A Dose of Delay: Emergency Department Boarding and Early Clinical Deterioration

Annals of Emergency Medicine · 2026-05-20

Clinical Features, <scp>CT</scp> Imaging Decisions and Yield by Age in Adults With Abdominal Pain in the Emergency Department

Academic Emergency Medicine · 2026-05-01

OBJECTIVES: Older adults with abdominal pain present diagnostic uncertainty due to less informative histories/exams, broader etiologies, and higher morbidity. Whether ED imaging decisions are calibrated to this risk is unclear. The objective of this study was to compare age-stratified clinical features, CT utilization, and CT diagnostic yield, and to assess how history/physical and clinician pretest suspicion relate to adverse outcomes. METHODS: This was a retrospective cohort analysis of data from a prospective cohort collected from March 2016-January 2017 at a single community teaching hospital emergency department in southwest Baltimore. We analyzed 1169 visits of adults presenting with nontraumatic abdominal pain including 229 (19.6%) aged ≥ 60 years. Patients < 18 years were excluded. Age groups were 18-39, 40-59, ≥ 60 years. Outcomes were CT ordering, acute actionable CT findings, admission, surgery, and a composite of adverse outcomes (any actionable CT finding, admission, surgery, or Emergency General Surgical diagnosis). History and physical examination operating characteristics (e.g., sensitivity/specificity of tenderness, rebound) were also calculated. RESULTS: Of 1169 visits, 19.6% were aged ≥ 60 years. CT ordering increased with age (41.7%, 66.2%, 70.7% for 18-39, 40-59, ≥ 60; p < 0.001), as did CT yield (18.4%, 31.2%, 37.7%; p < 0.001). Admissions (12.1%, 28.0%, 37.6%) and surgeries (4.6%, 9.0%, 10.6%) also rose with age. Clinician pretest suspicion was similar across age groups. Abdominal tenderness was less sensitive for adverse outcomes in older adults (sensitivity 0.58 in ≥ 60 vs. 0.73 in 18-39 and 0.73 in 40-59), while rebound tenderness was highly specific across ages (specificity 0.98, 0.96, 0.98). The number of potential diagnoses to consider rose with age. CONCLUSION: In this cohort, CT use and positivity increased with age and key exam findings (e.g., tenderness) being less informative in older adults, despite similar reported clinician pretest suspicion. These results support age-aware imaging decisions and motivate reframing ED abdominal pain as a geriatric-specific chief complaint.

Trends in Urgent Care Utilization Among Medicare Beneficiaries From 2012 to 2019

JAMA Network Open · 2026-01-26

Importance: Urgent care (UC) centers have proliferated rapidly, yet research on how utilization has changed among older adults is limited. Objectives: To examine UC utilization among older adults and assess whether utilization rates varied by beneficiary sociodemographic and community characteristics. Design, Setting, and Participants: This cross-sectional study used data from a 20% national sample of fee-for-service Medicare beneficiaries aged 65 years or older using UC centers from January 1, 2012, to December 31, 2019. Statistical analysis was performed from May 1, 2021, to November 24, 2025. Main Outcome and Measures: Among Medicare beneficiaries aged 65 years or older, unadjusted UC visits were calculated by year from 2012 to 2019 overall and stratified by demographic characteristics, frailty, community rurality, Social Deprivation Index (SDI), and physician supply. Adjusted incidence rate ratios (IRRs) were calculated for UC visits in 2018 and 2019 using negative binomial models. Trends in the distribution of UC visits among the most frequent clinician specialty categories (primary care, emergency medicine, and advanced practice practitioners [APPs]) were examined using linear models. Results: There were 3 516 816 UC visits among 9 514 946 beneficiaries (mean [SD] age across visits, 75.2 [7.5] years; 63.4% women). UC visits increased from 47.7 to 117.2 per 1000 from 2012 to 2019 (9.0 [95% CI, 9.0-9.1] visits per 1000 per year). The growth in UC utilization was slowest for beneficiaries aged 85 years or older (4.0 [95% CI, 3.8-4.1] visits per 1000 per year), Medicaid-eligible beneficiaries (4.0 [95% CI, 3.9-4.2] visits per 1000 per year), those residing in communities that were rural (5.0 [95% CI, 4.8-5.2] visits per 1000 per year), thow who were disadvantaged (6.8 [95% CI, 6.0-7.6] visits per 1000 per year), and those with fewer physicians (7.2 [95% CI, 5.5-8.8] visits per 1000 per year). In 2018 and 2019, beneficiaries residing in rural communities had 45% lower adjusted UC utilization compared with urban communities (IRR, 0.55 [95% CI, 0.54-0.55]) and those residing in zip codes in the SDI fourth quartile had 23% lower adjusted UC utilization (IRR, 0.77 [95% CI, 0.77-0.78]) compared with those in the most advantaged quartile. The percentage of beneficiaries managed by APPs increased from 21.0% in 2012 to 50.8% in 2019. Conclusions and Relevance: In this cross-sectional analysis, UC utilization increased markedly among older adults, with a disproportionate concentration in urban, less-disadvantaged communities. The distribution of clinician training and specialty also changed, with APPs delivering care for more than half of UC visits among older adults in 2019. These findings highlight the evolving patterns of acute care delivery for this growing population and the need for additional evidence on how these trends are associated with patient-centered outcomes and the efficiency of care.

Inside CORE Talks: The New Forum Shaping Emergency Medicine Policy Thinking

Emergency Medicine News · 2026-04-01

Triage, the Tip of the Shears

JAMA Network Open · 2025-05-02

Access to Unscheduled Care Across the Continental United States: Primary Care Clinics, Retail Clinics, Urgent Care Clinics, and Emergency Departments

Figshare · 2025-01-01

We sought to examine the effect of retail (RC) and urgent care clinics (UCC) on patient access to unscheduled care, compared to primary care clinics and emergency departments. We used secondary data from 2009-2012. National censuses of clinic locations were assembled from publicly-available sources, purchased from SK&amp;A, and requested from the Urgent Care Association of America. The U.S. Census and Area Health Resources Files provided area demographic, socioeconomic, and health system covariates. Negative binomial regression established the adjusted relationship between clinic counts by county, income, and uninsurance. Simulation methods were used to assess population access by distance. All clinic types were more likely to locate in more affluent, more densely-populated counties. Conditional on income, RCs and UCCs are more likely to locate in areas of higher uninsurance. The contribution of new clinics to disparities in patient access depends on the dimension of access and type of disparity being investigated.

<scp>NOTICE</scp> ‐ <scp>ED</scp> : Nurse or Technician Insights Into Cognitive Evaluations in the Emergency Department

Journal of the American Geriatrics Society · 2025-06-14

BACKGROUND: Several strategies have been proposed to increase chronic cognitive impairment (CI) screening in the emergency department (ED). Our goal was to assess the feasibility and acceptability of implementing specific CI screening tools and strategies in the ED from an ED registered nurse and technician perspective. METHODS: We performed a qualitative study using semi-structured interviews with a purposive sample of ED nurses and ED technicians (EDTs). Participants worked at an urban academic hospital and were interviewed between November 2023 and March 2024. Interviews assessed participants' opinions on the feasibility and acceptability of CI screening and the use of machine learning (ML) tools to identify high-risk patients for targeted CI screening, tablet-based screenings, and two validated CI screenings: the Ottawa 3DY (O3DY) and Short Blessed Test (SBT). We used the Consolidated Framework for Implementation Research (CFIR) to develop our interview guide and performed a rapid analysis with deductive and inductive codes based on CFIR constructs. RESULTS: Four major themes related to CI screening tools arose: (1) Benefits of CI screening; (2) feasibility of integrating screening tools into existing workflows; (3) professional role limitations; and (4) implementation requirements. Participants perceived CI screening as important for allocating limited ED resources. Shorter, less specific testing, including the O3DY, was seen as feasible during triage, while longer, more specific screening, including the SBT, was seen as more feasible in roomed care areas. Both ED nurses and EDTs identified the need for electronic health record tools and dedicated screening teams to facilitate implementation. CONCLUSION: ED nurses and EDTs support chronic CI screening if screening techniques and clinical teams can be optimized to make workflows feasible.

Electronic Health Record Tools for the Detection, Management, and Monitoring of Delirium in Emergency Departments: Examples from Five Healthcare Systems

Delirium · 2025-08-08 · 1 citations

Background Delirium is a state of acute brain failure causing confusion, reduced focus, and changes in alertness. It is common in older patients, occurring in 6-38% of older emergency department (ED) patients. Evidence suggests that systematic screening improves detection rates and early detection, management and reporting are critical. However, examples of operationalizing this in clinical non-research care are scarce. Objective To describe and disseminate examples of best practices for delirium screening, management, and monitoring within the ED. Methods A group of emergency physicians interested in geriatric emergency medicine (GEM) and evidence-based medicine gathered monthly to discuss ways of implementing delirium care. Members were asked to submit any electronic health record (EHR)-based interventions for delirium in current use at their institutions. One group member categorized the EHR tools by their use for screening, prevention, management, and monitoring of delirium. As a group, categorizations were reviewed and agreed upon and similarities, differences and themes were identified. Results Current EHR interventions from 5 EDs were included. We found that: 1) Screening for delirium in EDs is challenging due to the nature of the environment and the variety of tools available. 2) Prevention tools included order sets. 3) Management was accomplished with best practice alerts and order sets to help screen, prevent, address underlying causes, and manage agitation. Delirium prevention order sets emphasize optimizing patient mobility, comfort, and communication. Assessment order sets include routine labs and consultations, while management order sets for agitation provide safe medication options considering older adults’ unique physiology. 4) Utilizing dashboards for compliance monitoring offers real-time feedback, and provides an overview of adherence to clinical guidelines, regulatory standards, and patient safety protocols. Conclusion These real-world examples can be used in EDs implementing delirium programs. Further studies on how EHR interventions impact screening, diagnosis, and treatment of delirium in the ED are needed.

Waiting room and hallway care for older adults: a qualitative study with emergency nurses and technicians

BMC Geriatrics · 2025-11-26 · 1 citations

BACKGROUND: Emergency Department (ED) crowding places older ED patients at risk for adverse outcomes. Crowding often necessitates ED waiting room and hallway care, but there has been limited research on approaches to care for older adults in these settings. Frontline clinician insights can inform best practices for older adults in the context of the ongoing ED crowding crisis. Our objective was to describe the experiences of emergency nurses and technicians in providing waiting room and hallway care for older adults. METHODS: This qualitative study used individual, semi-structured interviews with a purposive sample of 20 ED nurses and technicians at a single urban, academic trauma center. Interviews took place between November 2023 and March 2024 and focused on challenges faced in triage and when providing care in the ED waiting room / hallways. We analyzed interview transcripts through thematic analysis with a deductive and inductive coding approach. RESULTS: Four major themes related to hallway and waiting room care for older adults emerged: (1) Unique safety concerns for older adults; (2) Limitations to person-centered care; (3) Needed resources; and (4) Adaptations to systemic dysfunction. Participants describe that dedicated waiting room staff, separate spaces for older adults, and rooming protocols that incorporate geriatric syndromes would likely enhance patient safety. CONCLUSIONS: Resource constraints restrict ED clinicians from ensuring safe, high-quality waiting room and hallway care for older adults. Systems-based solutions to improve care for older adults in these settings include transparency and reporting around hospital crowding, safe clinician staffing levels, and investment in dedicated ED spaces for older adults.

Images in Black and White: Disparities in Utilization of Computed Tomography and Ultrasound for Older Adults with Abdominal Pain

Western Journal of Emergency Medicine · 2025-02-28

INTRODUCTION: Abdominal pain is the leading emergency department (ED) chief complaint in older (≥65 years of age) adults, accounting for 1.4 million ED visits annually. Ultrasound and computed tomography (CT) are high-yield tests that offer rapid and accurate diagnosis for the most clinically significant causes of abdominal pain. In this study we used nationally representative data to examine racial/ethnic differences in cross-sectional imaging for older adults presenting to the ED with abdominal pain. METHODS: We performed a retrospective, cross-sectional analysis using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to assess differences in the rate of imaging between White and Black older adults presenting to the ED for abdominal pain. Our primary outcome was the receipt of abdominal CT and/or ultrasound imaging. RESULTS: Across 1,656 older adult ED visits for abdominal pain, White patients were 26.8% (relatively, 14.2% absolute) more likely to receive abdominal CT and/or ultrasound than Black patients: 802 of 1,197 (67.0%) White patients were 26.8% (relatively, 14.2% absolute) more likely to receive abdominal computed tomography and/ or ultrasound than Black patients (P=0.01). CONCLUSION: This study revealed that Black older adults presenting to the ED with abdominal pain receive significantly lower levels of cross-sectional imaging (CT/ultrasound) than White patients. Our findings highlight the need for further investigations into causes of disparities while initiating quality improvement processes to assess and address site- and clinician-specific patterns of care.