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Annually, approximately 30 million patients are discharged from the emergency department (ED) after a traumatic event 1 . These patients are at substantial psychiatric risk, with approximately 10–20% developing one or more disorders, including anxiety, depression or post-traumatic stress disorder (PTSD) 2 – 4 . At present, no accurate method exists to predict the development of PTSD symptoms upon ED admission after trauma 5 . Accurate risk identification at the point of treatment by ED services is necessary to inform the targeted deployment of existing treatment 6 – 9 to mitigate subsequent psychopathology in high-risk populations 10 , 11 . This work reports the development and validation of an algorithm for prediction of post-traumatic stress course over 12 months using two independently collected prospective cohorts of trauma survivors from two level 1 emergency trauma centers, which uses routinely collectible data from electronic medical records, along with brief clinical assessments of the patient’s immediate stress reaction. Results demonstrate externally validated accuracy to discriminate PTSD risk with high precision. While the predictive algorithm yields useful reproducible results on two independent prospective cohorts of ED patients, future research should extend the generalizability to the broad, clinically heterogeneous ED population under conditions of routine medical care. A machine-learning algorithm using electronic medical records and self-reported measures of stress at admission to the emergency department due to trauma can predict the risk and long-term trajectories of post-traumatic stress disorder in two independent cohorts.

Alcohol and drug use (substance use) is a risk factor for crash involvement. To assess the association between substance use and crash injury severity among older adults and how the relationship differs by rurality/urbanicity. We pooled 2017-2021 cross-sectional data from the United States National Emergency Medical Service (EMS) Information System. We measured injury severity (low acuity, emergent, critical, and fatal) predicted by substance use, defined as self-reported or officer-reported alcohol and/or drug use. We controlled for age, sex, race/ethnicity, road user type, anatomical injured region, roadway crash, rurality/urbanicity, time of the day, and EMS response time. We performed a partial proportional ordinal logistic regression and reported the odds of worse injury outcomes (emergent, critical, and fatal injuries) compared to low acuity injuries, and the predicted probabilities by rurality/urbanicity. Our sample consisted of 252,790 older adults (65 years and older) road users. Approximately 67%, 25%, 6%, and 1% sustained low acuity, emergent, critical, and fatal injuries, respectively. Substance use was reported in approximately 3% of the population, and this proportion did not significantly differ by rurality/urbanicity. After controlling for patient, crash, and injury characteristics, substance use was associated with 36% increased odds of worse injury severity. Compared to urban areas, the predicted probabilities of emergent, critical, and fatal injuries were higher in rural and suburban areas. Substance use is associated with worse older adult crash injury severity and the injury severity is higher in rural and suburban areas compared to urban areas.

Older adults account for a large proportion of emergency department visits, but those with serious life-limiting illness may benefit most from referral to home and community services instead of hospitalization. We aim to document emergency provider perspectives on facilitators and barriers to accessing home and community services for older adults with serious life-limiting illness. We conducted interviewer-administered semi-structured interviews with emergency providers from health systems across the United States to obtain provider perspectives on facilitators and barriers to accessing home and community services. We completed qualitative thematic analysis using an iterative process to develop themes and subthemes to summarize provider responses. We interviewed 8 emergency nurses and 10 emergency physicians across 11 health systems. Emergency providers were familiar with local home and community services. Facilitators to accessing these services include care management and social workers. Barriers include services that are not accessible full-time to receive referrals, insurance/payment, and the busy nature of the emergency department. The most helpful reported services were hospice, physical therapy, occupational therapy, and visiting nursing services. Home-based palliative care and full-time emergency department-based care management and social work were the services most desired by providers. Providers expressed support for improving access to home and community services in the hopes of decreasing unnecessary emergency visits and inpatient admissions, and to provide patients with greater options for supportive care. Obtaining the perspective of emergency providers highlights important considerations to accessing HCS for older-adults with serious life-limiting illness from the emergency department. This study provides foundational information for futures studies and initiatives for improving access to home and community services directly from the emergency department.

Background Healthy Days at Home (HDaH) is a patient-centered outcome measure quantifying the number of days individuals spend at home without hospitalizations or emergency department (ED) visits, while maintaining functional independence. This study examines the association between HDaH and prognosis among US older adults with serious life-limiting illnesses (commonly heart failure, chronic obstructive pulmonary disease, advanced cancer, and end-stage kidney disease) and explores how this relationship differs by cancer status. Methods For this prospective cohort design study, we pooled Medicare Claims data of older adults (aged 66 or greater) with serious life-limiting illnesses who visited one of 30 EDs participating in the Primary Palliative Care for Emergency Medicine study between 2015 and 2019. The main exposure was prognosis, measured using the Gagne index, a short-term predictor of mortality. We controlled for age, sex, race/ethnicity, and used cancer diagnosis as a secondary predictor and stratification variable. The outcome, HDaH, was defined as 180 days minus the days a patient spent in healthcare institutions, including hospitals, skilled nursing facilities, and hospice care. We used generalized linear mixed-effects models with a log (180) offset to estimate the adjusted rate ratios (aRR) and 95% confidence intervals. Results The cohort included 122,579 seriously ill older adults,11% ( n  = 13,452) of whom had cancer. The median (IQR) HDaH was 115 (26–174) days. Each unit increase in Gagne index score was associated with a 6.0% decrease in the rate of HDaH (aRR: 0.94; 95% CI: 0.94 to 0.94), a pattern observed in both cancer and non-cancer groups. Cancer diagnosis was associated with 7.0% increase in HDaH (aRR: 1.07; 95% CI: 1.07 to 1.07). Conclusion While poor prognosis is associated with fewer healthy days at home, cancer diagnosis is associated with more healthy days at home. Our findings highlight the need for tailored care models to reduce hospitalizations and increase HDaH for patients with serious life-limiting illnesses other than cancer.

Background The emergency department is a critical juncture in the trajectory of care of patients with serious, life-limiting illness. Implementation of a clinical decision support (CDS) tool automates identification of older adults who may benefit from palliative care instead of relying upon providers to identify such patients, thus improving quality of care by assisting providers with adhering to guidelines. The Primary Palliative Care for Emergency Medicine (PRIM-ER) study aims to optimize the use of the electronic health record by creating a CDS tool to identify high risk patients most likely to benefit from primary palliative care and provide point-of-care clinical recommendations. Methods A clinical decision support tool entitled Emergency Department Supportive Care Clinical Decision Support (Support-ED) was developed as part of an institutionally-sponsored value based medicine initiative at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health. A multidisciplinary approach was used to develop Support-ED including: a scoping review of ED palliative care screening tools; launch of a workgroup to identify patient screening criteria and appropriate referral services; initial design and usability testing via the standard System Usability Scale questionnaire, education of the ED workforce on the Support-ED background, purpose and use, and; creation of a dashboard for monitoring and feedback. Results The scoping review identified the Palliative Care and Rapid Emergency Screening (P-CaRES) survey as a validated instrument in which to adapt and apply for the creation of the CDS tool. The multidisciplinary workshops identified two primary objectives of the CDS: to identify patients with indicators of serious life limiting illness, and to assist with referrals to services such as palliative care or social work. Additionally, the iterative design process yielded three specific patient scenarios that trigger a clinical alert to fire, including: 1) when an advance care planning document was present, 2) when a patient had a previous disposition to hospice, and 3) when historical and/or current clinical data points identify a serious life-limiting illness without an advance care planning document present. Monitoring and feedback indicated a need for several modifications to improve CDS functionality. Conclusions CDS can be an effective tool in the implementation of primary palliative care quality improvement best practices. Health systems should thoughtfully consider tailoring their CDSs in order to adapt to their unique workflows and environments. The findings of this research can assist health systems in effectively integrating a primary palliative care CDS system seamlessly into their processes of care. Trial registration ClinicalTrials.gov Identifier: NCT03424109 . Registered 6 February 2018, Grant Number: AT009844–01.

PurposeMany patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes.MethodsWe conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition.ResultsThe study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status).ConclusionsPatients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.

Background Loneliness is a quality-of-life (QoL) concern for patients facing serious, life-limiting illnesses. Discerning risk factors of loneliness in palliative care patients allows providers to take preventative action and develop holistic treatment plans. Methods A planned sub-study of patients who completed the previously developed Three-Item Loneliness Scale upon enrollment into the multicenter, randomized clinical trial Emergency Medicine Palliative Care Access (EMPallA) with the objective of investigating the association of multimorbidity with loneliness in patients with late-stage illnesses. The EMPallA study included patients who were at least 50 years old and diagnosed with at least one end-stage illness (advanced cancer, advanced congestive heart failure (CHF), end-stage renal disease (ESRD), or advanced chronic obstructive pulmonary disease (COPD)). Results We analyzed 1,212 surveys using a mixed-effects logistic regression model. Our findings suggest those with a single illness are less likely to be lonely than those with multimorbidity (odds ratio [OR] = 0.5, 95% CI 0.3 to 0.8). Additionally, older age was associated with less loneliness (OR comparing age by 10-year increments is 0.7 [95% CI: 0.6 to 0.9]), after adjusting for disease type, education level, race, sex, immigrant status, having a caregiver, COVID-19 period, language, and site geographic location. Conclusions Patients suffering from multimorbidity self-report being “very lonely” more often than patients with a single advanced illness; furthermore, advanced illness patients who were middle-aged (versus elderly) were 25% more likely to report being “very lonely.” Trial registration Clinicaltrials.gov identifier: NCT03325985. Registered October 30, 2017.

AbstractObjectiveTo characterize the national distribution of COVID‐19 hospital and emergency department visitor restriction policies across the United States, focusing on patients with cognitive or physical impairment or receiving end‐of‐life care. MethodsCross‐sectional study of visitor policies and exceptions, using a nationally representative random sample of EDs and hospitals during the first wave of the COVID‐19 pandemic, by trained study investigators using standardized instrument. ResultsOf the 352 hospitals studied, 326 (93%) had a COVID‐19 hospital‐wide visitor restriction policy and 164 (47%) also had an ED‐specific policy. Hospital‐wide policies were more prevalent at academic than non‐academic (96% vs 90%; P < 0.05) and at urban than rural sites (95% vs 84%; P < 0.001); however, the prevalence of ED‐specific policies did not significantly differ across these site characteristics. Geographic region was not associated with the prevalence of any visitor policies. Among all study sites, only 58% of hospitals reported exceptions for patients receiving end‐of‐life care, 39% for persons with cognitive impairment, and 33% for persons with physical impairment, and only 12% provided policies in non‐English languages. Sites with ED‐specific policies reported even fewer exceptions for patients with cognitive impairment (29%), with physical impairments (24%), or receiving end‐of‐life care (26%). ConclusionAlthough the benefits of visitor policies towards curbing COVID‐19 transmission had not been firmly established, such policies were widespread among US hospitals. Exceptions that permitted family or other caregivers for patients with cognitive or physical impairments or receiving end‐of‐life care were predominantly lacking, as were policies in non‐English languages.

Background Emergency department (ED) visits among older adults are common near the end of life. Palliative care has been shown to reduce ED visits and to increase quality of life among patients, but recruitment into these programs is often challenging. This descriptive analysis explores the barriers to enrolling seriously ill patients scheduled for discharge from the ED into palliative care research. Methods This descriptive sub-study aims to assess the reasons why patients with advanced illness scheduled for discharge home from 11 EDs across the United States decline to participate in Emergency Medicine Palliative Care Access (EMPallA), a Phase IV randomized controlled trial (RCT) comparing two modes of palliative care delivery. Our aim was to understand why patients decline to enroll to improve future recruitment rates and expand care for patients discharged home from the ED. Research coordinators documented reasons that patients declined to enroll in the larger EMPallA trial; reasons for refusing participation were independently analyzed by two researchers to identify overarching themes. Results Enrollment rate across all sites was 45%; of the 504 eligible patients who declined participation, 47% ( n  = 237) declined for reasons related to illness severity. 28% of refusals ( n  = 143) were related to the mode of palliative care delivery, while 24% ( n  = 123) were due to misconceptions or stigma related to palliative care. Less commonly, patients refused due to general research barriers (16.5%), family/caregiver barriers (11.7%), and physician-related barriers (< 1%). Conclusions Patients with advanced illnesses presenting to the ED often refuse to participate in palliative care research due to the severity of their illness, the mode of care delivery, and misconceptions about palliative care. In contrast with other studies, our study found minimal physician gatekeeping, which may be the result of both changing attitudes toward palliative care and the nature of the ED setting. Robust training programs are crucial to overcome these misconceptions and to educate patients and providers about the role of palliative care. Future palliative care programs and study designs should recognize the burden this vulnerable population endures and consider alternative modes of care delivery in an effort to increase participation and enrollment. Clinical trials registration NCT03325985 , October 30, 2017.

Background Involving patient and community stakeholders in clinical trials adds value by ensuring research prioritizes patient goals both in conduct of the study and application of the research. The use of stakeholder committees and their impact on the conduct of a multicenter clinical trial have been underreported clinically and academically. The aim of this study is to describe how Study Advisory Committee (SAC) recommendations were implemented throughout the Emergency Medicine Palliative Care Access (EMPallA) trial. EMPallA is a multi-center, pragmatic two-arm randomized controlled trial (RCT) comparing the effectiveness of nurse-led telephonic case management and specialty, outpatient palliative care of older adults with advanced illness. Methods A SAC consisting of 18 individuals, including patients with palliative care experience, members of healthcare organizations, and payers was convened for the EMPallA trial. The SAC engaged in community-based participatory research and assisted in all aspects from study design to dissemination. The SAC met with the research team quarterly and annually from project inception to dissemination. Using meeting notes and recordings we completed a qualitative thematic analysis using an iterative process to develop themes and subthemes to summarize SAC recommendations throughout the project’s duration. Results The SAC convened 16 times between 2017 and 2020. Over the course of the project, the SAC provided 41 unique recommendations. Twenty-six of the 41 (63%) recommendations were adapted into formal Institutional Review Board (IRB) study modifications. Recommendations were coded into four major themes: Scientific, Pragmatic, Resource and Dissemination. A majority of the recommendations were related to either the Scientific (46%) or Pragmatic (29%) themes. Recommendations were not mutually exclusive across three study phases: Preparatory, execution and translational. A vast majority (94%) of the recommendations made were related to the execution phase. Major IRB study modifications were made based on their recommendations including data collection of novel dependent variables and expanding recruitment to Spanish-speaking patients. Conclusions Our study provides an example of successful integration of a SAC in the conduct of a pragmatic, multi-center RCT. Future trials should engage with SACs in all study phases to ensure trials are relevant, inclusive, patient-focused, and attentive to gaps between health care and patient and family needs. Trial Registration : Clinicaltrials.gov Identifier: NCT03325985, 10/30/2017. Plain English summary Clinical research should involve patient and community stakeholder perspectives to make sure the study addresses questions important to the studied population. One way to do this is by creating a group of stakeholders who can advise on the conduct of a study. We assembled a Study Advisory Committee (SAC) for the Emergency Medicine Palliative Care Access (EMPallA) trial. The purpose of this clinical trial is to compare the effectiveness of nurse-led telephonic case management and specialty, outpatient palliative care of older adults with advanced illness. This paper describes how the SACs involvement translated into direct impacts on the EMPallA trial. The trial research team held regular meetings with the SAC throughout the trial process. Their involvement led to many significant changes in the trial, such as  expanding recruitment inclusion criteria (Spanish-speaking patients), and including survey instruments to measure lonelines and caregiver burden. The SAC also devised strategies to overcome patient and caregiver recruitment and retention challenges, including the creation of patient-friendly materials and training for research coordinators. This study provides a successful example of how actively engaging patient and community stakeholders, through committee engagement, can promote patient priorities in all phases of a trial while facilitating patient recruitment and retention.