Objectives Methods to accurately identify elderly patients with a high likelihood of hospital admission or subsequent return to the emergency department (ED) might facilitate the development of interventions to expedite the admission process, improve patient care, and reduce overcrowding. This study sought to identify variables found among elderly ED patients that could predict either hospital admission or return to the ED. Methods All visits by patients 75 years of age or older during 2007 at an academic ED serving a large community of elderly were reviewed. Clinical and demographic data were used to construct regression models to predict admission or ED return. These models were then validated in a second group of patients 75 and older who presented during two 1-month periods in 2008. Results Of 4,873 visits, 3,188 resulted in admission (65.4%). Regression modeling identified five variables statistically related to the probability of admission: age, triage score, heart rate, diastolic blood pressure, and chief complaint. Upon validation, the c-statistic of the receiver operating characteristic (ROC) curve was 0.73, moderately predictive of admission. We were unable to produce models that predicted ED return for these elderly patients. Conclusions A derived and validated triage-based model is presented that provides a moderately accurate probability of hospital admission of elderly patients. If validated experimentally, this model might expedite the admission process for elderly ED patients. Our models failed, as have others, to accurately predict ED return among elderly patients, underscoring the challenge of identifying those individuals at risk for early ED returns.

OBJECTIVE. To describe the prevalence, characteristics, and appropriateness of systemic antibiotic use in assisted living (AL) and to conduct a preliminary quality improvement intervention trial to reduce inappropriate prescribing.DESIGN. Pre-post study, with a 13-month intervention period.SETTING. Four AL communities.PARTICIPANTS. All prescribers, all AL staff who communicate with prescribers, and all patients who had an infection during the baseline and intervention periods.INTERVENTION. A standardized form for AL staff, an online education course and 5 practice briefs for prescribers, and monthly quality improvement meetings with AL staff.MEASUREMENTS. Monthly inventory of all systemic antibiotic prescriptions; interviews with the prescriber, AL staff member, closest family member, and patient (when capable) regarding 85 antibiotic prescribing episodes (30 baseline, 55 intervention), with data review by an expert panel to determine prescribing appropriateness.RESULTS. The mean number of systemic antibiotic prescriptions was 3.44 per 1,000 resident-days at baseline and 3.37 during the intervention, a nonsignificant change (P = .30). Few prescribers participated in online training. AL staff use of the standardized form gradually increased during the program. The proportion of prescriptions rated as probably inappropriate was 26% at baseline and 15% during the intervention, a nonsignificant trend (P = .25). Drug selection was largely appropriate during both time periods.CONCLUSIONS. AL antibiotic prescribing rates appear to be approximately one-half those seen in nursing homes, with up to a quarter being potentially inappropriate. Interventions to improve prescribing must reach all physicians and staff and most likely will require long time periods to have the optimal effect. Infect Control Hosp Epidemiol 2014;35(S3):S62-S68Antimicrobial resistance among bacterial pathogens is an imsiderably in terms of their medical problems and functional portant and growing public health concern, 1 ' 2 and inapprostatus, 16 by inference it seems likely that antibiotic overprepriate overprescribing is believed to be a contributing factor. 3 scribing may also be a problem in AL. However, in spite of Since antibiotic prescribing rates are high in nursing homes the large and growing population served by AL, this setting (ranging from 3 to 5 prescriptions per resident annually), 4 " 9 has received virtually no attention in attempts to either deconcern has been raised about potentially inappropriate prescribe or optimize antibiotic prescribing. 8 Studying this setscribing in these settings. 1 " A few studies of attempts to reduce ting would be important both because of the number of antibiotic overprescribing in nursing homes have been pubpersons served and because its organizational structure differs lished, and these have met with mixed results. 11 " 13 considerably from that of nursing homes, making extrapoDue to changes in long-term care regulation and financing, lation of results from nursing home studies not necessarily ass...

OBJECTIVES To describe the provision of medical care in assisted living (AL) as provided by physicians who are especially active in providing care to older adults and AL residents; to identify characteristics associated with physician confidence in AL staff; and to ask physicians a variety of questions about their experience providing care to AL residents and how it compares with providing care in the nursing home and home care settings. DESIGN Cross-sectional descriptive study. SETTING AL communities in 27 states. PARTICIPANTS One hundred sixty-five physicians and administrators of 125 AL settings in which they had patients. MEASUREMENTS Interviews and questionnaires containing open- and close-ended questions regarding demographics, care arrangements, attitudes, and behaviors in managing medical problems. RESULTS Most respondents were certified in internal medicine (46%) or family medicine (47%); 32% were certified in geriatrics and 30% in medical directorship. In this select sample, 48% visited the AL setting once a year or less, and 19% visited once a week or more. Mean physician confidence in AL staff was 3.3 (somewhat confident), with greater confidence associated with smaller AL community size, nursing presence, and the physician being the medical director. Qualitative analyses identified differences between settings including lack of vital sign assessment in the home setting, concern about the ability of AL staff to assess and monitor problems, and greater administrative and regulatory requirements in AL than in the other settings. CONCLUSION Providing medical care for AL residents presents unique challenges and opportunities for physicians. Nursing presence and physician oversight and familiarity and communicating with AL staff who are highly familiar with a given resident and can monitor care may facilitate care.

Objectives To better understand the antibiotic prescribing process in assisted living (AL) communities given the growing rates of antibiotic resistance. Design Cross-sectional survey. Setting Four AL communities in North Carolina. Participants AL residents who received antibiotics (n=30) from October 20, 2010 to March 31, 2011, and their primary family member, staff, and the prescribing medical provider. Measurements Semi-structured interviews conducted about prescribing included the information available at the time of prescribing and the perceptions of the quality of communication among providers, staff, residents and family members about the case. Providers were asked an open-ended question regarding how to improve the communication process related to antibiotic prescribing for AL residents. Results Among 30 cases of antibiotic prescriptions, providers often had limited information about the case and lacked familiarity with the residents, the residents’ families, and/or staff. In addition, they felt cases were less severe and less likely to need an antibiotic than did residents, families, and staff. Providers identified several ways to improve the communication process including better written documentation and staff/family presence. Conclusion In our small sample of AL communities, providers faced an array of challenges in making antibiotic prescribing decisions. Our work confirms the complex nature of antibiotic prescribing in AL communities and reveals further work is needed to determine how to improve the appropriateness of antibiotic prescribing.