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Emergency department provider perspectives on elder abuse and development of a novel ED-based multidisciplinary intervention team.

ABSTRACT: BACKGROUND:An ED visit provides a unique opportunity to identify elder abuse, which is common and has serious medical consequences. Despite this, emergency providers rarely recognise or report it. We have begun the design of an ED-based multidisciplinary consultation service to improve identification and provide comprehensive medical and forensic assessment and treatment for potential victims. METHODS:We qualitatively explored provider perspectives to inform intervention development. We conducted 15 semistructured focus groups with 101 providers, including emergency physicians, social workers, nurses, technologists, security, radiologists and psychiatrists at a large, urban academic medical centre. Focus groups were transcribed, and data were analysed to identify themes. RESULTS:Providers reported not routinely assessing for elder mistreatment and believed that they commonly missed it. They reported 10 reasons for this, including lack of knowledge or training, no time to conduct an evaluation, concern that identifying elder abuse would lead to additional work, and absence of a standardised response. Providers believed an ED-based consultation service would be frequently used and would increase identification, improve care and help ensure safety. They made 21 recommendations for a multidisciplinary team, including the importance of 24/7 availability, the value of a positive attitude in a consulting service and the importance of feedback to referring ED providers. Participants also highlighted that geriatric nurse practitioners may have ideal clinical and personal care training to contribute to the team. CONCLUSIONS:An ED-based multidisciplinary consultation service has potential to impact care for elder abuse victims. Insights from providers will inform intervention development.

SUBMITTER: Rosen T

PROVIDER: S-EPMC6589031 | biostudies-literature | 2018 Oct

REPOSITORIES: biostudies-literature

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Emergency department provider perspectives on elder abuse and development of a novel ED-based multidisciplinary intervention team.

Rosen Tony T Stern Michael E ME Mulcare Mary R MR Elman Alyssa A McCarthy Thomas J TJ LoFaso Veronica M VM Bloemen Elizabeth M EM Clark Sunday S Sharma Rahul R Breckman Risa R Lachs Mark S MS

Emergency medicine journal : EMJ 20180809 10

<h4>Background</h4>An ED visit provides a unique opportunity to identify elder abuse, which is common and has serious medical consequences. Despite this, emergency providers rarely recognise or report it. We have begun the design of an ED-based multidisciplinary consultation service to improve identification and provide comprehensive medical and forensic assessment and treatment for potential victims.<h4>Methods</h4>We qualitatively explored provider perspectives to inform intervention developme ...[more]

PMID: 30093378

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Project description:BackgroundAn emergency department (ED) visit provides a unique opportunity to identify elder abuse and initiate intervention, but emergency providers rarely do. To address this, we developed the Vulnerable Elder Protection Team (VEPT), an ED-based interdisciplinary consultation service. We describe our initial experience in the first two years after the program launch.MethodsWe launched VEPT in a large, urban, academic ED/hospital. From 4/3/17 to 4/2/19, we tracked VEPT activations, including patient characteristics, assessment, and interventions. We compared VEPT activations to frequency of elder abuse identification in the ED before VEPT launch. We examined outcomes for patients evaluated by VEPT, including change in living situation at discharge. We assessed ED providers' experiences with VEPT via written surveys and focus groups.ResultsDuring the program's initial two years, VEPT was activated and provided consultation/care to 200 ED patients. Cases included physical abuse (59%), neglect (56%), financial exploitation (32%), verbal/emotional/psychological abuse (25%), and sexual abuse (2%). Sixty-two percent of patients assessed were determined by VEPT to have high or moderate suspicion for elder abuse. Seventy-five percent of these patients had a change in living/housing situation or were discharged with new or additional home services, with 14% discharged to an elder abuse shelter, 39% to a different living/housing situation, and 22% with new or additional home services. ED providers reported that VEPT made them more likely to consider/assess for elder abuse and recognized the value of the expertise and guidance VEPT provided. Ninety-four percent reported believing that there is merit in establishing a VEPT Program in other EDs.ConclusionVEPT was frequently activated and many patients were discharged with changes in living situation and/or additional home services, which may improve safety. Future research is needed to examine longer-term outcomes.

Project description:OBJECTIVES:To characterize assessments of a patient's ability to report elder abuse within the context of an emergency department (ED)-based screen for elder abuse. DESIGN:Cross-sectional study in which participants were screened for elder abuse and neglect. SETTING:Academic ED in the United States. PARTICIPANTS:Patients, aged 65 years and older, presenting to an ED for acute care were assessed by trained research assistants or nurses. MEASUREMENTS:All patients completed the four-item Abbreviated Mental Test 4 (AMT4), then completed a safety interview (using the Emergency Department Senior Abuse Identification tool) designed to detect multiple domains of elder abuse and received a physical examination. Based on the cognitive assessment and safety interview, assessors ranked their confidence in the patient's ability to report abuse as absolutely confident, confident, somewhat confident, or not confident. To assess interrater reliability, two assessors independently rated confidence for a subset of patients. RESULTS:Assessors suspected elder abuse in 18 of 276 patients (6.5%). Assessors were absolutely confident in the patient's ability to report abuse for 95.7% of patients, confident for 2.5%, somewhat confident for 1.5%, and not confident for 0.3%. Among patients with an AMT4 of 4 (n = 249), assessors were confident or absolutely confident in 100% of patients. Among patients with an AMT4 of less than 4 (n = 27), they were confident or absolutely confident in the patient's ability to report abuse for 81% of patients, including 11 of 12 patients with mild cognitive impairment and 7 of 11 patients with severe cognitive impairment. For patients receiving paired evaluations (n = 131), agreement between assessors regarding patient ability to report abuse was 97% (κ = 0.5). CONCLUSIONS:In this sample of older adults receiving care in an ED, research assistants and nurses felt that the vast majority were able to report elder abuse, including many patients with cognitive impairment. J Am Geriatr Soc 68:170-175, 2019.

Project description:OBJECTIVE:Benzodiazepines and opioids are prescribed simultaneously (i.e., "coprescribed") in many clinical settings, despite guidelines advising against this practice and mounting evidence that concomitant use of both medications increases overdose risk. This study sought to characterize the contexts in which benzodiazepine-opioid coprescribing occurs and providers' reasons for coprescribing. METHODS:We conducted focus groups with emergency department (ED) providers (resident and attending physicians, advanced practice providers, and pharmacists) from three hospitals using semistructured interviews to elicit perspectives on benzodiazepine-opioid coprescribing. Discussions were audio-recorded and transcribed. We performed qualitative content analysis of the resulting transcripts using a consensual qualitative research approach, aiming to identify priority categories that describe the phenomenon of benzodiazepine-opioid coprescribing. RESULTS:Participants acknowledged coprescribing rarely and reluctantly and often provided specific discharge instructions when coprescribing. The decision to coprescribe is multifactorial, often isolated to specific clinical and situational contexts (e.g., low back pain, failed solitary opioid therapy) and strongly influenced by a provider's beliefs about the efficacy of combination therapy. The decision to coprescribe is further influenced by a self-imposed pressure to escalate care or avoid hospital admission. When considering potential interventions to reduce the incidence of coprescribing, participants opposed computerized alerts but were supportive of a pharmacist-assisted intervention. Many providers found the process of participating in peer discussions on prescribing habits to be beneficial. CONCLUSIONS:In this qualitative study of ED providers, we found that benzodiazepine-opioid coprescribing occurs in specific clinical and situational contexts, such as the treatment of low back pain or failed solitary opioid therapy. The decision to coprescribe is strongly influenced by a provider's beliefs and by self-imposed pressure to escalate care or avoid admission.

Project description:BackgroundElder abuse is a worldwide problem with serious consequences for individuals and society. To effectively deal with elder abuse, a timely identification of signals as well as a systematic approach towards (suspected) elder abuse is necessary. This study aimed to develop and test the acceptability and appropriateness of ERASE (EldeR AbuSE) in the emergency department (ED) setting. ERASE is an early warning tool for elder abuse self-administered by the healthcare professional in patients ≥ 70 years.MethodsA systematic literature review was previously conducted to identify potential available instruments on elder abuse for use in the ED. Furthermore, a field consultation in Dutch hospitals was performed to identify practice tools and potential questions on the recognition of elder abuse that were available in clinical practice. Based on this input, in three subsequent rounds the ERASE tool was developed. The ERASE tool was tested in a pilot feasibility study in healthcare professionals (n = 28) working in the ED in three Dutch hospitals. A semi-structured online questionnaire was used to determine acceptability and appropriateness of the ERASE tool.ResultsThe systematic literature review revealed seven screening instruments developed for use in the hospital and/or ED setting. In total n = 32 (44%) hospitals responded to the field search. No suitable and validated instruments for the detection of elder abuse in the ED were identified. The ERASE tool was developed, with a gut feeling awareness question, that encompassed all forms of elder abuse as starting question. Subsequently six signalling questions were developed to collect information on observed signs and symptoms of elder abuse and neglect. The pilot study showed that the ERASE tool raised the recognition of healthcare professionals for elder abuse. The tool was evaluated acceptable and appropriate for use in the ED setting.ConclusionsERASE as early warning tool is guided by an initial gut feeling awareness question and six signalling questions. The ERASE tool raised the recognition of healthcare professionals for elder abuse, and was feasible to use in the ED setting. The next step will be to investigate the reliability and validity of the ERASE early warning tool.

Project description:BackgroundAlcohol use disorder (AUD) is ubiquitous and its sequelae contribute to high levels of healthcare utilization, yet AUD remains undertreated. The ED encounter represents a missed opportunity to initiate medication assisted treatment (MAT) for patients with AUD. The aims of this study are to identify barriers and facilitators to the treatment of AUD in the ED, and to design interventions to address identified barriers.MethodsUsing an implementation science approach based on the Behavior Change Wheel framework, we conducted qualitative interviews with staff to interrogate their perspectives on ED initiation of AUD treatment. Subjects included physicians, nurses, nurse practitioners, clinical social workers, and pharmacists. Interviews were thematically coded using both inductive and deductive approaches and constant comparative analysis. Themes were further categorized as relating to providers' capabilities, opportunities, or motivations. Barriers were then mapped to corresponding intervention functions.ResultsFacilitators at our institution included time allotted for continuing education, the availability of clinical social workers, and favorable opinions of MAT based on previous experiences implementing buprenorphine for opioid use disorder. Capability barriers included limited familiarity with naltrexone and difficulty determining which patients are candidates for therapy. Opportunity barriers included the limited supply of naltrexone and a lack of clarity as to who should introduce naltrexone and assess readiness for change. Motivation barriers included a sense of futility in treating patients with AUD and stigmas associated with alcohol use. Evidence-based interventions included multi-modal provider education, a standardized treatment algorithm and order set, selection of clinical champions, and clarification of roles among providers on the team.ConclusionsA large evidence-practice gap exists for the treatment of AUD with Naltrexone, and the ED visit is a missed opportunity for intervention. ED providers are optimistic about implementing AUD treatment in the ED but described many barriers, especially related to knowledge, clarification of roles, and stigma associated with AUD. Applying a formal implementation science approach guided by the Behavior Change Wheel allowed us to transform qualitative interview data into evidence-based interventions for the implementation of an ED-based program for the treatment of AUD.

Project description:IntroductionOpioid use disorder (OUD) and related comorbid conditions are highly prevalent among patients presenting to emergency department (ED) settings. Research has developed few comprehensive disease management strategies for at-risk patients presenting to the ED that both decrease illicit opioid use and improve initiation and retention in medication treatment for OUD (MOUD).MethodsThe research team conducted a pilot pragmatic clinical trial that randomized 40 patients presenting to a single ED to a collaborative care intervention (n = 20) versus usual care control (n = 20) conditions. Interviewers blinded to patient intervention and control group status followed-up with participants at 1, 3, and 6 months after presentation to the ED. The 3-month Emergency Department Longitudinal Integrated Care (ED-LINC) collaborative care intervention for patients at risk for OUD included: 1) a Brief Negotiated Interview at bedside, 2) overdose education and facilitation of MOUD, 3) longitudinal proactive care management, 4) utilization of the statewide health information exchange platform for 24/7 tracking of recurrent ED utilization, and 5) weekly caseload supervision that incorporated measurement-based care treatment assessment with stepped-up care for patients with recalcitrant symptoms.ResultsOverall, the ED-LINC intervention was feasibly delivered and acceptable to patients. The pilot study achieved >80% follow-up rates at 1, 3, and 6 months. In adjusted longitudinal mixed model regression analyses, no statistically significant differences existed in days of opioid use over the past 30 days for ED-LINC intervention patients when compared to patients receiving usual care (incidence-rate ratio (IRR) 1.50, 95% CI 0.54-4.16). The unadjusted mean number of days of illicit opioid use decreased at the 1-month and 3-month follow-up time points for both groups. ED-LINC intervention patients had increased rates of MOUD initiation compared to control patients (50% versus 30%); intervention versus control comparisons did not achieve statistical significance, although power to detect significant differences in the pilot was limited.ConclusionsThe ED-LINC intervention for patients with OUD can be feasibly implemented and warrants testing in larger scale, adequately powered randomized pragmatic clinical trial investigations.Clinicaltrialsgov NCT03699085.

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Emergency department provider perspectives on elder abuse and development of a novel ED-based multidisciplinary intervention team.

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Emergency department provider perspectives on elder abuse and development of a novel ED-based multidisciplinary intervention team.

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