Scaling the EQUIPPED medication safety program: Traditional and hub-and-spoke implementation models.

BACKGROUND: The EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) medication safety program is an evidence-informed quality improvement initiative to reduce potentially inappropriate medications (PIMs) prescribed by Emergency Department (ED) providers to adults aged 65 and older at discharge. We aimed to scale-up this successful program using (1) a traditional implementation model at an ED with a novel electronic medical record and (2) a new hub-and-spoke implementation model at three new EDs within a health system that had previously implemented EQUIPPED (hub). We hypothesized that implementation speed would increase under the hub-and-spoke model without cost to PIM reduction or site engagement. METHODS: We evaluated the effect of the EQUIPPED program on PIMs for each ED, comparing their 12-month baseline to 12-month post-implementation period prescribing data, number of months to implement EQUIPPED, and facilitators and barriers to implementation. RESULTS: The proportion of PIMs at all four sites declined significantly from pre- to post-EQUIPPED: at traditional site 1 from 8.9% (8.1-9.6) to 3.6% (3.6-9.6) (p < 0.001); at spread site 1 from 12.2% (11.2-13.2) to 7.1% (6.1-8.1) (p < 0.001); at spread site 2 from 11.3% (10.1-12.6) to 7.9% (6.4-8.8) (p = 0.045); and at spread site 3 from 16.2% (14.9-17.4) to 11.7% (10.3-13.0) (p < 0.001). Time to implement was equivalent at all sites across both models. Interview data, reflecting a wide scope of responsibilities for the champion at the traditional site and a narrow scope at the spoke sites, indicated disproportionate barriers to engagement at the spoke sites. CONCLUSIONS: EQUIPPED was successfully implemented under both implementation models at four new sites during the COVID-19 pandemic, indicating the feasibility of adapting EQUIPPED to complex, real-world conditions. The hub-and-spoke model offers an effective way to scale-up EQUIPPED though a speed or quality advantage could not be shown.

Moving the needle on fall prevention: A Geriatric Emergency Care Applied Research (GEAR) Network scoping review and consensus statement.

BACKGROUND: Although falls are common, costly, and often preventable, emergency department (ED)-initiated fall screening and prevention efforts are rare. The Geriatric Emergency Medicine Applied Research Falls core (GEAR-Falls) was created to identify existing research gaps and to prioritize future fall research foci. METHODS: GEAR's 49 transdisciplinary stakeholders included patients, geriatricians, ED physicians, epidemiologists, health services researchers, and nursing scientists. We derived relevant clinical fall ED questions and summarized the applicable research evidence, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The highest-priority research foci were identified at the GEAR Consensus Conference. RESULTS: We identified two clinical questions for our review (1) fall prevention interventions (32 studies) and (2) risk stratification and falls care plan (19 studies). For (1) 21 of 32 (66%) of interventions were a falls risk screening assessment and 15 of 21 (71%) of these were combined with an exercise program or physical therapy. For (2) 11 fall screening tools were identified, but none were feasible and sufficiently accurate for ED patients. For both questions, the most frequently reported study outcome was recurrent falls, but various process and patient/clinician-centered outcomes were used. Outcome ascertainment relied on self-reported falls in 18 of 32 (56%) studies for (1) and nine of 19 (47%) studies for (2). CONCLUSION: Harmonizing definitions, research methods, and outcomes is needed for direct comparison of studies. The need to identify ED-appropriate fall risk assessment tools and role of emergency medical services (EMS) personnel persists. Multifactorial interventions, especially involving exercise, are more efficacious in reducing recurrent falls, but more studies are needed to compare appropriate bundle combinations. GEAR prioritizes five research priorities: (1) EMS role in improving fall-related outcomes, (2) identifying optimal ED fall assessment tools, (3) clarifying patient-prioritized fall interventions and outcomes, (4) standardizing uniform fall ascertainment and measured outcomes, and (5) exploring ideal intervention components.

Illicit substance use after release from prison among formerly incarcerated primary care patients: a cross-sectional study.

BACKGROUND: More than 80% of people in jail or prison report having used illicit substances in their lifetimes. After release from incarceration, resumption of substance use carries risks, including parole revocation, exacerbation of mental health conditions, transmission of infectious diseases, and drug overdose. METHODS: This cross-sectional study used baseline data from the Transitions Clinic Network (TCN, www.transitionsclinic.org ), a multi-site prospective longitudinal cohort study of post-incarceration medical care. We investigated substance use among adults, with at least one chronic health condition or age ≥ 50 years, who had been recently released from incarceration and initiated care at a TCN site. Our primary outcome was any self-reported illicit substance use (heroin or other opioids, cocaine, cannabis, amphetamines, hallucinogens, MDMA, or illicit use of prescription medications) following release from incarceration. Alcohol use post-release was a secondary outcome. Using multivariable logistic regression, we also explored factors associated with illicit substance use. RESULTS: Among 751 participants, median age was 47; participants were mostly male (85%), non-white (47% black, 30% Hispanic), and on parole (80%). The proportion of participants reporting any illicit substance use and any alcohol use soon after release from incarceration was 18% and 23%, respectively. In multivariable regression, variables significantly associated with post-release illicit substance use were male gender (aOR = 3.91, 95% CI: 1.73-8.81), housing with friends or family (aOR = 3.33, 95% CI: 1.20-9.28), years incarcerated during latest prison term (aOR = 0.93, 95% CI: 0.89-0.98), weeks elapsed before engagement with TCN (aOR = 1.07, 95% CI: 1.03-1.10), being on parole (aOR = 0.58, 95% CI: 0.34-0.99), and having a drug use disorder (aOR = 2.27, 95% CI: 1.40-3.68). CONCLUSIONS: Among individuals seeking medical care after release from incarceration, self-reported substance use was lower than previously reported estimates of post-incarceration substance use. Known risk factors, such as male gender and having a drug use disorder, were associated with illicit substance use, as were novel risk factors, such as less supervised housing. Though illicit substance use post-incarceration can carry severe consequences, treatment and surveillance interventions should be targeted toward individuals with greatest risk.

History of Solitary Confinement Is Associated with Post-Traumatic Stress Disorder Symptoms among Individuals Recently Released from Prison.

This study assessed the relationship between solitary confinement and post-traumatic stress disorder (PTSD) symptoms in a cohort of recently released former prisoners. The cross-sectional design utilized baseline data from the Transitions Clinic Network, a multi-site prospective longitudinal cohort study of post-incarceration medical care. Our main independent variable was self-reported solitary confinement during the participants' most recent incarceration; the dependent variable was the presence of PTSD symptoms determined by primary care (PC)-PTSD screening when participants initiated primary care in the community. We used multivariable logistic regression to adjust for potential confounders, such as prior mental health conditions, age, and gender. Among 119 participants, 43% had a history of solitary confinement and 28% screened positive for PTSD symptoms. Those who reported a history of solitary confinement were more likely to report PTSD symptoms than those without solitary confinement (43 vs. 16%, p < 0.01). In multivariable logistic regression, a history of solitary confinement (OR = 3.93, 95% CI 1.57-9.83) and chronic mental health conditions (OR = 4.04, 95% CI 1.52-10.68) were significantly associated with a positive PTSD screen after adjustment for the potential confounders. Experiencing solitary confinement was significantly associated with PTSD symptoms among individuals accessing primary care following release from prison. Larger studies should confirm these findings.