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Introduction: Illinois hospitals have experienced a marked decrease in the number of uninsured patients after implementation of the Affordable Care Act (ACA). However, the full impact of health insurance expansion on trauma mortality is still unknown. The objective of this study was to determine the impact of ACA insurance expansion on trauma patients hospitalized in Illinois.Methods: We performed a retrospective cohort study of 87,001 trauma inpatients from third quarter 2010 through second quarter 2015, which spans the implementation of the ACA in Illinois. We examined the effects of insurance expansion on trauma mortality using multivariable Poisson regression.Results: There was no significant difference in mortality comparing the post-ACA period to the pre-ACA period incident rate ratio (IRR)=1.05 (95% confidence interval [CI] [0.93-1.17]). However, mortality was significantly higher among the uninsured in the post-ACA period when compared with the pre-ACA uninsured population IRR=1.46 (95% CI [1.14-1.88]).Conclusion: While the ACA has reduced the number of uninsured trauma patients in Illinois, we found no significant decrease in inpatient trauma mortality. However, the group that remains uninsured after ACA implementation appears to be particularly vulnerable. This group should be studied in order to reduce disparate outcomes after trauma.

Introduction: This study analyzes changes in hospital emergency department (ED) visit ratesbefore and after the 2014 Affordable Care Act (ACA) insurance expansions in Illinois. We comparethe association between population insurance status change and ED visit rate change between a24-month (2012-2013) pre-ACA period and a 24-month post-ACA (2014-2015) period across 88socioeconomically diverse areas of Illinois.Methods: We used annual American Community Survey estimates for 2012-2015 to obtain insurancestatus changes for uninsured, private, Medicaid, and Medicare (disability) populations of 88 IllinoisPublic Use Micro Areas (PUMAs), areas with a mean of about 90,000 age 18-64 residents. Over 12million ED visits to 201 non-federal Illinois hospitals were used to calculate visit rates by residents ofeach PUMA, using population-based mapping weights to allocate visits from zip codes to PUMAs. Wethen estimated n=88 correlations between population insurance-status changes and changes in EDvisit rates per 1,000 residents comparing the two years before and after ACA implementation.Results: The baseline PUMA uninsurance rate ranged from 6.7% to 41.1% and there was 4.6-fold variation in baseline PUMA ED visit rates. The top quartile of PUMAs had >21,000 reductionsin uninsured residents; 16 PUMAs had at least a 15,000 person increase in Medicaid enrollment.Compared to 2012-2013, 2014-2015 average monthly ED visits by the uninsured dropped 42%,but increased 42% for Medicaid and 10% for the privately insured. Areas with the largest increasesin Medicaid enrollment experienced the largest growth in ED use; change in Medicaid enrollmentwas the only significant correlate of area change in total ED visits and explained a third of variationacross the 88 PUMAs.Conclusion: ACA implementation in Illinois accelerated existing trends towards greater use of hospitalED care. It remains to be seen whether providing better access to primary and preventive care tothe formerly uninsured will reduce ED use over time, or whether ACA insurance expansion is a partof continued, long-term growth. Monitoring ED use at the local level is critical to the success of newhome- and community-based care coordination initiatives. [West J Emerg Med. 2017;18(5)811-820.]

Introduction: Emergency department (ED) patients’ Internet search terms prior to arrival have notbeen well characterized. The objective of this analysis was to characterize the Internet search termspatients used prior to ED arrival and their relationship to final diagnoses.Methods: We collected data via survey; participants listed Internet search terms used. Terms wereclassified into categories: symptom, specific diagnosis, treatment options, anatomy questions,processes of care/physicians, or “other.” We categorized each discharge diagnosis as either symptombasedor formal diagnosis. The relationship between the search term and final diagnosis was assignedto one of four categories of search/diagnosis combinations (symptom search/symptom diagnosis,symptom search/formal diagnosis, diagnosis search/symptom diagnosis, diagnosis search/formaldiagnosis), representing different “trajectories.”Results: We approached 889 patients; 723 (81.3%) participated. Of these, 177 (24.5%) used theInternet prior to ED presentation; however, seven had incomplete data (N=170). Mean age was 47years (standard deviation 18.2); 58.6% were female and 65.7% white. We found that 61.7% searchedsymptoms and 40.6% searched a specific diagnosis. Most patients received discharge diagnoses ofequal specificity as their search terms (34% flat trajectory-symptoms and 34% flat trajectory-diagnosis).Ten percent searched for a diagnosis by name but received a symptom-based discharge diagnosiswith less specificity. In contrast, 22% searched for a symptom and received a detailed diagnosis.Among those who searched for a diagnosis by name (n=69) only 29% received the diagnosis that theyhad searched.Conclusion: The majority of patients used symptoms as the basis of their pre-ED presentation Internetsearch. When patients did search for specific diagnoses, only a minority searched for the diagnosisthey eventually received. [West J Emerg Med. 2017;18(5)928-936.]

Introduction: Seniors represent the fasting growing population in the U.S., accounting for 20.3 million visits to emergency departments (EDs) annually. The ED visit can provide an opportunity for identifying seniors at high risk of falls. We sought to incorporate the Timed Up & Go Test (TUGT), a commonly used falls screening tool, into the ED encounter to identify seniors at high fall risk and prompt interventions through a geriatric nurse liaison (GNL) model.Methods: Patients aged 65 and older presenting to an urban ED were evaluated by a team of ED nurses trained in care coordination and geriatric assessment skills. They performed fall risk screening with the TUGT. Patients with abnormal TUGT results could then be referred to physical therapy (PT), social work or home health as determined by the GNL. Results: Gait assessment with the TUGT was performed on 443 elderly patients between 4/1/13 and 5/31/14. A prior fall was reported in 37% of patients in the previous six months. Of those screened with the TUGT, 368 patients experienced a positive result. Interventions for positive results included ED-based PT (n=63, 17.1%), outpatient PT referrals (n=56, 12.2%) and social work consultation (n=162, 44%).  Conclusion: The ED visit may provide an opportunity for older adults to be screened for fall risk. Our results show ED nurses can conduct the TUGT, a validated and time efficient screen, and place appropriate referrals based on assessment results. Identifying and intervening on high fall risk patients who visit the ED has the potential to improve the trajectory of functional decline in our elderly population.

Reducing adverse drug events among older adults in heterogeneous and often chaotic emergency department (ED) settings requires a multidisciplinary approach. Recent research evaluates the impact of multicomponent protocols designed to reduce ED physician prescribing of potentially inappropriate medications (PIMs), including transdisciplinary training and leveraging electronic health records to provide real‐time alternative safer pharmaceuticals while providing personalized feedback to prescribers. Most new research is not randomized trial data. Although this current research does not consistently demonstrate a reduction in the prescribing of PIMs, these studies provide a foundation for emergency medicine healthcare teams, geriatricians, and pharmacists to collaborate with health informatics to continue advancing the frontiers of safer medication prescribing during episodes of acute care. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The article focuses on emergency department (ED) visits each year increasing ED use by older adults is projected to exceed the capacity of the U.S. EDs. Topics include the traditional ED model of care is ill-equipped to address the many complex care needs of older adults, and the evolution of emergency care has developed as evidenced by consensus geriatric ED (GED) guidelines and the American College of Emergency Medicine's Geriatric Emergency Department Accreditation program.

Objectives: Transitional care nurse (TCN) care has been associated with decreased hospitalizations for older adults in the emergency department (ED). The objective of this study was to evaluate the association between TCN care and readmission for geriatric patients who visit the ED within 30 days of a prior hospital discharge. Methods: We studied a prospective cohort of ED patients aged 65 and older with an ED visit within 30 days of inpatient discharge. Patients with an Emergency Severity Index of 1 or prior TCN contact were excluded. Entropy balancing and logistic regression were used to estimate the average incremental effect of the TCN intervention on risk of admission during the index ED visit and within 30 days of prior discharge. Results: Of 6,838 visits, 608 included TCN care. TCN patients had lower risk of readmission during the index ED visit at Mount Sinai Medical Center (MSMC), −10.1 percentage points (95% confidence interval [CI] = −18.5 to −2.7), and Northwestern Memorial Hospital (NMH), −17.3 percentage points (95% CI = −23.1 to −11.5), but not St. Joseph's Regional Medical Center (SJRMC), −2.5 percentage points (95% CI = −10.5 to 5.5). TCN patients had fewer readmissions within 30 days of prior hospital discharge at NMH, −16.2 percentage points (95% CI = −22.0 to −10.3), but not at MSMC, −5.6 percentage points (95% CI = −13.1 to 1.8), or at SJRMC, 0.5 percentage points (95% CI = −7.2 to 8.2). Conclusions: Transitional care nurse care in the ED after a prior hospitalization was associated with decreased readmission of older adults during the index ED visit at two of three hospitals, with sustained reduction for the entire 30‐day readmission window at one hospital. TCN interventions in the ED may decrease readmissions for geriatric patients in the ED; however, these results may be dependent on implementation of the program and availability of ED, hospital, and local resources for older adults. [ABSTRACT FROM AUTHOR]