BACKGROUND:Frailty, a state of increased vulnerability, is a well-established risk factor of adverse outcomes following surgery. While its prognostic value has been demonstrated in various contexts, data are lacking on its impact in emergency general surgery within the Swiss healthcare system. This study aimed to evaluate the association between frailty and outcomes among older patients undergoing emergency general surgery in a Swiss tertiary hospital. METHODS:We conducted a retrospective cohort study including patients aged 65 years or over who underwent emergency general surgery between January 2016 and December 2019. Eligible procedures included laparotomy, bowel resection, peptic ulcer repair, appendectomy and cholecystectomy performed within 72 hours of admission. Frailty was assessed retrospectively using the Clinical Frailty Scale (CFS), based on clinical documentation. The primary outcome was 1-year mortality. Secondary outcomes included complications, hospital length of stay and discharge destination. Multivariable regression models were used to analyse associations. RESULTS:Of 683 patients (median age 76 years; 52.7% female), 38.2% were classified as living with frailty (CFS ≥5). One-year mortality was significantly higher among patients with frailty (25.6%) than those without (6.6%), with an adjusted odds ratio (aOR) of 3.0 (95% CI: 1.7-5.1). Frailty was associated with an increased risk of complications (aOR: 2.3; 95% CI: 1.5-3.6), prolonged hospital stay (+46.4%; 95% CI: 26.8-69.0%) and discharge to a location other than home (aOR: 2.1; 95% CI: 1.4-3.2). CONCLUSION:Frailty is associated with worse outcomes after emergency general surgery in older adults. Routine frailty screening could improve risk stratification and guide patient-centred surgical decision-making.

Vertebral compression fractures are a common ED presentation in older adults and often lead to significant pain and functional decline. Oligoanalgesia can worsen morbidity. We aimed to describe pain assessment and management practices for older adults presenting to the ED with fragility vertebral compression fractures. We conducted a retrospective health records review of adults ≥ 65 years presenting to two tertiary EDs with acute thoracic or lumbar fragility vertebral compression fractures between August 2017 and August 2022. Patients with polytrauma, pathologic, or age-indeterminate fractures were excluded. Eligible cases were identified by ICD-10-CA codes, and data were abstracted using a standardized form. Primary outcomes were initial pain assessment, pain reassessment, and analgesic administration. Secondary outcomes included use of consultant and allied health services, discharge prescriptions, disposition, and 30-day return ED visits. Descriptive statistics were used. Of 646 screened patients, 296 met inclusion criteria. Mean age was 81.4 (SD 8.3) years; 69.0

OBJECTIVE:The incidence of Emergency Department (ED) awake intubation is unexpectedly low despite evidence that awake intubation improves patient outcomes. We sought to identify barriers and facilitators to awake intubation by emergency physicians in patients with predictors of a difficult airway. METHODS:We conducted a qualitative study using semi-structured interviews at two Canadian EDs with different rates of awake intubation. The interview template was created using the Theoretical Domains Framework (TDF). Interviews were conducted, and transcribed verbatim. Two researchers then coded utterances into TDF domains, generated belief statements, and identified salient statements and domains. RESULTS:Nineteen physicians were interviewed. There was a marked difference in comfort with awake intubation between the two sites. Both sites agreed training in awake intubation is important for ED physicians. Rarity of the procedure (Environmental context and resources) and lack of training (Skills) were identified as barriers, while engagement in skill maintenance was a facilitator (Skills). Local expertise was markedly different between sites and was identified as a facilitator (Social influences). Support from the interdisciplinary team was identified as a facilitator (Social influences). There was marked divergence between sites in anesthesiology involvement for the management of difficult airways in the ED (Social or professional roles and identity). CONCLUSIONS:This study identified barriers and facilitators to the use of awake intubation by ED physicians. These barriers and facilitators must be addressed when designing interventions to increase the uptake of awake intubation in the ED. Future studies should aim to translate these factors into practical interventions.

Older adults commonly present to the emergency department after a fall. Head imaging is frequently ordered for these patients. Occasionally, head imaging finds evidence of chronic stroke when there is no clinical history of stroke. The clinical implications of undiagnosed prior stroke are unknown. Our objective was to explore the association between undiagnosed prior stroke and short-term mortality after a fall. This was a secondary analysis of a prospective multicenter cohort study enrolling patients ≥ 65 years presenting to the emergency department after a fall. Patients were included if they had a head CT scan during their visit, and their vital status was known at 42 days. We used a logistic regression model to examine the relationship between previously undiagnosed prior stroke and death within 42 days. The model adjusted for age, sex, use of antiplatelet/anticoagulant medications, and Clinical Frailty Scale score. Among 4308 enrolled patients, 2698 had a head CT scan at the index visit, of whom 2307 were known to be alive or dead at 42 days. The median age was 84 (IQR 77–89) years, and 62

Delirium complicates 20% to 62% of the estimated 1.5 million hip fractures annually. Meta-analyses suggest that point-of-care ultrasound-guided regional anesthesia (POCUS-GRA) may reduce delirium, but uptake by emergency department (ED) physicians is highly variable. To measure the impact of a knowledge-to-practice intervention on uptake of POCUS-GRA by ED physicians, incidence and number of days of delirium, analgesic effectiveness, safety, and procedure time. This stepped-wedge cluster randomized clinical trial was conducted at 7 academic EDs from 4 provinces in Canada. The order in which ED physicians were trained at each site was randomized. ED physicians working at least 1 shift per week who did not regularly perform POCUS-GRA and patients aged 65 years and older with a hip fracture who were not delirious on arrival were included. Data were analyzed in August 2025. A 2-hour structured training session on fascia iliaca blocks was followed by competency assessment, with a procedure bundle and email reminders provided. Incidence of delirium within 7 days of ED presentation was measured using the Confusion Assessment Method, and duration of delirium was measured in days. A total of 208 of 213 ED physicians (97.7%) who assessed 694 eligible patients with hip fracture (median [IQR] age, 81.0 [74.0-88.0] years; 483 female [69.6%]) were trained. Among these patients, 248 individuals were analyzed prior to training per intention-to-treat analysis, including 6 with protocol violations (control group), and 446 individuals after training (intervention group). The intervention increased blocks from 6 of 264 patients (2.2%) to 236 of 446 patients (52.9%) after training, for a change of 51.7%. After adjustment for a priori confounders, time, and clustering by site, delirium risk in the intervention group was reduced (odds ratio, 0.72; 95% CI, 0.57-0.93). Mean days of delirium was not reduced. Among 186 nerve blocks with pain effectiveness data, most nerve blocks were effective (107 nerve blocks [57.5%]with ≥50% pain reduction), quick (median [IQR] time, 15 [12-20] minutes; 113 nerve blocks [90.0%] <25 minutes), and safe (1 minor hematoma). In this study, a knowledge-to-practice intervention improved nerve block uptake, and nerve blocks were quick, safe, and mostly effective. Despite suboptimal uptake, the study adds to the evidence that POCUS-GRA reduces delirium. ClinicalTrials.gov Identifier: NCT02892968

The Targeted Engagement and Diversion (TED) program in Ottawa provides health care to unhoused or shelter/community housed adults outside of an emergency department (ED) setting. We sought to determine the proportion of patients diverted away from the ED by the TED program. We conducted a health records review of adult patients who visited the TED program from January to December 2022 using random sampling to account for seasonal variation. Data were extracted from the Ottawa Inner City Health database and hospital records from two university-affiliated EDs. The primary outcome was successful diversion from the ED, defined as any of the following: TED program patients (i) presenting in the evening or overnight; (ii) brought in by police/paramedic services; (iii) referred from the safe consumption site; (iv) assessed by a nurse or physician; (v) admitted for higher level of observation; or (vi) that received an antidote (e.g., naloxone). Data were described using descriptive statistics. We reviewed 500 total visits of 241 unique patients (76.3

BACKGROUND:Older adults consulting Emergency Departments (EDs) for minor injuries are at risk for new functional impairments in the 6 months following their injuries. OBJECTIVE:To compare the effects of exercise programs versus usual ED practices on functional status and physical performance at 3-6 months in at-risk older adults with minor injuries. DESIGN AND SETTINGS:Stepped-wedge randomized trial in six Canadian EDs from 2017 to 2020. Participants aged ≥ 65 years were screened for low, moderate, or high risk of functional decline and assessed three times: baseline at ED, 3 and 6 months. INTERVENTION AND MEASURES:Multicomponent (flexibility, balance, strengthening, aerobic) and risk-level adapted exercise programs targeting moderate- and high-risk patients, 3×/week for 12 weeks, at home or in community groups. CONTROL:Usual ED care. MEASURES:Functional decline was defined as a 2/28-point loss from baseline on the Older Americans Resources and Services (OARS) scale. Basic physical performance (leg strength, balance, walking speed) was measured using the Short Physical Performance Battery (SPPB) test. Generalized linear mixed log-binomial regressions were used to examine the effects of the intervention on outcomes compared to usual ED care, stratified by risk level. RESULTS:The intervention and control phases included 277 and 205 moderate-risk individuals, and 249 and 128 high-risk individuals, respectively. Among moderate-risk individuals, functional loss in intervention participants at 3 months was half that of controls: 12% [95% CI: 8%-17%] vs. 25% [95% CI: 18%-34%], RR: 0.48 [0.26, 0.90]. CONCLUSION:12-week multicomponent exercises implemented early after minor injuries are associated with lower proportions of functional decline at 3 months in moderate-risk seniors and may help those at high risk recover some physical performance. TRIAL REGISTRATION:ClinicalTrials.gov, ID Cedecoms NCT03991598.

Importance:Delirium complicates 20% to 62% of the estimated 1.5 million hip fractures annually. Meta-analyses suggest that point-of-care ultrasound-guided regional anesthesia (POCUS-GRA) may reduce delirium, but uptake by emergency department (ED) physicians is highly variable. Objectives:To measure the impact of a knowledge-to-practice intervention on uptake of POCUS-GRA by ED physicians, incidence and number of days of delirium, analgesic effectiveness, safety, and procedure time. Design, Setting, and Participants:This stepped-wedge cluster randomized clinical trial was conducted at 7 academic EDs from 4 provinces in Canada. The order in which ED physicians were trained at each site was randomized. ED physicians working at least 1 shift per week who did not regularly perform POCUS-GRA and patients aged 65 years and older with a hip fracture who were not delirious on arrival were included. Data were analyzed in August 2025. Intervention:A 2-hour structured training session on fascia iliaca blocks was followed by competency assessment, with a procedure bundle and email reminders provided. Main Outcome and Measures:Incidence of delirium within 7 days of ED presentation was measured using the Confusion Assessment Method, and duration of delirium was measured in days. Results:A total of 208 of 213 ED physicians (97.7%) who assessed 694 eligible patients with hip fracture (median [IQR] age, 81.0 [74.0-88.0] years; 483 female [69.6%]) were trained. Among these patients, 248 individuals were analyzed prior to training per intention-to-treat analysis, including 6 with protocol violations (control group), and 446 individuals after training (intervention group). The intervention increased blocks from 6 of 264 patients (2.2%) to 236 of 446 patients (52.9%) after training, for a change of 51.7%. After adjustment for a priori confounders, time, and clustering by site, delirium risk in the intervention group was reduced (odds ratio, 0.72; 95% CI, 0.57-0.93). Mean days of delirium was not reduced. Among 186 nerve blocks with pain effectiveness data, most nerve blocks were effective (107 nerve blocks [57.5%]with ≥50% pain reduction), quick (median [IQR] time, 15 [12-20] minutes; 113 nerve blocks [90.0%] <25 minutes), and safe (1 minor hematoma). Conclusion and Relevance:In this study, a knowledge-to-practice intervention improved nerve block uptake, and nerve blocks were quick, safe, and mostly effective. Despite suboptimal uptake, the study adds to the evidence that POCUS-GRA reduces delirium. Trial Registration:ClinicalTrials.gov Identifier: NCT02892968.

Objective To conduct a randomised, open label comparison of the effectiveness and safety of intravenous vernakalant and intravenous procainamide for the management of acute atrial fibrillation in the emergency department. Design Randomised clinical trial (RAFF4 trial). Setting 12 tertiary care emergency departments in Canada. Participants Patients with acute atrial fibrillation for whom acute rhythm control was a safe option. Interventions Patients were randomised (1:1) to an intravenous infusion of vernakalant or procainamide; when rapid conversion did not occur, patients were offered electrical cardioversion. Main outcomes and measures The primary outcome was conversion to sinus rhythm within 30 minutes of drug infusion completion. Secondary outcomes included time to conversion to sinus rhythm and whether the patient required electrical cardioversion. Results Of the 350 enrolled eligible patients, baseline characteristics were similar in the procainamide (n=172) and vernakalant (n=178) groups. For the primary outcome of conversion success, vernakalant was more effective (62.4% v 48.3%; adjusted absolute difference 15.0%, 95% confidence interval 4.6% to 25.0%, P=0.005; adjusted odds ratio 1.87, 95% confidence interval 1.2 to 2.9, P=0.006). With vernakalant, time to conversion was faster (21.8 v 44.7 minutes; mean difference −22.9, 95% confidence interval −29.9 to −16.0, P<0.001), and fewer patients underwent attempted electrical cardioversion (33.7% v 44.2%; odds ratio 0.62, 95% confidence interval 0.39 to 0.96, P=0.033). Adverse events were similar in both groups, were generally mild and brief, and most patients were discharged home. Subgroup analysis strongly favoured vernakalant for conversion in patients younger than 70 years (73.3% v 47.2%; adjusted odds ratio 3.1, 95% confidence interval 1.7 to 5.5, P=0.001, interaction P=0.005). Conclusions In this head-to-head comparison, vernakalant was superior to procainamide for patients with higher conversion rates and faster times to conversion. Therefore, vernakalant is a safe and highly effective intravenous alternative for the rapid cardioversion and discharge home of patients with acute atrial fibrillation. Trial registration ClinicalTrials.gov NCT04485195

OBJECTIVES:This portion of the Geriatric Emergency Department (GED) Guidelines 2.0 focuses on delirium in the emergency department (ED). METHODS:A multidisciplinary group applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and develop recommendations related to older ED patients with possible delirium. RESULTS:The GED Guidelines 2.0 Delirium Work Group derived six evidence-based recommendations for risk stratification, diagnosis, and brain imaging. To reduce universal screening, the Delirium Risk Score may be used to identify older adults at low risk for delirium, though the evidence certainty is very low. In adults over 65 admitted to ED observation units, Zucchelli's risk assessment tool (threshold ≥ 4) may stratify delirium risk, also with very low certainty. For adults over 75, the REDEEM Score may be used to identify low- or high-risk individuals, again with very low certainty. For diagnosis, 4AT, bCAM, CAM-ICU, mCAM, AMT-4, or RASS may be used to rule delirium in or out, based on very low certainty. The Delirium Triage Screen (DTS) may be used to rule out, but not to rule in, delirium, also with very low certainty. For diagnostic imaging, there is very low certainty of evidence to recommend for or against obtaining a head CT as part of the evaluation for older ED patients with delirium. All recommendations are conditional, reflecting very low certainty of evidence due to the lack of high-quality ED-based studies and comparative effectiveness research. CONCLUSION:Rigorous ED-based research is needed to strengthen evidence and guide delirium care for older adults in geriatric emergency medicine.

BACKGROUND:The Canadian CT Head Rule (CCTHR) is validated in adults who hit their head and experience loss of consciousness, amnesia, or disorientation. There is less evidence to guide brain imaging when the fall history is unclear. METHODS:This is a secondary analysis of a prospective study on adults aged ≥ 65 who presented to 11 emergency departments across Canada and the United States after a ground level fall. We reported the prevalence of adjudicated clinically important intracranial bleeding within 42 days of the emergency department visit among (a) patients who hit their head and met the application criteria for the CCTHR (experienced loss of consciousness, amnesia, or disorientation), (b) patients who hit their head and did not meet the CCTHR application criteria, (c) patients with an unclear history of the CCTHR application criteria, (d) patients with an unclear head injury history, and (e) patients with no head injury. RESULTS:4303 participants were analyzed. The prevalence of clinically important intracranial bleeding in the subgroups was (a) patients who fulfilled the CCTHR application criteria, 7.7% (54/703, 95% confidence interval [CI]: 5.9%-9.9%), (b) patients who hit their head but did not meet CCTHR application criteria, 2.5% (30/1204, 95% CI: 1.8%-3.5%), (c) patients with head injury but an unclear history of the CCTHR application criteria, 7.6% (19/251, 95% CI: 4.9%-12.0%), (d) patients with an unclear history of head injury, 4.6% (23/502, 95% CI: 3.2%-6.8%), and (e) patients who did not hit their head, 0.8% (13/1643, 95% CI: 0.5%-1.3%). CONCLUSIONS:Older adults presenting after a fall with an unclear history of head injury, or an unclear history of head injury-associated loss of consciousness, amnesia, or disorientation have an elevated risk for clinically important intracranial bleeding that merits emergency brain imaging.

This review summarizes the latest evidence in the evaluation of older adults presenting to the emergency department following head injury. The incidence of traumatic intracranial bleeding in older adults is rising. It is associated with significant morbidity and mortality. Early identification is critical to facilitate appropriate medical care. Evaluation of the older adult can be challenging due to frailty, delirium, and baseline cognitive and neurologic abnormalities. Clinical decision rules are helpful to identify patients who require advanced imaging. Warfarin slightly increases the risk of traumatic intracranial bleeding, and antiplatelet medications may also increase the risk.

Introduction: Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study. Methods: A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August-September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors. Results: In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include. Conclusions: Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

AIMS: Patients undergoing emergency general surgery are at high risk of complications and death. Our objectives were to estimate the incidence of emergency general surgery in a Swiss University Hospital, to describe the characteristics and outcomes of patients undergoing such procedures, and to study the impact of age on clinical outcomes. METHODS: This was a retrospective cohort study of adult patients who visited the emergency department (ED) of Geneva University Hospitals between January 2015 and December 2019. Routinely collected data were extracted from electronic medical records. The primary outcome was the incidence of emergency general surgery among patients visiting the emergency department, defined as general surgery within three days of emergency department admission. We also assessed demographic characteristics, mortality, intensive care unit admission and patient disposition. Multivariable log-binomial regression was used to study the associations of age with intensive care unit (ICU) admission, one-year mortality and dependence at discharge. Age was modelled as a continuous variable using restricted cubic splines and we compared older patients (75th percentile) with younger patients (25th percentile). RESULTS: Between January 2015 and December 2019, a total of 310,914 emergency department visits met our inclusion criteria. Among them, 3592 patients underwent emergency general surgery within 3 days of emergency department admission, yielding an annual incidence of 116 events per 10,000 emergency department visits (95% CI: 112–119), with a higher incidence in females and young patients. Overall, 5.3% of patients were admitted to ICU, 7.8% were dependent on rehabilitation or assisted living at discharge and 4.8% were dead after one year. Older patients had a higher risk of ICU admission (adjusted risk ratio (aRR) 2.9 [1.5–5.4]), dependence at discharge (aRR 15.3 [5.5–42.4]) and one-year mortality (aRR 5.4 [2.2–13.4]). CONCLUSION: Emergency department visits resulting in emergency general surgery are frequent, but their incidence decreases with patient age. Mortality, ICU admission and dependence at discharge following emergency general surgery are more frequent in older patients. Taking into account the increased risk for older patients, a shared process is appropriate for making more informed decisions about their options for care.