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: À9.9% risk of inpatient admission, 95% confidence interval (CI) = À12.3% to À7.5%; site 2: À16.5%, 95% CI = À18.7% to À14.2%; site 3: À4.7%, 95% CI = À7.5% to À2.0%). 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: À7.8%, 95% CI = À10.3% to À5.3%; site 2: À13.8%, 95% CI = À16.1% to À11.6%). CONCLUSION: Targeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission. J Am Geriatr Soc 2018.

for the GEDI-WISE InvestigatorsOlder adults account for a large and growing segment of the emergency department (ED) population. They are often admitted to the hospital for nonurgent conditions such as dementia, impaired functional status, and gait instability. The aims of this geriatric ED innovations (GEDI) project were to develop GEDI nurse liaisons by training ED nurses in geriatric assessment and care coordination skills, describe characteristics of patients that these GEDI nurse liaisons see, and measure the admission rate of these patients. Four ED nurses participated in the GEDI training program, which consisted of 82 hours of clinical rotations in geriatrics and palliative medicine, 82 hours of didactics, and a pilot phase for refinement of the GEDI consultation process. Individuals were eligible for GEDI consultation if they had an Identification of Seniors At Risk (ISAR) score greater than 2 or at ED clinician request. GEDI consultation was available Monday through Friday from 9:00 a.m. to 8:00 p.m. An extensive database was set up to collect clinical outcomes data for all older adults in the ED before and after GEDI implementation. The liaisons underwent training from January through March 2013. From April through August 2013, 408 GEDI consultations were performed in 7,213 total older adults in the ED (5.7%, 95% confidence interval (CI) = 5.2-6.2%), 2,124 of whom were eligible for GEDI consultation (19.2%, 95% CI = 17.6-20.9%); 34.6% (95% CI = 30.1-39.3%) received social work consultation, 43.9% (95% CI = 39.1-48.7) received pharmacy consultation, and more than 90% received telephone follow-up. The admission rate for GEDI patients was 44.9% (95% CI = 40.1-49.7), compared with 60.0% (95% CI = 58.8-61.2) non-GEDI. ED nurses undergoing a 3-month training program can develop geriatric-specific assessment skills. Implementation of these skills in the ED may be associated with fewer admissions of older adults. 1 The number of older adults who visit an ED has doubled in the last decade and continues to grow rapidly. Older adults presenting to EDs are highly likely to be admitted to the hospital, much more so than their younger counterparts.1 Prevention of hospital admission saves older adults from frequently encountered adverse events, including delirium, functional status impairment, cognitive loss, and nursing home admission. [2][3][4] It is unknown how many older adults are hospitalized for reasons other than acute medical illness, such as functional decline, polypharmacy, progressive dementia, caregiver stress, and unstable living situation. These nonurgent conditions are rarely addressed during a typical ED visit because of lack of resources, patient volume, and the need for rapid turnover of care spaces. 5 The predominant management strategy of emergency physicians at the Feinberg School of Medicine to handle these important but not imminently life-threatening geriatric problems is to recommend hospital admission.The main goal of the Geriatric Emergency Department Innovations through Workforce, Inform...

IMPORTANCE There has been a significant increase in the implementation and dissemination of geriatric emergency department (GED) programs. Understanding the costs associated with patient care would yield insight into the direct financial value for patients, hospitals, health systems, and payers. OBJECTIVE To evaluate the association of GED programs with Medicare costs per beneficiary.

Objectives: Despite increased focus on opioid prescribing, little is known about the influence of prescription opioid medication information given to patients in the emergency department (ED). The study objective was to evaluate the effect of an Electronic Medication Complete Communication (EMC 2 ) Opioid Strategy on patients' safe use of opioids and knowledge about opioids.Methods: This was a three-arm prospective, randomized controlled pragmatic trial with randomization occurring at the physician level. Consecutive discharged patients at an urban academic ED (>88,000 visits) with new hydrocodone-acetaminophen prescriptions received one of three care pathways: 1) usual care, 2) EMC 2 intervention, or 3) EMC 2 + short message service (SMS) text messaging. The ED EMC 2 intervention triggered two patient-facing educational tools (MedSheet, literacy-appropriate prescription wording [Take-Wait-Stop]) and three provider-facing reminders to counsel (directed to ED physician, dispensing pharmacist, follow-up physician). Patients in the EMC 2 + SMS arm additionally received one text message/day for 1 week. Follow-up at 1 to 2 weeks assessed "demonstrated safe use" (primary outcome). Secondary outcomes including patient knowledge and actual safe use (via medication diaries) were assessed 2 to 4 days and 1 month following enrollment.Results: Among the 652 enrolled, 343 completed follow-up (57% women; mean AE SD age = 42 AE 14.0 years).Demonstrated safe opioid use occurred more often in the EMC 2 group (adjusted odds ratio [aOR] = 2.46, 95% confidence interval [CI] = 1.19 to 5.06), but not the EMC 2 + SMS group (aOR = 1.87, 95% CI = 0.90 to 3.90) compared with usual care. Neither intervention arm improved medication safe use as measured by medication diary data. Medication knowledge, measured by a 10-point composite knowledge score, was greater in the EMC 2 + SMS group (b = 0.57, 95% CI = 0.09 to 1.06) than usual care. Conclusions:The study found that the EMC 2 tools improved demonstrated safe dosing, but these benefits did not translate into actual use based on medication dairies. The text-messaging intervention did result in improved patient knowledge.

IntroductionEmergency 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.MethodsWe 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.”ResultsWe 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.ConclusionThe 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.