ABSTRACTBackgroundAn emergency department (ED) visit or hospitalization provides an opportunity to identify elder mistreatment and initiate intervention, but this seldom occurs. To address this, we developed the Vulnerable Elder Protection Team (VEPT), a novel interdisciplinary consultation service. We explored the long‐term trajectories of patients receiving VEPT evaluation and intervention.MethodsWe followed up at multiple intervals for 12 months older adults seen by VEPT from 9/1/2020–3/27/2023 with high or moderate concern for mistreatment who were discharged to the community, an elder abuse shelter, or rehabilitation facilities. We collected information through telephone calls to the older adult and others involved. We also analyzed separately cases in which the patient re‐presented to the ED/hospital with VEPT consultation during the follow‐up period.ResultsA total of 157 older adults met criteria for follow‐up, and 30 of these (16.4%) died within 12 months. At 1 month, elder mistreatment was no longer occurring in 47.5% and still occurring but reduced in 20.3%, with 29.7% having no contact with the perpetrator and 17.8% having reduced contact. At 12 months, elder mistreatment was no longer occurring in 60.9% and still occurring but reduced in 14.5%, with 34.8% having no contact with the perpetrator and 17.4% having reduced contact. During the 12‐month follow‐up period, 16 (10.2%) patients re‐presented to the ED with VEPT consultation, with 12 having persistent concern for ongoing elder mistreatment. Reasons included older adults/caregivers not accepting intervention or being willing to separate as well as VEPT reliance on community‐based agencies and programs after discharge.ConclusionsWe observed improved post‐discharge safety for elder mistreatment victims who engaged with the VEPT program, with this increased safety durable over 1 year. Re‐presentations highlighted the complexity of elder mistreatment intervention. Overall, these findings demonstrate the potential value of an ED/hospital‐based elder mistreatment response team, a promising new geriatric care model.

Interdisciplinary Emergency Department/hospital-based teams represent a promising care model to improve identification of and intervention for elder mistreatment. Two institutions, Weill Cornell Medicine/NewYork-Presbyterian Hospital and the University of Colorado Anschutz Medical Campus have launched such programs and are exploring multiple strategies for effective dissemination. These strategies include: (1) program evaluation research, (2) framing as a new model of geriatric care, (3) understanding the existing incentives of health systems, EDs, and hospitals to align with them, (4) connecting to ongoing ED/hospital initiatives, (5) identifying and collaborating with communities with strong elder mistreatment response that want to integrate the ED/hospital, (6) developing and making easily accessible high-quality, comprehensive protocols and training materials, (7) offering technical assistance and support, (8) communications outreach to raise awareness, and (9) using an existing framework to inform implementation in new hospitals and health systems.

Elder mistreatment, including elder abuse and neglect, is a difficult diagnosis to make and manage for most providers. To address this, two elder abuse consultation teams were developed for patients in the hospital and emergency department settings. As these teams have developed, the providers involved have obtained specialized training and experience that we believe contributes to a new field of elder abuse geriatrics, a corollary to the well-established field of child abuse pediatrics. Providers working in this field require specialized training and have a specialized scope of practice that includes forensic evaluation, evaluation of cognition and capacity, care coordination and advocacy for victims of abuse, and collaboration with protective services and law enforcement. Here we describe the training, scope of practice, ethical role, and best practices for elder mistreatment medical consultation. We hope this will serve as a starting point for this new and important medical specialty.

BACKGROUND:Older adults discharged from our emergency department (ED) do not receive comprehensive fall risk evaluations. We conducted a quality improvement project using an existing Community Tele-Paramedicine (CTP) program to perform in-home fall risk assessment and mitigation after ED discharge. METHODS:High falls-risk patients, as defined by STEADI score >4, were referred for a CTP home visit by community paramedics supervised virtually by emergency physicians. Home hazards assessment, Timed Up and Go test (TUG), medication reconciliation, and psychosocial evaluation were used to develop fall risk mitigation plans. Outcomes assessed at 30 days post ED-discharge included: completed CTP visits, falls, ED revisits, hospital admissions, and referrals. RESULTS:Between November 2022 and June 2023, 104 (65%) patients were discharged and referred to CTP. The mean age of enrolled patients was 80 years, 66% were female, 63% White, 79% on Medicare or Medicaid, most lived with a family member (50%) or alone (38%). Sixty-one (59%) patients received an initial CTP visit, 48 (79%) a follow-up visit, and 12 (11%) declined a visit. Abnormal TUG tests (74%), home hazards (67%), high-risk medications (36%), or need for outpatient follow-up (49%) or additional home services (41%) were frequently identified. At 30 days, only one of the CTP patients reported a fall, one patient had a fall-related ED visit, and one patient was admitted secondary to a fall. CONCLUSIONS:A quality improvement initiative using CTP to perform fall risk reduction after ED discharge identified areas of risk mitigation in the home where most falls take place. Further controlled studies are needed to assess the impact of CTP on clinical outcomes important to patients and health systems.

ObjectivesElder mistreatment (EM), encompassing abuse and neglect, is a significant public health issue, affecting up to 10% of community-dwelling older adults annually. Elder mistreatment is a growing concern with a higher prevalence in institutional settings and substantial associated healthcare costs. Prehospital clinicians (PHCs) such as emergency medical technicians and paramedics are uniquely positioned to detect and report EM during their interactions with older adults in their homes. The objective of the study is to describe the rate and characteristics of EM documented by PHCs using the National Emergency Medical Services Information System (NEMSIS) database.MethodsThis study analyzed data from NEMSIS, which includes standardized information about PHC emergency response encounters across the United States. In 2018, 22,532,890 activations were included from 9,599 agencies in 43 states and US territories. Elder mistreatment was identified using specific International Classification of Diseases (ICD) codes related to EM. Demographic data, injury location, and associated physical findings were also examined.ResultsOut of 9,605,522 EMS encounters for patients aged >= 60, EM was coded in 1,765 encounters (0.02%). Most EM cases were listed as the cause of injury (64%), followed by the clinician's first impression (25.4%). Physical abuse was the most common type of mistreatment reported (20.8%), followed by sexual abuse (18.2%), neglect (9.7%), and psychological/emotional abuse (0.34%). The median age of patients with documented EM was 72, and 62.3% were female. The most common anatomic locations of injuries were the lower extremities, head, and upper extremities.ConclusionsDespite the high prevalence of EM, PHCs infrequently document EM in their encounters with older adults. Additional training and comprehensive protocols are needed to improve the identification and reporting of EM, mainly elder neglect. Empowering PHCs through education and protocol development can significantly impact the detection and intervention of EM.

Elder mistreatment is common, serious, and under-recognized, with Emergency Department and hospital clinical encounters offering a potential but currently unrealized opportunity to identify and help older adults experiencing mistreatment. Interdisciplinary emergency department and hospital-based response teams represent a promising care model to address this. This manuscript describes two such teams and introduces a special issue dedicated to this work.

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.

Elder mistreatment, defined as action or negligence against a vulnerable older adult that causes harm or risk of harm, either committed by a person in a relationship with an expectation of trust or when an older person is targeted based on age or disability, is common and may have serious medical and social consequences. Elder mistreatment includes physical abuse, sexual abuse, neglect, emotional/psychological abuse, financial exploitation, and self-neglect.

This scoping review aims to provide a broad overview of the research on the unassisted virtual physical exam performed over synchronous audio-video telemedicine to identify gaps in knowledge and guide future research. Searches for studies on the unassisted virtual physical exam were conducted in 3 databases. We included primary research studies in English on the virtual physical exam conducted via patient-to-provider synchronous, audio-video telemedicine in the absence of assistive technology or personnel. Screening and data extraction were performed by 2 independent reviewers. Seventy-four studies met inclusion criteria. The most common components of the physical exam performed over telemedicine were neurologic (38/74, 51%), musculoskeletal (10/74, 14%), multi-system (6/74, 8%), neuropsychologic (5/74, 7%), and skin (5/74, 7%). The majority of the literature focuses on the telemedicine physical exam in the adult population, with only 5% of studies conducted specifically in a pediatric population. During the telemedicine exam, the patients were most commonly located in outpatient offices (28/74, 38%) and homes and other non-clinical settings (25/74, 34%). Both patients and providers in the included studies most frequently used computers for the telemedicine encounter. Research evaluating the unassisted virtual physical exam is at an early stage of maturity and is skewed toward the neurologic, musculoskeletal, neuropsychologic, and skin exam components. Future research should focus on expanding the range of telemedicine exam maneuvers studied and evaluating the exam in the most relevant settings, which for telemedicine is trending toward exams conducted through mobile devices and in patients’ homes.

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.

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.

Many older adults in the United States are affected by unmet needs and social challenges that negatively impact their health and well-being. These include social isolation, inadequate care, inability to perform daily activities, food insecurity, housing insecurity, poverty, and abuse/neglect/exploitation. Such challenges make it more difficult to obtain medical and dental care and manage vision / hearing impairments. Affected patients have trouble obtaining medications and remaining adherent to medication regimens. These issues may compromise an older adults’ nutrition. They may contribute to anxiety, depression, and loneliness, which in turn can also negatively affect a person’s physical health and function.

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.

Journal of the American Geriatrics SocietyVolume 68, Issue 8 p. 1631-1635 Special Article Managing Older Adults with Presumed COVID-19 in the Emergency Department: A Rational Approach to Rationing Tony Rosen MD MPH, Corresponding Author Tony Rosen MD MPH [email protected] Department of Emergency Medicine, Weill Cornell Medicine / NewYork-Presbyterian Hospital, New York, New YorkAddress correspondence to Tony Rosen, MD MPH, 525 East 68 Street, Room 130, 212-746-1059, E-mail: [email protected]Search for more papers by this authorLauren E. Ferrante MD MHS, Lauren E. Ferrante MD MHS Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, ConnecticutSearch for more papers by this authorShan W. Liu MD SD, Shan W. Liu MD SD Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MassachusettsSearch for more papers by this authorEmily A. Benton MD, Emily A. Benton MD NewYork-Presbyterian Emergency Medicine Residency Program, New York, New YorkSearch for more papers by this authorMary R. Mulcare MD, Mary R. Mulcare MD Department of Emergency Medicine, Weill Cornell Medicine / NewYork-Presbyterian Hospital, New York, New YorkSearch for more papers by this authorMichael E. Stern MD, Michael E. Stern MD Department of Emergency Medicine, Weill Cornell Medicine / NewYork-Presbyterian Hospital, New York, New YorkSearch for more papers by this authorKevin Biese MD, Kevin Biese MD Department of Emergency Medicine, Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, North CarolinaSearch for more papers by this authorUla Hwang MD MPH, Ula Hwang MD MPH Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York Geriatrics Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New YorkSearch for more papers by this authorMartine Sanon MD, Martine Sanon MD Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New YorkSearch for more papers by this author Tony Rosen MD MPH, Corresponding Author Tony Rosen MD MPH [email protected] Department of Emergency Medicine, Weill Cornell Medicine / NewYork-Presbyterian Hospital, New York, New YorkAddress correspondence to Tony Rosen, MD MPH, 525 East 68 Street, Room 130, 212-746-1059, E-mail: [email protected]Search for more papers by this authorLauren E. Ferrante MD MHS, Lauren E. Ferrante MD MHS Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, ConnecticutSearch for more papers by this authorShan W. Liu MD SD, Shan W. Liu MD SD Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MassachusettsSearch for more papers by this authorEmily A. Benton MD, Emily A. Benton MD NewYork-Presbyterian Emergency Medicine Residency Program, New York, New YorkSearch for more papers by this authorMary R. Mulcare MD, Mary R. Mulcare MD Department of Emergency Medicine, Weill Cornell Medicine / NewYork-Presbyterian Hospital, New York, New YorkSearch for more papers by this authorMichael E. Stern MD, Michael E. Stern MD Department of Emergency Medicine, Weill Cornell Medicine / NewYork-Presbyterian Hospital, New York, New YorkSearch for more papers by this authorKevin Biese MD, Kevin Biese MD Department of Emergency Medicine, Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, North CarolinaSearch for more papers by this authorUla Hwang MD MPH, Ula Hwang MD MPH Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York Geriatrics Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New YorkSearch for more papers by this authorMartine Sanon MD, Martine Sanon MD Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New YorkSearch for more papers by this author First published: 23 June 2020 https://doi.org/10.1111/jgs.16651Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat References 1Farrell TW, Ferrante LE, Brown T, Francis L, Widera E, Rhodes R, Rosen T, Hwang U, Witt LJ, Thothala N, Liu SW, Vitale CA, Braun UK, Stephens C, Saliba D AGS Position Statement: Resource allocation strategies and age-related considerations in the COVID-19 era and beyond. J Am Geriatr Soc 2020. doi: https://doi.org/10.1111/jgs.16537. [Epub ahead of print] 10.1111/jgs.16537 Web of Science®Google Scholar 2Farrell TW, Francis L, Brown T, Ferrante LE, Widera E, Rhodes R, Rosen T, Hwang U, Witt LJ, Thothala N, Liu SW, Vitale CA, Braun UK, Stephens C, Saliba D Rationing limited health care resources in the COVID-19 era and Beyond: Ethical considerations regarding older adults. J Am Geriatr Soc 2020. doi: https://doi.org/10.1111/jgs.16539. [Epub ahead of print] 10.1111/jgs.16539 Web of Science®Google Scholar 3Ferrante LE, Pisani MA, Murphy TE, Gahbauer EA, Leo-Summers LS, Gill TM. 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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.

With improvement in antiretroviral therapies, human immunodeficiency virus (HIV) life expectancy is increasing, giving rise to a growing older HIV population. Little is known about management of this population in the emergency department (ED). While CD4 count and Viral Load (VL) determine risk for an acquired immunodeficiency syndrome-defining event (ADE), these values are often unknown in the ED setting. In this study, we aim to correlate outpatient CD4 and VL values with the risk of an ADE diagnosis in subsequent ED visits amongst a group of older HIV patients, and assess which value plays a stronger role in predicting ADE risk.

Background: Direct-to-consumer (DTC) telemedicine platforms have been increasingly implemented by large hospital systems. This care delivery mechanism shares similarities with bedside medical care, but also differs in key attributes such as the inability to perform a "hands-on" physical examination. Methods: We present a case of DTC telehealth evaluation that resulted in the diagnosis of acute appendicitis. The case of one female patient presenting to our urgent care mobile application and subsequently to the emergency department (ED) is discussed. Results: Physician-guided patient self-examination of the abdomen demonstrated concordance with findings on bedside physical examination in the ED, leading to the correct diagnosis of acute appendicitis. Conclusions: For the patient presented here, physician-guided patient self-examination resulted in appropriate referral to the ED and diagnosis of appendicitis. Additional research on the reproducibility of virtual physical examination findings and potential cost savings of telemedicine visits is warranted.

When we established an emergency department-based telemedicine program, we assumed that many older patients would be skeptical of the new technology and choose not to participate. Our assumption was incorrect. Of the 1052 patients we evaluated in the first several months, 355 (33%) were 60, 2 were 99. Satisfaction and quality assessment scores among older patients were similar to those for younger patients. Many of these older patients demonstrated flexibility and interest in the novel use of technology. Our emergency department-based telemedicine program resulted in safe and satisfactory care and was readily accepted by our older patients.

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.