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.

Trends in Inpatient Admission Comorbidity and Electronic Health Data: Implications for Resident Workload Intensity.

In the era of duty hour regulations, there is increasing concern regarding resident workload compression. We conducted a retrospective, observational assessment of all internal medicine resident admissions to a Veterans Affairs hospital over a 15-year period to evaluate several admission components that impact resident workload and workload intensity, including electronic health record (EHR) data burden and patient comorbidity. A total of 67,346 admissions were included in the analysis. Mean patient comorbidity, as measured by the Charlson Comorbidity Index, increased throughout the study period. EHR data burden, measured by numbers of notes, medications, and discharge summaries available per patient at the time of admission, also increased over the study period. These findings suggest that EHR data burden and comorbidity have increased over time, which impacts resident workload in the era of duty hour restrictions.

Transitioning Former Military Medics to Civilian Health Care Jobs: A Novel Pilot Program to Integrate Medics Into Ambulatory Care Teams for High-Risk Patients.

Despite their medical training, record of military service, and the unmet needs within the health care sector, numerous challenges face veterans who seek to leverage their health care skills for employment after leaving the military. Creative solutions are necessary to successfully leverage these skills into jobs for returning medics that also meet the needs of health care systems. To achieve this goal, we created a novel ambulatory care health technician position on the basis of existing literature and modeled after a program which incorporates former military medics in emergency departments. Through a quality improvement approach, a position description, interview process, training program with clinical competencies, and team integration plan were developed and implemented. To date, two medics have been hired, successfully trained on relevant skill sets, and are currently caring for medical outpatients (under the supervision of licensed clinical personnel) as crucial interdisciplinary team members. Taken together, a multifaceted approach is required to effectively harness military medics' skills and experiences to meet identified health delivery needs.

Clinical exposures during internal medicine acting internship: profiling student and team experiences.

BACKGROUND: The clinical learning model in medical education is driven by knowledge acquisition through direct patient-care experiences. Despite the emphasis on experiential learning, the ability of educators to quantify the clinical exposures of learners is limited. OBJECTIVE: To utilize Veterans Affairs (VA) electronic medical record information through a data warehouse to quantify clinical exposures during an inpatient internal medicine rotation. METHODS: We queried the VA clinical data warehouse for the patients encountered by each learner completing an acting internship rotation at the Cleveland VA Medical Center from July 2008 to November 2011. We then used discharge summary information to identify team exposures-patients seen by the learner's inpatient team who were not primarily assigned to the learner. Based on the learner and team exposures, we complied lists of past medical problems, medications prescribed, laboratory tests that resulted, radiology evaluated, and primary discharge diagnoses. RESULTS: Primary learner and team-based clinical exposures were evaluated for a total of 128 acting internship students. The percentage of learners who had a primary exposure to a medication/lab value/imaging result/diagnosis was calculated. The percentage of learners with at least 1 primary or team-based exposure to an item was also calculated. The most common exposures in each category are presented. CONCLUSIONS: Analysis of the clinical exposures during an inpatient rotation can augment the ability of educators to understand learners' experiences. These types of analyses could provide information to improve learner experience, implement novel curricula, and address educational gaps in clinical rotations.

Resonantlike phenomenon in short-pulse free-electron-laser oscillators with modulated desynchronism.

Recently a new method of controlling the pulse length of a short-pulse free-electron laser (FEL) has been developed. By modulating the synchronism between the optical and electron pulses in the FEL cavity, it was found that the output power and the micropulse length of the FEL beam oscillates at the modulation frequency. In this paper, we study theoretically the behavior of the micropulse length, both in the high loss (steady state) regime and the low loss (limit cycle) regime, when a modulated desynchronism is applied. In order to do this, we analyze the dynamics of a short-pulse FEL oscillator. The modulation frequency value plays an important role in the dynamics. We find that there is a resonantlike phenomenon between the externally applied desynchronism modulation and the limit cycle oscillation without modulation of a free-electron laser.