A new study suggests older patients are particularly vulnerable to functional decline in the six months following a visit to the ED. Investigators noted the findings suggest there are opportunities to short-circuit this trajectory with added assessment and arrangements for follow-up interventions at the time of the ED visit. . Investigators compared 754 older patients who visited the ED with a matched group of 813 patients who did not visit an ED. They also studied an unmatched group of older patients who were hospitalized following an ED visit. . At the beginning of the study, both the ED-visit and control groups exhibited similar functional abilities, with levels of disability ranging between 3 and 4 on a disability scale, where lower scores represented lower levels of disability. . The ED-visit group scored an average of 14% higher than the control group participants on the disability scale during the six months following the ED visit. The group with participants who had ED visits followed by hospitalization demonstrated disability scores that were 17% higher than the ED-visit only group. . Investigators pointed to studies showing that ED-based screening and follow-up of older patients can prevent the risk of functional decline, decrease readmissions, and potentially prevent admissions to the ICU.

The ED at the University of Colorado Hospital (UCH) has undergone a dramatic transformation in recent years, doubling in size while also using process improvement methods to dramatically reduce wait times, eliminate ambulance diversion, and boost patient satisfaction. Throughout this period, volume has continued to increase while the cost per patient and avoidable hospital admissions have experienced steady declines. Guiding the effort has been a series of core principles, with a particular focus on making sure that all processes are patient-centered. . To begin the improvement effort, ED leaders established a leadership team, and hired a process improvement chief with no previous experience in healthcare to provide fresh, outside perspective on processes. . In addition to mandating that all processes be patient-centered, the other guiding principles included a commitment to use and track data, to speak with one voice, to value everyone's perspective, to deliver high-quality care to all patients, and to set a standard for other academic medical centers. . To get points on the board early and win approval from staff, one of the first changes administrators implemented was to hire scribes for every physician so they wouldn't be bogged down with data input. The approach has essentially paid for itself. . Among the biggest changes was the elimination of triage, a process that improvement teams found no longer added value or quality to the patient experience. . Leadership also has moved to equilibrate the size and staff of the various zones in the ED so that they are more generic and less specialized. The move has facilitated patient flow, enabling patients in zones with resuscitation bays to connect with providers quickly.

With high-profile travel bans and well-publicized Immigration and Customs Enforcement (ICE) activities, frontline providers have noticed changes in the behavior of immigrant patients. Some emergency providers report there is more fear and a reluctance to share key information. Also, providers are concerned that worries about deportation will cause immigrant patients to refrain from accessing needed care. Investigators note that such concerns are valid, considering how heightened ICE activities previously have affected immigrant health. •Emergency providers who see a high number of immigrant patients report patients are very guarded about providing identifying information and recent travel history. They are concerned that medical staff will report them to ICE authorities. •Some emergency providers are wearing "safety pin" symbols to try to let patients know that they are safe in their care. Others are thinking about posting signs in multiple languages to inform immigrant patients that information about travel history only will be used for medical purposes. •Experts worry that restrictions on foreign-born physicians and medical students only will exacerbate anticipated shortages, particularly in rural areas. •In a previous period of increased immigration enforcement, researchers found that more than 40% of frontline providers reported that ICE activities produced negative health effects on their immigrant patients, including stress, anxiety, and avoidance of the healthcare system.

To boost performance on a range of metrics, the 55-bed ED at NYU Lutheran Medical Center in Brooklyn, NY, transitioned to a pod system in August 2016. The approach, which is designed to foster team-based care, involves assigning physicians and nurses to designated geographic areas throughout the day, minimizing the movement of physicians as well as the need for phone communication. When coupled with other changes, including the introduction of point-of- care testing, the pod initiative has enabled the ED to reduce lengths of stay for all treat-and-release patients to less than three hours for the first time in the history of the department, according to administrators. There were multiple challenges involved with the transition to a pod system, including the need to match physician schedules with patient volume, but clinicians note the approach has produced improved physician-nurse communications. Administrators credit the creation of a process improvement team with giving frontline staff a voice in planned improvements while also facilitating the change process.

A new clinical index tool designed specifically for the emergency environment predicts the risk for future firearms violence in young people 14-24 years of age. The approach employs a brief, 10-point instrument that can be administered in one to two minutes, according to investigators. They also note that while the tool is based on data from a single ED in Flint, Ml, the tool should be applicable to urban EDs in regions that have similar characteristics. To create the tool, investigators used data from the Flint Youth Injury Study, an investigation of a group of patients 14-24 years of age who reported using drugs in the previous six months and accessed care at a Level I trauma center. Using a machine learning classification approach, investigators combed through the data, finding that the most predictive factors for firearm violence could be categorized into four domains: peer and partner violence victimization, community violence exposure, peer/family influences, and fighting. Ideally, investigators note the tool will be employed along with interventions targeted toward patients at high risk for future firearms violence.

As the benefits of palliative care become more evident in clinical trials, there is growing interest in making such resources available to patients at an earlier stage, such as the ED. However, experts note that emergency staff first must identify available resources and make sure that providers have the primary palliative care skills needed to effectively introduce the topic to appropriate patients and families. Research shows that initiating the call for a palliative care consult while the patient is in the ED can deliver quality-of-life benefits even three months later. For EDs that lack resources in house, experts advise staff to form partnerships with hospices in the community; some offer sophisticated services and will come to the ED to evaluate patients. Emergency staff should establish flexible criteria to identify when palliative care is an appropriate option to introduce to patients and families.

Some health systems are piloting telemedicine solutions in the ED to address crowding and decrease patient wait times. One new program, implemented at the Lisa Perry Emergency Center at New York Presbyterian (NYP) Weill Cornell Medical Center in New York, involves offering low-acuity patients the option of visiting an off-site physician via telemedicine hookup. Administrators note that the approach can get patients in and out of the ED within 30 minutes, and patients have thus far been highly satisfied with the approach. However, an earlier telemedicine program piloted at the University of San Diego Health System’s (UCSD) Hillcrest Hospital in 2013 got bogged down due to administrative and insurance reimbursement hurdles, although the approach showed enough promise that there is interest in restarting the program. In the NYP program, patients are identified as appropriate candidates for the program at triage. They can opt to be seen remotely or through traditional means in the ED’s fast-track section. Administrators note that patients with complex problems requiring extensive workups are not suitable for the telemedicine approach. The most challenging aspect of implementing a successful telemedicine program in the ED is getting the workflows right, according to administrators. An earlier ED-based telemedicine program piloted at UCSD ran into difficulties because the model required the involvement of two physicians, and some insurers did not want to pay for the telemedicine visits. However, patients were receptive.

New findings from the Mission: Lifeline STEMI Systems Accelerator program suggest that a regionalized approach to ST-segment elevation myocardial infarctions (STEMI) can cut time-to-treatment for patients modestly, thereby improving the prospects for better outcomes. The approach encourages hospitals, emergency medical services (EMS) and cardiologists in a region to work together to optimize treatment and efficiency so that patients in need of percutaneous coronary intervention (PCI) receive this care more expeditiously. The research included 484 hospitals, 1,253 EMS agencies, and nearly 24,000 patients in 16 regions across the United States. The goal was to increase the number of STEMI patients who receive PCI bed time parameters. Overall, the percentage of STEMI patients receiving PCI in accordance with guidelines improved from 50% to 55% during the study period. Key to the Mission: Lifeline approach is a focus on starting the clock ticking on time-to-treatment at first medical contact (FMC) as opposed to the hospital door, but this requires coordination with EMS and other hospitals. Some observers question whether a push for regionalization is worth the effort, considering the modest results thus far.

With President Trump and congressional Republicans promising to repeal or replace parts of the entirety of the Affordable Care Act (ACA), emergency medicine stakeholders are making sure lawmakers know what provisions in the law must remain intact, and what new reforms are needed. They also are urging emergency medicine clinicians to stay informed on the issues, and to advocate for their interests. The American College of Emergency Physicians (ACEP) wants to ensure that emergency services remain essential covered benefits, and that freestanding EDs and other emerging healthcare delivery models are supported. Although ACEP calls on lawmakers to preserve Medicaid, Medicare, and the Children's Health Insurance Program, the organization is less than satisfied with the insurance products offered on the ACA exchanges. The organization wants lawmakers to address both the affordability and transparency of coverage options. The Emergency Nurses Association calls for an expanded role for advanced practice registered nurses in both primary and emergency care, and it wants more action to improve access to mental healthcare services.

Investigators have applied epidemiological principles to the study of workplace violence, producing results that offer intriguing information to hospitals struggling for a way forward on this issue. In a randomized, to hospitals struggling for a wary forward on this issue. In a randomized, controlled trial, the researchers found that a one-time, unit-based intervention can reduce the incidence of violent events, and that the approach offers some lasting effect over time. The intervention consisted of a 45-minute discussion with unit supervisors in which unit-specific data regarding violent incidents in their workplace were shared along with an array of improvement strategies. Unit supervisors then were directed to work with their teams to develop action plans to address violence, although they were free to adopt whatever solutions they deemed best. At six moths post-intervention, there was a clear reduction in the incident rate ratios of violent events on the intervention units as compared with control units that did not conduct an intervention. Experts note that the study demonstrates that an effective workplace violence intervention or program must be data-driven and based on principles of continuous quality improvement.

With influenza season intensifying, many EDs report strong surges in flu related volume. Although illness severity does not appear to be atypical, hospitals that see high numbers of older patients and the chronically ill face extra challenges meeting the needs of patients who have added susceptibility to flu-related complications. Experts note that all flu strains circulating this year appear to be sensitive to antiviral medications. In mid-February, the CDC reported the number of flu cases was still on the increase in most regions of the country, with 28 states reporting a high incidence of influenza-like illness. Hospitals in Portland, OR, have instituted "zone management" multiple times -- a process whereby ambulances are supervised closely and redirected so that individual hospitals do not become overwhelmed. EDs in both Pennsylvania and Missouri report that flu-related volume is much higher this year than in 2016. The vast majority of flu cases this year involve influenza A (H3N2), although the CDC notes that influenza B viruses also are circulating.

Although there is solid evidence to support how patients presenting with migraine headaches should be treated in the ED, studies show there is wide variation in the care that these patients receive. To reduce this variation, experts have unveiled guidelines based on a review of 68 randomized, controlled trials that looked at 28 injectable migraine medications. Investigators did not present any A-level, or "must offer," recommendations, but four medications received B-level, or "should offer," recommendations. The authors advised that intravenous metoclopramide and prochlorperazine, as well as subcutaneous sumatriptan, should be offered as a first-line treatment to adults who present to the ED with an acute migraine. Investigators also advised that dexamethasone should be offered to these patients to prevent their acute headache from recurring over the short term. Researchers noted that injectable morphine and hydromorphone should be avoided as a first-line therapy.