Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool.

Agitation and delirium are common reasons for older adults to seek care in the emergency department (ED). Providing care for this population in the ED setting can be challenging for emergency physicians. There are several knowledge translation gaps in how to best screen older adults for these conditions and how to manage them. A working group of subject-matter experts convened to develop an easy-to-use, point-of-care tool to assist emergency physicians in the care of these patients. The tool is designed to serve as a resource to address the knowledge translation and implementation gaps that exist in the field. The purpose of this article is present and explain the Assess, Diagnose, Evaluate, Prevent, and Treat tool. Participants were identified with expertise in emergency medicine, geriatric emergency medicine, geriatrics, and psychiatry. Background literature reviews were performed before the in-person meeting in key areas: delirium, dementia, and agitation in older adults. Participants worked electronically before and after an in-person meeting to finalize development of the tool in 2017. Subsequent work was performed electronically in the following months and additional expert review sought. EDs are an important point of care for older adults. Behavioral changes in older adults can be a manifestation of underlying medical problems, mental health concerns, medication adverse effects, substance abuse, or dementia. Five core principles were identified by the group that can help ensure adequate and thorough care for older adults with agitation or delirium: assess, diagnose, evaluate, prevent, and treat. This article provides background for and explains the importance of these principles related to the care of older adults with agitation. It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes and have the tools to screen older adults for those causes, and methods to treat the underlying causes and ameliorate their symptoms.

Concepts in Practice: Geriatric Emergency Departments.

In 2018, the American College of Emergency Physicians (ACEP) began accrediting facilities as "geriatric emergency departments" (EDs) according to adherence to the multiorganizational guidelines published in 2014. The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-effective manner and within the capabilities of their facilities and staff. Because all innovation is at heart local and must function within the constraints of local resources, different hospital systems have developed implementation processes for the geriatric ED guidelines according to their differing institutional capabilities and resources. This article describes 4 geriatric ED models of care to provide practical examples and guidance for institutions considering developing geriatric EDs: a geriatric ED-specific unit, geriatrics practitioner models, geriatric champions, and geriatric-focused observation units. The advantages and limitations of each model are compared and examples of specific institutions and their operational metrics are provided.

Severe hypernatremia and gastric dilation from chronic eating disorder and intentional salt ingestion.

We report the case of a 21-year-old female presenting with severe hypernatremia and a gastric outlet obstruction due to chronic purging behavior with salt water flushes. She presented obtunded following emesis and a witnessed seizure. She was found to have a corrected sodium level of 177 mmol/L. Following initial intubation and resuscitation, her CT imaging showed massive gastric dilation with high-density material in the gastric lumen. After orogastric flushing was unsuccessful and the patient's abdominal distention worsened, she was managed surgically and found to have a salt bezoar leading to bowel ischemia and perforation. This case details the complications and management of acute hypernatremia and gastric outlet obstruction in an otherwise healthy, young female. In a society where eating disorders are pervasive, Emergency Medicine physicians should be familiar with dangerous dietary behaviors as well as the management of their rare, but potentially life-threatening, complications.

Medical Student Learning Experience With Attending or Resident Preceptors in the Emergency Department.

Objectives The emergency department (ED) provides a unique learning environment for medical students. However, environment, patient, and preceptor factors limit standardized teaching. We explored the most effective educational interactions for fourth-year medical students during an emergency medicine (EM) clerkship designed to allow clinical interaction with both residents and faculty. Methods This is an exploratory, prospective, needs assessment study of objective cards and surveys submitted by medical students as part of their month-long fourth-year clinical rotation at a tertiary care academic ED. Students marked which topics or procedures they had reviewed, and who had precepted them. In an exit survey, students were asked to rate how often they received individualized teaching and whether their educational goals were met when working with residents and attendings. Qualitative and quantitative data were collected anonymously with institutional review board (IRB) exemption. Results Shift card data was collected from 69 of the rotating students. Attendings tended to precept visual diagnostics while residents tended to teach technical procedures. Forty-four students completed the exit survey. Results showed that students felt they received individualized teaching from both attendings and residents (7.9 and 8.0 respectively, p = 0.059). Students felt their goals were met more when reporting to the residents than the attendings but not significantly so (8.6 and 8.0, respectively, p = 0.088). Additional themes were that students wanted more individualized experiences with the attendings and requested more dedicated teaching shifts. Conclusions Fourth-year medical students in the ED felt they received individualized teaching on most shifts. They reported their education goals were met as often when working with residents as with attendings; however, interactions feature different educational content. Clerkship curricula design would benefit from resident and attending-directed teaching experiences to optimize the educational experience in the ED.

Determining the Educational Value of an Emergency Medicine Rotation for Non-Emergency Medicine Residents.

Background Residents from diverse specialties perform clinical rotations in the emergency department (ED). There is little research about the value of the ED rotation for them. Objectives We sought to determine the learning objectives of non-EM residents (NEMRs) in the ED, the effectiveness of the rotation, and the highest-yield components of their experience. Methods From 2017-2019, we surveyed NEMR on their pre-rotation learning objectives and their comfort level with 15 common ED presentations/procedures before and after the rotation. We assessed how well their objectives were met, the highest-yield components of their rotation, and opportunities for improvement. Results We collected responses from 56 (47%) pre-rotation and 61 (51%) post-rotation residents over a two-year period. The five most commonly cited learning goals were: management of acutely ill patients, triage skills, procedural competence, and ultrasound. Seventy-eight percent (78%) of residents reported their learning goals were moderately to very well met during their rotation. NEMRs' level of comfort improved in all the commonly encountered clinical experiences in the ED in a statistically significant manner. They cited on-shift teaching by attending physicians and senior EM residents as the most valuable learning resource. Conclusion NEMR from diverse medical and surgical specialties could identify specific learning objectives for their EM rotation with common themes, and the majority felt their educational goals were met. They gained comfort with the management and triage of all the assessed common ED conditions. By collecting and defining their specific needs and goals, we are better equipped to improve the quality and value of the rotation.

Addressing the Gender Gap in Academic Success: A History of the University of North Carolina Association of Professional Women in the Medical Sciences.

Despite efforts at many institutions, nationally, women still lag behind their male counterparts in leadership, promotion, and seniority. In this paper, we describe the efforts to improve the environment for women faculty at one large academic medical center through the creation of an Association of Professional Women in Medical Sciences. Over the years, the group has helped influence policies that directly affect women faculty, provided high-yield programming on topics related to women's success, and created interprofessional networking opportunities for women faculty. We describe the challenges and successes of this group to serve as a model and inspiration for other institutions.

Multivariate Modeling of Student Performance on NBME Subject Exams.

Aim This study sought to determine whether it was possible to develop statistical models which could be used to accurately correlate student performance on clinical subject exams based on their National Board of Medical Examiner (NBME) self-assessment performance and other variables, described below, as such tools are not currently available.  Methods Students at a large public medical school were provided fee vouchers for NBME self-assessments before clinical subject exams. Multivariate regression models were then developed based on how self-assessment performance correlated to student success on the subsequent subject exam (Medicine, Surgery, Family Medicine, Obstetrics-Gynecology, Pediatrics, and Psychiatry) while controlling for the proximity of the self-assessment to the exam, USMLE Step 1 score, and the academic quarter. Results The variables analyzed satisfied the requirements of linear regression. The correlation strength of individual variables and overall models varied by discipline and outcome (equated percent correct or percentile, Model R2 Range: 0.1799-0.4915). All models showed statistical significance on the Omnibus F-test (p<0.001). Conclusion The correlation coefficients demonstrate that these models have weak to moderate predictive value, dependent on the clinical subject, in predicting student performance; however, this varies widely based on the subject exam in question. The next step is to utilize these models to identify struggling students to determine if their use reduces failure rates and to further improve model accuracy by controlling for additional variables.

Use of a Brief Negotiation Interview in the emergency department to reduce high-risk alcohol use among older adults: A randomized trial.

OBJECTIVE: To determine whether a Brief Negotiation Interview (BNI) performed in the emergency department (ED) can reduce future rates of alcohol use among older adults who are high-risk drinkers. METHODS: Adults aged 65 years and older in a single academic ED were screened for high-risk alcohol use based on the National Institute for Alcohol Abuse and Alcoholism definition of >7 drinks per week or >3 drinks per occasion. Eligible individuals who were high-risk drinkers who passed a cognitive impairment screener and who consented to enrollment were randomly assigned to receive the BNI versus usual care. Outcomes were assessed at 3, 6, and 12 months.  The primary outcome was the rate of high-risk alcohol use at 6 months. RESULTS:  Of 2250 ED patients who were screened, 183 (8%) met the criteria for high-risk alcohol use. Of those, 98 (53%) patients met full criteria and consented to participation. Of the participants, 67% were men and 83% were non-Hispanic White. There was no significant difference in the primary outcome of high-risk alcohol use at 6 months between the BNI at 59.1% (95% confidence interval [CI], 45.5%-76.8%) and the control at 49.1% (95% CI, 36.9%-65.2%). However, there was a significant time-effect reduction in alcohol consumption and rates of high-risk alcohol use for both groups. CONCLUSION: Among older adults who met the criteria for high-risk alcohol use, the BNI in the ED did not result in a reduction in high-risk alcohol use at 6 months, although both groups showed significant reductions after their ED visit. Further work is needed to determine the optimal setting and time to use the BNI to impact high-risk alcohol use in this population.

What Makes a Near-Peer Learning and Tutoring Program Effective in Undergraduate Medical Education: a Qualitative Analysis.

Peer tutoring can benefit both learners and peer teachers that are distinct from the learning that occurs in expert-guided learning environments. This study sought to evaluate the peer tutoring program at a large public medical school to determine the strengths and weaknesses of a near-peer tutoring program and its benefits beyond students' typical classroom-based learning. This was a survey-based study of learners and tutors participating in the peer tutoring program. Fifty-six learners and 20 tutors participated in the survey; most learners received tutoring in the preclinical phase of the curriculum. Narrative responses were thematically analyzed to identify themes for both groups. Learners' responses about the benefit of the near-peer tutoring program were in three primary categories: creating a safe learning environment, direct coaching skills, and pitfalls around the need for individualized direction. Tutors' responses about what made a successful tutoring relationship centered around crucial activities used to engage with learners, beneficial intrinsic qualities of learners such as motivation, and qualifications of tutors that were most helpful such as knowledge base. Peer tutoring programs should emphasize individualized feedback for learners that focuses on metacognitive, content-based, and socio-emotional support. In doing so, such programs can provide a well-structured approach to improve learner success. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01680-0.

Reinvigorating an Academy of Medical Educators Using Ecological Systems Theory.

The educational framework of communities of practice postulates that early learners join medical communities as social networks that provide a common identity, role modeling and mentorship, and experiential learning. While being elected into a medical society is an honor, member engagement in these groups can falter if the society membership is seen as an honorific rather than one requiring continuing participation. As an example, Academies of Medical Educators have been established by many academic medical centers to encourage collaboration, skill development, professional identity formation, and scholarship. The University of North Carolina established the Academy of Educators in 2006 to create a diverse community of educators to promote the scholarship, teaching skills, and professional identity of educators. Despite rapid growth to over 500 members, we had less than 30 participants at events over the 2017-2018 academic year. To increase member engagement and participation, our academy leadership team used Bronfenbrenner's Ecological Systems Theory to design interventions at each layer of environmental influence, specifically at the microsystem, mesosystem, exosystem, macrosystem, and chronosystem levels. In this paper, we describe the multipronged approach used to increase the University of North Carolina Academy of Medical Educators event attendance from 30 to 1,000 faculty participants over the course of one academic year (2018-2019). This paper provides a model as to how medical societies can use ecological systems theory as a natural and comprehensive approach to plan and improve their member engagement and experience.