Developing a Geriatric Emergency Department: People, Processes, and Place.

Older patients' ED visits rose 30% over 5 years and EDs are now examining geriatric emergency department (GED) models of care. The 3 Ps model focuses on the GED's People, Processes, and the Place to provide a framework for GED development. Key resources include the: GED Collaborative, GED Guidelines, and Geriatric Emergency Department Accreditation process. Core to a GED's operation is its care processes including: (1) General approaches; (2) Screening for high-risk conditions; (3) Enhanced assessment; (4) Workflow alterations; and (5) Transitions. This article provides practical guidance to EDs seeking to enhance the ED experience of older people and improve the quality of their outcomes.

Lessons Learned From Emergency Department Fall Assessment and Prevention Programs.

Objectives This research describes the experiences of emergency departments (EDs) with geriatric fall programs and qualitatively synthesizes lessons learned to inform other EDs planning new fall program implementation. Methods By using grounded theory, we conducted semi-structured, open-ended telephone/skype interviews of emergency physicians and geriatric providers recruited from a purposeful sampling technique. The interviews were transcribed and reviewed by two investigators. The codes were generated and listed, and common concepts emerged. Lastly, the final codes were organized into concepts and themes with the aim to create a strong coding structure. Result The main lessons learned are: (1) understand the hospital's existing local environment and resources, (2) utilize champions and interdisciplinary teams, (3) acknowledge that specific fall assessment tools and interventions vary widely between institutions, (4) engage in routine plan-do-study-act (PDSA) cycles to improve the quality of fall initiatives, and (5) operate under the principle that falls are a syndrome, which must be incorporated within the multifactorial medical needs of geriatric fall patients. Conclusion Based on the lessons learned from our ED fall implementation pioneers, implementing an effective geriatric fall protocol in an ED setting is complicated. Understanding a hospital's resources, assigning champions, working as an interdisciplinary team, choosing proper fall assessment tools/interventions, and completing regular PDSA cycles are important lessons for ED programs planning to implement their own ED fall programs.

Tracking the Rise of Geriatric Emergency Departments in the United States.

The traditional model of emergency care no longer fits the growing needs of the over 20 million older adults annually seeking emergency department care. In 2007 a tailored "geriatric emergency department" model was introduced and rapidly replicated among hospitals, rising steeply over the past 5 years. This survey examined all U.S. emergency departments self-identifying themselves as Geriatric Emergency Departments (GEDs) and providing enhanced geriatric emergency care services. It was guided by the recently adopted Geriatric Emergency Department Guidelines and examined domains including, GED identity, staffing, and administration; education, equipment, and supplies; policies, procedures, and protocols; follow-up and transitions of care; and quality improvement. Results reveal a heterogeneous mix of GED staffing, procedures, physical environments and that GEDs' familiarity with the GED Guidelines is low. Findings will inform emergency departments and gerontologists nationwide about key GED model elements and will help hospitals to improve ED services for their older adult patients.

Contaminant Gradients in Trees: Directional Tree Coring Reveals Boundaries of Soil and Soil-Gas Contamination with Potential Applications in Vapor Intrusion Assessment.

Contaminated sites pose ecological and human-health risks through exposure to contaminated soil and groundwater. Whereas we can readily locate, monitor, and track contaminants in groundwater, it is harder to perform these tasks in the vadose zone. In this study, tree-core samples were collected at a Superfund site to determine if the sample-collection location around a particular tree could reveal the subsurface location, or direction, of soil and soil-gas contaminant plumes. Contaminant-centroid vectors were calculated from tree-core data to reveal contaminant distributions in directional tree samples at a higher resolution, and vectors were correlated with soil-gas characterization collected using conventional methods. Results clearly demonstrated that directional tree coring around tree trunks can indicate gradients in soil and soil-gas contaminant plumes, and the strength of the correlations were directly proportionate to the magnitude of tree-core concentration gradients (spearman's coefficient of -0.61 and -0.55 in soil and tree-core gradients, respectively). Linear regression indicates agreement between the concentration-centroid vectors is significantly affected by in planta and soil concentration gradients and when concentration centroids in soil are closer to trees. Given the existing link between soil-gas and vapor intrusion, this study also indicates that directional tree coring might be applicable in vapor intrusion assessment.

Tree Sampling as a Method to Assess Vapor Intrusion Potential at a Site Characterized by VOC-Contaminated Groundwater and Soil.

Vapor intrusion (VI) by volatile organic compounds (VOCs) in the built environment presents a threat to human health. Traditional VI assessments are often time-, cost-, and labor-intensive; whereas traditional subsurface methods sample a relatively small volume in the subsurface and are difficult to collect within and near structures. Trees could provide a similar subsurface sample where roots act as the "sampler' and are already onsite. Regression models were developed to assess the relation between PCE concentrations in over 500 tree-core samples with PCE concentrations in over 50 groundwater and 1000 soil samples collected from a tetrachloroethylene- (PCE-) contaminated Superfund site and analyzed using gas chromatography. Results indicate that in planta concentrations are significantly and positively related to PCE concentrations in groundwater samples collected at depths less than 20 m (adjusted R2 values greater than 0.80) and in soil samples (adjusted R2 values greater than 0.90). Results indicate that a 30 cm diameter tree characterizes soil concentrations at depths less than 6 m over an area of 700-1600 m2, the volume of a typical basement. These findings indicate that tree sampling may be an appropriate method to detect contamination at shallow depths at sites with VI.

Licensed nurse staffing and health service availability in residential care and assisted living.

OBJECTIVES: To create data-driven typologies of licensed nurse staffing and health services in residential care and assisted living (RC/AL). DESIGN: Cluster analysis was used to describe the patterns of licensed nurse staffing and 47 services and the extent to which these clusters were related. SETTING: RC/AL communities in the United States. PARTICIPANTS: A convenience sample of administrators and healthcare supervisors from 89 RC/AL communities in 22 states. MEASUREMENT: RC/AL characteristics, licensed nurse staffing (total number of hours that registered nurses (RNs) and licensed practical nurses (LPNs) worked), number of hours that contract nurses worked, and availability of 47 services. RESULTS: Analysis revealed four licensed nurse staffing clusters defined according to total number of hours and the type of nurse providing the hours (RN, LPN, or a mix of both). They ranged from no or minimal RN and LPN hours to high nursing hours with a mix of RNs and LPNs. The 47 services clustered into five clusters: basic services; technically complex services; assessments, wound care, and therapies; testing and specialty services; and gastrostomy and intravenous medications. The availability of services was related to the presence of nurses (RNs and LPNs) except for the gastrostomy and intravenous medication services, which were not readily available. CONCLUSION: The amount and skill mix of licensed nurse staffing varies in RC/AL and is related to the types of services available. These findings may have implications for resident care and outcomes. Future work in this area, including extension to include nonnurse direct care workers, is needed.

The Emerging Role of Health Care Supervisors in Assisted Living.

Historically, the assisted living (AL) industry has promoted a social, non-medical model of care. Rising health acuity of residents within AL, however, has brought about the need for providing increased health care services. This article examines the key staff role related to health care provision and oversight in AL, described as the health care supervisor. It briefly describes individuals in this role (N = 90) and presents their perspectives regarding their roles and responsibilities as the health care point person within this non-medical environment. Qualitative analyses identified four themes as integral to this position: administrative functions, supervision of care staff, provision of clinical and direct care, and clinical care coordination and communication. The article concludes with recommendations for AL organizations and practice of the emerging health care supervisor role in AL.

Understanding the intersection of individual needs and choices with organizational practices: the case of medication management in assisted living.

PURPOSE: Making choices about everyday activities is a normal event for many adults. However, when an adult moves into an assisted living (AL) community, making choices becomes complicated by perceived needs and community practices. This study examines the relationship between choice and need in the context of practices, using medication administration practices as the case in point. DESIGN AND METHODS: A 5-year ethnographic study collected information from 6 AL settings in Maryland. Ethnographic interviews (n = 323) and field notes comprise the data described in this article. RESULTS: AL organizations used practice rationales based on state regulations, professional responsibility, safety concerns, and social model values to describe and explain their setting-specific practices. The result was varying levels of congruence between the setting's practices and individual resident's needs and choices. That is, in some cases, the resident's needs were lost to the organization's practices, and in other cases, organizations adapted to resident need and choices. These findings suggest that individuals and organizations adapt to each other, resulting in practices that are not bound by state requirement or other practice rationales. IMPLICATIONS: AL residences vary due to both internal and external forces, not just the public policies that define them. State regulations need to be responsive to both the needs and the choices of individual residents and to the people who work in an AL.

Brief communication: physician interest in volunteer service during retirement.

BACKGROUND: Baby boomers approaching retirement will include unprecedented numbers of physicians, many of whom want to remain productive. OBJECTIVE: To determine interest in health care-related volunteering during retirement among physicians trained to provide general medical care to adults. DESIGN: Cross-sectional mailed survey conducted May through July 2006. SETTING: North Carolina. PARTICIPANTS: 910 physicians, 55 years of age or older, whose primary specialty involved direct, nonsurgical care of adults. MEASUREMENTS: Current volunteerism and future interest in selected activities. RESULTS: Of the respondents, 89.8% were male and 87.4% were white; 57.4% worked full-time, 21.7% worked part-time, and 21.0% were retired. Of current retirees, 37.1% expressed interest in volunteering. Areas of greatest interest were medical teaching, working in free medical clinics, and international care. Strong incentives included staying mentally active (67.3%) or involved in medicine (61.2%) and contributing to society (60.5%). Substantial barriers included concerns about malpractice (61.5%) and paperwork or bureaucracy (46.0%). The majority of respondents (66.7%) felt that lack of payment would not influence volunteering. LIMITATIONS: The 59% overall response rate and exclusion of unlicensed retired physicians limit study generalizability. The data were provided by self-response and could not be independently validated. CONCLUSION: Retired physicians are a potential source of manpower that could contribute to provision of health care, particularly in medical teaching and clinical care of underserved persons.

Examining the physician's role with assisted living residents.

In response to the rapid growth of the assisted living (AL) residents, this article considers the resulting range of roles, opportunities, and challenges physicians may face as increasing numbers of their older adult patients choose residence in AL facilities. The problem is framed by providing an overview of the AL industry and reviewing AL resident demographics and health status characteristics. The discussion section examines the pervasive involvement of physicians with AL residents, reviews professional position statements on health care in AL, and reviews the emerging AL-focused clinical literature. In conclusion, the paper proposes key elements of a research agenda including establishing baseline physician-AL activity levels, physician collaboration with mid-level practitioners, and exploring physician involvement in chronic care and health promotion in AL.

When do older adults become "disabled"? Social and health antecedents of perceived disability in a panel study of the oldest old.

Disability carries negative social meaning, and little is known about when (or if), in the process of health decline, persons identify themselves as "disabled." We examine the social and health criteria that older adults use to subjectively rate their own disability status. Using a panel study of older adults (ages 72+), we estimate ordered probit and growth curve models of perceived disability over time. Total prevalent morbidity, functional limitations, and cognitive impairment are predictors of perceived disability. Cessation of driving and receipt of home health care also influence older adults 'perceptions of their own disability. A dense social network slowed the rate of labeling oneself disabled, while health anxiety accelerated the process over time, independent of health status. When considering perceived disability, the oldest old use multidimensional criteria capturing function, recent changes in health status and social networks, and anxiety about their health.

Older adults in the Emergency Department: predicting physicians' burden levels.

The aging of the U.S population will have impact on hospital Emergency Departments (ED) nationwide. To date, ED research has focused on utilization rates and acuity without considering issues of burden and stress that emergency physicians may experience caring for the increasing numbers of older adult patients. Results of a survey of Emergency Medicine residents and their attendings indicates that physicians overestimate the percentage of their patient load aged 65 years and older, have less confidence managing older patients, and desire more geriatric Emergency Medicine training. Based on regression analysis, several factors predict higher levels of emergency physician burden including training level, experiences, patient census estimate gaps, and relational issues with patients. Findings suggest the need to systematically address how the profession of Emergency Medicine is responding to its growing older adult patient population.

Sociocultural aspects of transitions from assisted living for residents with dementia.

PURPOSE: Negotiating transitions and residential relocation are especially difficult for residents with dementia and their families. This article examined the decision-making process regarding retention or transfer of persons with dementia in assisted living facilities. DESIGN AND METHODS: Using an ethnographic approach, this study observed residents and facility life, and interviewed residents, staff, and family members in three assisted living facilities. RESULTS: Facility managers and administrators are pivotal figures in determining the timing of transitions and transitional care. Operating within the context of care requirements of dementia, they, the facility culture, and the family members' involvement in resident care mediate interpretations of and responses to change and decline, and ultimately influence decision making regarding retention or transfer. IMPLICATIONS: Transfer or retention may occur differently depending on whether managers are on- or off-site, the assisted living culture is dementia-friendly, and families are involved in care. Sensitizing assisted living managers and educating potential residents and family members to the importance of these factors may affect the eventual likelihood and timing of discharge.

Vapor-phase exchange of perchloroethene between soil and plants.

Tree core concentrations of tetrachloroethylene (perchloroethene, PCE) at the Riverfront Superfund Site in New Haven, MO, were found to mimic the profile of soil phase concentrations. The observed soil-tree core relationship was stronger than that of groundwater PCE to tree core concentrations atthe same site. Earlier research has shown a direct, linear relationship between tree core and groundwater concentrations of chlorinated solvents and other organics. Laboratory-scale experiments were performed to elucidate this phenomenon, including determining partitioning coefficients of PCE between plant tissues and air and between plant tissues and water, measured to be 8.1 and 49 L/kg, respectively. The direct relationship of soil to tree core PCE concentrations was hypothesized to be caused by diffusion between tree roots and the soil vapor phase in the subsurface. The central findings of this research are discovering the importance of subsurface vapor-phase transfer for VOCs and uncovering a direct relationship between soil vapor-phase chlorinated solvents and uptake rates that impact contaminant translocation from the subsurface and transfer into the atmosphere.