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Background: A straightforward decision aid to guide disposition of atrial fibrillation (AF) patients in the emergency department (ED) was developed for use by ED providers. The implementation of this decision aid in the ED has not been studied., Methods: A pragmatic stepped-wedge cluster approach for analysis of retrospectively collected electronic health record data was used in which 5 hospitals were selected to commence the intervention at periodic intervals following an initial 1-year baseline assessment with 5 additional hospitals included in the comparison group (all in North Carolina). The primary end point of analysis was hospitalization rate. Hierarchical multivariable logistic regression analyses for admission as a function of the intervention while controlling for prespecified patient and hospital predictors were performed with clustering done at the hospital level., Results: Between October 2017 and May 2020, a total of 11 458 patients (mean age, 71.4; 50.5% female) presented to 1 of the 10 hospitals with a primary diagnosis of AF. Absolute admission rate was reduced from 60.5% to 48.3% following the intervention (odds ratio, 0.83 [95% CI, 0.71-0.97]; P =0.016). After adjusting for covariates, the intervention was associated with a small increased rate of return to the ED for AF within 30 days of the initial presentation (1.6% to 2.7%; hazard ratio, 1.70 [95% CI, 1.26-2.31]; P <0.001)., Conclusions: We demonstrate that implementation of a novel decision aid to guide disposition of patients primary diagnosis of AF presenting to the ED was associated with a reduced admission rate independent of patient and hospital factors. Use of the protocol was associated with a small but significant increase in rate of repeat presentations for AF at 30-day follow-up. Use of a decision aid such as the one described here represents an important tool to reduce unnecessary AF hospitalizations., Competing Interests: Disclosures Dr Gehi has received research support from Bristol Myers Squib Foundation; speaker’s honoraria and consultancy fees from Biotronik, Zoll Medical, Abbott, and iRhythm. Dr Rosman has received research support from Bristol Myers Squib Foundation; consultancy fees from Pfizer, Biotronik. T Armbruster, J Walker, J Laux has received research support from Bristol Myers Squib Foundation. The other authors report no conflicts.

Context: Sport cancellations early in the COVID-19 pandemic had a significant negative effect on the health of US adolescents. The effect of restarting sports during the pandemic has not been described., Objective: To identify the effect of sport participation on the health of adolescents before and during the COVID-19 pandemic., Design: Cross-sectional study., Setting: Sample recruited via social media., Patients or Other Participants: Wisconsin adolescent athletes., Main Outcome Measure(s): Participants provided information regarding their age, sex, and sport(s) involvement and completed the Patient Health Questionnaire-9 Item to assess depression symptoms, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale to measure physical activity, and the Pediatric Quality of Life Inventory 4.0 to measure quality of life (QoL). Data were collected in spring 2021 (Spring21; n = 1906, age = 16.0 ± 1.2 years, females = 48.8%), when interscholastic sports had fully resumed, and were compared with similar cohorts of adolescent athletes at 2 time points: (1) spring 2020 (Spring20; n = 3243, age = 16.2 ± 1.2 years, females = 57.9%) when sports were cancelled and (2) 2016-2018 (PreCOVID-19) before the pandemic (n = 5231, age = 15.7 ± 1.1 years, females = 65.0%). Comparisons were conducted via analysis-of-variance models and ordinal regressions with age and sex as covariates., Results: The prevalence of moderate to severe depression was lower in Spring21 than in Spring20 but higher than in PreCOVID-19 (PreCOVID-19 = 5.3%, Spring20 = 37.8%, Spring21 = 22.8%; P < .001). Physical activity scores (mean [95% CI]) were higher in Spring21 than in Spring20 but lower than in PreCOVID-19 (PreCOVID-19 = 23.1 [22.7, 23.5], Spring20 = 13.5 [13.3, 13.7], Spring21 = 21.9 [21.6, 22.2]). Similarly, QoL scores were higher in Spring21 than in Spring20 but lower than in PreCOVID-19 (PreCOVID-19 = 92.8 [92.5, 93.1], Spring20 = 80.7 [80.3, 81.1], Spring21 = 84.3 [83.8, 84.8])., Conclusions: Although sports have restarted, clinicians should be aware that physical activity, mental health, and QoL are still significantly affected in adolescent athletes by the ongoing pandemic., (© by the National Athletic Trainers' Association, Inc.)

With the aging of our population, older adults are living longer with multiple chronic conditions, frailty, and life-limiting illnesses, which creates specific challenges for emergency departments (EDs). Older adults and those with serious illnesses have high rates of ED use and hospitalization, and the emergency care they receive may be discordant with their goals and values. In response, new models of care delivery have begun to emerge to address both geriatric and palliative care needs in the ED. However, these programs are typically siloed from one another despite significant overlap. To develop a new combined model, we assembled stakeholders and thought leaders at the intersection of emergency medicine, palliative care, and geriatrics and used a consensus process to define elements of an ideal model of a combined palliative care and geriatric intervention in the ED. This article provides a brief history of geriatric and palliative care integration in EDs and presents the integrated geriatric and palliative care model developed., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Introduction: Older adults constitute a large and growing proportion of the population and have unique care needs in the emergency department (ED) setting. The geriatric ED accreditation program aims to improve emergency care provided to older adults by standardizing care provided across accredited geriatric EDs (GED) and through implementation of geriatric-specific care processes. The purpose of this study was to evaluate select care processes at accredited level 1 and level 2 GEDs., Methods: This was a cross-sectional analysis of a cohort of level 1 and level 2 GEDs that received accreditation between May 7, 2018 and March 1, 2021. We a priori selected five GED care processes for analysis: initiatives related to delirium, screening for dementia, assessment of function and functional decline, geriatric falls, and minimizing medication-related adverse events. For all protocols, a trained research assistant abstracted information on the tool used or care process, which patients received the interventions, and staff members were involved in the care process; additional information was abstracted specific to individual care processes., Results: A total of 35 level 1 and 2 GEDs were included in this analysis. Among care processes studied, geriatric falls were the most common (31 GEDs, 89%) followed by geriatric pain management (25 GEDs, 71%), minimizing the use of potentially inappropriate medications (24 EDs, 69%), delirium (22 GEDs, 63%), medication reconciliation (21 GEDs, 60%), functional assessment (20 GEDs, 57%), and dementia screening (17 GEDs, 49%). For protocols related to delirium, dementia, function, and geriatric falls, sites used an array of different screening tools and there was heterogeneity in who performed the screening and which patients were assessed. Medication reconciliation protocols leveraged pharmacists, pharmacy technicians and/or nurses. Protocols on avoiding potentially inappropriate medication administration generally focused on ED administration of medications and used the BEERs criteria, and few sites indicated whether pain medications protocols had dosing modifications for age and/or renal function., Conclusion: This study provides a snapshot of care processes implemented in level 1 and level 2 accredited GEDs and demonstrates significant heterogeny in how these care processes are implemented., Competing Interests: CONFLICTS OF INTEREST Maura Kennedy, Nicole Tidwell, and Kevin Biese currently serve on the board of governors of ACEP’s Geriatric ED accreditation (GEDA) program. Christopher Carpenter previously served on the GEDA board of governors and currently serves on the GEDA advisory board. Ula Hwang previously served on the GEDA board of governors. Shan Liu and Lauren Southerland are reviewers for the GEDA program.

Background: Although sport specialization may be associated with stress and burnout among youth athletes, the relationship with quality of life (QOL) remains unknown. The purpose of this study was to evaluate the relationship between sport specialization, sleep, and QOL in female youth athletes., Hypothesis: Higher levels of specialization are associated with increased daytime sleepiness and worse QOL., Study Design: Cross-sectional study., Level of Evidence: Level 4., Methods: Female high school volleyball players completed preseason surveys to determine sport specialization (low, moderate, high), injury history, QOL, sleep duration, and daytime sleepiness. QOL and sleep variables were compared across specialization groups. Multivariable linear regression models were developed to evaluate the associations between sleepiness, QOL, specialization, grade in school, and injury history., Results: Of 1482 participants, 591 (40%), 436 (29%), and 455 (31%) were categorized as low, moderate, and high specialization, respectively. Highly specialized athletes demonstrated worse QOL (median 91.3 [interquartile range 86-96]) than low (92.4 [88-97], P = 0.05) and moderate (93.5 [88-99], P = 0.05) specialization groups and greater daytime sleepiness (11 [7-15]) than low (10 [6-14], P < 0.001) and moderate (10 [6-14], P < 0.001) specialization groups. In the multivariable model, QOL was negatively associated with prior injury occurrence (β = -1.1 ± 0.5, P = 0.02), but not grade in school (β = -0.08 ± 0.2, P = 0.71) or specialization (moderate: β = 0.08 ± 0.5, P = 0.88; high: β = -0.70 ± 0.5, P = 0.18). Daytime sleepiness increased with high specialization (β = 1.12 ± 0.3, P < 0.001) and grade (β = 0.76 ± 0.1, P < 0.001), but not prior injury (β = 0.51 ±0.3, P = 0.10)., Conclusion: Highly specialized female volleyball athletes demonstrate decreased QOL, perhaps because of higher rates of prior injury. Specialization is also associated with increased daytime sleepiness., Clinical Relevance: Sport participation patterns and injury may have implications for QOL in youth athletes.

Context: During the fall of 2020, some high schools across the United States allowed their students to participate in interscholastic sports while others cancelled or postponed their sport programs due to concerns regarding COVID-19 transmission. What effect this has had on the physical and mental health of adolescents is unknown., Objective: To identify the effect of playing a sport during the COVID-19 pandemic on the health of student-athletes., Design: Cross-sectional study., Setting: Sample recruited via email., Patients or Other Participants: A total of 559 Wisconsin high school athletes (age = 15.7 ± 1.2 years, female = 43.6%, male = 56.4%) from 44 high schools completed an online survey in October 2020. A total of 171 (30.6%) athletes played (PLY) a fall sport, while 388 (69.4%) did not play (DNP)., Main Outcome Measure(s): Demographic data included sex, grade, and sport(s) played. Assessments were the General Anxiety Disorder-7 Item for anxiety, Patient Health Questionnaire-9 Item for depression, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale for physical activity, and the Pediatric Quality of Life Inventory 4.0 for quality of life. Univariable comparisons between the 2 groups were made via t tests or χ2 tests. Means for each continuous outcome measure were compared between groups using analysis-of-variance models that controlled for age, sex, teaching method (virtual, hybrid, or in person), and the percentage of students eligible for free or reduced-price lunch., Results: The PLY group participants were less likely to report moderate to severe symptoms of anxiety (PLY = 6.6%, DNP = 44.1%, P < .001) and depression (PLY = 18.2%, DNP = 40.4%, P < .001). They also demonstrated higher (better) Pediatric Functional Activity Brief Scale scores (PLY = 23.2 [95% CI = 22.0, 24.5], DNP = 16.4 [95% CI = 15.0, 17.8], P < .001) and higher (better) Pediatric Quality of Life Inventory total scores (PLY = 88.4 [95% CI = 85.9, 90.9], DNP = 79.6 [95% CI = 76.8, 82.4], P < .001)., Conclusions: Adolescents who played a sport during the COVID-19 pandemic described fewer symptoms of anxiety and depression and had better physical activity and quality-of-life scores compared with adolescent athletes who did not play a sport., (© by the National Athletic Trainers' Association, Inc.)

Context: The relationships between different sports, face mask use and COVID-19 risk among high school athletes remains unknown., Objective: The purpose of this study was to evaluate the influence of sport characteristics and face mask use on COVID-19 incidence among high school athletes., Design: Descriptive Epidemiology Study Setting: United States High School Athletic Departments Participants: Athletic Directors Interventions: None Main Outcome Measures: Surveys were completed regarding sport re-initiation, COVID-19 cases, and risk reduction procedures in fall 2020. Separate mixed effects Poisson regression models were developed to evaluate the associations between reported COVID-19 incidence and 1) sport characteristics (contact/non-contact, individual/team, indoor/outdoor) and 2) face mask use while playing (yes/no)., Results: 991 schools had restarted fall sports, representing 152,484 athletes on 5,854 teams. 2,565 cases of COVID-19 were reported, representing a case rate of 1,682 cases per 100,000 athletes and an incidence rate of 24.6 cases per 100,000 player-days. COVID-19 incidence was lower among outdoor versus indoor sports (incidence rate ratio [IRR]=0.54, 95% CI=0.49-0.60, p<0.001) and non-contact versus contact sports (IRR=0.78 [0.70-0.87], p<0.001), but not team versus individual sports (IRR=0.96 [0.84-1.1], p=0.49). Face mask use was associated with a decreased incidence in girls' volleyball (IRR=0.53 [0.37-0.73], p<0.001), boys' basketball (IRR=0.53 [0.33-0.83], p=0.008) and girls' basketball (IRR=0.36 [0.19-0.63], p<0.001), and approached statistical significance in football (IRR=0.79 [0.59-1.04], p=0.10) and cheer/dance (IRR=0.75 [0.53-1.03], p=0.081)., Conclusions: In this nationwide survey of high school athletes, lower COVID-19 incidence was independently associated with participation in outdoor versus indoor and non-contact versus contact sports, but not team versus individual sports. Face mask use was associated with decreased COVID-19 incidence among indoor sports, and may be protective among outdoor sports with prolonged close contact between participants.

Objective: In the United States, atrial fibrillation (AF) accounts for over 400,000 hospitalizations annually. Emergency Department (ED) physicians have few resources available to guide AF/AFL (atrial flutter) patient triage, and the majority of these patients are subsequently admitted. Our aim is to describe the characteristics and disposition of AF/AFL patients presenting to the University of North Carolina (UNC) ED with the goal of developing a protocol to prevent unnecessary hospitalizations., Methods: We performed a retrospective electronic medical chart review of AF/AFL patients presenting to the UNC ED over a 15-month period from January 2015 to March 2016. Demographic and ED visit variables were collected. Additionally, patients were designated as either having primary or secondary AF/AFL where primary AF/AFL patients were those in whom AF/AFL was the primary reason for ED presentation. These primary AF/AFL patients were categorized by AF symptom severity score according to the Canadian Cardiovascular Society Severity of Atrial Fibrillation (CCS-SAF) Scale., Results: A total of 935 patients presented to the ED during the study period with 202 (21.5%) having primary AF/AFL. Of the primary AF/AFL patients, 189 (93.6%) had mild-moderate symptom severity (CCS-SAF ≤ 3). The majority of primary AF/AFL patients were hemodynamically stable, with a mean (SD) SBP of 123.8 (21.3), DBP of 76.6 (14.1), and ventricular rate of 93 (21.9). Patients with secondary AF/AFL were older 76 (13.1), p < 0.001 with a longer mean length of stay 6.1 (7.7), p = 0.31. Despite their mild-moderate symptom severity and hemodynamic stability, nearly 2/3 of primary AF/AFL patients were admitted., Conclusion: Developing a protocol to triage and discharge hemodynamically stable AF/AFL patients without severe AF/AFL symptoms to a dedicated AF/AFL clinic may help to conserve healthcare resources and potentially deliver more effective care., Competing Interests: Declaration of competing interest A.G. reports having received lecture fees from Biotronik, Zoll, St. Jude Medical and research funding support from Bristol Myers Squib Foundation. Other authors have no conflict of interest to report., (Copyright © 2021 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Delirium is a common and deadly problem in the emergency department affecting up to 30% of older adult patients. The 2013 Geriatric Emergency Department guidelines were developed to address the unique needs of the growing older population and identified delirium as a high priority area. The emergency department (ED) environment presents unique challenges for the identification and management of delirium, including patient crowding, time pressures, competing priorities, variable patient acuity, and limitations in available patient information. Accordingly, protocols developed for inpatient units may not be appropriate for use in the ED setting. We created a Delirium Change Package and Toolkit in the Emergency Department (ED-DEL) to provide protocols and guidance for implementing a delirium program in the ED setting. This article describes the multistep process by which the ED-DEL program was created and the key components of the program. Our ultimate goal is to create a resource that can be disseminated widely and used to improve delirium identification, prevention, and management in older adults in the ED., Competing Interests: The authors declare no conflict of interest., (© 2021 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Background: The relationships between sport specialization, physical activity, sleep, and illness in younger athletes are unknown. Therefore, the purpose of this study was to evaluate the independent effects of sport specialization, sleep, and physical activity on illness in middle school athletes., Hypothesis: Decreased sleep, decreased physical activity, and higher levels of sport specialization will be associated with an increased risk of illness among middle school athletes., Study Design: Prospective cohort study., Level of Evidence: Level 4., Methods: Parents of middle school-aged children reported baseline sport specialization (low, moderate, or high) as well as sleep duration, physical activity, and illnesses every week throughout the academic year. A mixed-effects logistic regression model was used to assess the association between illness and specialization while accounting for sleep and physical activity for the prior week as fixed effects and each individual as a random effect., Results: A total of 233 children (mean age, 12.1 ± 1.2 years; 61% male) participated, of whom 41%, 25%, and 34% were categorized as low, moderate, and high specialization, respectively. The proportion of individuals who experienced illness did not differ by specialization level (low, 76%; moderate, 70%; high, 59%; P = 0.064). In the multivariable model, the odds of illness compared with the low specialization group was not significantly different for moderate (odds ratio [OR], 0.93; 95% CI, 0.70-1.23; P = 0.61) or high specialization (OR, 0.76; 95% CI, 0.56-1.03; P = 0.073). A decreased risk of illness was associated with greater prior week sleep (OR, 0.79; 95% CI, 0.69-0.91; P < 0.001) and physical activity (OR, 0.94; 95% CI, 0.92-0.96; P < 0.001)., Conclusion: Sport specialization is not associated with an increased risk of illness among middle school athletes, while increased sleep duration and physical activity appear to reduce the risk of illness., Clinical Relevance: Interventions to promote physical activity and improve sleep may reduce the risk of illness in early adolescent athletes.

Background: Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions., Methods: GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci., Results: In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research., Conclusions: Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies., (© 2020 by the Society for Academic Emergency Medicine.)

Context: Girls high school volleyball is very popular across the United States. There is limited prospective data regarding the incidence and risk factors of time loss (TL) and non-time loss (NTL) injuries sustained in this population., Objectives: To estimate the incidence and describe the characteristics of injuries (TL and NTL) sustained in a girls' high school volleyball season., Design: Descriptive epidemiology study., Setting: Convenience sample of 78 high school interscholastic volleyball programs., Patients or Other Participants: High school volleyball players participating during the 2018 interscholastic season., Main Outcome Measures: TL and NTL injury rates, proportions, rate ratios, and with 95%CI., Results: A total of 2,072 girls enrolled in the study with 468 subjects (22.5%) sustaining 549 injuries (NTL=28.4%, TL=71.6%) for an overall injury rate of 5.31 [4.89, 5.79] per 1000 AEs. The competition injury rate was greater than the practice injury rate for all injuries (IRR: 1.19, [1.00, 1.41]) and TL injuries (IRR: 1.31, [1.07, 1.60]). Players with a previous musculoskeletal injury had a higher rate of TL than NTL injuries (IRR; 1.36 [1.12, 1.65]). Ankle injuries accounted for the greatest proportion of TL injuries (n=110, 28%), while the greatest proportion of NTL injuries occurred in the hand/fingers (n=34, 22%). Moreover, ligament sprains accounted for 40% of TL injuries (n=156), whereas muscle/tendon strains (n=79, 51%) accounted for over half of all NTL injuries., Conclusions: While the majority of injuries sustained by adolescent girls' volleyball athletes were TL in nature, nearly a third of all injuries were NTL injuries. Injury characteristics differed widely between TL and NTL injuries. Understanding the most common types and characteristics of injury among high school volleyball players is critical for the development of effective injury prevention programs., (© by the National Athletic Trainers' Association, Inc.)

The population of older adults in the United States is expanding rapidly. With this expansion, the healthcare system, and emergency departments (EDs) in particular, should provide geriatric-focused care tailored to the needs of this population. To this end, the American College of Emergency Physicians (ACEP) released a geriatric emergency department accreditation (GEDA) to certify EDs that have the staffing, training, and resources to provide high-quality, geriatric-focused, emergent care. Our healthcare system set out to achieve the GEDA at all system hospitals using a service-line approach and standardized policies. The implementation and application process was completed through strong partnerships between the Emergency Medicine Service Line and the Division of Geriatrics and Palliative Medicine. Further partnerships with ACEP were vital to completing the application process and using a standardized application. Through these partnerships, all 17 of our system hospitals achieved tier 3 accreditation. Through this process, we were able to identify opportunities to improve the care provided to older adults in the ED, particularly via staff education. We also gathered lessons learned for system-level accreditation, including fostering close partnerships, meeting the unique needs of each ED, and strategically planning when and where to increase tier levels. This practice of large-scale, system-wide standardization, rather than individual site implementation, is an effective measure to provide geriatric-focused care to the large and growing population of older adults., Competing Interests: The authors have no disclosures or conflicts of interest to report., (© 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.)

Improving emergency department (ED) care for older adults is a critical issue in emergency medicine. Institutions throughout the United States and Canada have recognized the growing need for a workforce of emergency physician (EP) leaders focused on clinical innovation, education, and research and have developed specialized fellowship training in geriatric emergency medicine (GEM). We describe here the overview, structure, and curricula of these fellowships as well as successes and challenges they have encountered. Seven GEM fellowships are active in the United States and Canada, with five offering postresidency training only, one offering fellowship training during residency only, and one offering both. The backbone of the curriculum for all fellowships is the achievement of core competencies in various aspects of GEM, and each includes clinical rotations, teaching, and a research project. Evaluation strategies and feedback have allowed for significant curricular changes as well as customization of the fellowship experience for individual fellows. Key successes include an improved collaborative relationship with geriatrics faculty that has led to additional initiatives and projects and former fellows already becoming regional and national leaders in GEM. The most critical challenges have been ensuring adequate funding and recruiting new fellows each year who are interested in this clinical area. We believe that interest in GEM fellowships will grow and that opportunities exist to combine GEM fellowship training with a focus in research, administration, or health policy to create unique new types of highly impactful specialized training. Future research may include exploring former fellows' postfellowship experiences, careers, accomplishments, and contributions to GEM to better understand the impact of GEM fellowships., (© 2019 by the Society for Academic Emergency Medicine.)

Objectives: This study sought to assess whether an atrial fibrillation (AF)-specific clinic is associated with improved adherence to American College of Cardiology (ACC)/American Heart Association (AHA) clinical performance and quality measures for adults with AF or atrial flutter., Background: There are significant gaps in care of patients with AF, including underprescription of anticoagulation and treatment of AF risk factors. An AF specialized clinic was developed to reduce admissions for AF but may also be associated with improved quality of care., Methods: This retrospective study compared adherence to ACC/AHA measures for patients who presented to the emergency department for AF between those discharged to a typical outpatient appointment and those discharged to a specialized AF transitions clinic run by an advanced practice provider and supervised by a cardiologist. Screening and treatment for common AF risk factors was also assessed., Results: The study enrolled 78 patients into the control group and 160 patients into the intervention group. Patients referred to the specialized clinic were more likely to have stroke risk assessed and documented (99% vs. 26%; p < 0.01); be prescribed appropriate anticoagulation (97% vs. 88%; p = 0.03); and be screened for comorbidities such as tobacco use (100% vs. 14%; p < 0.01), alcohol use (92% vs. 60%; p < 0.01), and obstructive sleep apnea (90% vs. 13%; p < 0.01) and less likely to be prescribed an inappropriate combination of anticoagulant and antiplatelet medications (1% vs. 9%; p < 0.01)., Conclusions: An AF specialized clinic was associated with improved adherence to ACC/AHA clinical performance and quality measures for adult patients with AF., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: No summative speaker evaluation form with validity and reliability evidence currently exists in the English medical education literature specifically to help conference planners make future decisions on speakers. We seek to perform a proof-of-concept evaluation of a concise, effective evaluation form to be filled out by audience members to aid conference planners., Methods: We created the Council of Emergency Medicine Residency Directors (CORD-EM) form, a novel, three-question speaker evaluation form for the CORD-EM national conference and evaluated it for proof of concept. The CORD-EM form was analyzed with three evaluators and randomized to select only two evaluators' ratings to make results more generalizable to a generic audience evaluating the speaker., Results: Forty-six total evaluations ranged from 6 to 9 (mean ± standard deviation = 8.1 ± 1.2). The form demonstrated excellent internal consistency (Cronbach's alpha = 0.923) with good inter-rater reliability (intraclass correlation = 0.617) in the conference context., Conclusions: The CORD-EM speaker evaluation form is, to our knowledge, the first evaluation form with early reliability and validity evidence specifically designed to help conference planners. Our results suggest that a short speaker evaluation form can be an effective instrument in the toolbox for conference planners.

Older emergency department patients have high rates of serious illness and injury, are at high risk for side effects and adverse events from treatments and diagnostic tests, and in many cases, have nuanced goals of care in which pursuing the most aggressive approach is not desired. Although some forms of shared decision making (SDM) are commonly practiced by emergency physicians caring for older adults, broader use of SDM in this setting is limited by a lack of knowledge of the types of patients and conditions for which SDM is most helpful and the approaches and tools that can best facilitate this process. We describe a research agenda to generate new knowledge to optimize the use of SDM during the emergency care of older adults., (© 2016 by the Society for Academic Emergency Medicine.)

Objectives: Older patients discharged from the emergency department (ED) have difficulty comprehending discharge plans and are at high risk of adverse outcomes. The authors investigated whether a postdischarge telephone call-mediated intervention by a nurse would improve discharge care plan adherence, specifically by expediting post-ED visit physician follow-up appointments and/or compliance with medication changes. The second objectives were to determine if this telephone call intervention would reduce return ED visits and/or hospitalizations within 35 days of the index ED visit and to determine potential cost savings of this intervention., Methods: This was a 10-week randomized, controlled trial among patients aged 65 and older discharged to home from an academic ED. At 1 to 3 days after each patient's index ED visit, a trained nurse called intervention group patients to review discharge instructions and assist with discharge plan compliance; placebo call group patients received a patient satisfaction survey call, while the control group patients were not called. Data collection calls occurred at 5 to 8 days and 30 to 35 days after the index ED visits for all three groups. Chi-square or Fisher's exact tests were performed for categorical data and the Kruskal-Wallis test examined group differences in time to follow-up., Results: A total of 120 patients completed the study. Patients were 60% female and 72% white, with a mean age of 75 years (standard deviation [SD] ± 7.58 years). Intervention patients were more likely to follow up with medical providers within 5 days of their ED visits than either the placebo or the control group patients (54, 20, and 37%, respectively; p = 0.04). All groups performed well in medication acquisition and comprehension of medication indications and dosage. There were no differences in return visits to the ED or hospital within 35 days of the index ED visit for intervention patients, compared to placebo or control group patients (22, 33, and 27%, respectively; p = 0.41). An economic analysis showed an estimated 70% chance that this intervention would reduce total costs., Conclusions: Telephone call follow-up of older patients discharged from the ED resulted in expedited follow-up for patients with their primary care physicians. Further study is warranted to determine if these results translate into improved patient outcomes, decreased return ED visits or hospital admissions, and cost savings resulting from this intervention., (© 2014 by the Society for Academic Emergency Medicine.)

Objectives: Many factors affect the clinical training experience of emergency medicine (EM) residents, and length of training currently serves as a proxy for clinical experience. Very few studies have been published that provide quantitative information about clinical experience. The goals of this study were to determine the numbers of clinical encounters for each resident in emergency department (ED) rotations during training in a 3-year program, to characterize these encounters by patient acuity and age, to determine the numbers of encounters for selected clinical disorders, and to assess the variation in clinical experience between residents., Methods: This was a retrospective analysis of the ED clinical and administrative databases at two hospitals that provide EM training for a southeastern U.S. EM residency program. Data were gathered for three complete cohorts of residents, with entering years of 2003, 2004, and 2005, so the total study period was 2003-2008. ED clinical encounter information included hospital training site (tertiary or community), postgraduate year (PGY) of the resident, patient triage acuity reflected by the Emergency Severity Index (ESI); patient International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code; and patient age group., Results: There were 25 residents with 120,240 total ED clinical encounters from 2003 to 2008. The median number of ED clinical encounters for a resident during his or her training was 4,836 (range = 3,831 to 5,780), based on a maximum of an 80-hour work week, and 24 or 25 four-week blocks of EM rotations. Overall, clinical encounters increased by 30% from PGY 1 to PGY 2, and another 14% from PGY 2 to PGY 3. There was 30% to 60% variation in clinical encounters between individual residents. Variability was most prominent in the care of children and in the care of time-sensitive critical illness. Resident encounters with lower-acuity problems during training were much less than the anticipated lower-acuity burden during practice. Additionally, residents did not encounter some high-risk conditions clinically during the study period., Conclusions: Methods should be developed to decrease resident variance in both numbers and types of clinical encounters and to provide curriculum supplementation for individuals and for the entire residency cohort in areas that are important for the clinical practice of EM, but that are rare or not encountered during residency training., (© 2011 by the Society for Academic Emergency Medicine.)

Background: The chief resident's role encompasses administrative, academic, educational, and social responsibilities and is traditionally filled by a small number of residents who are charged with various administrative and educational duties. These duties lay the groundwork that prepares chief residents to assume future leadership positions., Intervention: We propose a new model for multiple chief residents. In this system, there are leadership roles for resident and medical student education, ultrasonography, resident research, and high-fidelity simulation in addition to the traditional administrative roles. This model can be modified to match the needs of a given program and the aptitudes of the senior residents., Results: We describe the successful implementation of this model at our program, which has resulted in a progressive curriculum, increased resident leadership, and program ownership among the residents., Conclusions: Our intervention offers an alternative model for overcoming some of the limitations of the traditional chief resident model, including some chief residents who become overwhelmed by their duties and are discouraged from pursuing future leadership roles. It also has the potential to offer other senior residents with various skills and leadership abilities the opportunities to contribute to their program.

Objectives: Methods to accurately identify elderly patients with a high likelihood of hospital admission or subsequent return to the emergency department (ED) might facilitate the development of interventions to expedite the admission process, improve patient care, and reduce overcrowding. This study sought to identify variables found among elderly ED patients that could predict either hospital admission or return to the ED., Methods: All visits by patients 75 years of age or older during 2007 at an academic ED serving a large community of elderly were reviewed. Clinical and demographic data were used to construct regression models to predict admission or ED return. These models were then validated in a second group of patients 75 and older who presented during two 1-month periods in 2008., Results: Of 4,873 visits, 3,188 resulted in admission (65.4%). Regression modeling identified five variables statistically related to the probability of admission: age, triage score, heart rate, diastolic blood pressure, and chief complaint. Upon validation, the c-statistic of the receiver operating characteristic (ROC) curve was 0.73, moderately predictive of admission. We were unable to produce models that predicted ED return for these elderly patients., Conclusions: A derived and validated triage-based model is presented that provides a moderately accurate probability of hospital admission of elderly patients. If validated experimentally, this model might expedite the admission process for elderly ED patients. Our models failed, as have others, to accurately predict ED return among elderly patients, underscoring the challenge of identifying those individuals at risk for early ED returns., (Copyright (c) 2010 by the Society for Academic Emergency Medicine.)

Objectives: The study objective was to determine the sensitivity and specificity of the Emergency Severity Index (ESI) triage instrument for the identification of elder patients receiving an immediate life-saving intervention in the emergency department (ED)., Methods: The authors reviewed medical records for consecutive patients 65 years or older who presented to a single academic ED serving a large community of elders during a 1-month period. ESI triage scores were compared to actual ED course with attention to the occurrence of an immediate life-saving intervention. The sensitivity and specificity of an ESI triage level of 1 for the identification of patients receiving an immediate intervention was calculated. For 50 cases, the triage nurse ESI designation was compared to the triage level determined by an expert triage nurse based on retrospective record review., Results: Of 782 consecutive patients 65 years or older who presented to the ED, 18 (2%) had an ESI level of 1, 176 (23%) had an ESI level of 2, 461 (60%) had an ESI level of 3, 100 (13%) had an ESI level of 4, and 18 (2%) had an ESI level of 5. Twenty-six patients received an immediate life-saving intervention. ESI triage scores for these 26 individuals were as follows: ESI 1, 11 patients; ESI 2, nine patients; and ESI 3, six patients. The sensitivity of ESI to identify patients receiving an immediate intervention was 42.3% (95% confidence interval [CI]=23.3% to 61.3%); the specificity was 99.2% (95% CI=98.0% to 99.7%). For 17 of 50 cases in which actual triage nurse and expert nurse ESI levels disagreed, undertriage by the triage nurses was more common than overtriage (13 vs. 4 patients)., Conclusions: The ESI triage instrument identified fewer than half of elder patients receiving an immediate life-saving intervention. Failure to follow established ESI guidelines in the triage of elder patients may contribute to apparent undertriage., (Copyright (c) 2010 by the Society for Academic Emergency Medicine.)

Background: It is important to stimulate the interest of all medical students in emergency medicine to further its growth nationally and internationally. Students focused on other specialties can benefit from exposure to the more common, less acute problems seen in the emergency department (ED)., Aims: We developed a categorization system for chief complaints (CC) in an academic ED fast track (FT) area, so that a curriculum based upon actual CC and clinical experience could be designed for learners., Methods: Primary (first) FTCCs were obtained from the ED electronic record of an academic medical center from 1 to 10 July 2006 and 1 to 10 February 2007. Category definitions were developed, and CCs were collapsed into clinically coherent groups. Inter-rater reliability was assessed, and CC categories were compared for the two study periods. The study was exempted by the University Institutional Review Board., Results: In the July data set, 493 CCs were placed into 8 categories which captured 96.3% of CCs: pain 32.3%, injury 26.6%, infection 15%, psychiatric 8.1%, miscellaneous 6.1% (those with a frequency of