Faculty Bibliography

The Geriatric Emergency Care Applied Research (GEAR) Network (1) conducted a scoping review of the current literature on the identification of and interventions to address elder abuse among patients receiving care in emergency departments and (2) used this review to prioritize research questions for knowledge development. Two questions guided the scoping review: What is the effect of universal emergency department screening compared to targeted screening or usual practice on cases of elder abuse identified, safety outcomes, and health care utilization?; and What is the safety, health, legal, and psychosocial impact of emergency department-based interventions vs. usual care for patients experiencing elder abuse? We searched five article databases. Additional material was located through reference lists of identified publications, PsychInfo, and Google Scholar. The results were discussed in a consensus conference; and stakeholders voted to prioritize research questions. No studies were identified that directly addressed the first question regarding assessment strategies, but four instruments used for elder abuse screening in the emergency department were identified. For the second question, we located six articles on interventions for elder abuse in the emergency department; however, none directly addressed the question of comparative effectiveness. Based on these findings, GEAR participants identified five questions as priorities for future research - two related to screening, two related to intervention, and one encompassed both. In sum, research to identify best practices for elder abuse assessment and intervention in emergency departments is still needed. Although there are practical and ethical challenges, rigorous experimental studies are needed.

OBJECTIVES/OBJECTIVE:To present the three-site EQUIPPED academic health system research collaborative, which engaged in sequential implementation of the EQUIPPED medication safety program, as a learning health system; to understand how the organizations worked together to build resources for program scale-up. DESIGN/METHODS:Following the Replicating Effective Programs framework, we analyzed content from implementation teams' focus groups, local and cross-site meeting minutes and sites' organizational profiles to develop an implementation package. SETTING/METHODS:Three academic emergency departments that each implemented EQUIPPED over three successive years. PARTICIPANTS/METHODS:Implementation team members at each site participating in focus groups (n = 18), local meetings during implementation years, and cross-site meetings during all years of the projects. INTERVENTION(S)/METHODS:EQUIPPED provides Emergency Department providers with clinical decision support (education, order sets, and feedback) to reduce prescribing of potentially inappropriate medications to adults aged 65 years and older who received a prescription at time of discharge. MAIN OUTCOME MEASURE(S)/METHODS:Implementation process components assembled through successive implementation. RESULTS:Each site had clinical and environmental characteristics to be addressed in implementing the EQUIPPED program. We identified 10 process elements and describe lessons for each. Lessons guided the compilation of the EQUIPPED intervention package or toolkit, including the EQUIPPED logic model. CONCLUSIONS:Our academic health system research collaborative addressing medication safety through sequential implementation is a learning health system that can serve as a model for other quality improvement projects with multiple sites. The network produced an implementation package that can be vetted, piloted, evaluated, and finalized for large-scale dissemination in community-based settings.

BACKGROUND:Functional status in older adults predicts hospital use and mortality, and offers insight into independence and quality of life. The Patient-Reported Outcome Measurement Information System (PROMIS) was developed to improve and standardize patient-reported outcomes measurements. The PROMIS Physical Function (PROMIS PF) 10-Item Short Form was not created specifically for older adults. By comparing PROMIS with the Katz Index of Activities of Daily Living (Katz), we evaluated PROMIS for measurement of physical function versus general function in an older adult population seen in the ED. METHODS:A prospective, convenience sample of ED patients 65 years and older (from January 1, 2015 to June 30, 2015) completed Katz and PROMIS PF. Both were compared for scoring distributions and conventional scoring thresholds for severity of impairment (eg, minimal, moderate, severe). We assessed convergence through Spearman correlations, equivalents of conventional thresholds and ranges of physical function, and item-response frequencies. RESULTS:A total of 357 completed both function surveys. PROMIS PF and Katz have a modest positive correlation (r = .50, p < .01). Mean PROMIS PF scores within Katz scoring ranges for minimal (43, SD = 10), moderate (32, SD = 7), and severe (24, SD = 7) impairment fell within respective PROMIS PF scoring ranges (severe = 14-29, moderate = 30-39, mild = 40-45), indicating convergence. PROMIS identified impairment in 3× as many patients as did Katz, as PROMIS assesses vigorous physical function (eg, running, heavy lifting) not queried by Katz. However, PROMIS does not assess select activities of daily living (ADLs; eg, feeding, continence) important for assessment of function in older adults. CONCLUSIONS:There is a modest correlation between PROMIS and Katz. PROMIS may better assess physical function than Katz, but is not an adequate replacement for assessment of general functional status in older adults.

Coronavirus disease 2019 (COVID-19) continues to impact older adults disproportionately with respect to serious consequences ranging from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these issues have focused attention on how these resources are ultimately allocated and used. Some strategies, for example, misguidedly use age as an arbitrary criterion that disfavors older adults in resource allocation decisions. This is a companion article to the American Geriatrics Society (AGS) position statement, "Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond." It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations that should be considered when developing strategies for allocation of scarce resources during an emergency involving older adults. This review presents the legal and ethical background for the position statement and discusses these issues that informed the development of the AGS positions: (1) age as a determining factor, (2) age as a tiebreaker, (3) criteria with a differential impact on older adults, (4) individual choices and advance directives, (5) racial/ethnic disparities and resource allocation, and (6) scoring systems and their impact on older adults. It also considers the role of advance directives as expressions of individual preferences in pandemics. J Am Geriatr Soc 68:1143-1149, 2020.

Coronavirus disease 2019 (COVID-19) continues to impact older adults disproportionately, from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these needs have focused attention on how resources are ultimately allocated and used. Some strategies misguidedly use age as an arbitrary criterion, inappropriately disfavoring older adults. This statement represents the official policy position of the American Geriatrics Society (AGS). It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations to consider when developing strategies for allocating scarce resources during an emergency involving older adults. Members of the AGS Ethics Committee collaborated with interprofessional experts in ethics, law, nursing, and medicine (including geriatrics, palliative care, emergency medicine, and pulmonology/critical care) to conduct a structured literature review and examine relevant reports. The resulting recommendations defend a particular view of distributive justice that maximizes relevant clinical factors and deemphasizes or eliminates factors placing arbitrary, disproportionate weight on advanced age. The AGS positions include (1) avoiding age per se as a means for excluding anyone from care; (2) assessing comorbidities and considering the disparate impact of social determinants of health; (3) encouraging decision makers to focus primarily on potential short-term (not long-term) outcomes; (4) avoiding ancillary criteria such as "life-years saved" and "long-term predicted life expectancy" that might disadvantage older people; (5) forming and staffing triage committees tasked with allocating scarce resources; (6) developing institutional resource allocation strategies that are transparent and applied uniformly; and (7) facilitating appropriate advance care planning. The statement includes recommendations that should be immediately implemented to address resource allocation strategies during COVID-19, aligning with AGS positions. The statement also includes recommendations for post-pandemic review. Such review would support revised strategies to ensure that governments and institutions have equitable emergency resource allocation strategies, avoid future discriminatory language and practice, and have appropriate guidance to develop national frameworks for emergent resource allocation decisions. J Am Geriatr Soc 68:1136-1142, 2020.

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.

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.

OBJECTIVES:Published literature on national emergency department (ED) revisit rates among older adults with dementia is sparse, despite anecdotal evidence of higher ED utilization. Thus we evaluated the odds ratio (OR) of 30-day ED revisits among older adults with dementia using a nationally representative sample. DESIGN:We assessed the frequency of claims associated with a 30-day ED revisit among Medicare beneficiaries with and without a dementia diagnosis before or at index ED visit. We used a logistic regression model controlling for dementia, age, sex, race, region, Medicaid status, transfer to a skilled nursing facility after ED, primary care physician use 12 months before index, and comorbidity. SETTING:A nationally representative sample of claims data for Medicare beneficiaries aged 65 and older who maintained continuous fee-for-service enrollment during 2015 and 2016. Only outpatient claims associated with an ED visit between January 2016 and November 2016 were included as a qualifying index encounter. PARTICIPANTS:We identified 240 249 patients without dementia and 54 622 patients for whom a dementia code was recorded in the year before the index encounter in 2016. RESULTS:Our results indicate a significant difference in unadjusted 30-day ED revisit rates among those with an ED dementia diagnoses (22.0%) compared with those without (13.9%). Our adjusted results indicated that dementia is a significant predictor of 30-day ED revisits (P < .0001). Those with a dementia diagnosis at or before the index ED visit were more likely to have experienced an ED revisit within 30 days (OR = 1.27; 95% confidence interval = 1.24-1.31). CONCLUSION:Dementia diagnoses were a significant predictor of 30-day ED revisits. Further research should assess potential reasons why dementia is associated with markedly higher revisit rates, as well as opportunities to manage and transition dementia patients from the ED back to the community more effectively. J Am Geriatr Soc 67:2254-2259, 2019.