Journal of geriatric emergency medicine最新文献

Introduction: Older adults were critically vulnerable to disruptions in health care during the COVID-19 pandemic, but it is not known if changes in ED utilization varied based on patient characteristics. Using a cohort of older Veterans, we examined changes in ED visit rates based on four characteristics of interest: age, race, area deprivation index, and frailty.

Methods: Participants were aged ≥65, with ≥2 visits in primary or geriatric clinics between 02/02/2018-05/07/2019. An adjusted negative binomial regression model was constructed for each characteristic. We report mean counts of all ED visits by quarter for subgroups separately, and report rate ratios to compare ED visits in the first year of the COVID-19 pandemic to the year before.

Results: Patients with complete case data numbered 38,871. During the first two quarters, all subgroups had decreased ED visits, with more variation in the third and fourth quarters. The very highly frail, who had the highest mean estimated count of ED visits per person through both pre-COVID and COVID periods, also had a significant decrease in their ED visits during multiple quarters of the pandemic to a greater degree than other frailty subgroups.

Conclusion: Stratifying older adults by frailty identified patient subgroups with the greatest variation in ED visits during COVID. Very highly frail patients warrant special attention to understand how variation in ED utilization affects patient outcomes.

Background: Older adults treated in emergency departments (EDs) are at higher risk for adverse outcomes. Using multiple facilities can worsen this issue through service duplication and poor care transitions. Veterans with dual insurance coverage can access both Veterans Health Administration (VHA) and non-VHA EDs. This study aimed to identify factors associated with non-VHA ED use among veterans.

Methods: We conducted a retrospective observational study of patients aged ≥ 65 who had primary care at the James J Peters VA Medical Center and at least one VHA or non-VHA ED visit between October 2017 and February 2020. Data were collected from the Veterans Affairs Corporate Data Warehouse and the Bronx Regional Health Information Exchange Organization. Generalized linear mixed models were used to examine factors influencing non-VHA ED use.

Results: The study sample consisted of 3,897 veterans and a total of 13,312 ED visits. Compared to VHA-exclusive ED users, non-VHA ED users were more likely to live farther away (OR 1.04, CI 1.02 - 1.06) and seek care outside regular hours, including mornings (OR 1.61, CI 1.39 - 1.87), nights (OR 1.49, CI 1.33 - 1.66), weekends (OR 1.28, CI 1.16 - 1.42), and holidays (OR 1.32, CI 1.04 - 1.68). They were also more likely to present with emergency care sensitive conditions (OR 2.13, CI 1.90 - 2.37) and recent inpatient hospitalizations (OR 1.22, CI 1.05 - 1.41).

Conclusion: These findings suggested that distance and acuity are important predictors of non-VHA ED use in urban areas such as the Bronx, NY. Identifying veterans with key risk factors could improve care coordination and potentially reduce non-VHA ED use.

Introduction: Detailed information about caregivers is crucial for planning disposition from emergency departments (EDs), but it is unclear what specific information is useful for ED clinicians and how that information should be presented.

Methods: We used a Design Thinking approach to develop a standardized format-which we call a "Best Possible Caregiver History" (BPCH)-for displaying useful caregiver information to ED clinicians. The key steps of this approach are needfinding, followed by iterative cycles of ideation, rapid prototyping, and testing. For needfinding, we used semi-structured interviews of four ED clinicians on current practices for discovering and documenting caregiver information. For ideation and prototyping, we used rapid qualitative analysis to identify themes and used them as design constraints informing low-fidelity prototyping of the BPCH. For testing, we sought user feedback in interprofessional focus groups of ED social workers, nurses, therapists, and physicians. Focus group feedback was then analyzed to inform the design of subsequent prototypes, which were iteratively presented to subsequent focus groups five times.

Results: Initial needfinding interviews found that caregiver information is gathered but often dispersed throughout the medical record, collected redundantly, and difficult to find and interpret. A structured and accessible shared note such as a BPCH would be useful. In focus groups, several design constraints for the BPCH emerged: caregiving data must include details about transportation, power of attorney, and home environment to be relevant for disposition, comprehensive, paired with functional assessments, and systematically presented. The BPCH does not require detail about persons or services helping with instrumental activities like shopping or banking. After five iterations, ED clinicians described the BPCH as useful.

Conclusion: We illustrate how Design Thinking can help rapidly develop a novel format for displaying details about caregivers that could facilitate safer disposition from the ED. The BPCH embodies what ED clinicians at our institution consider clinically relevant for their practice. Further research is needed to determine the feasibility, acceptability, and generalizability of this intervention.