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Background: Hospice and palliative medicine (HPM) is a board-certified subspecialty within emergency medicine (EM), but prior studies have shown that EM residents do not receive sufficient training in HPM. Experts in HPM-EM created a consensus list of competencies for HPM training in EM residency. We evaluated how the HPM competencies integrate within the American Board of Emergency Medicine Milestones, which include the Model of the Clinical Practice of Emergency Medicine (EM Model) and the knowledge, skills, and abilities (KSA) list.Methods: Three emergency physicians independently mapped the HPM-EM competencies onto the 2019 EM Model items and the 2021 KSAs. Discrepancies were resolved by a fourth independent reviewer, and the final mapping was reviewed by all team members.Results: The EM Model included 78% (18/23) of the HPM competencies as a direct match, and we identified recommended areas for incorporating the other five. The KSAs included 43% (10/23). Most HPM competencies included in the KSAs mapped onto at least one level B (minimal necessary for competency) KSA. Three HPM competencies were not clearly included in the EM Model or in the KSAs (treating end-of-life symptoms, caring for the imminently dying, and caring for patients under hospice care).Conclusion: The majority of HPM-EM competencies are included in the current EM Model and KSAs and correspond to knowledge needed to be competent in EM. Programs relying on the EM Milestones to plan their curriculums may miss training in symptom management and care for patients at the end of life or who are on hospice.

Background: Emergency medicine (EM) resident training is guided by the American Board of Emergency Medicine Model of the Clinical Practice of Emergency Medicine (EM Model) and the EM Milestones as developed based on the knowledge, skills, and abilities (KSA) list. These are consensus documents developed by a collaborative working group of seven national EM organizations. External experts in geriatric EM also developed competency recommendations for EM residency education in geriatrics, but these are not being taught in many residency programs. Our objective was to evaluate how the geriatric EM competencies integrate/overlap with the EM Model and KSAs to help residency programs include them in their educational curricula.Methods: Trained emergency physicians independently mapped the geriatric resident competencies onto the 2019 EM Model items and the 2021 KSAs using Excel spreadsheets. Discrepancies were resolved by an independent reviewer with experience with the EM Model development and resident education, and the final mapping was reviewed by all team members.Results: The EM Model included 77% (20/26) of the geriatric competencies. The KSAs included most of the geriatric competencies (81%, 21/26). All but one of the geriatric competencies mapped onto either the EM Model or the KSAs. Within the KSAs, most of the geriatric competencies mapped onto necessary level skills (ranked B, C, D, or E) with only five (8%) also mapping onto advanced skills (ranked A).Conclusion: All but one of the geriatric EM competencies mapped to the current EM Model and KSAs. The geriatric competencies correspond to knowledge at all levels of training within the KSAs, from beginner to expert in EM. Educators in EM can use this mapping to integrate the geriatric competencies within their curriculums.

Background: The Geriatric Emergency Department (ED) Guidelines recommend screening older patients for need for evaluation by geriatric medicine, physical therapy (PT), and occupational therapy (OT), but explicit evidence that geriatric screening changes care compared to physician gestalt is lacking. We assessed changes in multidisciplinary consultation after implementation of standardized geriatric screening in the ED. Methods: Retrospective single‐site observational cohort of older adult ED patients from 2019 to 2023 with three time periods: (1) preimplementation, (2) implementation of geriatric screening, and (3) postimplementation. Geriatric, PT, and OT consultations/referrals were available during all time periods. Descriptive analysis was stratified by disposition: discharged, observation and discharged, observation and hospital admission, and hospital admission. The independent variable was completion of three geriatric screening tools by ED nurses. The dependent variable was consultation and/or referral to geriatrics, PT, and OT. Secondary outcomes were disposition, ED revisits, and 30‐day rehospitalizations. Results: There were 57,775 qualifying ED visits of patients age ≥ 65 years during the time periods: implementation increased geriatric screening from 0.5% to 63.2%; postimplementation, discharge patients who received screening had more consultations/referrals to geriatrics (1.5% vs. 0.4%), PT (7.9% vs. 1.9%), and OT (6.5% vs. 1.2%) compared to unscreened patients. Patients observed and then discharged had more consultations/referrals to geriatrics (15.1% vs. 11.3%), PT (74.1% vs. 64.5%), and OT (65.7% vs. 56.5%). Admitted patients had no change in consultation rates. Geriatric screening was not associated with a change in 7‐day ED revisits for discharged patients but was associated with decreased revisits for patients discharged from observation (11.6% vs. 42.9%, p < 0.001). Conclusion: Geriatric screening was associated with increased consultations/referrals to geriatrics, PT, and OT in the ED and ED observation unit. This suggests that geriatric screening changes ED care for older adults. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Community‐dwelling older adults are at high risk for unmet social service needs. We describe a novel partnership embedding county services case managers in the Emergency Department (ED) to connect older adults to community services alongside their medical care.Setting: A medium‐sized urban ED with 55,000 patient visits a year. Intervention: Case managers from the Franklin County, Ohio Office on Aging (OA) were embedded within the ED. The OA team worked with the ED social work team to identify community‐dwelling older patients, perform an in‐person intake assessment, and initiate needed community services (including home‐delivered meals, emergency response systems, house repairs, and transportation). Program logic model and development are reported in detail.From June to December 2023, there were 7284 ED visits for adults ≥60 years old. Referrals to the OA case manager ranged from 1 to 13 per day. The OA case managers performed 252 full intake assessments on unique patients. The population was 51% men. Only 11% (n = 28) were currently connected to OA services, and of those already connected 29% (n = 8) needed increased services. Of the remaining unconnected patients (n = 224), 8% (n = 20) were not county residents and the OA team connected them with other county OAs. Half 53% (n = 120) were accepting of services and had services from the OA or other community health programs initiated during the ED visit. The OA team made three new Adult Protective Services referrals and one referral to the long‐term care ombudsman. The program did not increase ED length of stay or hospital admission rates.Embedding county service enrollment within a community ED is a cost neutral intervention that reached a population without previous services. Future plans include expansion of the program and evaluation of the program's ability to detect elder mistreatment and self‐neglect. [ABSTRACT FROM AUTHOR]

Background: Pneumonia accounts for over half a million older adult emergency department (ED) visits annually, but ED pneumonia diagnosis is inaccurate. Geriatric‐specific pneumonia diagnostic criteria exist for other settings; no prospective data exist to determine if application in the older adult ED population is feasible. The objective was to prospectively evaluate the utility of four current diagnostic criteria (Loeb; Modified McGeer; Infectious Disease Society of America/American Thoracic Society; American College of Emergency Physicians) in older adult ED patients. Methods: This was a prospective, observational cohort study of older adult ED patients ≥65 years of age in two U.S. EDs with suspected pneumonia defined as having chest radiography ordered and treating physician suspicion. The standard we used for defining the presence, absence, or inability to determine a diagnosis of pneumonia diagnosis was expert physician chart adjudication. We report the summary statistics for demographic characteristics and symptoms/exam findings and sensitivity, specificity, and likelihood ratios with 95% confidence intervals of the existing diagnostic criteria. Pre‐specified cutoff values of a positive LR >10 and a negative LR <0.3 were considered clinically significant. Results: Of 135 patients enrolled, 27 had pneumonia by adjudicator review. Typical patient‐reported pneumonia symptoms, such as fever (18.5%) and new/worse cough (51.9%), were not consistently present in pneumonia. The IDSA/ATS and ACEP criteria had positive LR >10 and negative LR <0.3; however, all confidence intervals included pre‐specified cutoffs. Conclusions: Older adults presented to the ED with low frequency of typical pneumonia symptoms. Although existing diagnostic definitions had promising test characteristics, they may not perform well enough for clinical application without refinement. [ABSTRACT FROM AUTHOR]

Background Antimicrobial peptides (AMPs) are key effectors of urinary tract innate immunity. Identifying differences in urinary AMP levels between younger and older adults is important in understanding older adults' susceptibility and response to urinary tract infections (UTI) and AMP use as diagnostic biomarkers. We hypothesized that uninfected older adults have higher urinary human neutrophil peptides 1-3 (HNP 1-3), human alpha-defensin-5 (HD-5), and human beta-defensin-2 (hBD-2), but lower urinary cathelicidin (LL-37) than younger adults. Methods We conducted a cross-sectional study of patients aged ≥18 years completing a family medicine clinic nonacute visit. Enzyme-linked immunosorbent assays were performed for AMPs. We identified associations between age and AMPs using unadjusted and multivariable linear regression models. Results Of the 308 subjects, 144 (46.8%) were ≥65 years of age. Comparing age ≥65 versus < 65 years, there were no significant differences in HNP 1-3 (p  = .371), HD5 (p  = .834), or LL-37 (p  = .348) levels. Values for hBD-2 were lower in older adults versus younger (p  < .001). In multivariable analyses, older males and females had significantly lower hBD-2 levels (p  < .001 and p  = .004). Models also showed urine leukocyte esterase was associated with increased levels of HNP 1-3 and HD5; hematuria with increased hBD-2; and urine cultures with contamination with increased HNP 1-3 and hBD-2. Conclusions Baseline urinary HNP 1-3, HD-5, and LL-37 did not vary with age. Older adults had lower baseline hBD-2. This finding has implications for the potential use of urinary AMPs as diagnostic markers and will facilitate further investigation into the role of innate immunity in UTI susceptibility in older adults. [ABSTRACT FROM AUTHOR]

Involuntary sedation of agitated mental health patients in the Emergency Department (ED) is standard practice to obtain accurate medical assessments and maintain safety. However, the rate of this practice and what factors are associated with the use of involuntary sedation is unknown. The purpose of this study was to obtain baseline data on involuntary sedation in our EDs. Retrospective chart review of patients with ED visits for mental health care in 2020–2021. Patients >12 years old who received both a psychiatry consultation and involuntary sedation were included. Data variables included demographics, medical and mental health diagnoses, sedatives given, substance use, ED length of stay, and disposition. The primary outcome was repeated involuntary sedation. Involuntary sedation was used in 18.8% of the mental health patients screened for study inclusion. 334 patients were included in the study cohort and 31.6% (n = 106) required repeated involuntary sedation. Their average age was 35.5 ± 13.5 years with 58.4% men, 40.1% women, and 1.2% transgender persons. Most (90.0%, n = 299) had prior mental health diagnoses with the most common being substance use disorder (38.9%, n = 130), bipolar disorder (34.1%, n = 114), depressive disorder (29.0%, n = 97), and schizophrenia (24.3%, n = 81). Two-thirds (65.9%, n = 220) had current substance use and 41.9% (n = 142) reported current use with a chemical associated with aggression. Hospital security was called for 73.1% (n = 244). Current cocaine, methamphetamines, or alcohol use was associated with decreased odds of repeated sedation (0.52 OR, 95% CI 0.32–0.85). Prior mental health diagnosis and non-white race were associated with increased odds of repeated sedation. In the multivariable regression, the effect of race was more significant. Involuntary sedation was used in 18.8% of ED patients for mental health care and almost a third were repeatedly sedated, with race being a potential risk factor for repeated sedation. ED care could benefit from evidence-based interventions to reduce the need for involuntary sedation. [ABSTRACT FROM AUTHOR]

Background: EM Talk is a communication skills training program designed to improve emergency providers' serious illness conversational skills. Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, this study aims to assess the reach of EM Talk and its effectiveness. Methods: EM Talk consisted of one 4-h training session during which professional actors used role-plays and active learning to train providers to deliver serious/bad news, express empathy, explore patients' goals, and formulate care plans. After the training, emergency providers filled out an optional post-intervention survey, which included course reflections. Using a multi-method analytical approach, we analyzed the reach of the intervention quantitatively and the effectiveness of the intervention qualitatively using conceptual content analysis of open-ended responses. Results: A total of 879 out of 1,029 (85%) EM providers across 33 emergency departments completed the EM Talk training, with the training rate ranging from 63 to 100%. From the 326 reflections, we identified meaning units across the thematic domains of improved knowledge, attitude, and practice. The main subthemes across the three domains were the acquisition of Serious Illness (SI) communication skills, improved attitude toward engaging qualifying patients in SI conversations, and commitment to using these learned skills in clinical practice. Conclusion: Our study showed the extensive reach and the effectiveness of the EM Talk training in improving SI conversation. EM Talk, therefore, can potentially improve emergency providers' knowledge, attitude, and practice of SI communication skills. Trial registration: Clinicaltrials.gov: NCT03424109; Registered on January 30, 2018. [ABSTRACT FROM AUTHOR]

Background: Geriatric emergency department (GED) guidelines endorse screening older patients for geriatric syndromes in the ED, but there have been significant barriers to widespread implementation. The majority of screening programs require engagement of a clinician, nurse, or social worker, adding to already significant workloads at a time of record‐breaking ED patient volumes, staff shortages, and hospital boarding crises. Automated, electronic health record (EHR)‐embedded risk stratification approaches may be an alternate solution for extending the reach of the GED mission by directing human actions to a smaller subset of higher risk patients. Methods: We define the concept of automated risk stratification and screening using existing EHR data. We discuss progress made in three potential use cases in the ED: falls, cognitive impairment, and end‐of‐life and palliative care, emphasizing the importance of linking automated screening with systems of healthcare delivery. Results: Research progress and operational deployment vary by use case, ranging from deployed solutions in falls screening to algorithmic validation in cognitive impairment and end‐of‐life care. Conclusions: Automated risk stratification offers a potential solution to one of the most pressing problems in geriatric emergency care: identifying high‐risk populations of older adults most appropriate for specific GED care. Future work is needed to realize the promise of improved care with less provider burden by creating tools suitable for widespread deployment as well as best practices for their implementation and governance. [ABSTRACT FROM AUTHOR]

Background: The Institute for Healthcare Improvement's 4‐Ms framework of care for older adults recommends a multidisciplinary assessment of a patient's Medications, Mentation, Mobility, and What Matters Most. Electronic health record (EHR) systems were developed prior to this emphasis on the 4‐Ms. We sought to understand how healthcare providers across the healthcare system perceive their EHRs and to identify any current best practices and ideas for improvement regarding integration of the 4‐Ms. Methods: Anonymous survey of healthcare providers who care for older adults. The survey aimed to evaluate efficiency, error tolerance, and satisfaction (usefulness and likeability). The survey was distributed through organizational list serves that focus on the care of older adults and through social media. Results: Sixty‐six respondents from all geographic segments of the U.S. (n = 62) and non‐U.S. practices (n = 4) responded. Most (82%) were physicians. Respondents used a range of EHRs and 82% had >5 years of experience with their current EHR. Over half of respondents agreed that their EHR had easy to find contact information (56%) and advance directives. Finding a patient's prior cognitive status (26% agreement), goals of care (24%), functional status (14%), and multidisciplinary geriatric assessments (27%) was more difficult. Only 3% were satisfied with how their EHR handles geriatric syndromes. In free text responses, respondents (79%) described three areas that the EHR assists in the care of older adults: screening tied to actions or orders; advance care planning, and medication alerts or review. Common suggestions on how to improve the EHR included incorporating geriatric assessments in notes, establishing a unified place to review the 4‐Ms, and creating age‐specific best practice alerts. Conclusions: The majority of healthcare providers were not satisfied with how their EHR handles multidisciplinary geriatric assessment and geriatric care. EHR modifications would aide in reporting, communicating, and tracking the 4‐Ms in EHRs. [ABSTRACT FROM AUTHOR]

This editorial comments on the article by Haynesworth et al. in this issue. [ABSTRACT FROM AUTHOR]