasons for these deficits include a perception that care of older adults is not a core emergency medicine (EM) competency, a disjunction between traditional definitions of expertise and the GEM perspective, and lack of curricular capacity. This White Paper, prepared on behalf of the Academy of Geriatric Emergency Medicine, describes the state of GEM education, identifies the challenges it faces, and reviews innovations, including research presented at the 2018 Society for Academic Emergency Medicine (SAEM) Annual Scientific Meeting. The authors propose a number of recommendations. These include recognizing GEM as a core educational priority in EM, enhancing academic support for GEM clinician-educators, using social learning and practical problem solving to teach GEM concepts, emphasizing a whole-person multisystem approach to care of older adults, and identifying ageist attitudes as a hurdle to safe and effective GEM care.

Transfer of DNR orders to the ED from extended care facilities.

PURPOSE/OBJECTIVE: With an elderly and chronically ill patient population visiting the emergency department, it is important to know patients' wishes regarding care preferences and advanced directives. Ohio law states DNR orders must be transported with the patient when they leave an extended care facility (ECF). We reviewed the charts of ECF patients to evaluate which patients presenting to the ED had their DNR status recognized by the physician and DNR orders that were made during their hospital stay. METHODS: We prospectively enrolled patients presenting from ECFs to the ED, blinding the treating team to the purpose. We did a chart review for the presence of a DNR form, demographic data and acknowledgement of the DNR forms. RESULTS: Fifty patients were enrolled in this study. The mean age was 77.6years and 56% were female. Twenty-eight percent had a DNR order transported to the ED, but 68% had a DNR preference noted in their ECF notes. Registration only noted an advanced directive on 32% of patients (p=0.09). Eighteen percent had a DNR noted by the ED physician (p=0.42). Sixteen percent of patients had a DNR order written by an ED physician while 28% had a DNR order written by a non-ED physician during their inpatient evaluation. Thirty percent had a palliative care consult while in the hospital, but there was no significant association between DNR from the ECF and these consults. CONCLUSIONS: Hospital staff did a poor job of noting DNR preferences and ECFs were inconsistent with sending Ohio DNR forms.

Iatrogenic Spinal Cord Injury in a Trauma Patient with Ankylosing Spondylitis.

BACKGROUND: The recommended practice for over 30 years has been to routinely immobilize patients with unstable cervical spinal injuries using cervical spinal collars. It is shown that patients with Ankylosing spondylitis (AS) are four times more likely to suffer a spinal fracture compared to the general population and have an eleven-fold greater risk of spinal cord injury. Current protocols of spinal immobilization were responsible for secondary neurologic deterioration in some of these patients. OBJECTIVE: To describe an iatrogenic injury resulting from the use of a rigid spinal board and advocate for the use of alternative immobilization methods or no immobilization at all. CASE: We present our case here of a 68-year-old male with a history of AS. The patient was ambulatory on scene after a low speed car accident, but immobilized with a rigid backboard by paramedics. He developed back pain and paraplegia suddenly when the backboard was lifted for transport to the hospital. A CT scan revealed an extension fraction of T10 to T11 with involvement of the posterior column. Emergency spinal fusion was performed. Patient died of complications in the hospital. CONCLUSION: This case shows that spinal immobilization should be avoided in cases of ambulatory patients without a clear indication. Alternative transport methods such as vacuum mattresses should be considered when spinal immobilization is indicated, especially for patients with predispositions to spinal injury, particularly AS, to maintain the natural alignment of the spinal curvature.

Prevalence of strangulation in survivors of sexual assault and domestic violence.

OBJECTIVES: Both sexual assault (SA) survivors and domestic violence (DV) survivors are populations at risk of strangulation injury. Our goal was to identify the prevalence of strangulation in patients who are survivors of SA and DV, identify presence of lethality risk factors in intimate partner violence, and assess differences in strangulation between SA and DV populations. METHODS: We reviewed all patient encounters from our health system's SA/DV forensic nurse examiner program from 2004 to 2008. Medical records were reviewed for documented physical signs of strangulation or documentation of strangulation. Risk factors for lethality included presence of firearm, threats of suicide/homicide by the perpetrator, significant bodily injury, loss of consciousness, loss of bladder or bowel control, voice changes, or difficulty swallowing. Data were analyzed with Pearson χ(2) and 95% confidence intervals (CIs). RESULTS: A total of 1542 encounters were reviewed. The mean patient age was 30 (range, 13-98) years and 97% were female. Six hundred forty-nine encounters were for DV assaults and 893 were SA. An intimate partner was the assailant 46% of the time; 84% DV vs 16% SA (P<.001). Patients reported strangulation in 23% (351/1542; 95% CI, 21%-25%) of their assaults. The prevalence of strangulation was 38% with DV and 12% with SA (P<.001). Most of the intimate partner encounters with strangulation had significant risk for lethality (97%, 261/269; 95% CI, 94%-99%). CONCLUSIONS: Patients presenting to our forensic nurse examiner program who were survivors of DV were more likely than SA patients to sustain strangulation. Lethality risk factors were common.