Initial steps in addressing the challenges of elder mistreatment evaluation: Protocol for evaluating the Vulnerable Elder Protection Team.

INTRODUCTION: Although many programmes have been developed to address elder mistreatment, high-quality, rigorous evaluations to assess their impact are lacking. This is partly due to challenges in conducting programme evaluation for such a complex phenomenon. We describe here the development of a protocol to mitigate these challenges and rigorously evaluate a first-of-its-kind emergency department/hospital-based elder mistreatment intervention, the Vulnerable Elder Protection Team (VEPT). METHODS AND ANALYSIS: We used a multistep process to develop an evaluation protocol for VEPT: (1) creation of a logic model to describe programme activities and relevant short-term and long-term outcomes, (2) operationalisation of these outcome measures, (3) development of a combined outcome and (4) design of a protocol using telephone follow-up at multiple time points to obtain information about older adults served by VEPT. This protocol, which is informing an ongoing evaluation of VEPT, may help researchers and health system leaders design evaluations for similar elder mistreatment programmes. ETHICS AND DISSEMINATION: This project has been reviewed and approved by the Weill Cornell Medicine Institutional Review Board, protocol #20-02021422. We aim to disseminate our results in peer-reviewed journals at national and international conferences and among interested patient groups and the public.

Vulnerable Elder Protection Team: Initial experience of an emergency department-based interdisciplinary elder abuse program.

BACKGROUND: An 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. METHODS: We 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. RESULTS: During 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. CONCLUSION: VEPT 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.

Geriatric Burn Injuries Presenting to the Emergency Department of a Major Burn Center: Clinical Characteristics and Outcomes.

BACKGROUND: Burn injuries in geriatric patients are common and may have significant associated morbidity and mortality. Most research has focused on the care of hospitalized patients after admission to burn units. Little is known about the clinical characteristics of geriatric burn victims who present to the emergency department (ED) and their ED assessment and management. OBJECTIVE: Our aim was to describe the clinical characteristics and outcomes of geriatric patients presenting to the ED with burn injuries. METHODS: We performed a comprehensive retrospective chart review on all patients 60 years and older with a burn injury presenting from January 2011 through September 2015 to a large, urban, academic ED in a hospital with a 20-bed burn center. RESULTS: A total of 459 patients 60 years and older were treated for burn injuries during the study period. Median age of burn patients was 71 years, 23.7% were 80 years and older, and 56.6% were female. The most common burn types were hot water scalds (43.6%) and flame burns (23.1%). Median burn size was 3% total body surface area (TBSA), 17.1% had burns > 10% TBSA, and 7.8% of patients had inhalation injuries. After initial evaluation, 46.4% of patients were discharged from the ED. Among patients discharged from the ED, only 1.9% were re-admitted for any reason within 30 days. Of the patients intubated in the ED, 7.1% were extubated during the first 2 days of admission, and 64.3% contracted ventilator-associated pneumonia. CONCLUSIONS: Better understanding of ED care for geriatric burn injuries may identify areas in which to improve emergency care for these vulnerable patients.

Utilizing Telemedicine in a Novel Approach to COVID-19 Management and Patient Experience in the Emergency Department.

Background: The COVID-19 crisis has highlighted telemedicine as a care delivery tool uniquely suited for a disaster pandemic. Introduction: With support from emergency department (ED) leadership, our institution rapidly deployed telemedicine in a novel approach to large-scale ED infectious disease management at NewYork-Presbyterian/Weill Cornell Medical Center (NYP/WCMC) and NewYork-Presbyterian/Lower Manhattan Hospital (NYP/LMH). Materials and Methods: Nineteen telemedicine carts were placed in COVID-19 isolation rooms to conserve personal protective equipment (PPE) and mitigate infectious risk for patients and providers by decreasing in-person exposures. Results: The teleisolation carts were used for 261 COVID-19 patient interactions from March to May 2020, with 79% of overall use in March. Our urban academic site (NYP/WCMC) had 173 of these cases, and the urban community hospital (NYP/LMH) had 88. This initiative increased provider/patient communication and attention to staff safety, improved palliative care and patient support services, lowered PPE consumption, and streamlined clinical workflows. The carts also increased patient comfort and reduced the psychological toll of isolation. Discussion: Deploying customized placement strategies in these two EDs maximized cart availability for isolation patients and demonstrates the utility of telemedicine in various ED settings. Conclusions: The successful introduction of this program in both academic and urban community hospitals suggests that widespread adoption of similar initiatives could improve safe ED evaluation of potentially infectious patients. In the longer term, our experience underscores the critical role of telemedicine in disaster preparedness planning, as building these capabilities in advance allows for the agile scaling needed to manage unforeseen catastrophic scenarios.

Geriatric Emergency Medicine Fellowships: Current State of Specialized Training for Emergency Physicians in Optimizing Care for Older Adults.

Improving emergency department (ED) care for older adults is a critical issue in emergency medicine. Institutions throughout the United States and Canada have recognized the growing need for a workforce of emergency physician (EP) leaders focused on clinical innovation, education, and research and have developed specialized fellowship training in geriatric emergency medicine (GEM). We describe here the overview, structure, and curricula of these fellowships as well as successes and challenges they have encountered. Seven GEM fellowships are active in the United States and Canada, with five offering postresidency training only, one offering fellowship training during residency only, and one offering both. The backbone of the curriculum for all fellowships is the achievement of core competencies in various aspects of GEM, and each includes clinical rotations, teaching, and a research project. Evaluation strategies and feedback have allowed for significant curricular changes as well as customization of the fellowship experience for individual fellows. Key successes include an improved collaborative relationship with geriatrics faculty that has led to additional initiatives and projects and former fellows already becoming regional and national leaders in GEM. The most critical challenges have been ensuring adequate funding and recruiting new fellows each year who are interested in this clinical area. We believe that interest in GEM fellowships will grow and that opportunities exist to combine GEM fellowship training with a focus in research, administration, or health policy to create unique new types of highly impactful specialized training. Future research may include exploring former fellows' postfellowship experiences, careers, accomplishments, and contributions to GEM to better understand the impact of GEM fellowships.

Developing the Emergency Department Elder Mistreatment Assessment Tool for Social Workers Using a Modified Delphi Technique.

Elder mistreatment is common and has serious consequences. The emergency department (ED) may provide a unique opportunity to detect this mistreatment, with social workers often asked to take the lead in assessment and intervention. Despite this, social workers may feel ill-equipped to conduct assessments for potential mistreatment, due in part to a lack of education and training. As a result, the authors created the Emergency Department Elder Mistreatment Assessment Tool for Social Workers (ED-EMATS) using a multiphase, modified Delphi technique with a national group of experts. This tool consists of both an initial and comprehensive component, with 11 and 17 items, respectively. To our knowledge, this represents the first elder abuse assessment tool for social workers designed specifically for use in the ED. The hope is that the ED-EMATS will increase the confidence of ED social workers in assessing for elder mistreatment and help ensure standardization between professionals.

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

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.

Identifying and Initiating Intervention for Elder Abuse and Neglect in the Emergency Department.

Elder abuse and neglect are common and may have serious medical and social consequences but are infrequently identified. An emergency department (ED) visit represents a unique but usually missed opportunity to identify potential abuse and initiate intervention. ED assessment should include observation of patient-caregiver interaction, comprehensive medical history, and head-to-toe physical examination. Formal screening protocols may also be useful. ED providers concerned about elder abuse or neglect should document their findings in detail. ED interventions for suspected or confirmed elder abuse or neglect include treatment of acute medical, traumatic, and psychological issues; ensuring patient safety; and reporting to the authorities.

Improving Quality of Care in Hospitals for Victims of Elder Mistreatment: Development of the Vulnerable Elder Protection Team.

PROBLEM DEFINITION: Hospitals have an opportunity to improve the quality of care provided to a particularly vulnerable population: victims of elder mistreatment. Despite this, no programs to prevent or stop elder abuse in the acute care hospital have been reported. An innovative, multidisciplinary emergency department (ED)-based intervention for elder abuse victims, the Vulnerable Elder Protection Team (VEPT), was developed at NewYork-Presbyterian / Weill Cornell Medical Center (New York City). APPROACH: The VEPT is a consultation service available 24 hours a day/7 days a week to improve identification, comprehensive assessment, and treatment for potential victims of elder abuse or neglect. All ED providers have been trained on how to recognize signs of elder mistreatment. Any provider can activate the VEPT via a single page/telephone call, which triggers the VEPT's often time-consuming, complex assessment of the potential mistreatment victim. First, the ED social worker on duty performs the initial bedside assessment and separately interviews the potential perpetrator and/or caregiver. He or she then contacts the on-call VEPT medical provider to discuss next steps and other team members' potential involvement. For patients admitted to the hospital, the VEPT connects with the inpatient social workers and medical team to ensure appropriate follow-up and care planning. NEXT STEPS/PLANNED EVALUATION: The VEPT program was launched in April 2017 after comprehensive training. Its impact will be measured by tracking the short-term and long-term mistreatment-related outcomes, as well as medical, mental health, functional, psychosocial, and legal outcomes of the vulnerable ED patients for whom the team provides care.

Emergency Medical Services Perspectives on Identifying and Reporting Victims of Elder Abuse, Neglect, and Self-Neglect.

BACKGROUND: Emergency Medical Services (EMS) providers, who perform initial assessments of ill and injured patients, often in a patient's home, are uniquely positioned to identify potential victims of elder abuse, neglect, or self-neglect. Despite this, few organized programs exist to ensure that EMS concerns are communicated to or further investigated by other health care providers, social workers, or the authorities. OBJECTIVE: To explore attitudes and self-reported practices of EMS providers surrounding identification and reporting of elder mistreatment. METHODS: Five semi-structured focus groups with 27 EMS providers. RESULTS: Participants reported believing they frequently encountered and were able to identify potential elder mistreatment victims. Many reported infrequently discussing their concerns with other health care providers or social workers and not reporting them to the authorities due to barriers: 1) lack of EMS protocols or training specific to vulnerable elders; 2) challenges in communication with emergency department providers, including social workers, who are often unavailable or not receptive; 3) time limitations; and 4) lack of follow-up when EMS providers do report concerns. Many participants reported interest in adopting protocols to assist in elder protection. Additional strategies included photographically documenting the home environment, additional training, improved direct communication with social workers, a dedicated location on existing forms or new form to document concerns, a reporting hotline, a system to provide feedback to EMS, and community paramedicine. CONCLUSIONS: EMS providers frequently identify potential victims of elder abuse, neglect, and self-neglect, but significant barriers to reporting exist. Strategies to empower EMS providers and improve reporting were identified.

Geriatric assault victims treated at U.S. trauma centers: Five-year analysis of the national trauma data bank.

INTRODUCTION: While geriatric trauma patients have begun to receive increased attention, little research has investigated assault-related injuries among older adults. Our goal was to describe characteristics, treatment, and outcomes of geriatric assault victims and compare them both to geriatric victims of accidental injury and younger assault victims. PATIENTS AND METHODS: We conducted a retrospective analysis of the 2008-2012 National Trauma Data Bank. We identified cases of assault-related injury admitted to trauma centers in patients aged ≥60 using the variable "intent of injury." RESULTS: 3564 victims of assault-related injury in patients aged ≥60 were identified and compared to 200,194 geriatric accident victims and 94,511 assault victims aged 18-59. Geriatric assault victims were more likely than geriatric accidental injury victims to be male (81% vs. 47%) and were younger than accidental injury victims (67±7 vs. 74±9 years). More geriatric assault victims tested positive for alcohol or drugs than geriatric accident victims (30% vs. 9%). Injuries for geriatric assault victims were more commonly on the face (30%) and head (27%) than for either comparison group. Traumatic brain injury (34%) and penetrating injury (32%) occurred commonly. The median injury severity score (ISS) for geriatric assault victims was 9, with 34% having severe trauma (ISS≥16). Median length of stay was 3 days, 39% required ICU care, and in-hospital mortality was 8%. Injury severity was greater in geriatric than younger adult assault victims, and, even when controlling for injury severity, in-hospital mortality, length of hospitalization, and need for ICU-level care were significantly higher in older adults. CONCLUSIONS: Geriatric assault victims have characteristics and injury patterns that differ significantly from geriatric accidental injury victims. These victims also have more severe injuries, higher mortality, and poorer outcomes than younger victims. Additional research is necessary to improve identification of these victims and inform treatment strategies for this unique population.

Photographing Injuries in the Acute Care Setting: Development and Evaluation of a Standardized Protocol for Research, Forensics, and Clinical Practice.

BACKGROUND: Photographing injuries in the acute setting allows for improved documentation as well as assessment by clinicians and others who have not personally examined a patient. This tool is important, particularly for telemedicine, tracking of wound healing, the evaluation of potential abuse, and injury research. Despite this, protocols to ensure standardization of photography in clinical practice, forensics, or research have not been published. In preparation for a study of injury patterns in elder abuse and geriatric falls, our goal was to develop and evaluate a protocol for standardized photography of injuries that may be broadly applied. METHODS: We conducted a literature review for techniques and standards in medical, forensic, and legal photography. We developed a novel protocol describing types of photographs and body positioning for eight body regions, including instructional diagrams. We revised it iteratively in consultation with experts in medical photography; forensics; and elder, child, and domestic abuse. The resulting protocol requires a minimum of four photos of each injury at multiple distances with and without a ruler/color guide. To evaluate the protocol's efficacy, multiple research assistants without previous photography experience photographed injuries from a convenience sample of elderly patients presenting to a single large, urban, academic emergency department. A selection of these patients' images were then evaluated in a blinded fashion by four nontreating emergency medicine physicians and the inter-rater reliability between these physicians was calculated. RESULTS: Among the 131 injuries, from 53 patients, photographed by 18 photographers using this protocol, photographs of 25 injuries (10 bruises, seven lacerations, and eight abrasions) were used to assess characterization of the injury. Physicians' characterizations of the injuries were reliable for the size of the injury (κ = 0.91, 95% confidence interval [CI] = 0.77 to 1.00), side of the body (κ = 0.97, 95% CI = 0.88 to 1.00), precise location of the injury (κ = 0.74, 95% CI = 0.63 = 0.81), and type of abrasion (κ = 0.76, 95% CI = 0.45 to 1.00). The exact shape of the injury (κ = 0.44, 95% CI = 0.17 to 0.51), and the primary color of bruises (κ = 0.37, 95% CI = 0.25 to 0.48) were not as reliably characterized. CONCLUSIONS: Standardizing the documentation of injuries with photographs for clinical and research assessment can be conducted by nonprofessional photographers. A photography protocol will ensure that this important mechanism for documentation is optimized.

Interrater reliability of emergency physician-performed ultrasonography for diagnosing femoral, popliteal, and great saphenous vein thromboses compared to the criterion standard study by radiology.

PURPOSE: To assess the interrater reliability and test characteristics of lower limb sonographic examination for the diagnosis of deep venous and proximal great saphenous vein thrombosis when performed by Emergency Physicians (EPs) as compared to that by the Department of Radiology (Radiology). The secondary objective was to assess the effects of patient body mass index and EP satisfaction with bedside ultrasound on sensitivity and specificity. METHODS: A prospective study was conducted for patients with clinical suspicion for lower extremity thrombus. EPs evaluated for venous thrombosis in the common femoral vein, femoral vein of the thigh, popliteal vein, and proximal great saphenous vein. Subsequently, all patients received ultrasounds by Radiology, the criterion standard. RESULTS: One hundred ninety-seven patients (257 individual legs) were evaluated. There was 90-95% agreement between EP and Radiology, moderate kappa agreement for common femoral vein, and femoral vein of the thigh and fair kappa agreement for great saphenous vein and popliteal vein. The sensitivity and specificity of EP ultrasounds compared with criterion standard were lower than previously reported. There was no trend in patient body mass index or provider satisfaction influencing the test characteristics. CONCLUSIONS: Our study suggests that point-of-care sonography should not replace Radiology-performed scans. The required amount of training for EPs to be competent in this examination needs further investigation. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:360-367, 2016.

A Novel Clinical Protocol for Placement and Management of Indwelling Urinary Catheters in Older Adults in the Emergency Department.

OBJECTIVES: Indwelling urinary catheters (IUCs) are placed frequently in older adults (age ≥ 65 years) in the emergency department (ED) and carry significant risks. The authors developed, implemented, and assessed a novel clinical protocol to assist ED providers with appropriate indications for placement, reassessment, and removal of IUCs in elders in the ED. METHODS: A comprehensive, evidence-based clinical protocol was built from an extensive literature review and ED provider focus groups. It was implemented at a university-based medical center with a 20-minute scripted slide presentation. Written surveys were administered before, after, and at 6 months to assess providers' baseline practice and the protocol's effects. Surveys included asking providers for IUC management decisions in 25 unique clinical scenarios. Rates of IUC placement and catheter-associated urinary tract infections (CAUTIs) were compared in ED older adult patients admitted to the hospital in the 6 months before and after protocol implementation. RESULTS: A total of 111 ED providers participated in the all three surveys. Immediately after protocol introduction, providers anticipated that this intervention would reduce rates of IUC use and increase patient safety. At 6-month follow-up, 81% felt the protocol had changed their practice, and 39% reported frequently referencing the protocol. In the clinical vignettes, ED providers correctly identified the appropriate approach for IUC placement in 63% of cases at baseline with an increase of 22% (95% confidence interval [CI] = 19% to 25%) postintervention and an increase of 8% (95% CI = 6% to 12%) between baseline and 6 months. An absolute reduction in the use of IUCs of 3.5% (p < 0.001) for older adults admitted to the hospital was observed after implementation of the protocol. There were three CAUTIs attributable to the ED in the 6 months prior to implementation and none in the 6 months after. CONCLUSIONS: This comprehensive, evidence-based clinical protocol was well received by participants and was associated with a sustained change in self-reported practice, as supported by a reduction in IUC placement in admitted older adults and a reduction in CAUTIs attributable to the ED for this vulnerable population over the 6-month study period.

Emergency Department Placement and Management of Indwelling Urinary Catheters in Older Adults: Knowledge, Attitudes, and Practice.

UNLABELLED: Indwelling urinary catheters (IUCs) are placed frequently in older adults in the emergency department (ED). Though often a critical intervention, IUCs carry significant risks. Our objective was to examine current knowledge, attitudes, and practice of emergency nurses and other providers regarding IUC placement and management in older adults. METHODS: We surveyed ED providers at a large, urban, academic medical center. We developed questionnaires using items from previously validated instruments and questions created for this study. We also assessed providers' management of 25 unique clinical scenarios, each representing an established appropriate or inappropriate indication for IUC placement. RESULTS: 129 ED providers participated: 43 nurses and 86 other providers. Ninety-one percent of nurses and 87% of other providers reported comfort with appropriate indications for IUC placement. Despite this, on the clinical vignettes, nurses correctly identified the appropriate approach for IUC placement in only 40% of cases and other providers in only 37%. Practice varied widely between individual providers, with the nurse participants reporting appropriate practice in 16%-64% of clinical scenarios and other providers in 8%-68%. Few nurses or other providers reported reassessing their patients for IUC removal at transfer to the hospital (28% of nurses and 7% of other providers), admission (24% and 14%), or shift change (14% and 8%). DISCUSSION: Although emergency nurses and other providers report comfort with appropriate indications for IUC placement, reported practice patterns showed inconsistencies with established guidelines. Wide practice variation exists between individual providers. Moreover, nurses and other providers infrequently consider IUC removal after placement.

Provider perspectives on the use of indwelling urinary catheters in older adults in emergency department settings: developing a novel clinical protocol.

BACKGROUND: Indwelling urinary catheters (IUCs) are commonly placed in older adult (aged ≥ 65 years) patients in emergency department (ED) settings, often for inappropriate indications. The aim of our qualitative study was to explore ED provider knowledge, attitudes, and practice patterns surrounding use of IUCs in older adult patients in the ED setting, to better guide development of a clinical protocol. METHODS: We conducted 4 focus groups with 38 participants at a large academic medical center. Each focus group was conducted with a single ED provider type: attending physicians, residents, physician assistants, or nurses. Focus groups used a semistructured format, ranging in duration from 23-33 minutes. The sessions were audiorecorded, fully transcribed, and data were coded and analyzed to identify themes. RESULTS: Participants reported believing that IUCs are overutilized in ED settings, confirming that IUCs are infrequently removed once placed and often inserted for staff convenience. Participants reported that current clinical decision making about IUC placement varies widely; yet all acknowledged the known risks for patient safety and willingness to adopt a clinical protocol to standardize practice. Focus groups were a critical component for the development of a user-friendly protocol, identifying 10 key elements for successful implementation and 11 potential barriers. CONCLUSIONS: An evidence-based clinical protocol guiding ED providers in appropriate placement and management of IUCs in older adults would be welcomed.

Improving front-end flow in an urban academic medical center emergency department: the emergency department discharge facilitator team.

Length of stay (LOS) is an important determinant of patient satisfaction and overall emergency department (ED) operational efficiency. In an effort to reduce length of stay for low-acuity "treated and released" patients, our department created a discharge facilitator team (DFT) composed of an attending physician, physician assistant, and registered nurse. The DFT identified patients who could be rapidly treated and released in the low-acuity treatment Adult Urgent Care Center (AUCC) and provided them rapid treatment and discharge. To assess the efficacy of the DFT, linear regression was used to compare AUCC LOS at times the team was and was not active. Patients seen by the DFT had a LOS that was 35 % shorter than other AUCC patients. There was a 28-min reduction in AUCC LOS during periods where the DFT was active (95% CI 22 to 33 min). We conclude that the establishment of a DFT was associated with a significant reduction in LOS for all low-acuity patients. Other academic medical centers may consider implementing a similar program in order to reduce LOS and improve ED throughput for low acuity patients.

Third-year medical student rotations in emergency medicine: a survey of current practices.

OBJECTIVES: Exposure to emergency medicine (EM) is a crucial aspect of medical student education, yet one that is historically absent from third-year medical student training. There are limited data describing the existing third-year rotations. The goal of this study is to identify the content and structure of current EM rotations specific to third-year students. METHODS: An institutional review board-approved survey of clerkship characteristics was designed by consensus opinion of clerkship directors (CDs). The survey was distributed to 32 CDs at institutions with known EM clerkships involving third-year students. RESULTS: Twenty-three (72%) CDs responded to the survey. Sixty-five percent have rotations designed specifically for third-year students, of which 33% are required clerkships. Twenty-seven percent of rotations have prerequisite rotations; 37% of rotations include shifts in the pediatric ED. Clinical time averages four 8-hour shifts per week for 4 weeks; all rotations include weekly didactic time specific to third-year students. A wide variety of textbooks are used; some programs employ simulation labs. Two-thirds of the rotations have a required write-up or presentation; 53% include a final exam. Student evaluations are written and verbal. Most rotations receive more support from the EM departments than from the medical schools for physical space, administrative needs, and faculty time. Among those surveyed, students from institutions requiring a third-year EM rotation have a higher rate of application to EM residencies. CONCLUSIONS: There is variability in the content and structure of existing third-year EM rotations, as well as in financial and administrative needs and support. These data can help to inform CDs and departments that are starting or modifying EM third-year rotations, as well as contribute to the development of curricula for such rotations.