Search

Falls in older adults correlate with heightened morbidity and mortality. Assessing fall risk in the emergency department (ED) not only aids in identifying candidates for prevention interventions but may also offer insights into overall mortality risk. We sought to examine the link between fall risk and 30-day mortality in older ED adults. Observational cohort study of adults aged ≥ 75 years who presented to an academic ED and who were assessed for fall risk using the Memorial Emergency Department Fall Risk Assessment Tool (MEDFRAT), a validated, ED-specific screening tool. The fall risk was classified as low (0–2 points), moderate (3–4 points), or high (≥ 5) risk. The primary outcome was 30-day mortality. Hazard ratios (HR) with 95% confidence intervals (CIs) were calculated. A total of 941 patients whose fall risk was assessed in the ED were included in the study. Median age was 83.7 years; 45.6% were male, 75.6% lived in private residences, and 62.7% were admitted. Mortality at 30 days among the high fall risk group was four times that of the low fall risk group (11.8% vs 3.1%; HR 4.00, 95% CI 2.18 to 7.34, p < 0.001). Moderate fall risk individuals had nearly double the mortality rate of the low-risk group (6.0% vs 3.1%), but the difference was not statistically significant (HR 1.98, 95% CI 0.91 to 4.32, p = 0.087). ED fall risk assessments are linked to 30-day mortality. Screening may facilitate the stratification of older adults at risk for health deterioration. [ABSTRACT FROM AUTHOR]

To evaluate the association between delirium and subsequent short-term mortality in geriatric patients presenting to the emergency department (ED). This was an observational cohort study of adults age ≥75 years who presented to an academic ED and were screened for delirium during their ED visit. The Delirium Triage Screen followed by the Brief Confusion Assessment Method were used to ascertain the presence of delirium. In-hospital, 7-day, and 30-day mortality were compared between patients with and without ED delirium. Odds ratios with 95% confidence intervals (CIs) were calculated through logistic regression after adjusting for confounders including age, sex, history of dementia, ED disposition, and acuity. A total of 967 ED visits were included for analysis among which delirium was detected in 107 (11.1%). The median age of the cohort was 83 years (IQR 79, 88), 526 (54.4%) were female, 285 (29.5%) had documented dementia, and 171 (17.7%) had a high acuity Emergency Severity Index triage level 1 or 2. During the hospitalization, 5/107 (4.7%) of those with delirium and 4/860 (0.5%) of those without delirium died. Within 7 days of ED departure, 6/107 (5.6%) of those with delirium and 6/860 (0.7%) of those without delirium died (unadjusted OR 8.46, 95% CI 2.68–26.71). Within 30 days, 18/107 (16.8%) of those with delirium and 37/860 (4.3%) of those without delirium died (unadjusted OR 4.50, 95% CI 2.46–8.23). ED delirium remained associated with higher 7-day (adjusted OR 5.23, 95% CI 1.44–19.05, p = 0.008) and 30-day mortality (adjusted OR 2.82, 95% CI 1.45–5.46, p = 0.002). Delirium is an important prognostic factor that ED clinicians and nurses must be aware of to optimize delirium prevention, management, disposition, and communication with patients and families. [ABSTRACT FROM AUTHOR]

Study Objective: To evaluate the association between potential emergency department (ED)-based modifiable risk factors and subsequent development of delirium among hospitalized older adults free of delirium at the time of ED stay.Methods: Observational cohort study of patients aged ≥75 years who screened negative for delirium in the ED, were subsequently admitted to the hospital, and had delirium screening performed within 48 h of admission. Potential ED-based risk factors for delirium included ED length of stay (LOS), administration of opioids, benzodiazepines, antipsychotics, or anticholinergics, and the placement of urinary catheter while in the ED. Odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CIs) were calculated.Results: Among 472 patients without delirium in the ED (mean age 84 years, 54.2% females), 33 (7.0%) patients developed delirium within 48 h of hospitalization. The ED LOS of those who developed delirium was similar to those who did not develop delirium (312.1 vs 325.6 min, MD -13.5 min, CI -56.1 to 29.0). Patients who received opioids in the ED were as likely to develop delirium as those who did not receive opioids (7.2% vs 6.9%: OR 1.04, CI 0.44 to 2.48). Patients who received benzodiazepines had a higher risk of incident delirium, the difference was clinically but not statistically significant (37.3% vs 6.5%, OR 5.35, CI 0.87 to 23.81). Intermittent urinary catheterization (OR 2.05, CI 1.00 to 4.22) and Foley placement (OR 3.69, CI 1.55 to 8.80) were associated with a higher risk of subsequent delirium. After adjusting for presence of dementia, only Foley placement in the ED remained significantly associated with development of in-hospital delirium (adjusted OR 3.16, CI 1.22 to 7.53).Conclusion: ED LOS and ED opioid use were not associated with higher risk of incident delirium in this cohort. Urinary catheterization in the ED was associated with an increased risk of subsequent delirium. These findings can be used to design ED-based initiatives and increase delirium prevention efforts. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the short-term mortality of adult patients presenting to the emergency department (ED) with altered mental status (AMS) as compared to other common chief complaints.Methods: Observational cohort study of adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with five pre-specified complaints at ED triage: AMS, generalized weakness, chest pain, abdominal pain, and headache. Primary outcomes included 7 and 30-day mortality. Hazard ratios (HR) were calculated with 95% confidence intervals (CI) using Cox proportional hazards models adjusted for age, acuity level, and comorbidities.Results: A total of 9850 ED visits were included for analysis from which 101 (1.0%) and 295 (3.0%) died within 7 and 30 days, respectively. Among 683 AMS visits, the 7-day mortality rate was 3.2%. Mortality was lower for all other chief complaints, including generalized weakness (17/1170, 1.5%), abdominal pain (32/3609, 0.9%), chest pain (26/3548, 0.7%), and headache (4/840, 0.5%). After adjusting for key confounders, patients presenting with AMS had a significantly higher risk of death within 7 days of ED arrival than patients presenting with chest pain (HR 3.72, 95% CI 2.05 to 6.76, p < .001). Similarly, we found that patients presenting with AMS had a significantly higher risk of dying within 30 days compared to patients with chest pain (HR 3.65, 95% CI 2.49 to 5.37, p < .001), and headache (HR 2.09, 95% CI 1.09 to 4.01, p = .026). Differences were not statistically significant for comparisons with abdominal pain and generalized weakness, but confidence intervals were wide.Conclusion: Patients presenting with AMS have worse short-term prognosis than patients presenting to the ED with chest pain or headache. AMS may indicate an underlying brain dysfunction (delirium), which is associated with adverse outcomes and increased mortality. [ABSTRACT FROM AUTHOR]

Objective: To compare resource utilization and mortality between older and younger adult patients with similar ED chief complaints and ESI triage levels.Methods: This was an observational study of consecutive adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with chest pain, abdominal pain, altered mental status, generalized weakness, or headache. Patients were categorized into 40-64, 65-79, and ≥ 80-year old groups. Mortality and utilization outcomes were compared between age groups through logistic regression models or Cox proportional hazards adjusting for ESI level and chief complaint. Odds ratios (OR) and hazard ratios (HR) were calculated with 95% confidence intervals (CI).Results: A total of 9798 ED visits were included. As compared to younger adults (age 40-64), older adults, independently of ESI level and chief complaint, had higher ED laboratory use (OR 1.46 [CI 1.29, 1.66] for age 65-80; OR 1.33 [CI 1.15, 1.55] for age ≥ 80), ED radiology use (OR 1.40 [CI 1.26, 1.56]; OR 1.48 [CI 1.30, 1.69]), hospital admission (OR 1.56 [CI 1.42, 1.72]; OR 1.97 [CI 1.75, 2.21]), and ICU admission (OR 1.38 [CI 1.15, 1.65]; OR 1.23 [CI 0.99, 1.52]). Despite similar ESI and chief complaint, patients age 65-79 and ≥ 80 had higher 30-day mortality rates (HR 1.87 [CI 1.39 to 2.51] and 2.47 [CI 1.81 to 3.37], respectively).Conclusions: Older adults with similar chief complaints and ESI levels than younger adults, have significantly higher ED resource use, hospitalization rates, and mortality. [ABSTRACT FROM AUTHOR]

Objective: To identify predictors of 30-day emergency department (ED) return visits in patients age 65-79 years and age ≥ 80 years.Methods: This was a cohort study of older adults who presented to the ED over a 1-year period. A mixed-effects logistic regression model was used to identify predictors for returning to the ED within 30 days. We stratified the cohort into those aged 65-79 years and aged ≥80 years. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) were reported. This study adhered to the STROBE reporting guidelines.Results: A total of 21,460 ED visits representing 14,528 unique patients were included. The overall return rate was 15% (1998/13,300 visits) for age 65-79 years, and 16% (1306/8160 visits) for age ≥ 80 years. A history of congestive heart failure (CHF), dementia, or prior hospitalization within 2 years were associated with increased odds of returning in both age groups (for age 65-79: CHF aOR 1.36 [CI 1.16-1.59], dementia aOR 1.27 [CI 1.07-1.49], prior hospitalization aOR 1.36 [CI 1.19-1.56]; for age ≥ 80: CHF aOR 1.32 [CI 1.13-1.55], dementia aOR 1.22 [CI 1.04-1.42], and prior hospitalization aOR 1.27 [CI 1.09-1.47]). Being admitted from the ED was associated with decreased odds of returning to the ED within 30 days (aOR 0.72 [CI 0.64-0.80] for age 65-79 years and 0.72 [CI 0.63-0.82] for age ≥ 80).Conclusion: Age alone was not an independent predictor of return visits. Prior hospitalization, dementia and CHF were predictors of 30-day ED return. The identification of predictors of return visits may help to optimize care transition in the ED. [ABSTRACT FROM AUTHOR]

Objective: Determine if a comfort cart would improve older adults' comfort and facilitate communication during Emergency Department (ED) visits.Methods: A comfort cart containing low-cost, non-pharmacological interventions to improve patient comfort and ability to communicate (e.g., hearing amplifiers, reading glasses) were made available to patients aged ≥65 years. Patients and clinicians were surveyed to assess effectiveness. We followed the Standards for Quality Improvement Reporting Excellence: SQUIRE 2.0 guidelines.Results: Three hundred patients and 100 providers were surveyed. Among patients, 98.0%, 95.1%, and 67.5% somewhat or strongly agreed that the comfort cart improved comfort, overall experience, and independence, respectively. Among providers, 97.0%, 95.0%, 87.0%, and 83% somewhat or strongly agreed that the comfort cart provided comfort, improved patient satisfaction, increased ability to give compassionate care, and increased patient orientation.Conclusion: The comfort cart was an affordable and effective intervention that improved patients' comfort by facilitating communication, wellbeing, and compassionate care delivery. [ABSTRACT FROM AUTHOR]

Objectives: The Elderly Risk Assessment (ERA) score is a validated index for primary care patients that predict hospitalizations, mortality, and Emergency Department (ED) visits. The score incorporates age, prior hospital days, marital status, and comorbidities. Our aim was to validate the ERA score in ED patients.Methods: Observational cohort study of patients age ≥ 60 presenting to an academic ED over a 1-year period. Regression analyses were performed for associations with outcomes (hospitalization, return visits and death). Medians, interquartile range (IQR), odds ratios (OR) and 95% confidence intervals (CI) were calculated.Results: The cohort included 27,397 visits among 18,607 patients. Median age 74 years (66-82), 48% were female and 59% were married. Patients from 54% of visits were admitted to the hospital, 16% returned to the ED within 30 days, and 18% died within one year. Higher ERA scores were associated with: hospital admission (score 10 [4-16] vs 5 [1-11], p < 0.0001), return visits (11 [5-17] vs 7 [2-13], p < 0.0001); and death within one year (14 [7-20] vs 6 [2-13], p < 0.0001). Patients with ERA score ≥ 16 were more likely to be admitted to the hospital, OR 2.14 (2.02-2.28, p < 0.0001), return within 30 days OR 1.99 (1.85-2.14), and to die within a year, OR 2.69 (2.54-2.85).Conclusion: The ERA score can be automatically calculated within the electronic health record and helps identify patients at increased risk of death, hospitalization and return ED visits. The ERA score can be applied to ED patients, and may help prognosticate the need for advanced care planning. [ABSTRACT FROM AUTHOR]

Background: Droperidol is a dopamine receptor antagonist that functions as an analgesic, sedative, and antiemetic. In 2001, the U.S. Food and Drug Administration required a black box warning in response to case reports of QT prolongation and potential fatal arrhythmias. The aim of this study was to evaluate the effectiveness and safety of droperidol in patients presenting to a United States Emergency Department (ED).Methods: Observational cohort study of all droperidol administrations from 1/1/2012 through 4/19/2018 at an academic ED. The primary endpoint was mortality within 24 h of droperidol administration. Secondary endpoint included use of rescue analgesics.Results: A total of 6,881 visits by 5,784 patients received droperidol of whom 6,353 visits authorized use of their records for research, including 5.4% administrations in children and 8.2% in older adults (≥65). Droperidol was used as an analgesic for pain (N = 1,387, 21.8%) and headache (N = 3,622, 57.0%), as a sedative (N = 550, 8.7%), and as an antiemetic (N = 794, 12.5%). No deaths secondary to droperidol administration were recorded within 24 h. Need for rescue analgesia occurred in 5.2% of patients with headache (N = 188) and 7.4% of patients with pain (N = 102); 1.1% of patients with headache received rescue opioids (N = 38) after droperidol, as did 5.4% of patients with pain other than headache (N = 75). No patients had fatal arrhythmias. Akathisia occurred in 2.9%.Conclusion: No fatalities were seen among this large cohort of patients who received droperidol in the ED. Our findings suggest droperidol's effectiveness and safety when used as an analgesic, antiemetic and/or sedative. [ABSTRACT FROM AUTHOR]

Emergency nurses experience multiple traumatizing events during clinical work. Early identification of work-related tension could lead to a timely intervention supporting well-being. We sought to discover whether there is an immediately measurable effect on emotional stress, as determined by changes between pre- and postshift survey scores, associated with exposure to traumatizing events during a single emergency nursing shift. The Emotional Stress Reaction Questionnaire (ESRQ) is a real-time self-assessment tool based on positively, negatively, or neutrally loaded emotions. Participants voluntarily completed pre- and postshift ESRQs over a 6-month period at a quaternary academic emergency department and recorded the number of associated traumatizing events. Associations between number of traumatizing events and ESRQ scores were evaluated using Spearman rank correlation coefficients. Changes in positive-negative balance scores were compared between shifts using a 2-sample t -test. There were 203 responses by 94 nurses. The mean preshift ESRQ score was 11.3 (SD = 5.2), mean postshift score 6.8 (SD = 7.4), and mean change −4.4 (SD = 8.2; t = −7.26; P < 0.001). The total number of traumatizing events was correlated with change in ESRQ scores (correlation coefficient of −0.31; P < 0.001). The mean change in positive-negative scores for shifts without traumatizing events was −1.4 (SD = 6.0) compared with −5.0 (SD = 8.5) for shifts with at least 1 event (t = 2.27; P = 0.03). Our results suggest that repeated exposure to traumatizing events during a single clinical shift was associated with a measurable effect on negative emotional stress in emergency nurses as determined by ESRQ positive-negative balance scores. [ABSTRACT FROM AUTHOR]

Objective: To characterize pediatric Emergency Medicine Service (EMS) transports to the Emergency Department (ED) using a national claims database.Methods: We included children, 18 years and younger, transported by EMS to an ED, from 2007 to 2016 in the OptumLabs Data Warehouse. ICD-9 and ICD-10 diagnosis codes were used to categorize disease system involvement. Interventions performed were extracted using procedure codes. ED visit severity was measured by the Minnesota Algorithm.Results: Over a 10-year period, 239,243 children were transported. Trauma was the most frequent diagnosis category for transport for children ≥5 years of age, 35.1% (age 6-13) and 32.7% (age 14-18). The most common diagnosis category in children <6 years of age was neurologic (29.3%), followed by respiratory (23.1%). Over 10 years, transports for mental disorders represented 15.3% in children age 14 to 18, and had the greatest absolute increase (rate difference + 10.4 per 10,000) across all diagnoses categories. Neurologic transports also significantly increased in children age 14 to 18 (rate difference + 6.9 per 10,000). Trauma rates decreased across all age groups and had its greatest reduction among children age 14 to 18 (rate difference - 6.8 per 10,000). Across all age groups, an intervention was performed in 15.6%. Most children (83.3%) were deemed to have ED care needed type of visit, and 15.8% of the transports resulted in a hospital admission.Conclusion: Trauma is the most frequent diagnosis for transport in children older than 5 years of age. Mental health and neurologic transports have markedly increased, while trauma transports have decreased. Most children arriving by ambulance were classified as requiring ED level of care. These changes might have significant implication for EMS personnel and policy makers. [ABSTRACT FROM AUTHOR]

Understanding postsurgical prescribing patterns and their impact on persistent opioid use is important for establishing reasonable opioid prescribing protocols. We aimed to determine national variation in postoperative opioid prescription practices following elective lumbar spine surgery and their impact on short-term refill prescriptions. The OptumLabs Data Warehouse was queried from 2016 to 2017 for adults undergoing anterior lumbar fusion, posterior lumbar fusion, circumferential lumbar fusion, and lumbar decompression/discectomy for degenerative spine disease. Discharge opioid prescription fills were obtained and converted to morphine milligram equivalents (MMEs). Age- and sex-adjusted MMEs and frequency of discharge prescriptions >200 MMEs were determined for each U.S. census division and procedure type. The study included 43,572 patients with 37,894 postdischarge opioid prescription fills. There was wide variation in mean filled MMEs across all census divisions (anterior lumbar fusion: 774–1147 MMEs; posterior lumbar fusion: 717–1280 MMEs; circumferential lumbar fusion: 817–1271 MMEs; lumbar decompression/discectomy: 619–787 MMEs). A significant proportion of cases were found to have filled discharge prescriptions >200 MMEs (posterior lumbar fusion: 78.6%–95%; anterior lumbar fusion: 87.5%–95.6%; circumferential lumbar fusion: 81.4%–96.5%; lumbar decompression/discectomy: 80.5%–91%). Multivariable logistic regression showed that female sex and inpatient surgery were associated with a top-quartile discharge prescription and a short-term second opioid prescription fill, while the opposite was noted for elderly and opioid-naïve patients (all P ≤ 0.05). Prescriptions with long-acting opioids were associated with higher odds of a second opioid prescription fill (reference: nontramadol short-acting opioid). In analysis of filled opioid prescriptions, we observed a significant proportion of prescriptions >200 MMEs and wide regional variation in postdischarge opioid prescribing patterns following elective lumbar spine surgery. [ABSTRACT FROM AUTHOR]