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Department of Emergency Medicine

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https://hdl.handle.net/1813/116681

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    Current Emergency Medical Services Systems Approaches to Refusal of Assessment, Treatment, or Transport: Examination of Statewide Protocols
    Barghout, R.; Lachs, J.; Haussner, W.; Hancock, D.; Elman, A.; Benton, E.; Kupas, D.; Strony, R.; Rowe, D.; Henkel, C.; White, B.; Banner, P.; Lachs, M.; Rosen, T. (Taylor and Francis, 2025-08-06)
    OBJECTIVES: Many emergency medical services (EMS) 9-1-1 activations result in patients declining evaluation, treatment, or transport to the emergency department (ED). Assessment of a patient's decision-making capacity to refuse and taking appropriate actions based on that are critical elements of EMS practice. However, EMS clinician approaches in this area are under-studied, and variation may exist. As EMS practice is highly protocolized, our goal was to examine all publicly available United States (U.S.) state protocols and describe their guidance around refusals. METHODS: We used a structured, multi-step content analysis and published expert recommendations on managing refusal of care in health care settings to identify 35 specific elements within five domains of prehospital refusal management: decision-making capacity assessment, risk assessment, persuasion, escalation to medical oversight, and documentation. We systematically and comprehensively reviewed 34 state protocols and a U.S. national protocol for the presence of these elements. RESULTS: Among 34 state protocols examined, 24% (8) had no guidance on refusal, with 18% (6) including at least some guidance in all domains. Among states with any guidance on refusal, we found a median of 15, a mean of 15, and a range of 5-25 elements included. Three states (9%) discussed all four components of decision-making capacity. Seven (21%) emphasized assessing risk of a severe medical emergency when considering refusal. Guidance on persuasion for high-risk patients was included in 13 (38%). Escalation to direct medical oversight was present in 20 (59%). Only 21 (62%) of protocols provided specific documentation guidelines. Notably, guidance was identified in state protocols that is inconsistent with expert recommendations for management of refusal in the ED. Checklists were included in 4 (12%). CONCLUSIONS: Substantial variability exists among state protocols regarding patient refusal guidance. Few protocols address high-risk patients, provide strategies for persuasion, or include checklists for proper management. Standardizing and expanding protocols may enhance EMS care.
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    Leadership Perceptions, Educational Struggles and Barriers, and Effective Modalities for Teaching Vertigo and the HINTS Exam: A National Survey of Emergency Medicine Residency Program Directors.
    McLean, M.; Stowens, J.; Barnicle, R.; Mafi, N.; Shah, K. (eScholarship, 1/1/25)
    INTRODUCTION: The utility of the three-part bedside oculomotor exam HINTS (head impulse test, nystagmus, test of skew) in the hands of emergency physicians remains under debate despite being supported by the most recent literature. Educators historically lack consensus on how specifically to teach this skill to emergency medicine (EM) residents, and it is unknown whether and how EM residency programs have begun to implement HINTS training into their curricula. We aimed to characterize the state of HINTS education in EM residency and develop a needs assessment. METHODS: In this cross-sectional study, we administered a survey to EM residency directors, the themes of which centered around HINTS education perceptions, practices, resources, and needs. We analyzed Likert scales with means and 95% confidence intervals for normally distributed data, and with medians and interquartile ranges for non-normally distributed data. Frequency distributions, means, and standard deviations were used in all other analyses. RESULTS: Of 250 eligible participants, 201 (80.4%) responded and consented. Of the 192 respondents providing usable data, 149/191 (78.0%) believed the HINTS exam is valuable to teach; 124/192 (64.6%) reported HINTS educational offerings in conference; and 148/192 (77.1%) reported clinical bedside teaching by faculty. The most-effective educational modalities were clinical bedside teaching, online videos, and simulation. Subtopic teaching struggles with regard to HINTS were head impulse test and test-of-skew conduction and interpretation, selection of the correct patients, and overall HINTS interpretation. Teaching barriers centered around lack of faculty expertise, concern for poor HINTS reproducibility, and lack of resources. Leadership would dedicate a mean of 2.0 hours/year (SD 1.3 hours/year) to implementing a formal, standardized HINTS curriculum. CONCLUSION: Despite controversy surrounding the utility of the HINTS exam in EM, most residency directors believe it is important to teach. This needs assessment can guide development of formal educational and simulation curricula focusing on residency directors' cited HINTS exam educational struggles, barriers, and reported most-effective teaching modalities.
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    Long-Term Trajectories of Older Adults Served by an Emergency Department/Hospital-Based Elder Mistreatment Response Program.
    Baek, D.; Gottesman, E.; Makaroun, L. K.; Elman, A.; Stern, M. E.; Shaw, A.; Mulcare, M. R.; McAuley, J.; LoFaso, V. M.; Itzkowitz, J.; Chang, E. S.; Hancock, D.; Bloemen, E. M.; Lindberg, D. M.; Sharma, R.; Lachs, M. S.; Pillemer, K.; Rosen, T. (1/7/25)
    BACKGROUND: An emergency department (ED) visit or hospitalization provides an opportunity to identify elder mistreatment and initiate intervention, but this seldom occurs. To address this, we developed the Vulnerable Elder Protection Team (VEPT), a novel interdisciplinary consultation service. We explored the long-term trajectories of patients receiving VEPT evaluation and intervention. METHODS: We followed up at multiple intervals for 12 months older adults seen by VEPT from 9/1/2020-3/27/2023 with high or moderate concern for mistreatment who were discharged to the community, an elder abuse shelter, or rehabilitation facilities. We collected information through telephone calls to the older adult and others involved. We also analyzed separately cases in which the patient re-presented to the ED/hospital with VEPT consultation during the follow-up period. RESULTS: A total of 157 older adults met criteria for follow-up, and 30 of these (16.4%) died within 12 months. At 1 month, elder mistreatment was no longer occurring in 47.5% and still occurring but reduced in 20.3%, with 29.7% having no contact with the perpetrator and 17.8% having reduced contact. At 12 months, elder mistreatment was no longer occurring in 60.9% and still occurring but reduced in 14.5%, with 34.8% having no contact with the perpetrator and 17.4% having reduced contact. During the 12-month follow-up period, 16 (10.2%) patients re-presented to the ED with VEPT consultation, with 12 having persistent concern for ongoing elder mistreatment. Reasons included older adults/caregivers not accepting intervention or being willing to separate as well as VEPT reliance on community-based agencies and programs after discharge. CONCLUSIONS: We observed improved post-discharge safety for elder mistreatment victims who engaged with the VEPT program, with this increased safety durable over 1 year. Re-presentations highlighted the complexity of elder mistreatment intervention. Overall, these findings demonstrate the potential value of an ED/hospital-based elder mistreatment response team, a promising new geriatric care model.