Emergency department physician experiences managing patients labelled "community emergency" in Newfoundland and Labrador: A qualitative study.

Rural Emergency Medicine: Patient Volume and Training Opportunities

Identifying older emergency department (ED) patients with clinical features associated with adverse postdischarge outcomes may lead to improved clinical reasoning and better targeting for preventative interventions. Previous studies have used single-country samples to identify limited sets of determinants for a limited number of proxy outcomes. The objective of this study was to identify and compare geriatric syndromes that influence the probability of postdischarge outcomes among older ED patients from a multinational context. A multinational prospective cohort study of ED patients aged 75 years or older was conducted. A total of 13 ED sites from Australia, Belgium, Canada, Germany, Iceland, India, and Sweden participated. Patients who were expected to die within 24 hours or did not speak the native language were excluded. Of the 2,475 patients approached for inclusion, 2,282 (92.2%) were enrolled. Patients were assessed at ED admission with the interRAI ED Contact Assessment, a geriatric ED assessment. Outcomes were examined for patients admitted to a hospital ward (62.9%, n=1,436) or discharged to a community setting (34.0%, n=775) after an ED visit. Overall, 3% of patients were lost to follow-up. Hospital length of stay (LOS) and discharge to higher level of care was recorded for patients admitted to a hospital ward. Any ED or hospital use within 28 days of discharge was recorded for patients discharged to a community setting. Unadjusted and adjusted odds ratios (ORs) were used to describe determinants using standard and multilevel logistic regression. A multi-country model including living alone (OR=1.78, p≤0.01), informal caregiver distress (OR=1.69, p=0.02), deficits in ambulation (OR=1.94, p≤0.01), poor self-report (OR = 1.84, p≤0.01), and traumatic injury (OR=2.18, p≤0.01) best described older patients at risk of longer hospital lengths of stay. A model including recent ED visits (OR=2.10, p≤0.01), baseline functional impairment (OR=1.68, p≤0.01), and anhedonia (OR=1.73, p≤0.01) best described older patients at risk of proximate repeat hospital use. A sufficiently accurate and generalizable model to describe the risk of discharge to higher levels of care among admitted patients was not achieved. Despite markedly different health care systems, the probability of long hospital lengths of stay and repeat hospital use among older ED patients is detectable at the multinational level with moderate accuracy. This study demonstrates the potential utility of incorporating common geriatric clinical features in routine clinical examination and disposition planning for older patients in EDs.

Headaches are a common chief complaint in emergency departments (EDs), with rural patients facing unique challenges such as geographic isolation and limited access to care. This study aims to compare treatment efficacy for this top five ED chief complaint between rural and urban EDs. Patients treated for headaches from 2020-2023 were identified using diagnosis codes and electronic health records. Treatment plans and patient demographics were abstracted from identified charts. EDs were categorized as rural (populations under 50,000) or urban. A total of 13,375 patients were included (6,165 urban, 7,210 rural). Pain reduction was similar between urban (3.78) and rural EDs (3.61) (p = 0.094). Urban EDs had longer visit times (2.95 hours vs. 2.60 hours in rural EDs). Medication use varied: opioids were more frequently used in rural EDs (8.3% vs. 3.6%), while NSAIDs, acetaminophen, and prokinetics showed similar use across both settings. Demographics differed slightly, with a higher percentage of Native American patients in rural EDs (10% vs. 5.5% urban). Treatment efficacy for headaches did not differ significantly between urban and rural EDs. Rural patients spent less time in the ED, likely due to lower patient volume, and opioid use was higher in rural locations.

Rural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs). To compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals. This propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021. The primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization. The matched cohort included 473 152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI, 1.26-2.24), and abdominal pain (OR, 1.73 [95% CI, 1.42-2.10]). All findings were similar for CAHs. The findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings. Further research is needed to understand the sources of greater rural ED mortality for symptom-based conditions. These findings underscore the importance of ensuring access to treatment of life-threatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.

Over 50 million U.S. adults 65 years and older account for >20 million emergency departments (ED) visits each year. Increasing ED use by older adults is projected to exceed the capacity of U.S. EDs. The traditional ED model of care is ill-equipped to address the many complex care needs of older adults.

Mood disorders in the emergency department: the challenge of linking patients to appropriate services

Altered mental status (AMS) is a common presentation in the emergency department (ED). A previous study revealed 78% electroencephalogram (EEG) abnormalities, including nonconvulsive seizure (NCS; 5%), in ED patients with AMS. The objective of this study was to assess the impact of EEG on clinical management and outcomes of ED patients with AMS. This was a randomized controlled trial at two urban teaching hospitals. Adult patients (≥18 years old) with AMS were included. Excluded patients had immediately correctable AMS (e.g., hypoglycemia) or were admitted before enrollment. Patients were randomized to routine care (control) or routine care plus EEG (intervention). Research assistants used a scalp electrode set with a miniature, wireless EEG device (microEEG) to record standard 30-minute EEGs at presentation, and results were reported to the ED attending physician by an off-site epileptologist within 30 minutes. Primary outcomes included changes in ED management (differential diagnosis, diagnostic work-up, and treatment plan from enrollment to disposition) as determined by surveying the treating physicians. Secondary outcomes were length of ED and hospital stay, intensive care unit (ICU) requirement, and in-hospital mortality. A total of 149 patients were enrolled (76 control and 73 intervention). Patients in the two groups were comparable at baseline. EEG in the intervention group revealed abnormal findings in 93% (95% confidence interval [CI] = 85% to 97%), including NCS in 5% (95% CI = 2% to 13%). Using microEEG was associated with change in diagnostic work-up in 49% (95% CI = 38% to 60%) of cases and therapeutic plan in 42% (95% CI = 31% to 53%) of cases immediately after the release of EEG results. Changes in probabilities of differential diagnoses and the secondary outcomes were not statistically significant between the groups. An EEG can be obtained in the ED with minimal resources and can affect clinical management of AMS patients.

Increased rate of central venous catheterization procedures in community EDs

Analgesia and sedation for patients who are mechanically ventilated may improve endotracheal tube tolerance, alleviate pain, reduce agitation, and facilitate other aspects of care including imaging, procedures, and travel to different parts of the hospital. Notwithstanding these benefits, lighter levels of sedation are associated with improved patient outcomes in intensive care unit (ICU) settings, including decreased duration of mechanical ventilation and length of stay.

Recently published consensus guidelines for geriatric emergency departments (EDs)1 provide a significant milestone for the nascent subspecialty of geriatric emergency medicine, but real-world challenges reside between guidelines and bedside practice. In this issue of Academic Emergency Medicine, Tirrell et al.2 report a 1-year chart review of 350 randomly selected elderly patients presenting to an urban academic ED following falls. Their primary objective was to determine the extent to which the documented ED evaluation adhered to the Geriatric Emergency Department Guidelines1 and the American Geriatric Society (AGS) guidelines. Only two of the 16 fall-risk evaluation items recommended by the guidelines were reported over 80% of the time: fall location and cause of fall. Most (13 of 16) were reported fewer than 50% of the time, and nine of these fewer than 25% of the time. Four patient-level characteristics were significantly associated with better guideline adherence: older age, more comorbid conditions, residing in an assisted living facility, and admission to either an inpatient or an observation unit. While these findings offer reassurance that individuals deemed at higher risk were more likely to undergo more comprehensive evaluations for falls, there is clearly a missed opportunity to perform more complete risk assessments that may provide critical secondary prevention for falls in individuals at lower risk.

2 Evaluation of Mid-Regional Pro-Adrenomedullin, Mid-Regional Pro-atrial Natriuretic Peptide, and Procalcitonin for the Diagnosis and Risk Stratification of Emergency Department Patients With Dyspnea

High Diagnostic Uncertainty and Inaccuracy in Adult Emergency Department Patients With Dyspnea: A National Database Analysis.

Qualification discrepancies between urban and rural emergency department physicians

Is it time to implement clinical decision rules for upper GI bleeding? Barriers, facilitators, and the need for a collaborative approach

IntroductionAttempts to reduce low-value hospital care often focus on emergency department (ED) hospitalizations. We compared rural and urban EDs in Michigan on resources designed to reduce avoidable admissions.MethodsA cross-sectional, web-based survey was emailed to medical directors and/or nurse managers of the 135 hospital-based EDs in Michigan. Questions included presence of clinical pathways, services to reduce admissions, and barriers to connecting patients to outpatient services. We performed chi-squared comparisons, regression modeling, and predictive margins.ResultsOf 135 EDs, 64 (47%) responded with 33 in urban and 31 in rural counties. Clinical pathways were equally present in urban and rural EDs (67% vs 74%, p=0.5). Compared with urban EDs, rural EDs reported greater access to extended care facilities (21% vs 52%, p=0.02) but less access to observation units (52% vs 35%, p=0.04). Common barriers to connecting ED patients to outpatient services exist in both settings, including lack of social support (88% and 76%, p=0.20), and patient/family preference (68% and 68%, p=1.0). However, rural EDs were more likely to report time required for care coordination (88% vs 66%, p=0.05) and less likely to report limitations to home care (21% vs 48%, p=0.05) as barriers. In regression modeling, ED volume was predictive of the presence of clinical pathways rather than rurality.ConclusionWhile rural-urban differences in resources and barriers exist, ED size rather than rurality may be a more important indicator of ability to reduce avoidable hospitalizations.