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BACKGROUND: The Geriatric Emergency Department (ED) Guidelines recommend screening older adults during their ED visit for delirium, fall risk/safe mobility, and home safety needs. We used the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementation Change (ERIC) tool for pre-implementation planning. METHODS: The cross-sectional survey was conducted among ED nurses at an academic medical center. The survey was adapted from the CFIR Interview Guide Tool and consisted of 21 Likert scale questions based on four CFIR domains. Potential barriers identified by the survey were mapped to identify recommended implementation strategies using ERIC. RESULTS: Forty-six of 160 potential participants (29%) responded. Intervention Characteristics: Nurses felt geriatric screening should be standard practice for all EDs (76.1% agreed some/very much) and that there was good evidence (67.4% agreed some/very much). Outer setting: The national and regional practices such as the existence of guidelines or similar practices in other hospitals were unknown to many (20.0%). Nurses did agree some/very much (64.4%) that the intervention was good for the hospital/health system. Inner Setting: 67.4% felt more staff or infrastructure and 63.0% felt more equipment were needed for the intervention. When asked to pick from a list of potential barriers, the most commonly chosen were motivational (I often don’t remember (n=27, 58.7%) and It is not a priority (n=14, 30.4%)). The identified barriers were mapped using the ERIC tool to rate potential implementation strategies. Strategies to target culture change were: identifying champions, improve adaptability, facilitate the nurses performing the intervention, and increase demand for the intervention. CONCLUSION: CFIR domains and ERIC tools are applicable to an ED intervention for older adults. This pre-implementation process could be replicated in other EDs considering implementing geriatric screening.

Author(s): Hunold, Katherine M.; Caterino, Jeffrey M.; Bischof, Jason J. | Abstract: Objective: Dyspnea is the second most common symptom experienced by the approximately 4.5 million patients with cancer presenting to emergency departments (ED) each year. Distinguishing pneumonia, the most common reason for presentation, from other causes of dyspnea is challenging. This report characterizes the diagnostic uncertainty in patients with dyspnea and pneumonia presenting to an ED by establishing the rates of co-diagnosis, co-treatment, and misdiagnosis.Methods: Visits by individuals ≥18 years old with cancer who presented with a complaint of dyspnea were identified using the National Hospital Ambulatory Medical Care Survey between 2012-2014 and analyzed for rates of co-diagnosis, co-treatment (treatment or diagnosis for g1 of pneumonia, chronic obstructive pulmonary disease [COPD], and heart failure), and misdiagnosis of pneumonia. Additionally, we assessed rates of diagnostic uncertainty (co-diagnosis, co-treatment, or a lone diagnosis of dyspnea not otherwise specified [NOS]) .Results: Among dyspneic cancer visits (1,593,930), 15.2% (95% confidence interval [CI], 11.1-20.5%) were diagnosed with pneumonia, 22.5% (95% CI, 16.7-29.7%) with COPD, and 7.4% (95% CI 4.7-11.4%) with heart failure. Dyspnea NOS was diagnosed in 32.3% (95% CI, 25.7-39.7%) of visits and as the only diagnosis in 23.1% (95% CI, 16.3-31.6%) of all visits. Co-diagnosis occurred in 4.0% (95% CI, 2.0-7.6%) of dyspneic adults with cancer and co-treatment in 12.1% (95% CI, 7.5-18.9%). Agreement between emergency physician and inpatient documentation for presence of pneumonia was 57.7% (95% CI, 37.0-76.1%).Conclusion: Diagnostic uncertainty remains a significant concern in patients with cancer presenting to the ED with dyspnea. Clinical uncertainty among dyspneic patients results in both misdiagnosis and under-treatment of patients with pneumonia and cancer.

Introduction Low- and middle-income countries (LMICs) are continuing to experience a “triple burden” of disease - traumatic injury, non-communicable diseases (NCDs), and communicable disease with maternal and neonatal conditions (CD&Ms). The epidemiology of this triad is not well characterised and poses significant challenges to resource allocations, administration, and education of emergency care providers. The data collected in this study provide a comprehensive description of the emergency centre at Kenya's largest public tertiary care hospital. Methods This study is a retrospective chart review conducted at Kenyatta National Hospital of all patient encounters over a four-month period. Data were collected from financial and emergency centre triage records along with admission and mortality logbooks. Chief complaints and discharge diagnoses collected by specially trained research assistants were manually converted to standardised diagnoses using International Classification of Disease 10 (ICD-10) codes. ICD-10 codes were categorised into groups based on the ICD-10 classification system for presentation. Results A total of 23,941 patients presented to the emergency centre during the study period for an estimated annual census of 71,823. The majority of patients were aged 18-64 years (58%) with 50% of patients being male and only 3% of unknown sex. The majority of patients (61%) were treated in the emergency centre, observed, and discharged home. Admission was the next most common disposition (33%) followed by death (6%). Head injury was the overall most common diagnosis (11%) associated with admission. Conclusions Trends toward NCDs and traumatic diseases have been described by this study and merit further investigation in both the urban and rural setting. Specifically, the significance of head injury on healthcare cost, utilisation, and patient death and disability points to the growing need of additional resources at Kenyatta National Hospital for acute care. It further demonstrates the mounting impact of trauma in Kenya and throughout the developing world. African relevance • This is a comprehensive description of the emergency centre at Kenya's largest public tertiary hospital • It adds to descriptions of trends of non-communicable and traumatic diseases in low- and middle-income countries • It describes epidemiology in Kenya, one of Africa's largest countries

AimsTo describe the 1-year direct and indirect transition probabilities to premature discontinuation of statin therapy after concurrently initiating statins and CYP3A4-inhibitor drugs.MethodsA retrospective new-user cohort study design was used to identify (N=160828) patients who concurrently initiated CYP3A4-inhibitors (diltiazem, ketoconazole, clarithromycin, others) and CYP3A4-metabolized statins (statin DDI exposed, n = 104774) vs. other statins (unexposed, n = 56054) from the MarketScan Commercial claims database (2012 – 2017). These groups were matched (2:1) through propensity score-matching techniques. We applied a multistate transition model to compare the 1-year transition probabilities involving four distinct states (start, adverse drug events [ADEs], discontinuation of CYP3A4-inhibitor drugs, and discontinuation of statin therapy) between those exposed to statin DDIs, vs. unexposed. Statistically significant differences were assessed by comparing the 95% confidence intervals (CIs) of probabilities.ResultsPatients exposed to statin DDIs, vs. unexposed, were significantly less likely to discontinue statin therapy (71.4 [95% CI: 71.1, 71.6] vs. 73.3 [95% CI: 72.9, 73.6]) but more likely to experience an ADE (3.4 [95% CI: 3.3, 3.5] vs. 3.2 [95% CI: 3.1, 3.3]) and discontinue with CYP3A4-inhibitor therapy (21.0 [95% CI: 20.8, 21.3] vs. 19.5 [95% CI: 19.2, 19.8]) directly after concurrently starting stains and CYP3A. Subsequent to experiencing an ADE, those exposed to statin DDIs were still less likely to discontinue statin therapy but were significantly more likely to discontinue CYP3A4-inhibitor therapy.ConclusionWhile statin DDI exposure was associated with higher likelihood of ADEs, this did not increase the risk of premature statin discontinuation among patients exposed to statin DDIs, versus unexposed.

Dyspnea is the second leading cause of US emergency department (ED) visits and an independent predictor of morbidity and mortality1 in older adult patients aged ≥65 years. Unfortunately, the diagnosis of the cause of dyspnea presents diagnostic challenges to emergency physicians2-4 that disproportionately affects older adults.5 One in 5 dyspneic older adults experience missed diagnosis in the ED2 and 21% are treated for ≥1 pneumonia, acute exacerbation of chronic obstructive pulmonary disease [COPD], and acute exacerbation of heart failure [HF].5 Importantly, some may have multiple causes of their dyspnea but accurate diagnosis remains critical.

BackgroundSepsis, a life-threatening illness caused by the body’s response to an infection, is the leading cause of death worldwide and has become a global epidemiological burden. Early prediction of sepsis increases the likelihood of survival for septic patients.MethodsThe 2019 DII National Data Science Challenge enabled participating teams to develop models for early prediction of sepsis onset with de-identified electronic health records of over 100,000 unique patients. Our task is to predict sepsis onset 4 hours before its diagnosis using basic administrative and demographics, time-series vital, lab, nutrition as features. An LSTM-based model with event embedding and time encoding is proposed to model time-series prediction. We utilized the attention mechanism and global max pooling techniques to enable interpretation for the proposed deep learning model.ResultsWe evaluated the performance of the proposed model on 2 use cases of sepsis onset prediction which achieved AUC scores of 0.940 and 0.845, respectively. Our team, BuckeyeAI achieved an average AUC of 0.892 and the official rank is #2 out of 30 participants.ConclusionsOur model outperformed collapsed models (i.e., logistic regression, random forest, and LightGBM). The proposed LSTM-based model handles irregular time intervals by incorporating time encoding and is interpretable thanks to the attention mechanism and global max pooling techniques.AvailabilityThe code for this paper is available at: https://github.com/yinchangchang/DII-Challenge.

Background The use of computed tomography (CT) has been scrutinized in emergency medicine, particularly in patients with cancer. Previous studies have characterized the rate of CT use in this population; however, limited data are available about the yield of this modality compared with radiography and its clinical decision-making effect. Objective To determine whether CT imaging of the chest increases identification of clinically significant results compared with chest radiography (CXR) in patients with cancer. Methods This was a retrospective chart review of patients with a history of solid tumors presenting to an emergency department in 2017. Patients who received both CXR and CT (or CT angiography) of the chest during their assessment were identified and the rate of clinically significant findings on imaging was compared. Clinical findings were further categorized as requiring nonurgent, urgent, or emergent attention. Descriptive statistics and chi-squared testing were performed between the 2 imaging modalities. Results From 839 patients meeting inclusion criteria, 287 were randomly sampled. The predominant malignancies were lung (32.4%), breast (13.9%), and head and neck cancer (13.6%). A greater number of patients had clinically significant findings identified on CT imaging (n = 222) compared with CXR (n = 108). Stratification upon urgency of these findings (nonurgent, urgent, or emergent) reveals a significant difference in all strata (p Conclusions Compared with CXR, CT imaging of the chest identified significantly more clinically relevant findings requiring attention and consequently affecting clinical decision making.

Objectives To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED). Design Preplanned, secondary analysis of a prospective observational study. Setting Tertiary care, academic ED. Participants A total of 424 patients in the ED, 65 years or older, including all chief complaints. Measurements We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection. Results Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40-2.53) or malaise/lethargy (PLR range, 1.25-1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15-18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79-0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms. Conclusions The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484-492, 2019.

STUDY OBJECTIVES: The American College of Emergency Physicians’ Geriatric Emergency Department (GED) Guidelines recommend additional staff and geriatric equipment, which may not be financially feasible for every ED. Data from an accredited level 1 GED was used to report equipment costs and to develop a business model for financially sustainability of a GED. METHODS: Staff salaries including the cost of fringe benefits were obtained from a Midwestern hospital with an academic ED of 80,000 annual visits. Reimbursement assumptions included 100% Medicare/Medicaid insurance payor and 8 hour workdays with 4.5 weeks of leave annually. Equipment costs from hospital invoices were collated. Operational and patient safety metrics were compared before and after the GED. RESULTS: A Geriatric nurse practitioner in the ED is financially self-sustaining at 7.1 consultations, a pharmacist is self-sustaining at 7.7 medication reconciliation consultations, and physical and occupational therapist evaluations are self-sustaining at 5.7 and 4.6 consults per workday respectively. Total annual equipment costs for mobility aids, delirium aids, sensory aids, and personal care items for the GED was $4,513. Comparing the two years before and after, in regards to operational metrics the proportions of patients with lengths of stay > 8 hours and patients placed in observation did not change. In regards to patient safety, the rate of falls decreased from 0.60/1,000 patient visits to 0.42/1,000 in the ED Observation Unit and 0.42/1,000 to 0.36/1,000 in the ED. ED recividism at 7 and 30 days did not change. Estimated cost savings from the reduction in falls was $80,328. CONCLUSION: The additional equipment and personnel costs for comprehensive geriatric assessment in the ED are potentially financially justified by revenue generation and improvements in patient safety measures. A Geriatric ED was associated with a decrease in patient falls in the ED but did not decrease admissions or ED recidivism.

Introduction Triage protocols standardize and improve patient care in accident and emergency departments (A&Es). Kenyatta National Hospital (KNH), the largest public tertiary hospital in East Africa, is resource-limited and was without A&E-specific triage protocols. Objectives We sought to standardize patient triage through implementation of the South African Triage Scale (SATS). We aimed to (1) assess the reliability of triage decisions among A&E healthcare workers following an educational intervention and (2) analyze the validity of the SATS in KNH’s A&E. Methods Part 1 was a prospective, before and after trial utilizing an educational intervention and assessing triage reliability using previously validated vignettes administered to 166 healthcare workers. Part 2 was a triage chart review wherein we assessed the validity of the SATS in predicting patient disposition outcomes by inclusion of 2420 charts through retrospective, systematic sampling. Results Healthcare workers agreed with an expert defined triage standard for 64% of triage scenarios following an educational intervention, and had a 97% agreement allowing for a one-level discrepancy in the SATS score. There was “good” inter-rater agreement based on an intraclass correlation coefficient and quadratic weighted kappa. We analyzed 1209 pre-SATS and 1211 post-SATS patient charts and found a non-significant difference in undertriage and statistically significant decrease in overtriage rates between the pre- and post-SATS cohorts (undertriage 3.8 and 7.8%, respectively, p = 0.2; overtriage 70.9 and 62.3%, respectively, p

Summary Sepsis is a life-threatening condition with high mortality rates and expensive treatment costs. Early prediction of sepsis improves survival in septic patients. In this paper, we report our top-performing method in the 2019 DII National Data Science Challenge to predict onset of sepsis 4 h before its diagnosis on electronic health records of over 100,000 unique patients in emergency departments. A long short-term memory (LSTM)-based model with event embedding and time encoding is leveraged to model clinical time series and boost prediction performance. Attention mechanism and global max pooling techniques are utilized to enable interpretation for the deep-learning model. Our model achieved an average area under the curve of 0.892 and was selected as one of the winners of the challenge for both prediction accuracy and clinical interpretability. This study paves the way for future intelligent clinical decision support, helping to deliver early, life-saving care to the bedside of septic patients., Graphical Abstract, Highlights • We present benchmark results of sepsis-onset prediction in emergency department • An LSTM-based model captures irregular time intervals with time encodings • Our deep-learning model shows superior performance compared with existing methods • Model interpretation enables real-world clinical applications, The bigger picture Sepsis is the leading cause of death worldwide and has become a global epidemiological burden. Early prediction of sepsis enables early treatment and increases the likelihood of survival for septic patients. The broad adoption of electronic health records (EHRs) provides an opportunity for sepsis prediction. However, most existing prediction approaches do not consider irregular time intervals between neighboring clinical events in EHRs. Besides, many deep-learning models suffer from black-box problems and are not trusted in clinical settings. We propose a deep-learning model with time encodings, offering both high accuracy and high transparency as well as clinical interpretability. We have already made our code and its detailed documentations publicly available, enabling colleagues to apply it to their applications and eventually make clinical impacts., Electronic health records contain valuable temporal information for sepsis prediction. However, irregular time intervals between neighboring events are typically neglected. Besides, transparency and interpretability of deep-learning models with increasing complexity and superior performance has become a barrier to the models' clinical adoption. To this end, we propose an interpretable deep-learning model that better captures time information and achieves promising performance on sepsis prediction in the emergency department.

Objectives To estimate the proportion of visits to U.S. emergency departments (EDs) in which a diagnosis of elder abuse is reached using two nationally representative datasets. Design Retrospective cross-sectional analysis. Setting U.S. ED visits recorded in the 2012 Nationwide Emergency Department Sample (NEDS) or the 2011 National Hospital Ambulatory Medical Care Survey (NHAMCS). Participants All ED visits of individuals aged 60 and older. Measurements The primary outcome was elder abuse defined according to International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The proportion of visits with elder abuse was estimated using survey weights. Odds ratios (ORs) were calculated to identify demographic characteristics and common ED diagnoses associated with elder abuse. Results In 2012, NEDS contained information on 6,723,667 ED visits of older adults, representing an estimated 29,056,673 ED visits. Elder abuse was diagnosed in an estimated 3,846 visits, corresponding to a weighted diagnosis period prevalence of elder abuse in U.S. EDs of 0.013% (95% confidence interval (CI) = 0.012–0.015%). Neglect and physical abuse were the most common types diagnosed, accounting for 32.9% and 32.2% of cases, respectively. Multivariable analysis showed greater weighted odds of elder abuse diagnosis in women (odds ratio (OR) = 1.95, 95% CI = 1.68–2.26) and individuals with contusions (OR = 2.91, 95% CI = 2.36–3.57), urinary tract infection (OR = 2.21, 95% CI = 1.84–2.65), and septicemia (OR = 1.92, 95% CI = 1.44–2.55). In the 2011 NHAMCS dataset, no cases of elder abuse were recorded for the 5,965 older adult ED visits. Conclusion The proportion of U.S. ED visits by older adults receiving a diagnosis of elder abuse is at least two orders of magnitude lower than the estimated prevalence in the population. Efforts to improve the identification of elder abuse in EDs may be warranted.

A 78-year-old female was brought to the emergency department due to altered mental status (AMS) by her son who noted an acute change. Her AMS was deemed likely secondary to hypercalcemia and digoxin toxicity precipitated by Tums overconsumption for abdominal pain. After clinical improvement, the patient shared that she took the Tums rather than ask her family for a ride to the doctor. This case highlights the importance of caregiver burden, geriatric syndromes, and the important role of consultants to help arrange safe discharge.

BACKGROUND: Emergency Department (ED) Observation Units (Obs Units) are prevalent in the US, but little is known regarding older adults in observation. Our objective was to describe the Obs Units nationally and observation patients with specific attention to differences in care with increasing age. DESIGN: This is an analysis of 2010-2013 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national observational cohort study including ED patients. Weighted means are presented for continuous data and weighted percent for categorical data. Multivariable logistic regression was used to identify variables associated with placement in and admission from observation. RESULTS: The number of adult ED visits varied from 100 million to 107 million per year and 2.3% of patients were placed in observation. Adults ≥65 years old made up a disproportionate number of Obs Unit patients, 30.6%, compared to only 19.7% of total ED visits (odds ratio 1.5 (95% CI 1.5-1.6), adjusting for sex, race, month, day of week, payer source, and hospital region). The overall admission rate from observation was 35.6%, ranging from 31.3% for ages 18-64 years to 47.5% for adults ≥ 85 years old (p

Objectives Constipation is a common and potentially serious side effect of oral opioids. Accordingly, most clinical guidelines suggest routine use of laxatives to prevent opioid-induced constipation. The objective was to characterize emergency provider prescribing of laxatives to prevent constipation among adults initiating outpatient opioid treatment. Methods National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2010 were analyzed. Among visits by individuals aged 18 years and older discharged from the emergency department (ED) with opioid prescriptions, the authors estimated the survey-weighted proportion of visits in which laxatives were also prescribed. A subgroup analysis was conducted for individuals aged 65 years and older, as the potential risks associated with opioid-induced constipation are greater among older individuals. To examine a group expected to be prescribed laxative medication and confirm that NHAMCS captures prescriptions for these medications, the authors estimated the proportion of visits by individuals discharged with prescriptions for laxatives among those who presented with constipation. Results Among visits in 2010 by adults aged 18 years and older discharged from the ED with opioid prescriptions, 0.9% (95% confidence interval [CI] = 0.7% to 1.3%, estimated total n = 191,203 out of 21,075,050) received prescriptions for laxatives. Among the subset of visits by adults aged 65 years and older, 1.0% (95% CI = 0.5% to 2.0%, estimated total n = 18,681 out of 1,904,411) received prescriptions for laxatives. In comparison, among visits by individuals aged 18 years and older with constipation as a reason for visit, 42% received prescriptions for laxatives. Conclusions In this nationally representative sample, laxatives were not routinely prescribed to adults discharged from the ED with prescriptions for opioid pain medications. Routine prescribing of laxatives for ED visits may improve the safety and effectiveness of outpatient opioid pain management.

Objectives The authors sought to describe the frequency of short-term side effects experienced by older adults initiating treatment with opioid-containing analgesics for acute musculoskeletal pain. Methods This was a cross-sectional study of individuals age 65 years or older initiating analgesic treatment following emergency department (ED) visits for acute musculoskeletal pain. Patients were called by phone 4 to 7 days after their ED visits to assess the intensity of six common opioid-related side effects using a 0 to 10 scale and to assess medication discontinuation due to side effects. Propensity score matching was used to compare side effects among patients initiating treatment with any opioid-containing analgesics to side effects among those initiating treatment with only nonopioids. Results Of 104 older patients initiating analgesic treatment following ED visits for musculoskeletal pain, 71 patients took opioid-containing analgesics, 15 took acetaminophen, and 18 took ibuprofen. Among the patients who took opioids, at least one side effect of moderate or severe intensity (score ≥ 4) was reported by 62%. Among patients with matching propensity scores, those taking opioids were more likely to have had moderate or severe side effects than those taking only nonopioids (62%, 95% confidence interval [CI] = 48% to 74% vs. 4%, 95% CI = 1% to 20%) and were also more likely to have discontinued treatment due to side effects (16%, 95% CI = 8% to 29% vs. 0%, 95% CI = 0% to 13%). The most common side effects due to opioids were tiredness, nausea, and constipation. Conclusions Among older adults initiating treatment with opioid-containing analgesics for musculoskeletal pain, side effects were common and sometimes resulted in medication discontinuation. Resumen Efectos Secundarios de los Opioides Orales Utilizados para Tratar el Dolor Agudo Musculoesqueletico en Adultos Mayores Durante la Primera Semana de Tratamiento Objetivos Describir la frecuencia de los efectos secundarios a corto plazo experimentados por los adultos mayores que inician tratamiento con un analgesico que contiene opioides para el dolor agudo musculoesqueletico. Metodologia Estudio transversal de sujetos de 65 anos o mas que iniciaron tratamiento analgesico tras una visita al servicio de urgencias (SU) por dolor agudo musculoesqueletico. Se contacto con los pacientes por telefono de 4 a 7 dias despues de la visita al SU para valorar la intensidad de los seis efectos secundarios mas frecuentes relacionados con los opiaceos usando una escala de 0 a 10. Se valoro la interrupcion de la medicacion debido a los efectos secundarios. Se utilizo el emparejamiento mediante puntuacion de propension (propensity store) para comparar los efectos secundarios entre los pacientes que inician el tratamiento con cualquier analgesico que contiene opioides y los efectos secundarios en aquellos que inician tratamiento unicamente con no opioides. Resultados De los 104 pacientes mayores que iniciaron tratamiento analgesico tras una visita al SU por dolor musculoesqueletico, 71 tomaron un analgesico que contenia opioides, 15 acetaminofeno y 18 ibuprofeno. Entre los pacientes que tomaron un opioide, al menos se documento un efecto secundario de intensidad moderada o grave (puntuacion ≥ 4) en el 62% de ellos. Entre los pacientes con emparejamiento mediante puntuaciones de propension, aquellos que tomaron opioides tuvieron mayor probabilidad de haber tenido un efecto secundario moderado o grave que aquellos que tomaron unicamente un no opioide (62%, intervalo de confianza [IC] 95% = 48% a 74% vs. 4%, IC 95% = 1% a 20%) y tambien tuvieron mayor probabilidad de haber interrumpido el tratamiento debido a los efectos secundarios (16%, IC 95% = 8% a 29% vs. 0%, IC 95% = 0% a 13%). Los efectos secundarios mas frecuentes debido a los opioides fueron cansancio, nauseas y estrenimiento. Conclusiones En los adultos mayores que inician tratamiento analgesico que contiene opioides para el dolor musculoesqueletico, los efectos secundarios fueron comunes y algunas veces llevaron a la interrupcion de la medicacion.

Objectives To estimate the proportion of older adults in the emergency department (ED) who are willing and able to use a tablet computer to answer questions. Design Prospective, ED-based cross-sectional study. Setting Two U.S. academic EDs. Participants Individuals aged 65 and older. Measurements As part of screening for another study, potential study participants were asked whether they would be willing to use a tablet computer to answer eight questions instead of answering questions orally. A custom user interface optimized for older adults was used. Trained research assistants observed study participants as they used the tablets. Ability to use the tablet was assessed based on need for assistance and number of questions answered correctly. Results Of 365 individuals approached, 248 (68%) were willing to answer screening questions, 121 of these (49%) were willing to use a tablet computer; of these, 91 (75%) were able to answer at least six questions correctly, and 35 (29%) did not require assistance. Only 14 (12%) were able to answer all eight questions correctly without assistance. Individuals aged 65 to 74 and those reporting use of a touchscreen device at least weekly were more likely to be willing and able to use the tablet computer. Of individuals with no or mild cognitive impairment, the percentage willing to use the tablet was 45%, and the percentage answering all questions correctly was 32%. Conclusion Approximately half of this sample of older adults in the ED was willing to provide information using a tablet computer, but only a small minority of these were able to enter all information correctly without assistance. Tablet computers may provide an efficient means of collecting clinical information from some older adults in the ED, but at present, it will be ineffective for a significant portion of this population.

Objectives: Motor vehicle collisions (MVCs) are the second most common cause of nonfatal injury among U.S. adults age 65 years and older. However, the frequency of emergency department (ED) visits, disposition, pain locations, and pain severity for older adults experiencing MVCs have not previously been described. The authors sought to determine these characteristics using information from two nationally representative data sets. Methods: Data from the 2008 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (NEDS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to estimate MVC-related ED visits and ED disposition for patients 65 years and older. NHAMCS data from 2004 through 2008 were used to further characterize MVC-related ED visits. Results: In 2008, the NEDS contained 28,445,564 patient visits, of which 760,356 (2.7%) were due to MVCs. The NHAMCS contained 34,134 patient visits, of which 1,038 (3.0%) were due to MVCs. National estimates of MVC-related ED visits by patients 65 years and older in 2008 are 226,000 (95% confidence interval [CI] = 210,000 to 240,000) for NEDS and 270,000 (95% CI = 185,000 to 355,000) for NHAMCS. Most older adults with MVC-related ED visits were sent home from the ED (proportion discharged NEDS 78%, 95% CI = 78% to 79%; NHAMCS 77%, 95% CI = 66% to 86%). During the years 2004 through 2008, of MVC-related ED visits by older adults not resulting in hospital admission, moderate or severe pain was reported in 61% (95% CI = 52% to 70%) of those with recorded pain scores. Older patients sent home after MVC-related ED visits were less likely than younger patients to receive analgesics (35%, 95% CI = 26% to 43% vs. 47%, 95% CI = 44% to 50%) during their ED evaluations or as discharge prescriptions (52%, 95% CI = 41% to 62% vs. 65%, 95% CI = 61% to 68%). Conclusions: In 2008, adults age 65 years or older made more than 200,000 MVC-related ED visits. Approximately 80% of these visits were discharged home from the ED, but the majority of discharged patients reported moderate or severe pain. Further studies of pain and functional outcomes in this population are needed. Language: en

Objectives Musculoskeletal pain is a common reason for emergency department (ED) visit by older adults. Outpatient pain management following ED visits in this population is challenging as a result of contraindications to, and side effects from, available therapies. Shared decision-making (SDM) between patients and emergency physicians may improve patient experiences and health outcomes. Among older ED patients with acute musculoskeletal pain, we sought to characterize their desire for involvement in the selection of outpatient analgesics. We also sought to assess the impact of SDM on change in pain at 1 week, patient satisfaction, and side effects. Methods This was a prospective study of adults aged 60 years and older presenting to the ED with acute musculoskeletal pain. Participants' desire to contribute to outpatient analgesic selection was assessed by phone within 24 hours of ED discharge using the Control Preferences Scale and categorized as active, collaborative, or passive. The extent to which SDM occurred in the ED was also assessed within 24 hours of discharge using the 9-item Shared Decision Making Questionnaire, and scores were subsequently grouped into tertiles of low, middle, and high SDM. The primary outcome was change in pain severity between the ED visit and 1 week. Secondary outcomes included satisfaction regarding the decision about how to treat pain at home, satisfaction with the pain medication itself, and side effects. Results Desire of participants (N = 94) to contribute to the decision regarding selection of outpatient analgesics varied: 16% active (i.e., make the final decision themselves), 37% collaborative (i.e., share decision with provider), and 47% passive (i.e., let the doctor make the final decision). The percentage of patients who desired an active role in the decision was higher for patients who were college educated versus those who were not college educated (28% vs. 11%; difference 17%, 95% confidence interval [CI] = 0% to 35%), received care from a nurse practitioner versus a resident or an attending physician (32% vs. 9%; difference 23%, 95% CI = 4% to 42%), or received care from a female versus a male provider (24% vs. 5%; difference 19%, 95% = CI 5% to 32%). After potential confounders were adjusted for, the mean decrease in pain severity from the ED visit to 1-week follow-up was not significantly different across tertiles of SDM (p = 0.06). Higher SDM scores were associated with greater satisfaction with the discharge pain medications (p = 0.006). SDM was not associated with the class of analgesic received. Conclusions In this sample of older adults with acute musculoskeletal pain, the reported desire of patients to contribute to decisions regarding analgesics varied based on both patient and provider characteristics. SDM was not significantly related to pain reduction in the first week or type of pain medication received, but was associated with greater patient satisfaction.

Objectives Emergency departments (EDs) are an increasingly important site of care for older adults, but little is known about the priorities of emergency care in this population. We sought to describe and rank priorities of care among older adults receiving care in the ED. Methods We conducted a cross-sectional study of cognitively intact patients aged 65 years and older receiving care in two U.S. EDs. Participants provided up to three open-ended responses to a single question asking what would make their ED visit successful, useful, or valuable. A literature review and patient responses were used to generate priority categories and larger metacategories. Each response was then assigned to one of the categories by independent reviewers. We report the percentage of patients identifying a priority in each category and metacategory and the relative weight of each category based on the frequency and order of priorities provided by patients. Results A total of 185 participants provided 351 priorities. Twenty-four categories and seven metacategories were identified. Sixty-two percent (N = 114) of participants reported at least one priority in the "evaluation, treatment, and outcomes" metacategory. Of these, the most common priorities included treatment of the medical problem (n = 37, 20%), accurate diagnosis (n = 36, 19%), competent staff and provider (n = 28, 15%), and desirable health outcome (n = 24, 13%). The second and third most common metacategories were "timely care" (n = 67, 36%), and "service" (n = 38, 21%). Nineteen patients (10%) expressed a desire to be discharged; one patient (1%) expressed a desire for admission. The ranking of weighted priorities were identical to the unweighted rank order by frequency. Conclusions Among a sample of cognitively intact older ED patients, the most common priorities were related to the accuracy and efficiency of the medical evaluation. These priorities should be considered by those attempting to improve the emergency care of older adults.

To the Editor: Older adults are a growing injury population in the United States.1 We analyzed US climbing and mountaineering- related injuries and illness including fatalities recorded in Accidents in North American Mountaineering2 as an indirect assessment of changes during the past several decades in the proportion of older adults involved in mountaineering accidents. Statistical tables from this source summarize mountaineering accidents occurring in the United States from 1951 to 2010. From 1973 onward, cases were grouped into 7 age categories, with the oldest age group being individuals older than 50. Before 1973, the oldest age group recognized was individuals older than 35. Data from Canada were not included in the analysis because data were not available from 2006 onward. Cases are identified by the editors of Accidents in North American Mountaineering for possible inclusion in the tables in a number of ways. The most common means of case identification are reports submitted by climbers and members of search and rescue organizations. In national parks with a large volume of climbing activity (eg, Yosemite, Denali, Grand Teton), accident reports are submitted by climbing rangers. During the past decade, cases have also been identified by editors using searches of online sources including general climbing websites such as The Mountain Project (www.themountainproject.com) and Supertopo (www.supertopo.com) as well as area-specific websites (eg, www.redriverclimbing.org). Cases are included in the statistical tables and used for this analysis if they occur in the United States and involved people participating in climbing and mountaineering activities including rock or ice climbing, mountain climbing, and ski mountaineering. Duplicate recording of cases is avoided because the details of each case are reviewed by the editor. Accidents occurring during bouldering, climbing indoors, or climbing buildings are not included in the tables used for this analysis. We calculated the annual percentage of cases involving individuals older than 50 by dividing the number of individuals older than 50 by the total number of individuals of known age; individuals of unknown age were not included in the denominator. Temporal changes in the percentage of cases occurring in individuals older than 50 are summarized and presented graphically for years 1973 through 2010. For descriptive purposes, a loess procedure was used to fit a locally weighted regression line and graphed using Sigma Plot 12 (Systat Software Inc, Chicago, IL). Between 1973 and 2010, there were 6603 US climbing and mountaineering accidents reported; 1281 (19%) of these were fatalities. Most accidents occurred on rock (63%) as opposed to snow or ice (37%); during ascent (77%); and during the months of June, July, August, and September (63%). More than half of the US accidents occurred in California (21%), Washington (18%), and Colorado (12%). For years in which type of accident was recorded (1984–2010), the most common types of accident were injury (83%), frostbite or hypothermia (6%), and altitude-related illness (3%). Of the 6603 accidents reported, age was known for 5513 cases (83%). The number of accidents involving climbers older than 50 each year ranged from 0 in 1975 to 31 in 2010. Among the 5513 cases for which the age of the victim was known, the percentage of injured climbers older than 50 ranged from 0% in 1975 to 22% in 2008 (Figure). The mean percentage of injuries or fatalities occurring in individuals older than 50 increased from 3% between 1973 and 1989 to 16% between 2006 and 2010. Figure Percentage of US mountaineering-related injuries and illnesses involving climbers older than 50 reported in Accidents in North American Mountaineering, 1973–2010.2 We observe a large increase in the percentage of adults older than 50 with mountaineering-related injury or illness as reported during the last 4 decades in Accidents in North American Mountaineering. Accidents in North American Mountaineering depends on the voluntary submission of information by injured parties and rescuers and captures only a fraction of the total number of US mountaineering accidents. Further, the purpose of these reports is to understand the etiology of injuries, not to quantify the total number of injuries occurring each year. As a result, the data used for this analysis do not represent the actual number of accidents that occurred each year, and interpretation of trends from this source of data must be made with caution. Additionally, changes in reporting practices with time have the potential to introduce bias in temporal trends. Despite these important limitations, we think the observed trend is not simply a result of changes in reporting practices. Increased use of Internet-based communication would not be anticipated to favor older adults. Similarly, although reporting of accidents by climbing rangers from national parks may be biased toward older climbers, we would not expect that such a bias would favor reports regarding older adults during the past decade but not in the 1970s and 1980s. Given the magnitude of the change observed and its agreement with trends in other forms of recreational trauma in older adults,3,4 we think it likely that the observed increase in reporting in Accidents in North American Mountaineering represents an actual increase in the number of older US adults experiencing climbing or mountaineering-related injury or illness. Between 1980 and 2010, the percentage of the US population age 50 and older increased from 26% to 32%.5 Thus, the approximately fivefold increase in reports of older adults experiencing mountaineering accidents from Accidents in North American Mountaineering during the same time is not explained solely by the increase in the population of older adults. We think that the most likely explanation for the observed trend is a disproportionate increase in mountaineering activity by older adults. Whether this increase reflects a general increase in climbing activities of older adults that will be sustained or reflects the aging of a cohort that began climbing in the 1970s is unknown. The data presented are not coupled with information about the age distribution of participants in climbing and mountaineering activities, so our analysis is unable to determine the rate of accidents in older vs younger adults. However, even if the risk of injury is lower in older than younger climbers, 6 the results suggest that older adults are now a substantial US climbing and mountaineering accident population. If representative of actual trends in the epidemiology of mountaineering accidents, these findings are important because age is a risk factor for adverse outcomes after trauma.7–9 Further, because targeted education and additional rescue resources can reduce mountaineering-related fatalities,10 a better understanding of these trends has potential implications for prevention and rescue preparedness. Further work is needed to confirm these observations and, if confirmed, to identify and implement practices to minimize mountaineering-related injury and illness in older adults. The National Center for Research Resources had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript.

BackgroundResource-limited settings are increasingly experiencing a ‘triple burden’ of disease, composed of trauma, non-communicable diseases (NCDs) and known communicable disease patterns. However, the epidemiology of acute and emergency care is not well characterised and this limits efforts to further develop emergency care capacity.ObjectiveTo define the burden of disease by describing the patient population presenting to the Accident and Emergency Department (A&E) at Kenyatta National Hospital (KNH) in Kenya.MethodsWe completed a prospective descriptive assessment of patients in KNH’s A&E obtained via systematic sampling over 3 months. Research assistants collected data directly from patients and their charts. Chief complaint and diagnosis codes were grouped for analysis. Patient demographic characteristics were described using the mean and SD for age and n and percentages for categorical variables. International Classification of Disease 10 codes were categorised by 2013 Global Burden of Disease Study methods.ResultsData were collected prospectively on 402 patients with an average age of 36 years (SD 19), and of whom, 50% were female. Patients were most likely to arrive by taxi or bus (39%), walking (28%) or ambulance (17%). Thirty-five per cent of patients were diagnosed with NCDs, 24% with injuries and 16% with communicable diseases, maternal and neonatal conditions. Overall, head injury was the single most common final diagnosis and occurred in 32 (8%) patients. The most common patient-reported mechanism for head injury was road traffic accident (39%).ConclusionThis study estimates the characteristics of the A&E population at a tertiary centre in Kenya and highlights the triple burden of disease. Our findings emphasise the need for further development of emergency care resources and training to better address patient needs in resource-limited settings, such as KNH.

Objectives: To assess the relationship between the number of primary care providers (PCPs) in an area and emergency department (ED) visits by older adults. Design: Population-based cross-sectional observational study. Setting: Nonfederal EDs in North Carolina in 2010. Participants: All older adults (n = 640,086) presenting to a nonfederal ED in North Carolina in 2010. Measurements: The primary outcome was the number of ED visits by older adults in each ZIP code per 100 adults aged 65 and older living in that ZIP code. A secondary outcome was the number of ED visits not resulting in hospital admission per 100 older adults. The primary predictor variable was the number of PCPs per 100 older residents for each ZIP code. Covariates included those representing healthcare need (Medicare hospitalizations, nursing home beds), predisposing factors for healthcare use (race, education, population density of older adults), and enabling factors (distance to the nearest ED). Results: In a multivariable regression model corrected for spatial clustering, ZIP code characteristics associated with ED visits included more hospitalizations by Medicare beneficiaries, more nursing home beds, and closer proximity to an ED. Number of PCPs per 100 older adult residents in each ZIP code was not associated with ED use, and the 95% confidence limit indicates at most a small effect of PCP availability on ED use. Conclusion: These findings suggest that primary care availability has at most a limited effect on ED use by older adults in North Carolina.

Objectives: To assess the relationship between older adults' perceptions of shared decision-making in the selection of an analgesic to take at home for acute musculoskeletal pain and (1) patient satisfaction with the analgesic and (2) changes in pain scores at 1 week. Design: Cross-sectional study. Setting: Single academic emergency department. Participants: Individuals aged 65 and older with acute musculoskeletal pain. Measurements: Two components of shared decision-making were assessed: information provided to the patient about the medication choice and patient participation in the selection of the analgesic. Optimal satisfaction with the analgesic was defined as being �a lot� satisfied. Pain scores were assessed in the ED and at 1 week using a 0-to-10 scale. Results: Of 159 individuals reached by telephone, 111 met all eligibility criteria and completed the survey. Fifty-two percent of participants reported receiving information about pain medication options, and 31% reported participating in analgesic selection. Participants who received information were more likely to report optimal satisfaction with the pain medication than those who did not (67% vs 34%; P < .001). Participants who participated in the decision were also more likely to report optimal satisfaction with the analgesic (71% vs 43%; P = .008) and had a greater average decrease in pain score (4.1 vs 2.9; P = .05). After adjusting for measured confounders, participants who reported receiving information remained more likely to report optimal satisfaction with the analgesic (63% vs 38%; P = .04). Conclusion: Shared decision-making in analgesic selection for older adults with acute musculoskeletal pain may improve outcomes.