Academic Emergency Medicine最新文献

Background: Older adults are frequent users of the Emergency Department (ED), with a significant proportion presenting with pre-existing or acute cognitive impairment. While negative post-ED outcomes associated with cognitive status are well documented, their direct impact on care processes and resource allocation within the hospital remains poorly understood. This study aims to quantify how different cognitive profiles affect costs and care needs for acutely ill older adults.

Methods: We conducted a secondary analysis of a prospective cohort study at a single, tertiary care hospital. We included patients aged ≥ 65 years admitted to the hospital through the ED. They were stratified into three groups based on the brief Confusion Assessment Method (bCAM) and the 10-Point Cognitive Screener (10-CS): normal cognition, cognitive impairment without delirium, and delirium. Primary outcome was cost of care. Resource utilization, characterized by the number of medical specialties involved, geriatric consultation, type of inpatient bed allocated from the ED, time to hospitalization, and patient satisfaction, were explored as secondary outcomes. Multiple regression models were used to assess associations, adjusting for sociodemographic factors, clinical severity, and geriatric vulnerability.

Results: The sample comprised 824 patients: 429 (52.1%) with normal cognition, 165 (20.0%) with delirium, and 230 (27.9%) with cognitive impairment without delirium. Clinical severity, but not cognitive status, was independently associated with costs (B = 0.18; 95% CI: 0.08, 0.27). Delirium was independently associated with allocation to high-complexity bed and receiving a geriatric consultation. Cognitive impairment was independently associated with a greater number of specialties involved.

Conclusions: Clinical severity showed the strongest association with costs. In contrast, cognitive profiles were independently associated with the care pathway and complexity, with delirium linked to higher-acuity allocation and preexisting cognitive impairment without delirium to broader multidisciplinary involvement. Recognizing these distinct cognitive profiles is fundamental for anticipating care demands and optimizing resource allocation for this vulnerable population.

Study objective: To characterize opioid and nonopioid drug use in the week following emergency department (ED)-initiated extended-release buprenorphine (XR-BUP) treatment using both self-reported data and urine drug screens (UDS).

Methods: This study uses data collected during a nonrandomized clinical trial of patients with untreated opioid use disorder (OUD), testing the safety and feasibility of initiating XR-BUP in patients presenting with minimal to mild withdrawal. The study was conducted from July 2020 to May 2023 across four urban academic EDs in the Northeast, Mid-Atlantic, and Pacific regions of the United States. A total of 100 participants, 18 years or older with OUD defined by DSM-5 criteria, a clinical opiate withdrawal scale (COWS < 8), and a positive opioid urine screen were included. Individuals with recent MOUD treatment, presentation for overdose, or concurrent methadone use were excluded. All participants received a single subcutaneous injection of 24 mg XR-BUP (CAM2038) during their ED visit. The primary outcomes were self-reported daily opioid and nonopioid drug use over 7 days postinjection using daily Qualtrics surveys and UDS results on day 7.

Results: Among participants who received XR-BUP and completed daily surveys, 98% reported at least one opioid-free day, and 63% reported no opioid use across all 7 days. Day 7 UDS results showed decreased detection of opioids, stimulants, and benzodiazepines. Reported polysubstance use also declined over the observation period.

Conclusions: ED-initiated XR-BUP was associated with substantial reductions in opioid and polysubstance use during the first week post-discharge, supporting its role in early overdose risk mitigation and highlighting its value as an ED-based intervention for opioid use disorder.

Trial registration: ClinicalTrials.gov Identifier: NCT03658642.

Background: Older adults are susceptible to adverse drug effects due to age-related changes, a higher prevalence of comorbidities, and complexities in medication management. Nearly half of geriatric patients are prescribed at least one new medication at ED discharge. This study evaluated potential pharmacist interventions on ED discharge prescriptions for older adults using the Geriatric Emergency Medicine Safety Recommendations (GEMS-Rx) list.

Methods: This single-center, IRB-approved, retrospective review analyzed ED discharge prescriptions for potentially inappropriate medications based on GEMS-Rx criteria from October 2021 to September 2024 for patients ≥ 65 years who were discharged from the ED. Prescriptions were reviewed by a trained pharmacist for medication-related problems (MRPs). Outcomes included: rate of potential pharmacist intervention, number of prescriptions with at least one MRP, MRP types, missing risk vs. benefit documentation, rates of current practice pharmacist review, two or more GEMS-Rx prescriptions at discharge, and polypharmacy. All prescriptions during the study period were reviewed to determine medication sub-class distribution, with a random sample of 250 patients, ensuring at least 10 prescriptions per sub-class, if available. Descriptive statistics were utilized.

Results: During the study period, 1458 prescriptions were written for included sub-classes. Of 284 prescriptions screened, 265 (for 250 patients) were included. The median (IQR) age was 69.5 (67-75) years with patients on a median (IQR) of 5 (3-8) scheduled home medications and discharged with a median (IQR) of 2 (1-3) new medications. Skeletal muscle relaxants (37.0%) and first-generation antihistamines (28.7%) were most frequent. Pharmacist intervention was potentially needed in 204 patients (81.6.%) with a median (IQR) of 2 (1, 2) MRPs per patient. Common MRPs included dose adjustment (53.2%), indication mismatch (41.1%), and frequency (38.1%).

Conclusions: Most GEMS-Rx prescriptions had at least one MRP, indicating an opportunity for enhanced prescribing. Future research should target strategies to optimize medications at ED discharge for older adults.

Background: Alcohol misuse among midlife and older adults is increasing, and age-related physiological vulnerability heightens the risk for adverse outcomes. Emergency departments (EDs) are key health system touchpoints for identifying alcohol misuse, yet the delivery of evidence-based interventions following screening in this population remains poorly described.

Methods: We conducted a retrospective cohort study of ED encounters from January 1, 2019-December 31, 2023, across 11 hospital-based EDs in a large integrated health system. We included patients aged ≥ 55 years old who screened positive for alcohol misuse using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C; ≥ 4 for men, ≥ 3 for women). Primary outcomes were delivery of evidence-based interventions, including brief intervention and referral to treatment and provision of medication for alcohol use disorder (MAUD). Secondary measures included demographics, co-occurring substance use, clinical presentation, and health care utilization. Age-adjusted logistic regression evaluated associations between AUDIT-C score and outcomes.

Results: Of 698,308 ED encounters among adults aged ≥ 55 years old, 39,912 (5.7%) screened positive for alcohol misuse. Men accounted for 58% of encounters, with gender differences narrowing with age. Co-use of substances was common: 21% reported illicit drug use, 27% cannabis use, and 23% tobacco use, with higher prevalence in younger age groups. Recent opioid and benzodiazepine prescriptions were documented in 12% and 6% of encounters, respectively. Brief intervention and referral to treatment occurred in 30% of encounters overall and in 46% among those with severe misuse. Despite guideline support for pharmacotherapy, MAUD was prescribed in only 3% of encounters.

Conclusions: Among midlife and older ED patients who screen positive for alcohol misuse, delivery of evidence-based interventions, particularly pharmacotherapy, is uncommon despite substantial healthcare utilization and co-occurring risk factors. These findings highlight a gap between identification and treatment and underscore the ED's potential role in initiating evidence-based interventions for alcohol misuse.

Background: Emergency department (ED) fall-risk screening often relies on measures that incompletely capture body movement signals relevant to future falls.

Objective: Test whether inertial measurement unit (IMU) features from a brief, modified, instrumented Timed Up and Go (miTUG) provide incremental prognostic value for 6-month falls after ED discharge beyond a clinical screening tool.

Methods: We conducted a prospective cohort study of community-dwelling adults ≥ 60 years discharged from an urban academic ED (September 2023-May 2024). Before discharge, participants completed a miTUG; four IMU features (sit-to-stand dominant frequency and duration; turn-to-sit spectral power and dominant frequency) were added to nine clinical predictors. The primary outcome was any fall within 180 days (6 months). Model performance was assessed using discrimination (AUC/C-index) and operating characteristics at ED-relevant thresholds. Secondary analyses examined models predicting time to first fall. Exploratory analyses examined patient sub-groups that may benefit from additional testing.

Results: Among 360 participants, 94 (26.1%) fell within 180 days. The combined clinical+IMU model demonstrated modestly improved discrimination compared with the clinical-only model (AUC 0.72 vs. 0.67; Wilcoxon p = 0.19). At a prespecified 30% fall risk threshold, addition of IMU features improved sensitivity (0.57 vs. 0.45), specificity (0.80 vs. 0.76) and positive predictive value (0.50 vs. 0.39). In time-to-event analyses, the combined clinical+IMU model showed higher concordance (C-index 0.73 vs. 0.69) and better fit (likelihood-ratio p = 0.0006). Incremental gains were largest among adults ≥ 70 years, those with a recent prior fall, and those classified as lower risk by the clinical screen.

Conclusions: In older adults discharged from the ED, IMU features from a brief, mobility assessment added modest improvements in fall risk stratification beyond a clinical screen. These findings are hypothesis-generating and support the need for external validation and implementation studies before clinical adoption.

Background: ED disposition decisions for older adults are complex and often uncertain, yet studies rarely capture emergency physicians' real-time perspectives.

Objective: To assess patient outcomes based on emergency physician-perceived need for admission.

Design: Single-site prospective cohort study conducted between July and November 2024.

Setting: A Boston-area academic tertiary care ED.

Participants: Patients aged 65 and older dispositioned by attending physicians, excluding patients who were handed off, left without being seen, or eloped.

Measurements: Physicians rated admission need using a 5-point Likert scale (2-4 considered marginal). Primary outcome was ED disposition stratified by rating. Secondary outcomes were hospital length-of-stay (LOS), 7-day ED return, and 30-day mortality.

Results: Of the 489 patients (mean age 76.9 years [SD 7.5], 51.1% female), 55.8% were non-marginal admissions, 26.0% were non-marginal discharges, and 18.2% were marginal dispositions. Patients with marginal dispositions had longer workup times than non-marginal admissions or discharges (3.3 vs. 2.8 vs. 2.4 h, p < 0.05). Thirty-day mortality was greater for non-marginal admissions (8.8%) than non-marginal discharges (1.6%, p = 0.01), but not significantly different than marginal dispositions (3.4%). Marginal admissions had shorter median LOS (3.1 vs. 5 days, p < 0.01) and higher early discharge rates (27.8% vs. 13.2%, p = 0.01) than non-marginal admissions. Marginal discharges had fewer 7-day returns than non-marginal discharges (0% vs. 11.7%, p = 0.04). For marginal cases, physicians discussed admission benefits more than risks (70.1% vs. 43.3%, p < 0.01) for marginal cases.

Limitations: Single-site and need for admission were reported contemporaneous with disposition decision.

Conclusions: One in six older adult ED dispositions was identified as marginal. These patients are potential targets for shared decision-making and alternative care pathways.