Population-Level Surveillance of Domestic Assaults in the Home Using the National Emergency Medical Services Information System (NEMSIS).

Violence in the home, including partner violence, child abuse, and elder abuse, is pervasive in the United States. An informatics approach allowing automated analysis of administrative data to identify domestic assaults and release timely and localized data would assist preventionists to identify geographic and demographic populations of need and design tailored interventions. This study examines the use of an established national dataset, the NEMSIS 2019, as a potential annual automated data source for domestic assault surveillance. An algorithm was used to identify individuals who utilized emergency medical services (EMS) for a physical assault in a private residence (N = 176,931). Descriptive analyses were conducted to define the identified population and disposition of patients. A logistic regression was performed to predict which characteristics were associated with consistent domestic assault identification by the on-scene EMS clinician and dispatcher. The sample was majority female (52.2%), White (44.7%), urban (85.5%), and 21-29 years old (24.4%). A disproportionate number of those found dead on scene were men (74.5%), and female patients more often refused treatment (57.8%) or were treated and then released against medical advice (58.4%). Domestic assaults against children and seniors had higher odds of being consistently identified by both the dispatcher and EMS clinician than those 21-49, and women had lower odds of consistent identification than men. While a more specific field to identify the type of domestic assault (e.g., intimate partner) would help inform specialized intervention planning, these data indicate an opportunity to systematically track domestic assaults in communities and describe population-specific needs.

Clinical Trauma Severity of Indoor and Outdoor Injurious Falls Requiring Emergency Medical Service Response.

Background: Injurious falls represent a significant public health burden. Research and polices have primarily focused on falls occurring indoors despite evidence that outdoor falls account for 47-58% of all falls requiring some medical attention. This study compared the clinical trauma severity of indoor versus outdoor injurious falls requiring Emergency Medical Services (EMS) response. Methods: Using the 2019 National Emergency Medical Services Information System (NEMSIS) dataset, we identified the location of patients injured from falls that required EMS response. We classified injury severity using 1) the Revised Trauma Score for Triage (T-RTS): ≤ 11 indicated the need for transport to a Trauma Center; 2) Glasgow Coma Scale (GCS): ≤8 and 9-12 indicated moderate and severe neurologic injury; and 3) patient clinical acuity by EMS: Dead, Critical, Emergent, Low. Results: Of 1,854,909 encounters for patients with injurious falls, the vast majority occurred indoors (n=1,596,860) compared to outdoors (n=152,994). The proportions of patients with moderate or severe GCS scores, were comparable between those with indoor falls (3.0%) and with outdoor falls on streets or sidewalks (3.8%), T-RTS scores indicating need for transport to a Trauma Center (5.2% vs 5.9%) and EMS acuity rated as Emergent or Critical (27.7% vs 27.1%).Injurious falls were more severe among male patients compared to females: and males injured by falling on streets or sidewalks had higher percentages for moderate or severe GCS scores (4.8% vs 3.6%) and T-RTS scores indicating the need for transport to a Trauma Center (7.3% vs 6.5%) compared to indoor falls. Young and middle-aged patients whose injurious falls occurred on streets or sidewalks were more likely to have a T-RTS score indicating the need for Trauma Center care compared to indoor falls among this subgroup. Yet older patients injured by falling indoors were more likely to have a T-RTS score indicating the need for Trauma Center than older patients who fell on streets or sidewalks. Conclusions: There was a similar proportion of patients with severe injurious falls that occurred indoors and on streets or sidewalks. These findings suggest the need to determine outdoor environmental risks for outdoor falls to support location-specific interventions.

Perspectives from persons living with dementia and their caregivers on emergency department visits, care transitions, and outpatient follow-up: A qualitative study.

BACKGROUND: Persons living with dementia (PLWD) experience frequent and costly emergency department (ED) visits, with poor outcomes attributed to suboptimal care and postdischarge care transitions. Yet, patient-centered data on ED care experiences and postdischarge needs are lacking. The objective of this study was to examine the facilitators and barriers to successful ED care and care transitions after discharge, according to PLWD and their caregivers. METHODS: We conducted a qualitative study involving ED patients ages 65 and older with confirmed or suspected dementia and their caregivers. The semistructured interview protocol followed the National Quality Forum's ED Transitions of Care Framework and addressed ED care, care transitions, and outpatient follow-up care. Interviews were conducted during an ED visit at an urban, academic ED. Traditional thematic analysis was used to identify themes. RESULTS: We interviewed 11 patients and 19 caregivers. Caregivers were more forthcoming than patients about facilitators and challenges experienced. Characteristics of the patients' condition (e.g., resistance to care, forgetfulness), the availability of family resources (e.g., caregiver availability, primary care access), and system-level factors (e.g., availability of timely appointments, hospital policies tailored to persons with dementia) served as facilitators and barriers to successful care. Some resources that would ameliorate care transition barriers could be easily provided in the ED, for example, offering clear discharge instructions and care coordination services and improving patient communication regarding disposition timeline. Other interventions would require investment from other parts of the health care system (e.g., respite for caregivers, broader insurance coverage). CONCLUSIONS: ED care and care transitions for PLWD are suboptimal, and patient-level factors may exacerbate existing system-level deficiencies. Insight from patients and their caregivers may inform the development of ED interventions to design specialized care for this patient population. This qualitative study also demonstrated the feasibility of conducting ED-based studies on PLWD during their ED visit.

A National Study on the Comparative Burden of Pedestrian Injuries from Falls Relative to Pedestrian Injuries from Motor Vehicle Collisions.

Pedestrian injuries from falls are an understudied cause of morbidity. Here, we compare the burden of pedestrian injuries from falls occurring on streets and sidewalks with that from motor vehicle collisions. Data on injurious falls on streets and sidewalks, and pedestrian-motor vehicle collisions, to which Emergency Medical Services responded, along with pedestrian and incident characteristics, were identified in the 2019 National Emergency Medical Services Information System database. In total, 118,520 injurious pedestrian falls and 33,915 pedestrians-motor vehicle collisions were identified, with 89% of the incidents occurring in urban areas. Thirty-two percent of pedestrians struck by motor vehicles were coded as Emergent or Critical by Emergency Medical Services, while 19% of pedestrians injured by falls were similarly coded. However, the number of pedestrians whose acuity was coded as Emergent or Critical was 2.1 times as high for injurious falls as compared with pedestrians-motor vehicle collisions. This ratio was 3.9 for individuals 50 years and older and 6.1 for those 65 years and older. In conclusion, there has been substantial and appropriate policy attention given to preventing pedestrian injuries from motor vehicles, but disproportionately little to pedestrian falls. However, the population burden of injurious pedestrian falls is significantly greater and justifies an increased focus on outdoor falls prevention, in addition to urban design, policy, and built environment interventions to reduce injurious falls on streets and sidewalks, than currently exists across the USA.

Emergency department resource utilization among nursing home residents, a National Cross-Sectional Study.

OBJECTIVES: Persons 65 years and older (older persons), particularly residents of nursing homes (NHs), disproportionately access the emergency department (ED) and utilize more medical resources. The goal of this study is to provide a contemporary description of healthcare utilization patterns and disposition decisions for United States (US) NH residents presenting to EDs. METHODS: Older persons presenting to EDs in the US were identified in the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2017, 2018 and 2019 datasets. We examined demographic, clinical, and resource use characteristics and outcomes. After survey weighting, we compared the frequency of different imaging, medications, clinical interventions, and outcomes in the ED between NH residents and those residing outside NHs. RESULTS: From 2017 to 2019, older persons made 24,441,285 annual visits to the ED, comprising 17.5% of all visits. Among these, 1,579,916 visits (6.5%) were by NH residents. Compared with non-NH residents, NH residents were older (mean age: 81.2 [95%CI 81.5-82.9] vs 76.1 [95%CI 75.8-76.4]), underwent more imaging (82.8% [95%CI 79.5-86.1] vs 71.6% [95%CI 69.9-73.3]), were administered fewer potentially inappropriate medications (PIMs) in the ED or upon discharge (9.5% [95%CI 6.2-2.7] vs 17.1% [95%CI 15.8-18.4]), and had a higher proportion of visits resulting in hospital admission (44.1% [95%CI 38.2-49.9] vs 26.0% [95%CI 23.3, 28.7]). CONCLUSIONS: Older NH residents presenting to the ED use more resources and are more likely to be hospitalized compared to older persons residing outside NHs. The resource-intensive nature of these visits highlights the importance of targeted, multi-disciplinary interventions that optimize ED care for this population.

Frailty assessment tools in the emergency department: A geriatric emergency department guidelines 2.0 scoping review.

Objective: Given the aging population and growing burden of frailty, we conducted this scoping review to describe the available literature regarding the use and impact of frailty assessment tools in the assessment and care of emergency department (ED) patients older than 60 years. Methods: A search was made of the available literature using the Covidence system using various search terms. Inclusion criteria comprised peer-reviewed literature focusing on frailty screening tools used for a geriatric population (60+ years of age) presenting to EDs. An additional search of PubMed, EBSCO, and CINAHL for articles published in the last 5 years was conducted toward the end of the review process (January 2023) to search specifically for literature describing interventions for frailty, yielding additional articles for review. Exclusion criteria comprised articles focusing on an age category other than geriatric and care environments outside the emergency care setting. Results: A total of 135 articles were screened for inclusion and 48 duplicates were removed. Of the 87 remaining articles, 20 were deemed irrelevant, leaving 67 articles for full-text review. Twenty-eight were excluded for not meeting inclusion criteria, leaving 39 full-text studies. Use of frailty screening tools were reported in the triage, care, and discharge decision-making phases of the ED care trajectory, with varying reports of usefulness for clinical decision-making. Conclusion: The literature reports tools, scales, and instruments for identifying frailty in older patients at ED triage; multiple frailty scores or tools exist with varying levels of utilization. Interventions for frailty directed at the ED environment were scant. Further research is needed to determine the usefulness of frailty identification in the context of emergency care, the effects of care delivery interventions or educational initiatives for front-line medical professionals on patient-oriented outcomes, and to ensure these initiatives are acceptable for patients.

Life-Space Mobility: Normative Values From a National Cohort of U.S. Older Adults.

BACKGROUND: Life-space mobility, which measures the distance, frequency, and independence achieved as individuals move through their community, is one of the most important contributors to healthy aging. The University of Alabama at Birmingham Life-Space Assessment (LSA) is the most commonly used measure of life-space mobility in older adults, yet U.S. national norms for LSA have not previously been reported. This study reports such norms based on age and sex among community-dwelling older adults. METHODS: A cross-sectional analysis using data from the national REasons for Geographic and Racial Disparities in Stroke cohort study. LSA data were available for 10 118 Black and White participants over age 50, which were grouped by age (in 5-year increments) and sex, weighted for the U.S. national population. Correlations were calculated between LSA and measures of functional and cognitive impairment and physical performance. RESULTS: The weighted mean LSA ranged from 102.9 for 50-54-year-old males to 69.5 for males aged 85 and older, and from 102.1 for 50-54-year-old females to 60.1 for females aged 85 and older. LSA was strongly correlated with measures of timed walking, activities of daily living, cognition, depressive symptoms, and quality of life (all p < .001). CONCLUSIONS: We report U.S. national norms for LSA among community-dwelling Black and White older adults. These norms can serve as a reference tool for determining if clinical and research samples have greater or lesser life-space mobility than typical older adults in the United States for their age and sex.

A National Study on the Comparative Burden of Pedestrian Injuries from Falls Relative to Pedestrian Injuries from Motor Vehicle Collisions.

Pedestrian injuries from falls are an understudied cause of morbidity. Here we compare the burden of pedestrian injuries from falls occurring on streets and sidewalks with that from motor vehicle collisions. Data on injurious falls on streets and sidewalks, and pedestrian-motor vehicle collisions, to which Emergency Medical Services responded, along with pedestrian and incident characteristics, were identified in the 2019 National Emergency Medical Services Information System database. In total, 129,343 injurious falls and 33,910 pedestrians-motor vehicle collisions were identified, with 89% of the incidents occurring in urban areas. Thirty two percent of pedestrians struck by motor vehicles were coded as Emergent or Critical by Emergency Medical Services, while 20% of pedestrians injured by falls were similarly coded. However, the number of pedestrians whose acuity was coded as Emergent or Critical was 2.33 times as high for injurious falls as compared with pedestrians-motor vehicle collisions. This ratio was nearly double at 4.3 for individuals 50 years and older, and almost triple at 6.5 for those 65 years and older. In conclusion, there has been substantial and appropriate policy attention given to preventing pedestrian injuries from motor vehicles, but disproportionately little to pedestrian falls. However, the population burden of injurious pedestrian falls is significantly greater and justifies an increased focus on outdoor falls prevention, in addition to urban design, policy and built environment interventions to reduce injurious falls on streets and sidewalks, than currently exists across the U.S.

Delirium, confusion, or altered mental status as a risk for abnormal head CT in older adults in the emergency department: A systematic review and meta-analysis.

BACKGROUND: Altered mental status (including delirium) is a common presentations among older adults to the emergency department (ED). We aimed to report the association between altered mental status in older ED patients and acute abnormal findings on head computed tomogram (CT). METHODS: A systematic review was conducted using Ovid Medline, Embase, Clinicaltrials.gov, Web of Science, and Cochrane Central from conception to April 8th, 2021. We included citations if they described patients aged 65 years or older who received head imaging at the time of ED assessment, and reported whether patients had delirium, confusion, or altered mental status. Screening, data extraction, and bias assessment were performed in duplicate. We estimated the odds ratios (OR) for abnormal neuroimaging in patients with altered mental status. RESULTS: The search strategy identified 3031 unique citations, of which two studies reporting on 909 patients with delirium, confusion or altered mental status were included. No identified study formally assessed for delirium. The OR for abnormal head CT findings in patients with delirium, confusion or altered mental status was 0.35 (95% CI 0.031 to 3.97) compared to patients without delirium, confusion or altered mental status. CONCLUSION: We did not find a statistically significant association between delirium, confusion or altered mental status and abnormal head CT findings in older ED patients.

A methodology for the public health surveillance and epidemiologic analysis of outdoor falls that require an emergency medical services response.

BACKGROUND: Falls are a common cause of injury with significantly associated medical costs yet public health surveillance of injuries from falls is underdeveloped. In addition, the epidemiologic understanding of outdoor falls, which have been reported to account for 47% of all injurious falls, is scant. Here we present methods to use emergency medical services (EMS) data as a public health surveillance tool for fall injuries, including those that occur secondary to syncope and heat illness, with a focus on the scope and epidemiology of outdoor fall injuries. METHODS: Using the 2019 National Emergency Medical Services Information System (NEMSIS) data, we developed an approach to identify EMS encounters for fall injuries, syncope and heat illness. NEMSIS variables used in our algorithm included the EMS respondent's impression of the encounter, the reported major symptoms and the cause of injury. With these data we identified injuries from falls and, using the NEMSIS data on the location of the encounter, we identified fall injuries as occurring indoors or outdoors. We present the descriptive epidemiology of the identified patients. RESULTS: There were 1,854,909 injuries from falls that required an EMS response identified in the NEMSIS data, with 4% of those injuries secondary to episodes of syncope (n = 73,126) and heat illness. Sufficient data were available from 94% of injurious falls that they could be assigned to indoor or outdoor locations, with 9% of these fall injuries occurring outdoors. Among fall injuries identified as occurring outdoors, 85% occurred on streets and sidewalks. Patient age was the primary sociodemographic characteristic that varied by location of the injurious fall. Sixty-six percent of fall injuries that occurred indoors were among those age 65 years or older, while this figure was 34% for fall injuries occurring outdoors on a street or sidewalk. CONCLUSION: The occurrence of outdoor fall injuries identified in the NEMSIS data were substantially lower than reported in other data sets. However, numerically fall injuries occurring outdoors represent a substantial public health burden. The strengths and weaknesses of using this approach for routine public health surveillance of injuries from falls, syncope and heat illness are discussed.

Head computed tomography findings in geriatric emergency department patients with delirium, altered mental status, and confusion: A systematic review.

BACKGROUND: Delirium, altered mental status (AMS), or confusion among older adults are common presentations to the emergency department (ED). We aimed to report the proportion of older ED patients presenting with delirium who have acute abnormal findings on head imaging. We also assessed whether anticoagulation, neurological deficits, trauma, or headache were associated with head imaging abnormalities in these patients. METHODS: A systematic review was performed using Ovid Medline, Embase, Clinicaltrials.gov, Web of Science, and Cochrane Central from conception to April 8, 2021. Citations were included if they described patients aged 65 years or older who received neuroimaging at the time of ED assessment for delirium, confusion, or AMS. Screening, data extraction, and bias assessment were performed in duplicate. The estimated proportion of patients with abnormal neuroimaging and odds ratios (ORs) for each predictor were calculated. RESULTS: The search strategy identified 3014 unique citations, of which six studies reporting on 909 patients with confusion or AMS were included. None of the studies formally diagnosed delirium. Overall, the proportions of older ED patients with AMS or confusion were found to have an abnormal head computed tomography (CT) was 15.6% (95% confidence interval [CI] 7.3%-26.2%). The prevalence of focal neurologic findings was 13.0% (66/506) and for anticoagulation was 9.8% (33/337) among the studies who reported them. The presence of a focal neurological deficit was associated with abnormal head CT (OR 101.8, 95% CI 30.5-340.1). Anticoagulation was not associated with abnormal head CT (OR 1.2, 95% CI 0.4-3.3). No studies reported on the association between headache or trauma and abnormal neuroimaging. CONCLUSIONS: The proportion of abnormal findings on CT neuroimaging in older ED patients with AMS or confusion was 15.6%. The presence of a focal neurological deficit was a strong predictor for the presence of acute abnormality, whereas anticoagulation was not.

COVID-19 hospital and emergency department visitor policies in the United States: Impact on persons with cognitive or physical impairment or receiving end-of-life care.

OBJECTIVE: To characterize the national distribution of COVID-19 hospital and emergency department visitor restriction policies across the United States, focusing on patients with cognitive or physical impairment or receiving end-of-life care. METHODS: Cross-sectional study of visitor policies and exceptions, using a nationally representative random sample of EDs and hospitals during the first wave of the COVID-19 pandemic, by trained study investigators using standardized instrument. RESULTS: Of the 352 hospitals studied, 326 (93%) had a COVID-19 hospital-wide visitor restriction policy and 164 (47%) also had an ED-specific policy. Hospital-wide policies were more prevalent at academic than non-academic (96% vs 90%; P < 0.05) and at urban than rural sites (95% vs 84%; P < 0.001); however, the prevalence of ED-specific policies did not significantly differ across these site characteristics. Geographic region was not associated with the prevalence of any visitor policies. Among all study sites, only 58% of hospitals reported exceptions for patients receiving end-of-life care, 39% for persons with cognitive impairment, and 33% for persons with physical impairment, and only 12% provided policies in non-English languages. Sites with ED-specific policies reported even fewer exceptions for patients with cognitive impairment (29%), with physical impairments (24%), or receiving end-of-life care (26%). CONCLUSION: Although the benefits of visitor policies towards curbing COVID-19 transmission had not been firmly established, such policies were widespread among US hospitals. Exceptions that permitted family or other caregivers for patients with cognitive or physical impairments or receiving end-of-life care were predominantly lacking, as were policies in non-English languages.

Safety and Feasibility of Tele-Supervised Home-Based Transcranial Direct Current Stimulation for Major Depressive Disorder.

Major depressive disorder (MDD) is a worldwide cause of disability in older age, especially during the covid pandemic. Transcranial direct current stimulation (tDCS) is a non-invasive neuromodulation technique that has shown encouraging efficacy for treatment of depression. Here, we investigate the feasibility of an innovative protocol where tDCS is administered within the homes of older adults with MDD (patient participants) with the help of a study companion (i.e. caregiver). We further analyze the feasibility of a remotely-hosted training program that provides the knowledge and skills to administer tDCS at home, without requiring them to visit the lab. We also employed a newly developed multi-channel tDCS system with real-time monitoring designed to guarantee the safety and efficacy of home-based tDCS. Patient participants underwent a total of 37 home-based tDCS sessions distributed over 12 weeks. The protocol consisted of three phases each lasting four weeks: an acute phase, containing 28 home-based tDCS sessions, a taper phase containing nine home-based tDCS sessions, and a follow up phase, with no stimulation sessions. We found that the home-based, remotely-supervised, study companion administered, multi-channel tDCS protocol for older adults with MDD was feasible and safe. Further, the study introduces a novel training program for remote instruction of study companions in the administration of tDCS. Future research is required to determine the translatability of these findings to a larger sample. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04799405?term=NCT04799405&draw=2&rank=1, identifier NCT04799405.

Older adult visits to the emergency department for ambulatory care sensitive conditions.

OBJECTIVES: Ambulatory-care-sensitive conditions (ACSCs) represent emergency department (ED) visits and hospital admissions that might have been avoided through earlier primary care intervention. We characterize the current frequency and cost of ACSCs among older adults (≥65 years of age) in the ED. METHODS: This study is a retrospective analysis of Centers for Medicare and Medicaid Services (CMS) national claims data distributed by the Research Data Assistance Center, a CMS contractor based at the University of Minnesota. We analyzed outpatient ED-based national claims data for visits made by traditional fee-for-service (FFS) Medicare beneficiaries in 2016. ACSCs were identified according to the Agency for Healthcare Research and Quality's Prevention Quality Indicators criteria, which require that the ACSC be the primary diagnosis for the visit. Analysis was done in Alteryx and R. RESULTS: We documented nearly 1.8 million ACSC ED visits in 2016, finding that ≈10.6% of all ED visits by older adult FFS Medicare beneficiaries were associated with an ACSC. ACSC ED visits resulted in admission more often (39.7%) than non-ACSC ED visits (23.9%). Notably, 83% of patients with short-term complications from diabetes were admitted. CONCLUSIONS: ED visits for a primary diagnosis of an ACSC highlight opportunities to improve access to preventive care, particularly earlier recognition and treatment of patients' deteriorating conditions that could have potentially precluded the need for the ED visit. An opportunity exists to leverage ED-based initiatives during an ACSC ED visit to support appropriate community and care transitions of these high-risk patients.