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Introduction: Delirium affects 15% of older adults presenting to emergency departments (EDs) but is detected in only one-third of cases. Evidence-based guidelines for ED delirium screening exist, but are underutilized. Frontline staff perceptions about delirium and time and resource constraints are known barriers to ED delirium screening uptake. Early adopters of ED delirium screening can offer valuable lessons about successful implementation., Methods: We conducted semi-structured interviews with clinician-administrators leading ED delirium screening initiatives from 20 EDs in the United States and Canada. Interviews focused on experiences of planning and implementing ED delirium screening. Interviews lasted 15 to 50 minutes and were digitally recorded and transcribed. To identify factors that commonly impacted implementation of ED delirium screening, we used constructs from the Consolidated Framework for Implementation Research (CFIR), an Implementation Science framework widely used to evaluate healthcare improvement initiatives., Results: Overall, notable facilitators of successful implementation were having institutional and ED leadership support and designated clinical champions to longitudinally engage and educate frontline staff. We found specific examples of factors affecting implementation drawn from the following seven CFIR constructs: (1) intervention complexity, (2) intervention adaptability, (3) external policies and incentives, (4) peer pressure from other institutions, (5) the implementation climate of the ED, (6) staff knowledge and beliefs, and (7) engaging deliverers of intervention, that is, frontline ED staff., Conclusion: Implementing ED delirium screening is complex and requires institutional resources as well as clinical champions to engage frontline staff in a sustained fashion., (© 2024 The American Geriatrics Society.)

Introduction: The intersection of ageism and racism is underexplored in geriatric emergency medicine (GEM) research., Methods: We performed a scoping review of research published between January 2016 and December 2021. We included original emergency department-based research focused on falls, delirium/dementia, medication safety, and elder abuse. We excluded manuscripts that did not include (1) original research data pertaining to the four core topics, (2) older adults, (3) subjects from the United States, and (4) for which full text publication could not be obtained. The primary objective was to qualitatively describe reporting about older adults' social identities in GEM research. Secondary objectives were to describe (1) the extent of inclusion of minoritized older adults in GEM research, (2) GEM research about health equity, and (3) feasible approaches to improve the status quo of GEM research reporting., Results: After duplicates were removed, 3277 citations remained and 883 full-text articles were reviewed, of which 222 met inclusion criteria. Four findings emerged. First, race and ethnicity reporting was inconsistent. Second, research rarely provided a rationale for an age threshold used to define geriatric patients. Third, GEM research more commonly reported sex than gender. Fourth, research commonly excluded older adults with cognitive impairment and speakers of non-English primary languages., Conclusion: Meaningful assessment of GEM research inclusivity is limited by inconsistent reporting of sociodemographic characteristics, specifically race and ethnicity. Reporting of sociodemographic characteristics should be standardized across different study designs. Strategies are needed to include in GEM research older adults with cognitive impairment and non-English primary languages., (© 2024 The American Geriatrics Society.)

The Agency for Healthcare Research and Quality (AHRQ) report "Diagnostic Errors in the Emergency Department" generated significant mass media interest with negative implications for the safety of contemporary emergency care. The assumptions and methodology underlying this report are problematic, while multiple ongoing efforts to improve the quality and quantity of diagnostic research are missed, neglected, or ignored. The AHRQ report identifies reasonable target diseases for targeting diagnostic quality improvement efforts, as well as viable methods by which to measure any initiatives impact on diagnostic error. We note additional opportunities to improve the status quo by funding emergency department-based diagnostic research and healthcare system-level patient safety research and highlighting innovative approaches to diagnostic science within emergency medicine., (Copyright 2023 by the Missouri State Medical Association.)

Background: In 2014, the Geriatric Emergency Department (GED) Guidelines were published and endorsed by four major medical organizations. The multidisciplinary GED Guidelines characterized the complex needs of the older emergency department (ED) patient and current best practices, with the goal of promoting more cost-effective and patient-centered care. The recommendations are extensive and most EDs then and now have neither the resources nor the hospital administrative support to provide this additional service., Discussion: At the 2021 American Academy of Emergency Medicine's Scientific Assembly, a panel of emergency physicians and geriatricians discussed the GED Guidelines and the current realities of EDs' capacity to provide best practice and guideline-recommended care of GED patients. This article is a synthesis of the panel's presentation and discussion. With the substantial challenges in providing guideline-recommended care in EDs, this article will explore three high-impact GED clinical conditions to highlight guideline recommendations, challenges, and opportunities, and discuss realistically achievable expectations for non-GED-accredited institutions., Conclusions: In 2014, the GED Guidelines were published, describing the current best practices for GED patients. Unfortunately, most of the EDs worldwide do not provide the level of service recommended by the GED Guidelines. The GED Guidelines can best be termed aspirational for U.S. EDs at the present time., (Copyright © 2022. Published by Elsevier Inc.)

Study Objective: The objectives of this study were to describe the reach and adoption of Geriatric Emergency Department Accreditation (GEDA) program and care processes instituted at accredited geriatric emergency departments (EDs)., Methods: We analyzed a cross-section of a cohort of US EDs that received GEDA from May 2018 to March 2021. We obtained data from the American College of Emergency Physicians and publicly available sources. Data included GEDA level, geographic location, urban/rural designation, and care processes instituted. Frequencies and proportions and median and interquartile ranges were used to summarize categorical and continuous data, respectively., Results: Over the study period, 225 US geriatric ED accreditations were issued and included in our analysis-14 Level 1, 21 Level 2, and 190 Level 3 geriatric EDs; 5 geriatric EDs reapplied and received higher-level accreditation after initial accreditation at a lower level. Only 9 geriatric EDs were in rural regions. There was significant heterogeneity in protocols enacted at geriatric EDs; minimizing urinary catheter use and fall prevention were the most common., Conclusion: There has been rapid growth in geriatric EDs, driven by Level 3 accreditation. Most geriatric EDs are in urban areas, indicating the potential need for expansion beyond these areas. Future research evaluating the impact of GEDA on health care utilization and patient-oriented outcomes is needed., (Copyright © 2021 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: The Society for Academic Emergency Medicine Board of Directors convened a task force to elucidate the current state of workforce, operational, and educational issues being faced by academic medical centers related to advanced practice providers (APPs). The task force surveyed academic emergency department (ED) chairs and residency program directors (PDs)., Methods: The survey was distributed to the Association of Academic Chairs of Emergency Medicine (AACEM)-member chairs and their respective residency PDs in 2021. We surveyed 125 chairs with their self-identified PDs. The survey sampled hiring, state-independent practice laws, scope of practice, teaching and supervision, training opportunities, delegation of procedures between physician learners and APPs, and perceptions of the impact on resident and medical student education., Results: Of the AACEM-member chairs identified, 73% responded and 47% of PDs responded. Most (98%) employ either physician assistants or nurse practitioners. Among responding departments, 86% report APPs working in fast-track settings, 80% work in the main ED, and 54% work in the waiting room. In 44% of departments, APPs and residents evaluate patients concurrently, and 2% of respondents reported that APPs manage high-acuity patients without attending involvement. Two-thirds of chairs believe that APPs contribute positively to the quality of patient care, while 44% believe that APPs contribute to the academic environment. One-third of PDs believe that the presence of APPs interferes with resident education. Although 75% of PDs believe that residents require training to work effectively with APPs in the ED, almost half (49%) report zero hours of training around APP supervision or collaborative skills., Conclusions: APPs are ubiquitous across academic EDs. Future research is required for academic ED leaders to balance physician and APP deployment across the academic ED within the context of patient care, resident education, institutional resources, professional development opportunities for APP staff, and standardization of APP EM training., (© 2021 by the Society for Academic Emergency Medicine.)

Objectives: To characterize emergency department sedation practices in mechanically ventilated patients, and test the hypothesis that deep sedation in the emergency department is associated with worse outcomes., Design: Multicenter, prospective cohort study., Setting: The emergency department and ICUs of 15 medical centers., Patients: Mechanically ventilated adult emergency department patients., Interventions: None., Measurements and Main Results: All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as Richmond Agitation-Sedation Scale of -3 to -5 or Sedation-Agitation Scale of 2 or 1. A total of 324 patients were studied. Emergency department deep sedation was observed in 171 patients (52.8%), and was associated with a higher frequency of deep sedation in the ICU on day 1 (53.8% vs 20.3%; p < 0.001) and day 2 (33.3% vs 16.9%; p = 0.001), when compared to light sedation. Mean (SD) ventilator-free days were 18.1 (10.8) in the emergency department deep sedation group compared to 20.0 (9.8) in the light sedation group (mean difference, 1.9; 95% CI, -0.40 to 4.13). Similar results according to emergency department sedation depth existed for ICU-free days (mean difference, 1.6; 95% CI, -0.54 to 3.83) and hospital-free days (mean difference, 2.3; 95% CI, 0.26-4.32). Mortality was 21.1% in the deep sedation group and 17.0% in the light sedation group (between-group difference, 4.1%; odds ratio, 1.30; 0.74-2.28). The occurrence rate of acute brain dysfunction (delirium and coma) was 68.4% in the deep sedation group and 55.6% in the light sedation group (between-group difference, 12.8%; odds ratio, 1.73; 1.10-2.73)., Conclusions: Early deep sedation in the emergency department is common, carries over into the ICU, and may be associated with worse outcomes. Sedation practice in the emergency department and its association with clinical outcomes is in need of further investigation.

Purpose: Renal colic is common and CT (computerized tomography) is frequently utilized when the diagnosis of kidney stone is suspected. CT is accurate, but exposes patients to ionizing radiation and has not been shown to alter either interventional approaches or hospital admission rates. This multi-organizational transdisciplinary collaboration sought evidence-based, multispecialty consensus on optimal imaging across different clinical scenarios in patients with suspected renal colic in the acute setting., Materials and Methods: In conjunction with the ACEP (American College of Emergency Physicians®) E-QUAL (Emergency Quality Network) we formed a nine-member panel with three physician representatives each from the ACEP, the ACR® (American College of Radiology) and the AUA (American Urological Association). A systematic literature review was used as the basis for a 3-step modified Delphi process to seek consensus on optimal imaging in 29 specific clinical scenarios., Results: From an initial search yielding 6,337 records there were 232 relevant articles of acceptable evidence quality to guide the literature summary. At the completion of the Delphi process consensus, agreement was rated as perfect in 15 (52%), excellent in 8 (28%), good in 3 (10%) and moderate in 3 (10%) of the 29 scenarios. There were no scenarios where at least moderate consensus was not reached. CT was recommended in 7 scenarios (24%) with ultrasound in 9 (31%) and no further imaging needed in 13 (45%)., Conclusions: Evidence and multispecialty consensus support ultrasound or no further imaging in specific clinical scenarios, with reduced-radiation dose CT to be employed when CT is needed in patients with suspected renal colic.

Study Objective: Nearly 20 million adolescents receive emergency department (ED) care each year, many of whom have untreated reproductive health issues. ED visits represent an opportunity to provide appropriate care, however, ED physician reproductive health care practices and capabilities in the United States have not been described. We sought to characterize pediatric ED director's individual practice and ED system resources for providing adolescent reproductive health care., Design, Setting, Participants, and Interventions: We invited pediatric ED division and/or medical directors nationally to participate in an anonymous, online survey., Main Outcome Measures: Outcomes included ED directors' personal practice regarding providing adolescent patients reproductive health care, and their ED's resources and standard practice regarding screening adolescents for sexually transmitted infections (STIs) and other reproductive health concerns., Results: One hundred thirty-five of 442 (30.5%) ED directors responded. Respondents were 73% (90/124) male, with a median of 18 (interquartile range, 13-23) years of experience and 63% (84/134) working in urban EDs. Seventy-one percent (90/130) preferred face-to-face interviews for obtaining a sexual history, but only 59% (77/130) of participants "always ask parents to leave the room for sensitive questions." Eighty-four percent (106/127) were receptive to pregnancy prevention interventions being initiated in the ED, with 75% (80/106) of those willing to provide an intervention. Only 16% (21/128) indicated their ED has a universal STI screening program, and only 18% (23/126) "always" successfully notify patients of a positive STI test., Conclusion: ED directors are comfortable providing adolescent reproductive health care, and many individual- and ED-level opportunities exist to provide improved reproductive health care for adolescents in the ED., (Copyright © 2018 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Through the National Institute on Aging's (NIA's) "Grants for Early Medical/Surgical Specialists" Transition to Aging Research (GEMSSTAR) U13 grant, the NIA and the American Geriatrics Society (AGS) developed three transdisciplinary research conferences with a focus on mentoring and leadership skills development. The NIA's GEMSSTAR program evolved from two earlier programs, the AGS' Dennis W. Jahnigen and the Association of Specialty Professors' T. Franklin Williams Career Development Scholars Awards. It supports the continued cultivation of the next generation of medical and surgical specialty researchers with an interest in aging research. The award requires both geriatrics and specialty mentoring and currently provides up to $150,000 a year in direct support to scholars. Additionally, the award requires that scholars have a professional development plan that is complementary to the GEMSSTAR award. The U13 conferences, focused on frailty, models of aging, and cognition, brought together GEMSSTAR scholars, former scholars, innovators, mentors, and leaders in aging research, the specialties, and geriatric medicine. This article describes the themes of each of the GEMSSTAR U13 conferences and highlights the lessons learned on mentoring, team science, aging research networks, and work-life balance. We plan to use these lessons to guide the support we provide to the growing group of emerging leaders who are poised to lead the transdisciplinary research network of the future. J Am Geriatr Soc 67:650-656, 2019., (© 2019 The American Geriatrics Society.)

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., (© 2018 The American Geriatrics Society.)

OBJECTIVEThere remains uncertainty regarding the appropriate level of care and need for repeating neuroimaging among children with mild traumatic brain injury (mTBI) complicated by intracranial injury (ICI). This study's objective was to investigate physician practice patterns and decision-making processes for these patients in order to identify knowledge gaps and highlight avenues for future investigation.METHODSThe authors surveyed residents, fellows, and attending physicians from the following pediatric specialties: emergency medicine; general surgery; neurosurgery; and critical care. Participants came from 10 institutions in the United States and an email list maintained by the Canadian Neurosurgical Society. The survey asked respondents to indicate management preferences for and experiences with children with mTBI complicated by ICI, focusing on an exemplar clinical vignette of a 7-year-old girl with a Glasgow Coma Scale score of 15 and a 5-mm subdural hematoma without midline shift after a fall down stairs.RESULTSThe response rate was 52% (n = 536). Overall, 326 (61%) respondents indicated they would recommend ICU admission for the child in the vignette. However, only 62 (12%) agreed/strongly agreed that this child was at high risk of neurological decline. Half of respondents (45%; n = 243) indicated they would order a planned follow-up CT (29%; n = 155) or MRI scan (19%; n = 102), though only 64 (12%) agreed/strongly agreed that repeat neuroimaging would influence their management. Common factors that increased the likelihood of ICU admission included presence of a focal neurological deficit (95%; n = 508 endorsed), midline shift (90%; n = 480) or an epidural hematoma (88%; n = 471). However, 42% (n = 225) indicated they would admit all children with mTBI and ICI to the ICU. Notably, 27% (n = 143) of respondents indicated they had seen one or more children with mTBI and intracranial hemorrhage demonstrate a rapid neurological decline when admitted to a general ward in the last year, and 13% (n = 71) had witnessed this outcome at least twice in the past year.CONCLUSIONSMany physicians endorse ICU admission and repeat neuroimaging for pediatric mTBI with ICI, despite uncertainty regarding the clinical utility of those decisions. These results, combined with evidence that existing practice may provide insufficient monitoring to some high-risk children, emphasize the need for validated decision tools to aid the management of these patients.

Opioid misuse is reducing Americans' life expectancy, thereby catalyzing professional societies and legislators to action. Efforts to combat the opioid epidemic must work hand-in-hand with appropriate efforts to reduce the severity and duration of suffering. Pharmacologic analgesia is temporizing. Current opioid prescribing guidelines focus on reducing the frequency and quantity of narcotics prescribed, but lack attention to alleviation of the source of pain. Conditions eliciting acute pain sometimes require additional specialist management following discharge from the emergency department. Patients frequently lack timely access to these specialists, particularly if underinsured. This essay explores acute dental pain, extremity fractures, and back pain as three common examples whereby complex healthcare systems must efficiently adapt in order to serve the dual objectives of reducing the risk of opioid-related adverse consequences and minimizing the duration of patient suffering.

This manuscript provides a brief overview of the history of communication of scientific research and reporting of scientific research impact outcomes. Current day practices are outlined along with examples of how organizations and libraries are providing tools to evaluate and document the impact of scientific research to provide a meaningful narrative suitable for a variety of purposes and audiences.

In the United States and around the world, effective, efficient, and reliable strategies to provide emergency care to aging adults is challenging crowded emergency departments (EDs) and a strained health care system. In response, geriatric emergency medicine (EM) clinicians, educators, and researchers collaborated with the American College of Emergency Physicians (ACEP), American Geriatrics Society (AGS), Emergency Nurses Association (ENA), and the Society for Academic Emergency Medicine (SAEM) to develop guidelines intended to improve ED geriatric care by enhancing expertise, educational, and quality improvement expectations; equipment; policies; and protocols. These "Geriatric Emergency Department Guidelines" represent the first formal society-led attempt to characterize the essential attribute of the geriatric ED and received formal approval from the boards of directors for each of the four societies in 2013 and 2014. This article is intended to introduce EM and geriatric health care providers to the guidelines, while providing proposals for educational dissemination, refinement via formal effectiveness evaluations and cost-effectiveness studies, and institutional credentialing., (© 2014 by the Society for Academic Emergency Medicine.)

Already crowded and stressful, US emergency departments (EDs) are facing the challenge of serving an aging population that requires complex and lengthy evaluations. Creative solutions are necessary to improve the value and ensure the quality of emergency care delivered to older adults while more fully addressing their complex underlying physical, social, cognitive, and situational needs. Developing models of geriatric emergency care, including some that are already in use at dedicated geriatric EDs, incorporate a variety of physical, procedural, and staffing changes. Among the options for "geriatricizing" emergency care are approaches that may eliminate the need for an ED visit, such as telemedicine; for initial hospitalization, such as patient observation units; and for rehospitalization, such as comprehensive discharge planning. By transforming their current safety-net role to becoming a partner in care coordination, EDs have the opportunity to become better integrated into the broader health care system, improve patient health outcomes, contribute to optimizing the health care system, and reduce overall costs of care-keys to improving emergency care for patients of all ages.

Background: The "BEEM" (best evidence in emergency medicine) rater scale was created for emergency physicians (EPs) to evaluate the physician-derived clinical relevance score of recently published, emergency medicine (EM)-related studies. BEEM therefore is designed to help make EPs aware of studies most likely to confirm or change current clinical practice., Objectives: The objective was to validate the BEEM rater score as a predictor of literature citation, using a bibliometric construct of clinical relevance to EM based on author-, document-, and journal-level measures (first and last author h-indices, number of authors including corporate and group authors, citations from date of publication to 2011, and journal impact factor scores) and study characteristics (design, category, and sample size)., Methods: Each month from 2007 through 2012, approximately 200 EPs from around the world voluntarily reviewed the titles and conclusions of recently published EM-related studies identified by BEEM faculty via the McMaster Health Information Research Unit. Using the BEEM rater scale, a reliable seven-item instrument that evaluates the clinical relevance of studies, raters independently assigned BEEM scores to approximately 10 to 20 articles each month. Two investigators independently abstracted the bibliometric indices for these articles. A citation rate for each article was calculated by dividing the Thomson Reuters Web of Science (WoS) total citation count by the number of years in publication. BEEM rater scores were correlated with the citation rate using Spearman's rho. The performance of the BEEM rater score was assessed for each article using negative binomial regression with composite citation count as the criterion standard, while controlling for other independent bibliometric variables in three models., Results: The BEEM raters evaluated 605 articles with a mean (±SD) BEEM score of 3.84 (±0.7) and a median BEEM score of 3.85 (interquartile range = 3.38 to 4.30). Articles were primarily therapeutic (59%) and diagnostic (27%), with various designs, including 37% systematic reviews, 32% randomized controlled trials (RCTs), and 30% observational designs. The citation rate and BEEM rater score correlated positively (0.144), while the BEEM rater score and the Journal Citation Report (JCR) impact factor score were minimally correlated (0.053). In the first model, the BEEM rater score significantly predicted WoS citation rate (p < 0.0001) with an odds ratio (OR) of 1.24 (95% confidence interval [CI] = 1.106 to 1.402). In subsequent models adjusting for the JCR impact factor score, the h-indices of the first and last authors, number of authors, and study design, the BEEM rater score was not significant (p = 0.08)., Conclusions: To the best of our knowledge, the BEEM rater score is the only known measure of clinical relevance. It has a high interrater reliability and face validity and correlates with future citations. Future research should assess this instrument against alternative constructs of clinical relevance., (© 2013 by the Society for Academic Emergency Medicine.)

Background: Improving quality in children's mental health and social service settings will require implementation strategies capable of moving effective treatments and other innovations (e.g., assessment tools) into routine care. It is likely that efforts to identify, develop, and refine implementation strategies will be more successful if they are informed by relevant stakeholders and are responsive to the strengths and limitations of the contexts and implementation processes identified in usual care settings. This study will describe: the types of implementation strategies used; how organizational leaders make decisions about what to implement and how to approach the implementation process; organizational stakeholders' perceptions of different implementation strategies; and the potential influence of organizational culture and climate on implementation strategy selection, implementation decision-making, and stakeholders' perceptions of implementation strategies., Methods/design: This study is a mixed methods multiple case study of seven children's social service organizations in one Midwestern city in the United States that compose the control group of a larger randomized controlled trial. Qualitative data will include semi-structured interviews with organizational leaders (e.g., CEOs/directors, clinical directors, program managers) and a review of documents (e.g., implementation and quality improvement plans, program manuals, etc.) that will shed light on implementation decision-making and specific implementation strategies that are used to implement new programs and practices. Additionally, focus groups with clinicians will explore their perceptions of a range of implementation strategies. This qualitative work will inform the development of a Web-based survey that will assess the perceived effectiveness, relative importance, acceptability, feasibility, and appropriateness of implementation strategies from the perspective of both clinicians and organizational leaders. Finally, the Organizational Social Context measure will be used to assess organizational culture and climate. Qualitative, quantitative, and mixed methods data will be analyzed and interpreted at the case level as well as across cases in order to highlight meaningful similarities, differences, and site-specific experiences., Discussion: This study is designed to inform efforts to develop more effective implementation strategies by fully describing the implementation experiences of a sample of community-based organizations that provide mental health services to youth in one Midwestern city.

Emergency services constitute crucial and frequently used safety nets for older persons, an emergency visit by a senior very often indicates high vulnerability for functional decline and death, and interventions via the emergency system have significant opportunities to change the clinical course of older patients who require its services. However, the evidence base for widespread employment of emergency system-based interventions is lacking. In this article, we review the evidence and offer crucial research questions to capitalize on the opportunity to optimize health trajectories of older persons seeking emergency care in four areas: prehospital care, delirium, adverse drug events, and falls.

Multidisciplinary orthogeriatric care can enhance prompt ED diagnosis, optimal pre- and postoperative care, and functional recovery in older adults with bony injuries. Emergency care providers should be cognizant of prevalent geriatric syndromes including delirium and standing level falls to minimize fracture-related morbidity. Recognizing the implications of aging physiology, acute care physicians should be aware of effective alternatives to analgesia, procedural sedation, and definitive imaging to promote early surgical management and postoperative recovery., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: The Accreditation Council for Graduate Medical Education (ACGME) invokes evidence-based medicine (EBM) principles through the practice-based learning core competency. The authors hypothesized that among a representative sample of emergency medicine (EM) residency programs, a wide variability in EBM resident training priorities, faculty expertise expectations, and curricula exists., Objectives: The primary objective was to obtain descriptive data regarding EBM practices and expectations from EM physician educators. Our secondary objective was to assess differences in EBM educational priorities among journal club directors compared with non-journal club directors., Methods: A 19-question survey was developed by a group of recognized EBM curriculum innovators and then disseminated to Council of Emergency Medicine Residency Directors (CORD) conference participants, assessing their opinions regarding essential EBM skill sets and EBM curricular expectations for residents and faculty at their home institutions. The survey instrument also identified the degree of interest respondents had in receiving a free monthly EBM journal club curriculum., Results: A total of 157 individuals registered for the conference, and 98 completed the survey. Seventy-seven (77% of respondents) were either residency program directors or assistant/associate program directors. The majority of participants were from university-based programs and in practice at least 5 years. Respondents reported the ability to identify flawed research (45%), apply research findings to patient care (43%), and comprehend research methodology (33%) as the most important resident skill sets. The majority of respondents reported no formal journal club or EBM curricula (75%) and do not utilize structured critical appraisal instruments (71%) when reviewing the literature. While journal club directors believed that resident learners' most important EBM skill is to identify secondary peer-reviewed resources, non-journal club directors identified residents' ability to distinguish significantly flawed research as the key skill to develop. Interest in receiving a free monthly EBM journal club curriculum was widely accepted (89%)., Conclusions: Attaining EBM proficiency is an expected outcome of graduate medical education (GME) training, although the specific domains of anticipated expertise differ between faculty and residents. Few respondents currently use a formalized curriculum to guide the development of EBM skill sets. There appears to be a high level of interest in obtaining EBM journal club educational content in a structured format. Measuring the effects of providing journal club curriculum content in conjunction with other EBM interventions may warrant further investigation., (© 2010 by the Society for Academic Emergency Medicine.)

Background: The emergency department (ED) visit rate for older patients exceeds that of all age groups other than infants. The aging population will increase elder ED patient utilization to 35% to 60% of all visits. Older patients can have complex clinical presentations and be resource-intensive. Evidence indicates that emergency physicians fail to provide consistent high-quality care for elder ED patients, resulting in poor clinical outcomes., Objectives: The objective was to develop a consensus document, "Geriatric Competencies for Emergency Medicine Residents," by identified experts. This is a minimum set of behaviorally based performance standards that all residents should be able to demonstrate by completion of their residency training., Methods: This consensus-based process utilized an inductive, qualitative, multiphase method to determine the minimum geriatric competencies needed by emergency medicine (EM) residents. Assessments of face validity and reliability were used throughout the project., Results: In Phase I, participants (n=363) identified 12 domains and 300 potential competencies. In Phase II, an expert panel (n=24) clustered the Phase I responses, resulting in eight domains and 72 competencies. In Phase III, the expert panel reduced the competencies to 26. In Phase IV, analysis of face validity and reliability yielded a 100% consensus for eight domains and 26 competencies. The domains identified were atypical presentation of disease; trauma, including falls; cognitive and behavioral disorders; emergent intervention modifications; medication management; transitions of care; pain management and palliative care; and effect of comorbid conditions., Conclusions: The Geriatric Competencies for EM Residents is a consensus document that can form the basis for EM residency curricula and assessment to meet the demands of our aging population., (Copyright (c) 2010 by the Society for Academic Emergency Medicine.)

Three recently published Institute of Medicine reports, Hospital-Based Emergency Care: At the Breaking Point, Emergency Medical Services: At the Crossroads, and Emergency Care for Children: Growing Pains, examined the current state of emergency care in the United States. They concluded that the emergency medicine system as a whole is overburdened, underfunded, and highly fragmented. These reports did not specifically discuss the effect the aging population has on emergency care now and in the future and did not discuss special needs of older patients. This report focuses on the emergency care of older patients, with the intent to provide information that will help shape discussions on this issue.

Nursing interest in computer use is on the increase; to date, however, its focus has been on clinical applications. Manually processing the volume of information needed to effectively and efficiently manage a modern nursing department becomes more difficult daily. This paper investigates published nursing management computer applications. It points to the need to look beyond the simple administrative to true management information systems, and outlines a role for the nurse administrator in preparing and implementing automatic data processing (ADP) plans.

Through analysis of medical and administrative director positions it is possible to identify an organizational structure for medical departments that enhances departmental operations. Possible roles and tasks that describe managerial responsibilities are considered, and a review of the literature identifies options for how these roles or tasks can be shared between medical and nonmedical managers at the departmental level. These options are refined based on interviews with department-level managers at a case study hospital. Three models are then explored: unity of command, shared accountability, and split accountability. The unity of command model is recommended. In this model, the medical director assumes total authority and accountability for departmental operations through some sort of "enfranchisement." A more formal planning process and a review of job descriptions are also recommended.