Neal Flomenbaum

A Systematic Review and Qualitative Analysis to Inform the Development of a New Emergency Department-Based Geriatric Case Management Model

STUDY OBJECTIVE We inform the future development of a new geriatric emergency management practice model. We perform a systematic review of the existing evidence for emergency department (ED)-based case management models designed to improve the health, social, and health service utilization outcomes for noninstitutionalized older patients within the context of an index ED visit. METHODS This was a systematic review of English-language articles indexed in MEDLINE and CINAHL (1966 to 2010), describing ED-based case management models for older adults. Bibliographies of the retrieved articles were reviewed to identify additional references. A systematic qualitative case study analytic approach was used to identify the core operational components and outcome measures of the described clinical interventions. The authors of the included studies were also invited to verify our interpretations of their work. The determined patterns of component adherence were then used to postulate the relative importance and effect of the presence or absence of a particular component in influencing the overall effectiveness of their respective interventions. RESULTS Eighteen of 352 studies (reported in 20 articles) met study criteria. Qualitative analyses identified 28 outcome measures and 8 distinct model characteristic components that included having an evidence-based practice model, nursing clinical involvement or leadership, high-risk screening processes, focused geriatric assessments, the initiation of care and disposition planning in the ED, interprofessional and capacity-building work practices, post-ED discharge follow-up with patients, and evaluation and monitoring processes. Of the 15 positive study results, 6 had all 8 characteristic components and 9 were found to be lacking at least 1 component. Two studies with positive results lacked 2 characteristic components and none lacked more than 2 components. Of the 3 studies with negative results demonstrating no positive effects based on any outcome tested, one lacked 2, one lacked 3, and one lacked 4 of the 8 model components. CONCLUSION Successful models of ED-based case management models for older adults share certain key characteristics. This study builds on the emerging literature in this area and leverages the differences in these models and their associated outcomes to support the development of an evidence-based normative and effective geriatric emergency management practice model designed to address the special care needs and thereby improve the health and health service utilization outcomes of older patients.

Emergency Department Presentations for Injuries in Older Adults Independently Known to be Victims of Elder Abuse

BACKGROUND Elder abuse is under-recognized by emergency department (ED) providers, largely due to challenges distinguishing between abuse and accidental trauma. OBJECTIVE To describe patterns and circumstances surrounding elder abuse-related and potentially abuse-related injuries in ED patients independently known to be physical elder abuse victims. METHODS ED utilization of community-dwelling victims of physical elder abuse in New Haven, CT from 1981-1994 was analyzed previously. Cases were identified using Elderly Protective Services data matched to ED records. Sixty-six ED visits were judged to have high probability of being related to elder abuse and 244 were of indeterminate probability. We re-examined these visits to assess whether they occurred due to injury. We identified and analyzed in detail 31 injury-associated ED visits from 26 patients with high probability of being related to elder abuse and 108 visits from 57 patients with intermediate probability and accidental injury. RESULTS Abuse-related injuries were most common on upper extremities (45% of visits) and lower extremities (32%), with injuries on head or neck noted in 13 visits (42%). Bruising was observed in 39% of visits, most commonly on upper extremities. Forty-two percent of purportedly accidental injuries had suspicious characteristics, with the most common suspicious circumstance being injury occurring more than 1 day prior to presentation, and the most common suspicious injury pattern being maxillofacial injuries. CONCLUSION Victims of physical elder abuse commonly have injuries on the upper extremities, head, and neck. Suspicious circumstances and injury patterns may be identified and are commonly present when victims of physical elder abuse present with purportedly accidental injuries.

Assessment and Management of Delirium in Older Adults in the Emergency Department: Literature Review to Inform Development of a Novel Clinical Protocol.

Delirium occurs frequently in older patients in the emergency department (ED), is underrecognized, and has potentially serious consequences. Despite its seriousness, delirium is frequently missed by emergency providers, and patients with unrecognized delirium are often discharged from the ED. Even when it is appropriately recognized, managing delirium in older adults poses a significant challenge for ED providers. Geriatric delirium is typically caused by the interaction of multiple factors, including several that are commonly missed: pain, urinary retention, constipation, dehydration, and polypharmacy. Appropriate management includes nonpharmacological management with medication intervention reserved for emergencies. We have developed a new, comprehensive, evidence-based protocol for diagnosis/recognition, management, and disposition of geriatric delirium patients in the ED with a focus on identifying and treating commonly missed contributing causes.

Alterations of preliminary readings on radiographic examinations minimally affect outcomes of trauma patients discharged from the emergency department.

BACKGROUND We hypothesized that trauma patients could be discharged safely from the emergency department (ED) before the availability of official readings for their radiologic examinations. We also sought to determine whether trauma patients were more prone to alterations of preliminary interpretations than other ED patients. METHODS Alterations of preliminary readings (PR) for patients discharged from the ED were reviewed. If the official readings conflicted with the PR used for the patients disposition, attempts were made to contact the patient and provide the appropriate follow-up. Data recorded included the type of radiographic examination, the presence of a missed injury, and the follow-up. By using institutional data, the incidence of inaccurate PR were compared for trauma patients and other ED patients (chi2 test, Fisher exact test, p < 0.05). RESULTS Between January of 1998 and December of 1998, 102 of 38,260 discharged ED patients had official readings differing from PR. Forty-three of the changed readings involved 42 of the 1,073 discharged trauma patients, who were more likely to harbor inaccurate PR (<0.0001) than other discharged ED patients. Twenty-eight altered readings involved plain films and 15 involved computed tomographic scans. The most common altered readings involved computed tomographic scans of the head and face (n = 13). Twelve missed injuries were detected, most commonly related to a missed injury of the extremity (7 cases). Nine other cases involved the detection of incidental pathologic conditions. Eight patients required repeat ED visits for clinical and radiographic evaluation, and one patient required subsequent hospital admission. CONCLUSION Discharged trauma patients are more likely to harbor alterations of preliminary interpretations than other ED patients. Although the official readings for these trauma patients will occasionally reveal previously undetected pathologic conditions, the majority of such cases can be managed with outpatient follow-up.

Emergency Medical Services Perspectives on Identifying and Reporting Victims of Elder Abuse, Neglect, and Self-Neglect

BACKGROUND Emergency Medical Services (EMS) providers, who perform initial assessments of ill and injured patients, often in a patients home, are uniquely positioned to identify potential victims of elder abuse, neglect, or self-neglect. Despite this, few organized programs exist to ensure that EMS concerns are communicated to or further investigated by other health care providers, social workers, or the authorities. OBJECTIVE To explore attitudes and self-reported practices of EMS providers surrounding identification and reporting of elder mistreatment. METHODS Five semi-structured focus groups with 27 EMS providers. RESULTS Participants reported believing they frequently encountered and were able to identify potential elder mistreatment victims. Many reported infrequently discussing their concerns with other health care providers or social workers and not reporting them to the authorities due to barriers: 1) lack of EMS protocols or training specific to vulnerable elders; 2) challenges in communication with emergency department providers, including social workers, who are often unavailable or not receptive; 3) time limitations; and 4) lack of follow-up when EMS providers do report concerns. Many participants reported interest in adopting protocols to assist in elder protection. Additional strategies included photographically documenting the home environment, additional training, improved direct communication with social workers, a dedicated location on existing forms or new form to document concerns, a reporting hotline, a system to provide feedback to EMS, and community paramedicine. CONCLUSIONS EMS providers frequently identify potential victims of elder abuse, neglect, and self-neglect, but significant barriers to reporting exist. Strategies to empower EMS providers and improve reporting were identified.

Increasing frequency and fatality of poison control center reported exposures involving medication and multiple substances: data from reports of the American Association of Poison Control Centers 1984–2013

Abstract Context: Medication use has become increasingly prevalent in the United States, with up trending use of both prescription and over the counter medication. The increasing use and availability of medication may be changing the nature of poisoning fatality. Objective: To evaluate changes in fatal poisoning over time, with respect to fatalities involving one or more medications, using annual reports published by the American Association of Poison Control Centers (AAPCC). Materials and methods: AAPCC annual reports were reviewed from 1984 to 2013. Data from tables in each annual report titled Number of Substances Involved in Human Exposure Cases and Summary of Fatal Exposures were abstracted. Fatality rates and changes in these rates over time were calculated for exposures to 1, 2, or ≥ 3 substances. All substances detailed in Summary of Fatal Exposures tables were then coded as medication or non-medication. The percentage of fatalities involving 1, 2, or ≥ 3 medications was calculated and trended over time. Subset analysis was performed to compare the periods 1984-2005 and 2006-2013 in order to limit confounding from changes in reporting. Secondary analysis linking the number of substances cases were exposed to and the fatality rate was performed for data from 2006-2013. Results: There were 59,866,357 human exposures and 29,659 fatalities reported from 1984 to 2013. There were 49.5 fatalities per 100,000 exposures. The majority of fatalities (52.2%) involved more than one substance, although multiple substances were involved in only 8.3% of exposures. Fatality rates increased over time and were higher for cases involving multiple substances. Medications were involved in 79.2% of fatalities, a percentage that increased from 70% in the 1980s to nearly 90% after 2010. In recent years, the majority of fatalities have involved multiple medications. For data from 2006-2013 there was a strong association between fatality rate and number of substances involved in an exposure (221 additional fatalities per 100,000 exposures for each additional substance involved in an exposure). Discussion and conclusion: Multiple substance exposures have become a greater percentage of cases reported to the AAPCC and have higher fatality rates than single substance exposures. The majority of fatal poisonings reported to the AAPCC between 1984 and 2013 involved medication. The percentage of fatal poisonings involving medication increased over the interval, as did the percentage of fatalities involving more than one medication. Fatalities involving multiple medications are now the most common type of fatal poisoning reported to the AAPCC.

Imaging findings in elder abuse: a role for radiologists in detection

Purpose Emergency department assessment represents a critical but often missed opportunity to identify elder abuse, which is common and has serious consequences. Among emergency care providers, diagnostic radiologists are optimally positioned to raise suspicion for mistreatment when reviewing imaging of geriatric injury victims. However, little literature exists describing relevant injury patterns, and most radiologists currently receive neither formal nor informal training in elder abuse identification. Methods We present 2 cases to begin characterisation of the radiographic findings in elder abuse. Results Findings from these cases demonstrate similarities to suspicious findings in child abuse including high-energy fractures that are inconsistent with reported mechanisms and the coexistence of acute and chronic injuries. Specific injuries uncommon to accidental injury are also noted, including a distal ulnar diaphyseal fracture. Conclusions We hope to raise awareness of elder abuse among diagnostic radiologists to encourage future large-scale research, increased focus on chronic osseous findings, and the addition of elder abuse to differential diagnoses.

The ED as the primary source of hospital admission for older (but not younger) adults

INTRODUCTION The elderly population in the United States is growing. This age shift has important implications for emergency departments (EDs), which currently account for more than 50% of inpatient hospitalizations. Our objective was to compare the percentage of inpatient admissions starting in the ED between elderly and younger patients. METHODS We conducted a retrospective analysis using the National Hospital Discharge Survey. Source of admission to the hospital was evaluated for years 2003 to 2009. Total admissions from the ED and trends over time were analyzed for the following age groups: 22 to 64, 65 to 74, 75 to 84, and 85+ years old. Likelihood of having been admitted from the ED was evaluated with logistic regression. RESULTS A total of 1.7 million survey visits representing 216 million adult hospitalizations were analyzed. A total of 93 million (43.2%) were among patients 65 years and older. The ED was the source of admission for 57.3% of patients 65 years and older and 44.4% of patients 64 years and younger (95% confidence interval difference, 12.97%-13.00%). By 2009, more than 75% of nonelective admissions for patients 85 years and older were through the ED. There was a linear relationship between age and the ED as the source of admission, the odds increasing by 2.9% per year (95% confidence interval, 1.029-1.029) for each year beyond age 65 years. CONCLUSION Emergency departments are increasingly used as the gateway for hospital admission for older adults. An aging US population may increase the effect of this trend, a prospect that should be planned for. From the patient perspective, barriers to care contributing to the age-based discrepancy in the use of the ED as source of admission should be investigated.

Acute Precipitants of Physical Elder Abuse: Qualitative Analysis of Legal Records From Highly Adjudicated Cases.

Elder abuse is a common phenomenon with potentially devastating consequences for older adults. Although researchers have begun to identify predisposing risk factors for elder abuse victims and abusers, little is known about the acute precipitants that lead to escalation to physical violence. We analyzed legal records from highly adjudicated cases to describe these acute precipitants for physical elder abuse. In collaboration with a large, urban district attorney’s office, we qualitatively evaluated legal records from 87 successfully prosecuted physical elder abuse cases from 2003 to 2015. We transcribed and analyzed narratives of the events surrounding physical abuse within victim statements, police reports, and prosecutor records. We identified major themes using content analysis. We identified 10 categories of acute precipitants that commonly triggered physical elder abuse, including victim attempting to prevent the abuser from entering or demanding that he or she leave, victim threatening or attempting to leave/escape, threat or perception that the victim would involve the authorities, conflict about a romantic relationship, presence during/intervention in ongoing family violence, issues in multi-generational child rearing, conflict about the abuser’s substance abuse, confrontation about financial exploitation, dispute over theft/destruction of property, and disputes over minor household issues. Common acute precipitants of physical elder abuse may be identified. Improved understanding of these acute precipitants for escalation to physical violence and their contribution to elder abuse may assist in the development of prevention and management strategies.

Introductory Emergency Medicine Clinical Skills Course: A Daylong Course Introducing Preclinical Medical Students to the Role of First Responders

Introduction A complete medical school curriculum must include an introduction to first aid; the management of airway, breathing, and circulation; and basic medical emergencies. The September 11, 2001, terrorist attacks in New York underscored the need for such training for US students even in their preclinical years. During that tragedy, many Weill Cornell Medical College (WCMC) preclinical students were eager to volunteer at Ground Zero and in the emergency department, yet it was clear they were not prepared for even basic medical emergencies this early in their training. To address this gap, in 2002 we incorporated this expanded first-responder course into the first-year doctoring class at WCMC. Methods The course includes a morning of lectures followed by related workshops. Students also practice managing ill patients in multiple case scenarios and participate in a tabletop disaster-management exercise. Results This course has become a mainstay of our first-year curriculum, receiving high praise from students annually. It generates tremendous interest in emergency medicine and lays a foundation of basic emergency medicine knowledge for students at an early point in their education. Discussion The unique experience of our medical school during the 9/11 tragedy highlighted the need for a course that would introduce preclinical medical students to the basic skills needed to assist in emergency scenarios in the field. Over the past 13 years, this course has developed into an essential part of our preclinical curriculum and has been strengthened through changes made based on student feedback.