Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use

OBJECTIVES: To examine the effect of an emergency department (ED)-based transitional care nurse (TCN) on hospital use. DESIGN: Prospective observational cohort. SETTING: Three U.S. (NY, IL, NJ) EDs from January 1, 2013, to June 30, 2015. PARTICIPANTS: Individuals aged 65 and older in the ED (N = 57,287). INTERVENTION: The intervention was first TCN contact. Controls never saw a TCN during the study period. MEASUREMENTS: We examined sociodemographic and clinical characteristics associated with TCN use and outcomes. The primary outcome was inpatient admission during the index ED visit (admission on Day 0). Secondary outcomes included cumulative 30-day admission (any admission on Days 0-30) and 72-hour ED revisits. RESULTS: A TCN saw 5,930 (10%) individuals, 42% of whom were admitted. After accounting for observed selection bias using entropy balance, results showed that when compared to controls, TCN contact was associated with lower risk of admission (site 1: -9.9% risk of inpatient admission, 95% confidence interval (CI) = -12.3% to -7.5%; site 2: -16.5%, 95% CI = -18.7% to -14.2%; site 3: -4.7%, 95% CI = -7.5% to -2.0%). Participants with TCN contact had greater risk of a 72-hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7-2.3%; site 2: 1.4%, 95% CI = 0.7-2.1%). Risk of any admission within 30 days of the index ED visit also remained lower for TCN patients at both these sites (site 1: -7.8%, 95% CI = -10.3% to -5.3%; site 2: -13.8%, 95% CI = -16.1% to -11.6%). CONCLUSION: Targeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission

The Geriatric Emergency Care Applied Research (GEAR) network approach: A protocol to advance stakeholder consensus and research priorities in geriatrics and dementia care in the emergency department

INTRODUCTION: Increasingly, older adults are turning to emergency departments (EDs) to address healthcare needs. To achieve these research demands, infrastructure is needed to both generate evidence of intervention impact and advance the development of implementation science, pragmatic trials evaluation and dissemination of findings from studies addressing the emergency care needs of older adults. The Geriatric Emergency Care Applied Research Network (https://gearnetwork.org) has been created in response to these scientific needs-to build a transdisciplinary infrastructure to support the research that will optimise emergency care for older adults and persons living with dementia. METHODS AND ANALYSIS: In this paper, we describe our approach to developing the GEAR Network infrastructure, the scoping reviews to identify research and clinical gaps and its use of consensus-driven research priorities with a transdisciplinary taskforce of stakeholders that includes patients and care partners. We describe how priority topic areas are ascertained, the process of conducting scoping reviews with integrated academic librarians performing standardised searches and providing quality control on reviews, input and support from the taskforce and conducting a large-scale consensus workshop to prioritise future research topics. The GEAR Network approach provides a framework and systematic approach to develop a research agenda and support research in geriatric emergency care. ETHICS AND DISSEMINATION: This is a systematic review of previously conducted research; accordingly, it does not constitute human subjects research needing ethics review. These reviews will be prepared as manuscripts and submitted for publication to peer-reviewed journals, and the results will be presented at conferences.Open Science Framework registered DOI: 10.17605/OSF.IO/6QRYX, 10.17605/OSF.IO/AKVZ8, 10.17605/OSF.IO/EPVR5, 10.17605/OSF.IO/VXPRS

Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic

Inpatient Trauma Mortality after Implementation of the Affordable Care Act in Illinois

Introduction: Illinois hospitals have experienced a marked decrease in the number of uninsured patients after implementation of the Affordable Care Act (ACA). However, the full impact of health insurance expansion on trauma mortality is still unknown. The objective of this study was to determine the impact of ACA insurance expansion on trauma patients hospitalized in Illinois.Methods: We performed a retrospective cohort study of 87,001 trauma inpatients from third quarter 2010 through second quarter 2015, which spans the implementation of the ACA in Illinois. We examined the effects of insurance expansion on trauma mortality using multivariable Poisson regression.Results: There was no significant difference in mortality comparing the post-ACA period to the pre-ACA period incident rate ratio (IRR)=1.05 (95% confidence interval [CI] [0.93-1.17]). However, mortality was significantly higher among the uninsured in the post-ACA period when compared with the pre-ACA uninsured population IRR=1.46 (95% CI [1.14-1.88]).Conclusion: While the ACA has reduced the number of uninsured trauma patients in Illinois, we found no significant decrease in inpatient trauma mortality. However, the group that remains uninsured after ACA implementation appears to be particularly vulnerable. This group should be studied in order to reduce disparate outcomes after trauma

Disk Storage and File Systems with Quality-of-Service Guarantees

ii Modern disk-storage systems have to accomplish the requirements of a variety of application classes. Applications that process continuous-media data such as video and audio streams require the storage system to guarantee sustained bandwidths. Interactive applications demand the storage system to ensure bounded response times, posing timing constraints on the execution of individual disk requests. Traditional timesharing applications may require both high throughput or overall short response times. With the described applications being more and more used together in todays computing systems, the disk-storage subsystems have to efficiently combine the different requirements of this application mix. In this thesis, I develop the design of a storage system that comprehensively addresses the various challenges posed by including the support for quality-of-service guarantees in disk-storage systems. The presented storage system provides three main properties. First, the admission control includes the support for statistical guarantees to increase the share of the disk bandwidth that can be utilized by the admission control. Second, the disk-request scheduling clearly separates the enforcement o

An Investigation of the Relationship Between Emergency Medicine Trainee Burnout and Clinical Performance in a High-fidelity Simulation Environment.

Objective: Burnout is prevalent among emergency medicine (EM) physicians, with physicians experiencing burnout more likely to report committing medical errors or delivering suboptimal care. The relationship between physician burnout and identifiable differences in clinical care, however, remains unclear. We examined if EM trainee burnout was associated with differences in clinical performance using high-fidelity simulation as a proxy for patient care. Methods: In this cross-sectional study across six institutions, we measured trainee performance over four simulation scenarios based on recognized EM milestones. For each scenario a faculty rater assessed whether the trainee performed predefined critical actions specific to each case. A summation of performed actions across all cases resulted in a cumulative task (CT) score (range = 0-85). Raters also assigned an impression score on a 10-point scale (0 = poor; 10 = outstanding) assessing the trainee\u27s overall performance after each scenario, with the mean of the scores resulting in an overall impression (OI) score. After the simulation assessment, we measured trainees\u27 burnout via the Maslach Burnout Inventory through a confidential, electronic survey. Trainee depression, quality of life (QOL) and daytime sleepiness were also evaluated. Survey results were compared to simulation scores using analysis of variance and covariance. Results: Fifty-eight of 89 (65.2%) eligible participants completed the survey and simulation assessment. Thirty-one of 58 (53.4%, 95% CI = 40.2% to 66.7%) trainees reported burnout. In trainees with burnout compared to those without, mean CT scores (73.4 vs. 75.2, 95% CI of difference Conclusion: Emergency medicine trainees with burnout received lower cumulative performance scores over four high-fidelity simulation scenarios than trainees without burnout

Tele-Follow-Up of Older Adult Patients from the Geriatric Emergency Department Innovation (GEDI) Program

The objective of this study was to characterize the content and interventions performed during follow-up phone calls made to patients discharged from the Geriatrics Emergency Department Innovation (GEDI) Program and to demonstrate the benefit of these calls in the care of older adults discharged from the emergency department (ED). This study utilizes retrospective chart review with qualitative analysis. It was set in a large, urban, academic hospital emergency department utilizing the Geriatric Emergency Department Innovations (GEDI) Program. The subjects were adults aged 65 and over who visited the emergency department for acute care. Follow-up telephone calls were made by geriatric nurse liaisons (GNLs) at 24⁻72 h and 10⁻14 days post-discharge from the ED. The GNLs documented the content of the phone calls, and these notes were analyzed through a constant comparative method to identify emergent themes. The results showed that the most commonly arising themes in the patients’ questions and nurses’ responses across time-points included symptom management, medications, and care coordination (physician appointments, social services, therapy, and medical equipment). Early follow-up presented the opportunity for nurses to address needs in symptom management and care coordination that directly related to the ED admission; later follow-up presented a unique opportunity to resolve sub-acute issues that were not addressed by the initial discharge plan and to manage newly arising symptoms and patient needs. Thus, telephone follow-up after emergency department discharge presents an opportunity to better connect older adults with appropriate outpatient care and to address needs arising shortly after discharge that may not have otherwise been detected. By following up at two discrete time-points, this intervention identifies and addresses distinct patient needs

Explaining regional departures from national patterns of industrial specialisation: regional institutions, policies and state coordination

The aim of the paper is to identify the basis of regional competence in industry sectors that are not key performers at the national level. The paper examines the ICT sector in two regions: Dresden (Germany) and Adelaide (Australia). The performance of Australia and Germany in ICT is not high by OECD standards. However, both Dresden and Adelaide have some competence in parts of the ICT sector that departs from national patterns. In Dresden the development of the ICT sector is more advanced than in Adelaide. In both regions, there are distinctive institutional features and policies that explain the development of the ICT sector. Further, in Dresden, the state has coordinated the ICT sector within the regional space, giving focus to institutional strengths in research and training, such that it is possible to describe the institutional environment as thick and coherent. As such, the regional space of Dresden has experienced an agglomeration of ICT and can be regarded as more successful than Adelaide, where institutions and state initiatives are fragmented and incoherent

What Did You Google? Describing Online Health Information Search Patterns of ED patients and Their Relationship with Final Diagnoses

Introduction: Emergency department (ED) patients’ Internet search terms prior to arrival have not been well characterized. The objective of this analysis was to characterize the Internet search terms patients used prior to ED arrival and their relationship to final diagnoses. Methods: We collected data via survey; participants listed Internet search terms used. Terms were classified into categories: symptom, specific diagnosis, treatment options, anatomy questions, processes of care/physicians, or “other.” We categorized each discharge diagnosis as either symptom-based or formal diagnosis. The relationship between the search term and final diagnosis was assigned to one of four categories of search/diagnosis combinations (symptom search/symptom diagnosis, symptom search/formal diagnosis, diagnosis search/symptom diagnosis, diagnosis search/formal diagnosis), representing different “trajectories.” Results: We approached 889 patients; 723 (81.3%) participated. Of these, 177 (24.5%) used the Internet prior to ED presentation; however, seven had incomplete data (N=170). Mean age was 47 years (standard deviation 18.2); 58.6% were female and 65.7% white. We found that 61.7% searched symptoms and 40.6% searched a specific diagnosis. Most patients received discharge diagnoses of equal specificity as their search terms (34% flat trajectory-symptoms and 34% flat trajectory-diagnosis). Ten percent searched for a diagnosis by name but received a symptom-based discharge diagnosis with less specificity. In contrast, 22% searched for a symptom and received a detailed diagnosis. Among those who searched for a diagnosis by name (n=69) only 29% received the diagnosis that they had searched. Conclusion: The majority of patients used symptoms as the basis of their pre-ED presentation Internet search. When patients did search for specific diagnoses, only a minority searched for the diagnosis they eventually received