Faculty Bibliography

To better understand and prioritize research on emergency care for Veterans, the Department of Veteran Affairs (VA) Health Services Research and Development convened the 16th State of the Art Conference on VA Emergency Medicine (SAVE) in Winter 2022 with emergency clinicians, researchers, operational leaders, and additional stakeholders in attendance. Three specific areas of focus were identified including older Veterans, Veterans with mental health needs, and emergency care in the community (non-VA) settings. Among older Veterans, identified priorities included examination of variation in care and its impact on patient outcomes, utilization, and costs; quality of emergency department (ED) care transitions and strategies to improve them; impact of geriatric ED care improvement initiatives; and use of geriatric assessment tools in the ED. For Veterans with mental health needs, priorities included enhancing the reach of effective, multicomponent suicide prevention interventions; development and evaluation of interventions to manage substance use disorders; and identifying and examining safety and effective acute psychosis practices. Community (non-VA) emergency care priorities included examining changes in patterns of use and costs in VA and the community care settings as a result of recent policy and coverage changes (with an emphasis on modifiable factors); understanding quality, safety, and Veteran experience differences between VA and community settings; and better understanding follow-up needs among Veterans who received emergency care (or urgent care) and how well those needs are being coordinated, communicated, and met. Beyond these three groups, cross-cutting themes included the use of telehealth and implementation science to refine multicomponent interventions, care coordination, and data needs from both VA and non-VA sources. Findings from this conference will be disseminated through multiple mechanisms and contribute to future funding applications focused on improving Veteran health.

OBJECTIVES:In 2018, the U.S. Department of Veterans Affairs (VA) National Office of Geriatrics and Extended Care (GEC) and the National Emergency Medicine (EM) Program partnered to improve emergency care for older Veterans. A core team disseminated age-friendly models of care via education and standardization of practice with the goal of multisite geriatric emergency department (GED) accreditation. We compare rates of GED screening at VAs with GED implementation to those without. METHODS:Observational evaluation of GED screening of older Veterans (≥65 years) at VA Emergency Departments (ED) from January 2018 to March 2022, during peak pandemic years. Data were extracted from the VA Corporate Data Warehouse of Veteran ED visit encounters to track documented GED screens and Veteran demographic data. Generalized estimating equation models were used to compare screening completion across different levels of GED accreditation, adjusting for potential confounding. RESULTS:During this period, over 1.07 million Veterans ≥ 65 years of age made 4.07 million VA ED visits. Mean (±SD) age was 73.4 (±7.2) years, 96.5% were male, 68% were White, and 89.9% made their index ED visit at a non-GED VA ED. As of early 2022, a total of 50 of 111 VA EDs have achieved or applied for GED accreditation. During early 2022, 8.3% of all visits by older Veterans had at least one GED screen documented; 15% were screened at Levels 1-3 GED versus 2.2% at non-GED facilities. Screens identifying older adults at risk for poor outcomes, for delirium, and for falls had the highest usage rates within VA GEDs. Veterans seen at Level 1 GEDs had a 76-fold greater odds of having a GED screen than at Level 3 GEDs (odds ratio 75.8, 95% confidence interval 72.8-79.0). CONCLUSIONS:Through VA National Office of GEC and EM Program partnership, the VA has created, standardized, and disseminated a GED Model of Care, despite the pandemic. GED accreditation was associated with GED screen implementation, with Level 1 having the highest screening prevalence.

BACKGROUND:Over one-half of older adults are discharged to the community after emergency department (ED) visits, and studies have shown there is increased risk of adverse health outcomes in the immediate post-discharge period. Understanding the experiences of older adults during ED-to-community care transitions has the potential to improve geriatric emergency clinical care and inform intervention development. We therefore sought to assess barriers experienced by older adults during ED-to-community care transitions. METHODS:We conducted a qualitative analysis of community-dwelling cognitively intact patients aged 65 years and older receiving care in four diverse EDs from a single U.S. healthcare system. We constructed a conceptual framework a priori to guide the development and iterative revision of a codebook, used purposive sampling, and conducted recorded, semi-structured interviews using a standardized guide. Two researchers coded the professionally transcribed data using a combined deductive and inductive approach and analyzed transcripts to identify dominant themes and representative quotations. RESULTS:Among 25 participants, 20 (80%) were women and 17 (68%) were white. We identified four barriers during the ED-to-community care transition: (1) ED discharge process was abrupt with missing information regarding symptom explanation and performed testing, (2) navigating follow-up outpatient clinical care was challenging, (3) new physical limitations and fears hinder performance of baseline activities, and (4) major and minor ramifications for caregivers impact an older adult's willingness to request or accept assistance. CONCLUSIONS:Older adults identified barriers to successful ED-to-community care transitions that can inform the development of novel and effective interventions.

Pragmatic clinical trials (PCTs) focus on correlation between treatment and outcomes in real-world clinical practice, yet a guide highlighting key study considerations and design types for emergency medicine investigators pursuing this important study type is not available. Investigators conducting ED-based PCTs face multiple decisions within the planning phase to ensure robust and meaningful study findings. The PRagmatic Explanatory Continuum Indicator Summary 2 (PRECIS-2) tool allows trialists to consider both pragmatic and explanatory components across nine domains, shaping the trial design to the purpose intended by the investigators. Aside from the PRECIS-2 tool domains, ED-based investigators conducting PCTs should also consider randomization techniques, human subjects concerns, and integration of trial components within the electronic health record. The authors additionally highlight the advantages, disadvantages, and rationale for the use of four common randomized study design types to be considered in PCTs: parallel, crossover, factorial, and stepped-wedge. With increasing emphasis on the conduct of PCTs, emergency medicine investigators will benefit from a rigorous approach to clinical trial design.

BACKGROUND:The growing population of patients over the age of 65 faces particular vulnerability following discharge after hospitalization or an emergency room visit. Specific areas of concern include a high risk for falls and poor comprehension of discharge instructions. Emergency medical technicians (EMTs), who frequently transport these patients home from the hospital, are uniquely positioned to aid in mitigating transition of care risks and are both trained and utilized to do so using the Transport PLUS intervention. METHODS:Existing literature and focus groups of various stakeholders were utilized to develop two checklists: the fall safety assessment (FSA) and the discharge comprehension assessment (DCA). EMTs were trained to administer the intervention to eligible patients in the geriatric population. Using data from the checklists, follow-up phone calls, and electronic health records, we measured the presence of hazards, removal of hazards, the presence of discharge comprehension issues, and correction or reinforcement of comprehension. These results were validated during home visits by community health workers (CHWs). Feasibility outcomes included patient acceptance of the Transport PLUS intervention and accuracy of the EMT assessment. Qualitative feedback via focus groups was also obtained. Clinical outcomes measured included 3-day and 30-day readmission or ED revisit. RESULTS:One-hundred three EMTs were trained to administer the intervention and participated in 439 patient encounters. The intervention was determined to be feasible, and patients were highly amenable to the intervention, as evidenced by a 92% and 74% acceptance rate of the DCA and FSA, respectively. The majority of patients also reported that they found the intervention helpful (90%) and self-reported removing 40% of fall hazards; 85% of such changes were validated by CHWs. Readmission/revisit rates are also reported. CONCLUSIONS:The Transport PLUS intervention is a feasible, easily implemented tool in preventative community paramedicine with high levels of patient acceptance. Further study is merited to determine the effectiveness of the intervention in reducing rates of readmission or revisit. A randomized control trial has since begun utilizing the knowledge gained within this study.

OBJECTIVES:To summarize research on optimal emergency department (ED) care practices for persons living with dementia (PLWDs) and develop research priorities. DESIGN:Systematic scoping review. SETTINGS AND PARTICIPANTS:PLWDs in the ED. METHODS:The following Patient-Intervention-Comparison-Outcome (PICO) questions were developed: PICO 1, What components of emergency department care improve patient-centered outcomes for persons with dementia? PICO 2, How do emergency care needs for persons with dementia differ from other patients in the emergency department? A scoping review was conducted following PRISMA-ScR guidelines and presented to the Geriatric Emergency care Applied Research 2.0 Advancing Dementia Care network to inform research priorities. RESULTS:From the 6348 publications identified, 23 were abstracted for PICO 1 and 26 were abstracted for PICO 2. Emergency care considerations for PLWDs included functional dependence, behavioral and psychological symptoms of dementia, and identification of and management of pain. Concerns regarding ED care processes, the ED environment, and meeting a PWLD's basic needs were described. A comprehensive geriatric assessment and dedicated ED unit, a home hospital program, and a low-stimulation bed shade and contact-free monitor all showed improvement in patient-centered or health care use outcomes. However, all were single-site studies evaluating different outcomes. These results informed the following research priorities: (1) training and dementia care competencies; (2) patient-centric and care partner-centric evaluation interventions; (3) the impact of community- and identity-based factors on ED care for PLWDs; (4) economic or other implementation science measures to address viability; and (5) environmental, operational, personnel, system, or policy changes to improve ED care for PLWDs. CONCLUSIONS AND IMPLICATIONS:A wide range of components of both ED care practices and ED care needs for PLWDs have been studied. Although many interventions show positive results, the lack of depth and reproducible results prevent specific recommendations on best practices in ED care for PLWDs.

OBJECTIVES:To synthesize published research exploring emergency department (ED) communication strategies and decision-making with persons living with dementia (PLWD) and their care partners as the basis for a multistakeholder consensus conference to prioritize future research. DESIGN:Systematic scoping review. SETTINGS AND PARTICIPANTS:PLWD and their care partners in the ED setting. METHODS:Informed by 2 Patient-Intervention-Comparison-Outcome (PICO) questions, we conducted systematic electronic searches of medical research databases for relevant publications following standardized methodological guidelines. The results were presented to interdisciplinary stakeholders, including dementia researchers, clinicians, PLWD, care partners, and advocacy organizations. The PICO questions included: How does communication differ for PLWD compared with persons without dementia? Are there specific communication strategies that improve the outcomes of ED care? Future research areas were prioritized. RESULTS:From 5451 studies identified for PICO-1, 21 were abstracted. From 2687 studies identified for PICO-2, 3 were abstracted. None of the included studies directly evaluated communication differences between PLWD and other populations, nor the effectiveness of specific communication strategies. General themes emerging from the scoping review included perceptions by PLWD/care partners of rushed ED communication, often exacerbated by inconsistent messages between providers. Care partners consistently reported limited engagement in medical decision-making. In order, the research priorities identified included: (1) Barriers/facilitators of effective communication; (2) valid outcome measures of effective communication; (3) best practices for care partner engagement; (4) defining how individual-, provider-, and system-level factors influence communication; and (5) understanding how each member of ED team can ensure high-quality communication. CONCLUSIONS AND IMPLICATIONS:Research exploring ED communication with PLWD is sparse and does not directly evaluate specific communication strategies. Defining barriers and facilitators of effective communication was the highest-ranked research priority, followed by validating outcome measures associated with improved information exchange.