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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.

Objective: To assess the association of sport specialization combined with sport-related concussion (SRC) history on depression and health-related quality of life (HRQoL) in a population of high school athletes., Design: Cross-sectional study., Setting: High schools., Participants: Two thousand four hundred fifty-three athletes through the State of Wisconsin., Independent Variables: Sport specialization and SRC history., Main Outcome Measures: Athletes completed questionnaires reporting their SRC history, sports participation (single-sport or multisport), Patient Health Questionnaire-9 (PHQ-9), and Pediatric Quality of Life 4.0 (PedsQL). We used multivariate binary logistic regression to assess the odds ratio (OR) for depressive symptoms based on SRC and sport participation history. Separate multilinear regression evaluated the association between the PedsQL, SRC, and sport participation history. The interaction of sport specialization and SRC history was explored in both regression models., Results: High school athletes who participated in single-sport activities had a greater odds of reporting higher severity of depressive symptoms on PHQ-9 scores (OR, 1.50; 95% CI, 1.11-2.02) and reduced PedsQL ( P < 0.001) compared with their multisport counterparts. There were no associations between SRC history and either PHQ-9 or PedsQL scores. Statistically significant interactions between sport specialization and SRC were not found among all models., Conclusion: Single-sport high school athletes reported a reduction in HRQoL measures along with higher depressive symptoms when compared with the multisport athletes. The SRC history did not have a lingering effect on depression or HRQoL in this study. These findings raise some interesting concerns regarding the quality of mental health in adolescent athletes solely focused on single-sport endeavors., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate the changes in mental health, quality of life (QOL) and physical activity (PA) among adolescent athletes during the COVID-19 pandemic as organised sports resumed., Methods: Adolescent athletes completed surveys including demographic and sport participation information, 7-item Generalized Anxiety Disorder, 9-item Patient Health Questionnaire, Pediatric Quality of Life Inventory and the Hospital for Special Surgery Pediatric Functional Activity Brief Scale in May 2020 following COVID-19-related sport cancellations (Spring20) and after returning to sports in May 2021 (Spring21). The groups were balanced by inverse propensity score weighting and compared using analysis of variance models and ordinal regression models., Results: 17 421 participants were included (Spring20=13 002; Spring21=4419; 16.2±1.2 years; 53% female). Anxiety was significantly lower (better) in Spring21 (Spring20=7.0, 95% CI 6.9 to 7.1; Spring21=4.9, 95% CI 4.8 to 5.0, p<0.001), as was the prevalence of moderate to severe anxiety (Spring20=29.4%, Spring21=17.1%, p<0.001). Depression was significantly improved in Spring21 (Spring20=7.6, 95% CI 7.5 to 7.7; Spring21=4.6, 95% CI 4.5 to 4.8, p<0.001), as was the prevalence of moderate to severe depression (Spring20=32.2%, Spring21=15.4%, p<0.001). Athletes in Spring21 reported higher QOL (Spring20=79.6, 95% CI 79.3 to 79.9; Spring21=84.7, 95% CI 84.4 to 85.0, p<0.001) and increased levels of PA (Spring20=13.8, 95% CI 13.6 to 13.9; Spring21=22.7, 95% CI 22.6 to 22.9, p<0.001)., Conclusion: Early COVID-19 sports restrictions were associated with worsening mental health in adolescents. In 2021, after returning to sports, athletes reported significant improvements in mental health, QOL and PA, although mental health adversities remain an important priority., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

The COVID-19 pandemic elevated telehealth as a prevalent care delivery modality for older adults. However, guidelines and best practices for the provision of healthcare via telehealth are lacking. Principles and guidelines are needed to ensure that telehealth is safe, effective, and equitable for older adults. The Collaborative for Telehealth and Aging (C4TA) composed of providers, experts in geriatrics, telehealth, and advocacy, developed principles and guidelines for delivering telehealth to older adults. Using a modified Delphi process, C4TA members identified three principles and 18 guidelines. First, care should be person-centered; telehealth programs should be designed to meet the needs and preferences of older adults by considering their goals, family and caregivers, linguistic characteristics, and readiness and ability to use technology. Second, care should be equitable and accessible; telehealth programs should address individual and systemic barriers to care for older adults by considering issues of equity and access. Third, care should be integrated and coordinated across systems and people; telehealth should limit fragmentation, improve data sharing, increase communication across stakeholders, and address both workforce and financial sustainability. C4TA members have diverse perspectives and expertise but a shared commitment to improving older adults' lives. C4TA's recommendations highlight older adults' needs and create a roadmap for providers and health systems to take actionable steps to reach them. The next steps include developing implementation strategies, documenting current telehealth practices with older adults, and creating a community to support the dissemination, implementation, and evaluation of the recommendations., (© 2022 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

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.

Objective: To evaluate the association between COVID-19 incidence among high-school athletes participating in different indoor winter sports and attending schools with in-person versus virtual instructional delivery., Design: Cross-sectional survey., Setting: US high schools., Participants: High-school athletic directors., Independent Variables: Indoor winter sports, school instructional delivery method, and state COVID-19 incidence., Main Outcome Measures: Surveys were distributed to high-school athletic directors throughout the United States regarding sport reinitiation and COVID-19 cases in winter 2020 to 2021. Separate mixed effects Poisson regression models were developed to evaluate the associations between reported COVID-19 incidence and (1) different sports and (2) school instructional delivery method, while adjusting for the background, state COVID-19 incidence., Results: Four hundred thirty schools had restarted fall sports, representing 31 274 athletes on 1404 teams from 14 states. One thousand four hundred sixty cases of COVID-19 were reported, representing a case rate of 4668 cases per 100 000 athletes and an incidence rate of 58.7 cases per 100 000 player-days. Reported COVID-19 incidence was greatest among girls' hockey (82.1 cases per 100 000 player-days (95% CI, 56.8-115) and boys' hockey [76.7 (61.8-94.2)] and lowest among swimming [39.0 (31.1-48.2)] and gymnastics [28.5 (13.1-54.2)]. No difference in reported COVID-19 incidence was identified among athletes attending schools with virtual versus in-person instruction [incidence rate ratio = 0.86 (0.52-1.4)]., Conclusions: In this nationwide survey of US high-school athletic directors regarding indoor winter sports, reported COVID-19 incidence was lower in noncontact sports but unrelated to school instructional delivery method. This information may help guide decision-making regarding high-school sport participation during the COVID-19 pandemic., Competing Interests: T. McGuine serves on the Sports Medicine Advisory Council of the National Federation of State High School Associations. The remaining authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

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: 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.)

Objectives: The psychological impacts of injuries in youth athletes remain poorly defined. The purpose of this study was to evaluate the influence of injury on quality of life (QOL) and sleep in female high school volleyball athletes., Methods: 2073 female high school volleyball players (15.6±1.1 years) completed the Pediatric Quality of Life survey (total QOL, physical, social, school, emotional and psychosocial function) and reported average sleep duration at the start and end of the season. Injury data were collected by school athletic trainers. Mixed effects linear regression models were used to compare changes in QOL and sleep duration during the season between (1) injured and uninjured athletes and (2) injured athletes who did or did not suffer a season-ending injury., Results: Time-loss injuries were reported in 187 athletes with complete preseason and postseason data. During the season, injured athletes demonstrated a greater decrease in total QOL (β=-1.3±0.5, p=0.012), as well as physical function (β=-1.6±0.6, p=0.012), school function (β=-2.0±0.76, p=0.01) and psychosocial function domains (β=-1.2±0.6, p=0.039) compared with uninjured athletes. Athletes who sustained a season-ending injury had a significantly greater decrease in total QOL (β=-6.8±2.0, p=0.006) and physical function (β=-17±2.9, p<0.001) compared with injured athletes who were able to return to play during the season., Conclusion: In-season injuries are associated with significant decreases in total QOL as well as physical and psychosocial function. Healthcare providers should consider the impacts of injuries on QOL and sleep in youth athletes in order to optimise management and improve overall health., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/objective: Emergency department (ED) visits have declined while excess mortality, not attributable to COVID-19, has grown. It is not known whether older adults are accessing emergency care differently from their younger counterparts. Our objective was to determine patterns of ED visit counts for emergent conditions during the COVID-19 pandemic for older adults., Design: Retrospective, observational study., Setting: Observational analysis of ED sites enrolled in a national clinical quality registry., Participants: One hundred and sixty-four ED sites in 33 states from January 1, 2019 to November 15, 2020., Main Outcome and Measures: We measured daily ED visit counts for acute myocardial infarction (AMI), stroke, sepsis, fall, and hip fracture, as well as deaths in the ED, by age categories. We estimated Poisson regression models comparing early and post-early pandemic periods (defined by the Centers for Disease Control and Prevention) to the pre-pandemic period. We report incident rate ratios to summarize changes in visit incidence., Results: For AMI, stroke, and sepsis, the older (75-84) and oldest old (85+ years) had the greatest decline in visit counts initially and the smallest recovery in the post-early pandemic periods. For falls, visits declined early and partially recovered uniformly across age categories. In contrast, hip fractures exhibited less change in visit rates across time periods. Deaths in the ED increased during the early pandemic period, but then fell and were persistently lower than baseline, especially for the older (75-84) and oldest old (85+ years)., Conclusions: The decline in ED visits for emergent conditions among older adults has been more pronounced and persistent than for younger patients, with fewer deaths in the ED. This is concerning given the greater prevalence and risk of poor outcomes for emergent conditions in this age group that are amenable to time-sensitive ED diagnosis and treatment, and may in part explain excess mortality during the COVID-19 era among older adults., (© 2021 The American Geriatrics Society.)

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.)

In 2018, the American College of Emergency Physicians (ACEP) began accrediting facilities as "geriatric emergency departments" (EDs) according to adherence to the multiorganizational guidelines published in 2014. The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-effective manner and within the capabilities of their facilities and staff. Because all innovation is at heart local and must function within the constraints of local resources, different hospital systems have developed implementation processes for the geriatric ED guidelines according to their differing institutional capabilities and resources. This article describes 4 geriatric ED models of care to provide practical examples and guidance for institutions considering developing geriatric EDs: a geriatric ED-specific unit, geriatrics practitioner models, geriatric champions, and geriatric-focused observation units. The advantages and limitations of each model are compared and examples of specific institutions and their operational metrics are provided., (Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

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.)

Numerous emergency department (ED) atrial fibrillation (AF) protocols have been developed to reduce hospitalizations, focusing on the use of cardioversion in the ED. An alternative strategy of rate control with early specialty follow-up may be more widely applicable. The likelihood of spontaneous cardioversion with such a protocol is unknown. Between 2015 and 2018, 157 patients who presented to the ED with a primary diagnosis of AF and were hemodynamically stable and with low to moderate symptom severity were discharged with early follow-up at an AF specialty clinic. Rhythm at short-term (within 72 hours), within 30-day follow-up, and need for electrical cardioversion was tabulated. Various demographic and co-morbidity variables were assessed to determine their association with likelihood of spontaneous cardioversion. At an average of 2.3 days, 63% and within 30 days, 83% had spontaneous cardioversion. By 90 days, only 6.3% required electrical cardioversion. Diabetes (38% vs 69%, p <0.01), coronary artery disease (39% vs 66%, p = 0.02), reduced ejection fraction (40% vs 72%, p <0.01), dilated right atrium (43% vs 73%, p <0.01) and moderate-to-severely dilated left atrium (38% vs 78%, p <0.01) predicted those who were less likely to convert to sinus rhythm. Most patients who present to the ED with AF will spontaneously convert to sinus rhythm by short-term (2 to 3 days) follow-up with a rate control strategy. In conclusion, aggressive use of electrical cardioversion in the ED may be unnecessary in hemodynamically stable patients without severe symptoms., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To investigate the effects of sex as an effect modifier of objectively measured moderate-to-vigorous physical activity (MVPA) in individuals following ACLR and healthy controls., Design: Cross-sectional research study., Setting: University community., Participants: 59 participants (42.4% male) with a history of ACLR and 55 healthy control participants (40.0% male)., Main Outcome Measures: Participants were outfitted with an ActiGraph wGT3X-BT accelerometer for a period of 7 days to assess MVPA. Weekly time engaged in MVPA (in bouts≥ 10 min), % of total time engaged in MVPA, and odds of meeting national physical activity guidelines (MVPA≥ 150 min/wk) were compared between males and females with a history of ACLR and healthy controls., Results: There were significant sex X group interactions for weekly MVPA (p = 0.02) and % total time in MVPA (p = 0.01). The odds of a female ACLR participant meeting national physical activity guidelines were significantly worse (X 2  = 4.18, OR = 2.54, CI 95  = 1.03-6.27) when compared to participants without ACLR., Conclusions: Female participants with ACLR were found to be less active than healthy control participants and their odds of meeting national MVPA guidelines were also 2.54 times worse than healthy participants., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

BACKGROUND Older adults who are discharged following emergency department evaluation are at increased risk for functional decline and health care utilization, and are likely to benefit from close follow-up and additional care services. Understanding factors associated with a return emergency department visit within 30 days among older fee-for-service Medicare beneficiaries discharged to the community may assist in identifying patients at greatest need for interventions. METHOD Predictors from Medicare data and public sources were evaluated in a retrospective data analysis of North and South Carolina residents (2011-2012) aged ≥ 65 years using Cox regression proportion hazards ratios (HR) and 95% confidence intervals (CI) for time-to-30-day return events. RESULTS 30-day return rates varied markedly among the 167 emergency department facilities studied (18%-39%). Predictors of 30-day return included: age (85+ versus 65-74; HR, 1.24; 95% CI, 1.22-1.27); male sex (HR, 1.11; 95% CI, 1.14-1.10); non-white race (HR, 1.07; 95% CI, 1.05-1.09); Medicaid eligibility (HR, 1.20; 95% CI, 1.18-1.22); Charlson Score (3+ vs. 0; HR, 1.33; 95% CI, 1.30-1.36); and prior emergency department encounter (3+ vs. 0; HR, 2.35; 95% CI 2.30-2.41). LIMITATIONS This study was limited to Medicare beneficiaries in North Carolina and South Carolina, 2011-2012. Administrative claims data are limited to information required for financial reimbursement. Because we limited our study to older fee-for-service patients, our findings may not be generalizable to managed care patients and other age groups. Patients transferred to another emergency department or facility were not included in the analysis. CONCLUSION Factors predicting 30-day return to the emergency department or hospitalization suggest the potential for care transition improvement efforts to better meet patient needs, thereby potentially improving post-emergency department outcomes., (©2019 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Context: Sport specialization is theorized to increase the risk of sustaining overuse musculoskeletal injuries., Objective: To complete a systematic review and meta-analysis of the literature to determine if sport specialization is associated with overuse musculoskeletal injuries., Data Sources: An electronic search was conducted using the search terms "specialization," "year-round," "overuse," "repetitive stress," "injury," "young," "pediatric," and "sports.", Study Selection: Studies were included if their population was ≤18 years of age, if they compared athletes with high or single-sport specialization with athletes with low or multisport specialization, and focused on overuse injuries., Data Extraction: Of the 12 articles that were identified for full-text review, 5 studies met all the inclusion criteria. Four studies provided adequate data for the meta-analysis. Quality scores on the modified Downs and Black scale ranged from 69% to 81%., Results: Athletes with high specialization were at an increased risk of sustaining an overuse injury compared with athletes with low (pooled relative risk [RR] ratio: 1.81; 95% confidence interval [CI]: 1.26-2.60) and moderate (pooled RR: 1.18; 95% CI: 1.05-1.33) specialization. Athletes with moderate specialization were at a higher risk of injury compared with athletes with low specialization (RR: 1.39 [95% CI: 1.04-1.87])., Limitations: Four of the 5 studies included in this systematic review were included in the meta-analysis because of the lack of access to the original data set for 1 article., Conclusions: Sport specialization is associated with an increased risk of overuse musculoskeletal injuries (Strength of Recommendation Taxonomy grade: B)., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

There is evidence that an emergency department (ED) visit signifies a period of vulnerability for older adults. Transition between the ED and community care can be fraught with challenges. There are essential elements for improved care transition from the ED to the community. Starting a new program requires buy-in from leaders, clinical team, and community. Improving care within an ED requires looking beyond the ED. Following implementation science will increase the success of program implementation and dissemination. There are successful alternative approaches that can be learned from when striving to improve care and transitions., (Copyright © 2018 Elsevier Inc. All rights reserved.)