A protocol to determine the acceptability and feasibility of a pilot intervention emergency department virtual observation unit fall prevention program.

BACKGROUND: As a third of all community dwellers aged 65+ fall each year, falls are common reasons for older adults to present to an Emergency Department (ED). Although EDs should assess patients' multifactorial fall risks to prevent future fall-related injuries, this frequently does not occur. We describe our protocol to determine the feasibility, acceptability, and safety of a pilot ED Virtual Observation Unit (VOU) Falls program. METHODS: To ensure standardized conduct and reporting, the Standard Protocol Items for Intervention Trials (SPIRIT) guidelines will be used. The VOU is a program where patients are sent home from the ED but are part of a virtual observation unit in that they can call on-call ED physicians while they are being treated for conditions such as cellulitis, congestive heart failure, or pneumonia. A paramedic conducts daily visits with the patient and facilitates a telemedicine consult with an ED physician. VOU nursing staff conduct daily assessments of patients via telemedicine. The ED VOU Falls program is one of the VOU pathways and is a multi-component fall prevention program for fall patients who present after an ED visit. The paramedic conducts a home safety evaluation, a Timed Up and Go Test (TUG). During the VOU visit, the ED physician conducts a telemedicine visit, while the paramedic is visiting the home, to review patients' fall-risk-increasing drugs and their TUG test. We will determine feasibility by calculating rates of patient enrollment refusal, and adherence to fall-risk prevention recommendations using information from 3-month follow-up telephone calls, as well as qualitative interviews with the paramedics. We will determine the acceptability of the ED VOU Falls program based on patient and provider surveys using a Likert scale. We will ask VOU nursing staff to report any safety issues encountered while the patient is in the ED VOU Falls program (e.g., tripping hazards). We will use the chi-square test or Fisher's exact test for categorical variables, Student's t-test for continuous variables, and Mann-Whitney for nonparametric data. We will review interview transcripts and generate codes. Codes will then be extracted and organized into concepts to generate an overall theme following grounded theory methods. This is a pilot study; hence, results cannot be extrapolated. However, a definite trial would be the next step in the future to determine if such a program could be implemented as part of fall prevention interventions. DISCUSSION: This study will provide insights into the feasibility and acceptability of a novel ED VOU Falls program with the aim of ultimately decreasing falls. In the future, such a program could be implemented as part of fall prevention interventions.

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.

Code De-Escalation: Decreasing restraint use during agitation management in a community hospital emergency department.

INTRODUCTION: Restraint use in the emergency department (ED) can pose significant risks to patients and health care workers. We evaluate the effectiveness of Code De-escalation- a standardized, team-based approach for management and assessment of threatening behaviors- in reducing physical restraint use and workplace violence in a community ED. METHODS: A retrospective observational study of a pathway on physical restraint use among patients placed on an involuntary psychiatric hold in a community ED. This pathway includes a built-in step for the team members to systematically assess perceptions of threats from the patient behavior and threats perceived by the patient. Our primary outcome was the change in the rate of physical restraint use among patients on an involuntary psychiatric hold. Our secondary outcome was the change in the rate of workplace violence events involving all ED encounters. We evaluated our outcomes by comparing all encounters in a ten-month period before and after implementation, and compared our results to rates at neighboring community hospitals within the same hospital network. RESULTS: Pre intervention there were 434 ED encounters involving a psychiatric hold, post-intervention there were 535. We observed a significant decrease in physical restraint use, from 7.4% to 3.7% (ARR 0.028 [95% CI 0.002-0.055], p < 0.05). This was not seen at the control sites. CONCLUSIONS: A standardized de-escalation algorithm can be effective in helping ED's decrease their use of physical restraints in management of psychiatric patients experiencing agitation.

Older Adult Falls in Emergency Medicine, 2023 Update.

Of 4 older adults, 1 will fall each year in the United States. Based on 2020 data from the Centers of Disease Control, about 36 million older adults fall each year, resulting in 32,000 deaths. Emergency departments see about 3 million older adults for fall-related injuries with falls having the ability to cause serious injury such as catastrophic head injuries and hip fractures. One-third of older fall patients discharged from the ED experience one of these outcomes at 3 months.

Diversity, Equity, and Inclusion: Considerations in the Geriatric Emergency Department Patient.

This article introduces core topics in health equity scholarship and provides examples of how diversity, equity, and inclusion impact the aging population and emergency care of older adults. It offers strategies for promoting diversity, equity, and inclusion to both strengthen the patient-clinician therapeutic relationship and to address operations and systems that impact care of the geriatric emergency department patient.

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

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

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

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

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

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

High touch, high trust: Using community health advocates and lawyers to address ED high utilizers.

BACKGROUND: Emergency department (ED) high utilizers are a costly group of patients due to their higher utilzation of acute care costs. At a safety-net hospital, we enrolled patients in a program which partnered with lawyers and community health advocates (CHAs) to navigate patients' social, medical and legal needs. Our aim was to decrease costs and utilization and address the patient's social determinants of heath (SDOH). METHODS: We enrolled patients with 4 or more ED visits in the prior 6 months and gave them SDOH and medical questionnaires. Patients were followed for 6 months on a weekly, then bi-monthly basis. All utilization and cost data were obtained through an internal data warehouse and evaluated using a pre-post analysis and broken down into quartiles. RESULTS: ED, admission, and total costs did not differ significantly between the 12 months pre-enrollment and the 12 months post-enrollment. Outpatient costs did increase ($2182 increase, p < 0.005). ED visits declined significantly in the post-enrollment period (IRR = 0.84, p = 0.048), with the highest impact on those with <7 ED visits. Total admissions did not decline (IRR 0.84, p = 0.059). But, among those with 4 or 5 ED visits, admission costs and visits decreased. On average, six SDOH issues were identified. Of these, approximately 30.3% were mitigated with up to 17% requiring legal help. CONCLUSION: While outpatient costs did increase, total costs did not decrease in this program. This type of non-clinical intervention may be best served for patients who are less clinically complex but significant social needs.

Emergency department falls: a longitudinal analysis of revisits and hospitalisations between patients who fall and patients who did not fall.

OBJECTIVE: Older adult falls are a national issue comprising 3 million emergency department (ED) visits and significant mortality. We sought to understand whether ED revisits and hospitalisations for fallers differed from non-fall patients through a secondary analysis of a longitudinal, statewide cohort of patients. DESIGN: We performed a secondary analysis using the non-public Patient Discharge Database and the ED data from the California Office of Statewide Health Planning and Development. This is a 5-year, longitudinal observational dataset, which was used to assess outcomes for fallers and non-fall patients, defined as anyone who did not carry a fall diagnosis during this time period. SETTING: 2005-2010 non-public Patient Discharge Database and the ED Data from the state of California. PARTICIPANTS: Older adults 65 years and older MAIN OUTCOME MEASURE: ED revisits and hospitalisations for fallers and non-fall patients. RESULTS: Patients who came to the ED with an index visit of a fall were more likely to be discharged home after their fall (61.1% vs 45.0%, p<0.001). Fallers who were discharged or hospitalised after their index visit were more likely to come back to the ED for a fall related complaint compared with non-fallers (median time: 151 days vs 352 days, p<0.001 and hospitalised: 45 days vs 119 days, p<0.01) and fallers who were initially discharged also returned to the ED sooner for a non-fall related complaint (median time: 325 days vs 352 days, p<0.001). CONCLUSION: Fall patients tend to be discharged home more often after their index visit, but returned to the ED sooner compared with their non-fall counterparts. Given a faller's rates of ED revisits and hospitalisations, EDs should consider a fall as a poor prognostic indicator for future healthcare utilisation.

The social informatics of knowledge.

In the Introduction to this special issue on the Social Informatics of Knowledge, the editors of the issue reflect on the history of the term "social informatics" and how the articles in this issue both reflect and depart from the original concept. We examine how social informatics researchers have studied knowledge, computerization, and the workplace, and how all of those have evolved over time. We describe the process by which articles were included, how they help us understand the field of social informatics scholarship today, and reflect briefly on what the future of the field holds.

A scoping review of simulation models of peer review.

Peer review is a process used in the selection of manuscripts for journal publication and proposals for research grant funding. Though widely used, peer review is not without flaws and critics. Performing large-scale experiments to evaluate and test correctives and alternatives is difficult, if not impossible. Thus, many researchers have turned to simulation studies to overcome these difficulties. In the last 10 years this field of research has grown significantly but with only limited attempts to integrate disparate models or build on previous work. Thus, the resulting body of literature consists of a large variety of models, hinging on incompatible assumptions, which have not been compared, and whose predictions have rarely been empirically tested. This scoping review is an attempt to understand the current state of simulation studies of peer review. Based on 46 articles identified through literature searching, we develop a proposed taxonomy of model features that include model type (e.g. formal models vs. ABMs or other) and the type of modeled peer review system (e.g. peer review in grants vs. in journals or other). We classify the models by their features (including some core assumptions) to help distinguish between the modeling approaches. Finally, we summarize the models' findings around six general themes: decision-making, matching submissions/reviewers, editorial strategies; reviewer behaviors, comparisons of alternative peer review systems, and the identification and addressing of biases. We conclude with some open challenges and promising avenues for future modeling work.

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

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

Trends and Characteristics of Emergency Department Visits for Fall-Related Injuries in Older Adults, 2003-2010.

INTRODUCTION: One third of older adults fall each year, and falls are costly to both the patient in terms of morbidity and mortality and to the health system. Given that falls are a preventable cause of injury, our objective was to understand the characteristics and trends of emergency department (ED) fall-related visits among older adults. We hypothesize that falls among older adults are increasing and examine potential factors associated with this rise, such as race, ethnicity, gender, insurance and geography. METHODS: We conducted a secondary analysis of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to determine fall trends over time by examining changes in ED visit rates for falls in the United States between 2003 and 2010, detailing differences by gender, sociodemographic characteristics and geographic region. RESULTS: Between 2003 and 2010, the visit rate for falls and fall-related injuries among people age ≥ 65 increased from 60.4 (95% confidence interval [CI][51.9-68.8]) to 68.8 (95% CI [57.8-79.8]) per 1,000 population (p=0.03 for annual trend). Among subgroups, visits by patients aged 75-84 years increased from 56.2 to 82.1 per 1,000 (P <.01), visits by women increased from 67.4 to 81.3 (p = 0.04), visits by non-Hispanic Whites increased from 63.1 to 73.4 (p < 0.01), and visits in the South increased from 54.4 to 71.1 (p=0.03). CONCLUSION: ED visit rates for falls are increasing over time. There is a national movement to increase falls awareness and prevention. EDs are in a unique position to engage patients on future fall prevention and should consider ways they can also partake in such initiatives in a manner that is feasible and appropriate for the ED setting.

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

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

An Integrated Approach to Falls Prevention: A Model for Linking Clinical and Community Interventions through the Massachusetts Prevention and Wellness Trust Fund.

Older adult falls continue to be a public health priority across the United States-Massachusetts (MA) being no exception. The MA Prevention and Wellness Trust Fund (PWTF) program within the MA Department of Public Health aims to reduce the physical and economic burdens of chronic health conditions by linking evidence-based clinical care with community intervention programs. The PWTF partnerships that focused on older adult falls prevention integrated the Centers for Disease Control and Prevention's Stopping Elderly Accidents, Death and Injuries toolkit into clinical settings. Partnerships also offer referrals for home safety assessments, Tai Chi, and Matter of Balance programs. This paper describes the PWTF program implementation process involving 49 MA organizations, while highlighting the successes achieved and lessons learned. With the unprecedented expansion of the U.S. Medicare beneficiary population, and the escalating incidence of falls, widespread adoption of effective prevention strategies will become increasingly important for both public health and for controlling healthcare costs. The lessons learned from this PWTF initiative offer insights and recommendations for future falls prevention program development and implementation.

Exploring Older Adult ED Fall Patients' Understanding of Their Fall: A Qualitative Study.

OBJECTIVE: We sought to understand older patients' perspectives about their fall, fall risk factors, and attitude toward emergency department (ED) fall-prevention interventions. METHODS: We conducted semistructured interviews between July 2015 and January 2016 of community-dwelling, nondemented patients in the ED, who presented with a fall to an urban, teaching hospital. Interviews were halted once we achieve thematic saturation with the data coded and categorized into themes. RESULTS: Of the 63 patients interviewed, patients blamed falls on the environment, accidents, a medical condition, or themselves. Three major themes were generated: (1) patients blamed falls on a multitude of things but never acknowledged a possible multifactorial rationale, (2) patients have variable level of concerns regarding their current fall and future fall risk, and (3) patients demonstrated a range of receptiveness to ED interventions aimed at preventing falls but provided little input as to what those interventions should be. CONCLUSIONS: Many older patients who fall do not understand their fall risk. However, based on the responses provided, older adults tend to be more receptive to intervention and more concerned about their future fall risk, making the ED an appropriate setting for intervention.

OPEN ACCESS TO DIABETES CENTER FROM THE EMERGENCY DEPARTMENT REDUCES HOSPITALIZATIONS IN THE SUSEQUENT YEAR.

OBJECTIVE: Patients who present to the emergency department (ED) for diabetes without hyperglycemic crisis are at risk of unnecessary hospitalizations and poor outcomes. To address this, the ED Diabetes Rapid-referral Program (EDRP) was designed to provide ED staff with direct booking into the diabetes center. The objective of this study was to determine the effects of the EDRP on hospitalization rate, ED utilization rate, glycemic control, and expenditures. METHODS: We conducted a single-center analysis of the EDRP cohort (n = 420) and compared 1-year outcomes to historic controls (n = 791). We also compared EDRP patients who arrived (ARR) to those who did not show (NS). The primary outcome was hospitalization rate over 1 year. Secondary outcomes included ED recidivism rate, hemoglobin A1c (HbA1c), and healthcare expenditures. RESULTS: Compared with controls, the EDRP cohort was less likely to be hospitalized (27.1% vs. 41.5%, P<.001) or return to the ED (52.2% vs. 62.3%, P = .001) at the end of 1 year. Total hospitalizations were also lower in the EDRP (157 ± 19 vs. 267 ± 18 per 1,000 persons per year, P<.001). The EDRP cohort had a greater reduction in HbA1c (-2.66 vs. -2.01%, P<.001), which was more pronounced when ARR patients were compared with NS (-2.71% vs. -1.37%, P<.05). The mean per patient institutional healthcare expenditures were lower by $5,461 compared with controls. CONCLUSION: Eliminating barriers to scheduling diabetes-focused ambulatory care for ED patients was associated with significant reductions in hospitalization rate, ED recidivism rate, HbA1c, and healthcare expenditures in the subsequent year. ABBREVIATIONS: ARR = arrived ED = emergency department EDRP = emergency department diabetes rapid-referral Program HbA1c = hemoglobin A1c NS = no show.