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Background: There is an increased interest in the role artists can play in care for older people. This momentum comes with the need to closer investigate the nature of boundary work of creative professionals in arts and health projects., Methods: We conducted a responsive evaluation to provide a thick description of the boundary work involved in ENCOUNTER#9, an intergenerational arts project taking place within an older person care setting., Results: Boundary work proved to be rewarding, yet messy and unruly. Although the lead artist had carefully planned and prepared the project and gained a broad commitment, not everything went according to plan. This led to friction and all involved put effort into adjusting goals and expectations., Conclusion: We add to the conceptualisation of boundary work in arts and health by showing that it takes place on different levels: personal, relational, organisational and public.

Background: A wide variation of emergency medical system configurations across countries has limited the value of comparison of quality and performance measures in the past. Furthermore, lack of quantitative data on EDs prevents definition of the problems and possibilities for data driven improvement of quality of care. Therefore, the objective is to describe and compare Emergency Department (ED) populations and characteristics, and their outcomes in the Netherlands, Denmark and Australia, using a recently developed template for uniform reporting of standardized measuring and describing of care provided in the ED (structure, staffing and governance, population, process times and outcomes)., Methods: This international multicenter cohort included all consecutive ED visits from National Quality Registries or Databases from participating sites from three countries. Patient and ED characteristics (using the template for uniform reporting) and relevant clinical outcomes were described and compared per country., Results: We included 212,515 ED visits in the Netherlands, 408,673 in Denmark and 556,652 in Australia. Patient characteristics differed markedly, with Australian ED patients being younger, less often triaged as "immediate", and less often triaged with the high-risk chief complaints "feeling unwell" compared to Danish and Dutch patients. ED characteristics mainly differed with respect to the mean annual census per ED (Netherlands 26,738 (SD 2630), Denmark 36,675 (SD 12974), Australia 50,712 (4884)), median (IQR) lengths of stay of patients discharged home (Netherlands 2.1 (1.4-3.1); Denmark 2.8 (1.7-5.0); Australia 3.3 (2.0-5.0) hrs) and proportion of hospitalizations (ranging from 30.6 to 39.8%). In-hospital mortality was 4.0% in Australia, higher compared to the Netherlands and Denmark (both 1.6%). Not all indicators of the framework were available in all registries., Conclusions: Patient and ED characteristics and outcomes varied largely across countries. Meaningful interpretation of outcome differences across countries could be improved if quality registries would more consistently register the measures of the recently developed template for uniform reporting., (© 2024. The Author(s).)

Background and Importance: Various biases can impact decision-making and judgment of case quality in the Emergency Department (ED). Outcome and hindsight bias can lead to wrong retrospective judgment of care quality, and implicit bias can result in unjust treatment differences in the ED based on irrelevant patient characteristics., Objectives: First, to evaluate the extent to which knowledge of an outcome influences physicians' quality of care assessment. Secondly, to examine whether patients with functional disorders receive different treatment compared to patients with a somatic past medical history., Design: A web-based cross-sectional study in which physicians received case vignettes with a case description and care provided. Physicians were informed about vignette outcomes in a randomized way (no, good, or bad outcome). Physicians rated quality of care for four case vignettes with different outcomes. Subsequently, they received two more case vignettes. Physicians were informed about the past medical history of the patient in a randomized way (somatic or functional). Physicians made treatment and diagnostic decisions for both cases., Setting and Participants: One hundred ninety-one Dutch emergency physicians (EPs) and general practitioners (GPs) participated., Outcome Measures and Analysis: Quality of care was rated on a Likert scale (0-5) and dichotomized as adequate (yes/no). Physicians estimated the likelihood of patients experiencing a bad outcome for hindsight bias. For the second objective, physicians decided on prescribing analgesics and additional diagnostic tests., Main Results: Large differences existed in rated quality of care for three out of four vignettes based on different case outcomes. For example, physicians rated the quality of care as adequate in 44% (95% CI 33-57%) for an abdominal pain case with a bad outcome, compared to 88% (95% CI 78-94%) for a good outcome, and 84% (95% CI 73-91%) for no outcome ( P  < 0.01). The estimated likelihood of a bad outcome was higher if physicians received a vignette with a bad patient outcome. Fewer diagnostic tests were performed and fewer opioids were prescribed for patients with a functional disorder., Conclusion: Outcome, hindsight, and implicit bias significantly influence decision-making and care quality assessment by Dutch EPs and GPs., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Sub-optimal adherence to immunosuppressant medications reduces graft survival for kidney transplant recipients and adherence-enhancing interventions are resource and time intensive. We performed a multi-center randomized controlled trial to investigate the impact of an electronically delivered intervention on adherence. Of 203 adult kidney transplant recipients who received a de novo kidney transplant n = 173 agreed to participate (intent-to-treat population) and were randomized to the intervention (video education plus behavior contract n = 91) or the control (standard education, n = 82). No significant differences were found between the groups for medication adherence measured by the Basel Assessment of Adherence to Immunosuppressive Medications Scale, intrapatient variability in tacrolimus levels, time in therapeutic range for any immunosuppressant, knowledge, self-efficacy, QOL, or hospitalizations. Among a subgroup of 64 participants randomized to the intervention group who completed a post-intervention questionnaire, two-thirds (67%, n = 43) reported watching at least 80% of the videos and 58% (n = 37) completed the electronic goal setting exercise and adherence contract. An autonomous goal setting exercise and electronic behavioural contract added to standard of care did not improve any outcomes. Our findings reiterate that nonadherence in transplantation is a difficult multifactorial problem that simple solutions will not solve. Trial registration number NCT03540121., Competing Interests: HM, NR, RM, and AS developed the video intervention used in this project. HM reports grants from the American Society of Transplantation (AST) Research Network, Saskatchewan Health Research Foundation (SHRF), Saskatchewan Center for Patient Oriented Research (SCPOR), during the conduct of the study. The other authors declare no conflicts of interest in this work., (© 2024 Mansell et al.)

Introduction: The COVID-19 outbreak disrupted regular health care, including the Emergency Department (ED), and resulted in insufficient ICU capacity. Lockdown measures were taken to prevent disease spread and hospital overcrowding. Little is known about the relationship of stringency of lockdown measures on ED utilization., Objective: This study aimed to compare the frequency and characteristics of ED visits during the COVID-19 outbreak in 2020 to 2019, and their relation to stringency of lockdown measures., Material and Methods: A retrospective multicentre study among five Dutch hospitals was performed. The primary outcome was the absolute number of ED visits (year 2018 and 2019 compared to 2020). Secondary outcomes were age, sex, triage category, way of transportation, referral, disposition, and treating medical specialty. The relation between stringency of lockdown measures, measured with the Oxford Stringency Index (OSI) and number and characteristics of ED visits was analysed., Results: The total number of ED visits in the five hospitals in 2019 was 165,894, whereas the total number of visits in 2020 was 135,762, which was a decrease of 18.2% (range per hospital: 10.5%-30.7%). The reduction in ED visits was greater during periods of high stringency lockdown measures, as indicated by OSI., Conclusion: The number of ED visits in the Netherlands has significantly dropped during the first year of the COVID-19 pandemic, with a clear association between decreasing ED visits and increasing lockdown measures. The OSI could be used as an indicator in the management of ED visits during a future pandemic., Competing Interests: No authors have competing interests, (Copyright: © 2024 Booij-Tromp et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Aim(s): The aim of this research study is to collaboratively generate insights in the current institutional long-term care environment for activity and mobility of older adults, and of solutions that could be used to increase the activity and improve the mobility of the older adults., Design: This research constitutes a qualitative study with a critical approach., Methods: Data were collected using photo-elicitation in four long-term care units in Finland during the spring of 2022. Older adults participated in individual data collection sessions which combined photographing and discussion. Staff members individually took photographs and later participated in a group discussion based on the photographs. Reflexive thematic analysis was used to analyse all data together., Results: Ten older adults and 12 staff members participated in the research study. Four themes were identified: (1) facilities should be designed and equipped for their users, (2) moving in the institutional environment, (3) passivity as a norm, and (4) nurses should act differently and have the resources to do so., Conclusion: To increase the activity and improve the mobility of older adults, improvements are needed in terms of the design of facilities, opportunities for freedom of movement, outdoor activity, daily life activities, exercise, nurses' role in activating older adults and resources., Implications for the Profession And/or Patient Care: Increased attention to the support of activity and mobility could benefit older adults in institutional long-term care. Physical activity promotion should be incorporated as an integral part of nursing practice., Patient or Public Contribution: Directors of units were consulted when planning the study. Older adults and nurses contributed to the data collection and interpretation of data., Impact: (ADDRESSING): What problem did the study address? ○Older adults have recurrently been reported as living inactive lives in institutional long-term care. ○There is evidence of the relationship between the environment and the activity and mobility of older adults, but there seems to be a research-practice gap in terms of implementing activity- and mobility-promoting environments. ○Older adults and staff members are important in developing practice and change-oriented knowledge that can be used to increase the activity and improve the mobility of older adults in institutional long-term care. What were the main findings? ○Various environmental improvements are recommended to increase the activity and improve the mobility of older adults in institutional long-term care settings. ○Improvements for the design of facilities, opportunities for freedom of movement, outdoor activity, daily life activities, exercise, nurses' role in activating older adults and resources for activity support would benefit older adults' activity and mobility. Where and on whom will the research have an impact? ○Increasing the activity of older adults requires better activity promotion and mobility support by nurses in institutional care. Sufficient education and resources should be organized for activity promotion, in addition to a care and organizational culture that values activity. ○Environmental aspects to promote activity and mobility need to be considered already at the planning, building and renovating phases of facilities. ○Policymakers and care organizers should consider evidence of the harms and benefits of different institutional living environments when making decisions on organizing care., Reporting Method: The study is reported using the Consolidated Criteria for Reporting Qualitative Research (COREQ)., (© 2023 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Background: Education is crucial for pediatric patients and caregivers throughout the transplant continuum, yet data are lacking around which interventions are effective and in what circumstances., Methods: We undertook a scoping review with the objectives of (a) describing the types, effects, and outcomes of patient-focused educational interventions before and after pediatric transplant and (b) understanding the educational experiences of patients and caregivers. Five scientific databases were explored for relevant literature using the JBI methodology. Educational interventions published in English, targeting pediatric solid organ transplant patients (0-25 years) and their caregivers were included. Relevant data from eligible articles (n = 27) were extracted and summarized., Results: Eighteen articles describing 17 educational interventions were identified for objective A, and nine articles qualitatively assessing patient or parental learning needs were identified for objective B. Most interventions were directed toward teenage patients and their caregivers post kidney transplant, primarily focusing on medication self-management and adherence, or providing general information on transplant using multicomponent delivery formats. Most interventions achieved statistically significant improvements in knowledge (n = 8/9) and patients or caregivers expressed satisfaction with the intervention (n = 7/7) but health-related outcomes such as medication adherence (n = 2/6) or behavior change (n = 1/3) rarely achieved statistically significant results. In objective B, patients and caregivers described the transplant process as overwhelming, but indicated that social supports and education helped them cope. Participants consistently wanted more information than they received., Conclusion: Caregivers and pediatric patients value transplant education, but high-quality studies are limited. Since education is a fundamental part of the transplant process, future research in this area should be prioritized., (© 2023 The Authors. Pediatric Transplantation published by Wiley Periodicals LLC.)

Background: Syncope management is fraught with unnecessary tests and frequent failure to establish a diagnosis. We evaluated the potential of implementing the 2018 European Society of Cardiology (ESC) Syncope Guidelines regarding diagnostic yield, accuracy and costs., Methods: A multicentre pre-post study in five Dutch hospitals comparing two groups of syncope patients visiting the emergency department: one before intervention (usual care; from March 2017 to February 2019) and one afterwards (from October 2017 to September 2019). The intervention consisted of the simultaneous implementation of the ESC Syncope Guidelines with quick referral routes to a syncope unit when indicated. The primary objective was to compare diagnostic accuracy using logistic regression analysis accounting for the study site. Secondary outcome measures included diagnostic yield, syncope-related healthcare and societal costs. One-year follow-up data were used to define a gold standard reference diagnosis by applying ESC criteria or, if not possible, evaluation by an expert committee. We determined the accuracy by comparing the treating physician's diagnosis with the reference diagnosis., Results: We included 521 patients (usual care, n = 275; syncope guidelines intervention, n = 246). The syncope guidelines intervention resulted in a higher diagnostic accuracy in the syncope guidelines group than in the usual care group (86% vs.69%; risk ratio 1.15; 95% CI 1.07 to 1.23) and a higher diagnostic yield (89% vs. 76%, 95% CI of the difference 6 to 19%). Syncope-related healthcare costs did not differ between the groups, yet the syncope guideline implementation resulted in lower total syncope-related societal costs compared to usual care (saving €908 per patient; 95% CI €34 to €1782)., Conclusions: ESC Syncope Guidelines implementation in the emergency department with quick referral routes to a syncope unit improved diagnostic yield and accuracy and lowered societal costs., Trial Registration: Netherlands Trial Register, NTR6268., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Academics aim to understand the experiences of people living with cognitive and/or language impairment in their search for epistemic justice. Methods that do not rely solely on verbal information (e.g., interviews, focus groups) but also employ an attunement to the non-verbal - such as participant observation and creative methods, are seen as a suitable way to do justice to people's non-verbal interactions. However, in practice, researchers still experience ethical issues in everyday encounters with participants with cognitive and/or language impairment even when trying to address epistemic issues while employing such methods. This article aims to demonstrate 1) the importance of attending to the non-verbal in order to prevent epistemic injustice in research and 2) how a case-study approach and discussing ethical dilemmas with peers may help to unpack some of the ethical tensions that the researchers experience., Aim and Methods: This article focuses on ethical dilemmas the authors encountered during their research projects in the past. Three cases chosen by the authors illustrate these dilemmas. Dilemmas are presented as auto-ethnographical written accounts, which were discussed during ten retrospective dialogical sessions (60-90 min) organized by the research group consisting of six academic researchers., Results: Ethically sound research, in which older people living with cognitive and/or language impairment are engaged, entails much more than following procedures about informed consent, privacy, submitting a proposal to an ethics committee, and using suitable methods and techniques. Ethical issues in these studies relate to everyday situations in which researchers tried to do justice to the knowledge of people who have difficulties expressing themselves verbally, but were challenged by what they have initially experienced as 'having it wrong,' 'not knowing,' and 'losing something in translation' in their practice. Finally, we learned that the interactions the researchers encountered were complex. They had to constantly evaluate the appropriateness of their approach, balance rational and intuitive forms of interaction and interpretation, and consider ways of communicating the research findings., Discussion and Conclusion: Approximating epistemic justice in research with people with cognitive and/or language impairment requires extra effort in daily research routines. Sharing everyday ethical issues via case stories and reflecting on these issues encourages moral learning and brings new knowledge about the craftsmanship of researchers. Especially the collaborative and dialogical reflection helped the researchers to dig deeper and find words for intangible processes that often remain unaddressed. However, sharing stories about ethical issues requires mutual trust and safety because sharing and reflecting may bring discomfort, messiness, and uncertainty., Competing Interests: Declaration of Competing Interest No potential competing interest was reported by the authors., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: Early Warning Scores (EWSs) have a great potential to assist clinical decision-making in the emergency department (ED). However, many EWS contain methodological weaknesses in development and validation and have poor predictive performance in older patients. The aim of this study was to develop and externally validate an International Early Warning Score (IEWS) based on a recalibrated National Early warning Score (NEWS) model including age and sex and evaluate its performance independently at arrival to the ED in three age categories (18-65, 66-80, > 80 yr)., Design: International multicenter cohort study., Setting: Data was used from three Dutch EDs. External validation was performed in two EDs in Denmark., Patients: All consecutive ED patients greater than or equal to 18 years in the Netherlands Emergency department Evaluation Database (NEED) with at least two registered vital signs were included, resulting in 95,553 patients. For external validation, 14,809 patients were included from a Danish Multicenter Cohort (DMC)., Measurements and Main Results: Model performance to predict in-hospital mortality was evaluated by discrimination, calibration curves and summary statistics, reclassification, and clinical usefulness by decision curve analysis. In-hospital mortality rate was 2.4% ( n = 2,314) in the NEED and 2.5% ( n = 365) in the DMC. Overall, the IEWS performed significantly better than NEWS with an area under the receiving operating characteristic of 0.89 (95% CIs, 0.89-0.90) versus 0.82 (0.82-0.83) in the NEED and 0.87 (0.85-0.88) versus 0.82 (0.80-0.84) at external validation. Calibration for NEWS predictions underestimated risk in older patients and overestimated risk in the youngest, while calibration improved for IEWS with a substantial reclassification of patients from low to high risk and a standardized net benefit of 5-15% in the relevant risk range for all age categories., Conclusions: The IEWS substantially improves in-hospital mortality prediction for all ED patients greater than or equal to18 years., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer Health, Inc.)

Background: Guidelines and textbooks assert that tachycardia is an early and reliable sign of hypotension, and an increased heart rate (HR) is believed to be an early warning sign for the development of shock, although this response may change by aging, pain, and stress., Objective: To assess the unadjusted and adjusted associations between systolic blood pressure (SBP) and HR in emergency department (ED) patients of different age categories (18-50 years; 50-80 years; > 80 years)., Methods: A multicenter cohort study using the Netherlands Emergency department Evaluation Database (NEED) including all ED patients ≥ 18 years from three hospitals in whom HR and SBP were registered at arrival to the ED. Findings were validated in a Danish cohort including ED patients. In addition, a separate cohort was used including ED patients with a suspected infection who were hospitalized from whom measurement of SBP and HR were available prior to, during, and after ED treatment. Associations between SBP and HR were visualized and quantified with scatterplots and regression coefficients (95% confidence interval [CI])., Results: A total of 81,750 ED patients were included from the NEED, and a total of 2358 patients with a suspected infection. No associations were found between SBP and HR in any age category (18-50 years: -0.03 beats/min/10 mm Hg, 95% CI -0.13-0.07, 51-80 years: -0.43 beats/min/10 mm Hg, 95% CI -0.38 to -0.50, > 80 years: -0.61 beats/min/10 mm Hg, 95% CI -0.53 to -0.71), nor in different subgroups of ED patient. No increase in HR existed with a decreasing SBP during ED treatment in ED patients with a suspected infection., Conclusion: No association between SBP and HR existed in ED patients of any age category, nor in ED patients who were hospitalized with a suspected infection, even during and after ED treatment. Emergency physicians may be misled by traditional concepts about HR disturbances because tachycardia may be absent in hypotension., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: A growing body of evidence suggests the positive impact of arts on health and wellbeing. The mechanisms underlying the impact however, remain overlooked., Methods: 38 Semi-structured interviews were held with 30 older adults and 10 artists, involved in five participatory art projects in the Netherlands. Case-based framework and cross-over analyses were done on the basis of Cousins et al.'s taxonomy., Results: Participatory art initiatives contributed to the wellbeing of older adults in a complex interplay with the artist, art form, group of participants, material aspects and continuity of activities. A welcoming environment appeared a consistent underlying mechanism for participants to grow on a personal and artistic level, connect with others and feel supported in their psychosocial wellbeing., Conclusion: This article demonstrates the important social function participatory art can have for older adults, and argues for the importance of a thorough consideration of the context wherein underlying mechanisms and outcomes emerge.

Background: The ROX index combines respiratory rate and oxygenation to predict the response to oxygen therapy in pneumonia. It is calculated by dividing the patient's oxygen saturation, by the inspired oxygen concentration, and then by the respiratory rate (e.g. 95%/0.21/16 = 28). Since this index includes the most essential physiological variables to detect deterioration, it may be a helpful risk tool in the emergency department (ED). Although small studies suggest it can predict early mortality, no large study has compared it with the National Early Warning Score (NEWS), the most widely validated risk score for death within 24 h., Aim: The aim of this study was to compare the ability of the ROX index with the NEWS to predict mortality within 24 h of arrival at the hospital., Methods: This was a retrospective observational multicentre analysis of data in the Netherlands Emergency Department Evaluation Database (NEED) on 270 665 patients attending four participating Dutch EDs. The ROX index and NEWS were determined on ED arrival and prior to ED treatment., Results: The risk of death within 24 h increased with falling ROX and rising NEWS values. The area under the receiving operating characteristic curves for 24-h mortality of NEWS was significantly higher than for the ROX index [0.92; 95% confidence interval (CI), 0.91-0.92 versus 0.87; 95% CI, 0.86-0.88; P  < 0.01]. However, the observed and predicted mortality by the ROX index was identical to mortality of 5%, after which mortality was underestimated. In contrast, up to a predicted 24-h mortality of 3% NEWS slightly underestimates mortality, and above this level over-estimates it. The standardized net benefit of ROX is slightly higher than NEWS up to a predicted 24-h mortality of 3%., Conclusion: The prediction of 24-h mortality by the ROX index is more accurate than NEWS for most patients likely to be encountered in the ED. ROX may be used as a first screening tool in the ED., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

In the residential care sector we have witnessed throughout the previous decades a development from a rather paternalistic approach towards a more democratic way of care giving. In many care organizations, however, residents are still rarely involved in the daily routine. In a participatory study on a somatic care unit in the Netherlands, we examined the challenges around the involvement of residents in the care residence. We organized two homogeneous group sessions, with staff and residents separately; reflected on new ways for involving residents; and concluded with a heterogeneous focus group, bringing staff and residents together. Both staff and residents recognized the importance of resident involvement in daily care. However, the difference in perspective on what this should look like created challenges. We found three dilemmas that made the engagement of residents challenging: autonomy versus dependence, personal experiences versus privacy, and happiness versus honesty. We found different ways staff and residents dealt with these dilemmas in practice and defined them in terms of bottlenecks and opportunities. Attention to these dilemmas, pitfalls, and potentials, promotes mutual understanding and ultimately resident involvement in daily care.

The COVID-19 pandemic emphasises the importance of care for our societies, yet underscores the inferiority of relational caring practices. During this time, we studied the participatory work of artists working with older adults using participant observations, in-depth interviews and visual ethnography. In this article, we present a case study of one arts initiative, a theatre company engaging seniors in the Netherlands, using ethics and aesthetics of care as sensitising concepts. The findings reveal that this work can promote relational forms of care. This study makes visible how different forms of care can be identified in a participatory art project., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Purpose: This research paper examines how contouring of a wheelchair seating base can help prevent pressure sores by distributing pressure over the buttocks. Contouring wheelchair cushioning is already done to some extent and has proved to be beneficial for pressure distribution. We researched the effect of contouring the seating base, and whether contouring the seating base affects effectiveness in pressure distribution and perceived discomfort., Materials & Methods: 13 healthy participants performed a within-subject experiment with three differently contoured seating bases. Perceived comfort and seating pressure were measured for each condition., Results: Results indicate that a more contoured base is positive for both comfort and increased pressure distribution., Conclusions: Contoured seating bases can provide increased comfort and improved pressure distribution over flat seating bases. Future research should examine the effect of contouring on stability, as well as compare the effects of contoured seating bases and contoured cushions.Implications for rehabilitationWe evaluated the comfort and pressure characteristics of three differently contoured hard seating bases for a wheelchair. The outcomes of the research shows that providing increased contour to seatings could be beneficial to reduce pressure peaks in the buttocks.Contour in the seating is conventionally created by shaping the cushions, this research shows the possibility of using a hard base underneath a cushion to create the desired contour.

Background: Appropriate interpretation of vital signs is essential for risk stratification in the emergency department (ED) but may change with advancing age. In several guidelines, risk scores such as the Systemic Inflammatory Response Syndrome ( SIRS) and Quick Sequential Organ Failure Assessment (qSOFA) scores, commonly used in emergency medicine practice (as well as critical care) specify a single cut-off or threshold for each of the commonly measured vital signs. Although a single cut-off may be convenient, it is unknown whether a single cut-off for vital signs truly exists and if the association between vital signs and in-hospital mortality differs per age-category., Aims: To assess the association between initial vital signs and case-mix adjusted in-hospital mortality in different age categories., Methods: Observational multicentre cohort study using the Netherlands Emergency Department Evaluation Database (NEED) in which consecutive ED patients ≥18 years were included between 1 January 2017 and 12 January 2020. The association between vital signs and case-mix adjusted mortality were assessed in three age categories (18-65; 66-80; >80 years) using multivariable logistic regression. Vital signs were each divided into five to six categories, for example, systolic blood pressure (SBP) categories (≤80, 81-100, 101-120, 121-140, >140 mm Hg)., Results: We included 101 416 patients of whom 2374 (2.3%) died. Adjusted ORs for mortality increased gradually with decreasing SBP and decreasing peripheral oxygen saturation (SpO 2 ). Diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) had quasi-U-shaped associations with mortality. Mortality did not increase for temperatures anywhere in the range between 35.5°C and 42.0°C, with a single cut-off around 35.5°C below which mortality increased. Single cut-offs were also found for MAP <70 mm Hg and respiratory rate >22/min. For all vital signs, older patients had larger increases in absolute mortality compared with younger patients., Conclusion: For SBP, DBP, SpO 2 and HR, no single cut-off existed. The impact of changing vital sign categories on prognosis was larger in older patients. Our results have implications for the interpretation of vital signs in existing risk stratification tools and acute care guidelines., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Treatment and the clinical course during Emergency Department (ED) stay before Intensive Care Unit (ICU) admission may affect predicted mortality risk calculated by the Acute Physiology and Chronic Health Evaluation (APACHE)-IV, causing lead-time bias. As a result, comparing standardized mortality ratios (SMRs) among hospitals may be difficult if they differ in the location where initial stabilization takes place. The aim of this study was to assess to what extent predicted mortality risk would be affected if the APACHE-IV score was recalculated with the initial physiological variables from the ED. Secondly, to evaluate whether ED Length of Stay (LOS) was associated with a change (delta) in these APACHE-IV scores., Methods: An observational multicenter cohort study including ICU patients admitted from the ED. Data from two Dutch quality registries were linked: the Netherlands Emergency department Evaluation Database (NEED) and the National Intensive Care Evaluation (NICE) registry. The ICU APACHE-IV, predicted mortality, and SMR based on data of the first 24 h of ICU admission were compared with an ED APACHE-IV model, using the most deviating physiological variables from the ED or ICU., Results: A total of 1398 patients were included. The predicted mortality from the ICU APACHE-IV (median 0.10; IQR 0.03-0.30) was significantly lower compared to the ED APACHE-IV model (median 0.13; 0.04-0.36; p < 0.01). The SMR changed from 0.63 (95%CI 0.54-0.72) to 0.55 (95%CI 0.47-0.63) based on ED APACHE-IV. Predicted mortality risk changed more than 5% in 321 (23.2%) patients by using the ED APACHE-IV. ED LOS > 3.9 h was associated with a slight increase in delta APACHE-IV of 1.6 (95% CI 0.4-2.8) compared to ED LOS < 1.7 h., Conclusion: Predicted mortality risks and SMRs calculated by the APACHE IV scores are not directly comparable in patients admitted from the ED if hospitals differ in their policy to stabilize patients in the ED before ICU admission. Future research should focus on developing models to adjust for these differences., (© 2022. The Author(s).)

Purpose: To assess how often baseline systolic blood pressure (SBP) could be retrieved from the Electronic Health Record (EHR) in older Emergency Department (ED) patients. Second, to assess whether the difference between baseline SBP and initial SBP in the ED (ΔSBP) was associated with 30-day mortality., Methods: A multicenter hypothesis-generating cohort study including patients  ≥ 70 years. EHRs were searched for baseline SBPs. The association between ΔSBP and 30-day mortality was investigated., Results: Baseline SBP was found in 220 out of 300 patients (73.3%; 95%CI 68.1-78.0%). In 72 patients with normal initial SBPs (133-166 mmHg) in the ED, fifteen (20.8%) had a negative ΔSBP with 20.0% mortality. A negative ΔSBP was associated with 30-day mortality (AHR 4.7; 1.7-12.7)., Conclusion: Baseline SBPs are often available in older ED patients. The ΔSBP has prognostic value and could be used as an extra variable to recognize hypotension in older ED patients. Future studies should clarify whether the ΔSBP improves risk stratification in the ED., (© 2021. The Author(s), under exclusive licence to European Geriatric Medicine Society.)

Purpose: Drug-Related Admissions (DRAs) are a well-known problem among older patients in the Emergency Department (ED). The aim of this study was (a) to investigate the prevalence and clinical manifestations of DRAs and the responsible drugs, (b) to study the association between geriatric characteristics and DRAs, and (c) to study the predictive performance of geriatric screeners for identifying DRAs in older ED patients., Methods: Patients aged ≥ 70 hospitalized from the ED were included. Demographics, geriatric characteristics and medications were collected. The the Acutely Presenting Older Patient (APOP)-screener, the Identification of Seniors At Risk (ISAR) and the ISAR-Hospitalized Patients (ISAR-HP) were used as geriatric screeners. Potential DRAs were identified retrospectively, the association between geriatric screeners and DRAs was investigated with logistic regression and the predictive performance was assessed by calculating the Area under the Curve (AUC) of the Receiver Operator Characteristics (ROC)., Results: The mean age of patients was 78 (IQR 73-83), using an average of 6 medications. Out of 240 admissions, 77 (30%) were classified as a DRA. Independent risk factors for DRAs were polypharmacy (OR 2.42; 95% CI 1.23-4.74) and the ADL dependency (OR 1.23; 95%CI 1.05-1.44). ISAR (OR 3.27; 95%CI 1.60-6.69) and ISAR-HP (OR 1.83; 95% CI 1.02-3.27) associated with increased risk of DRAs, whereas the APOP screener did not (OR 1.56; 95% CI 0.82-2.97). The predictive performance of all geriatric screeners for predicting DRAs was poor (AUC for all screeners < 0.60)., Conclusion: DRAs are highly prevalent in older ED patients. Polypharmacy, ADL dependency and a high ISAR or ISAR-HP are associated with higher risk for DRAs, but the predictive value of geriatric screeners is insufficient., (© 2021. The Author(s), under exclusive licence to European Geriatric Medicine Society.)

Purpose: Older people often present to the Emergency Department with nonspecific complaints. We aimed (1) to examine characteristics of older patients presenting to the ED triaged with the presentational flowchart 'unwell adult' of the Manchester triage system (MTS) and (2) to assess the different mortality and admission rates among triage categories., Methods: Retrospective cohort study including all consecutive patients aged 70 years and older who visited the ED of a tertiary care hospital in the Netherlands during a 1-year period. The primary outcome was 30-day mortality. Secondary outcomes were 7-day mortality, hospital admission and ED length of stay., Results: 4255 patients were included in this study. Mean age was 78 years (IQR 73.9-83.4) and 2098 were male (49.3%). The MTS presentational flowchart 'unwell adult' was the most commonly used flowchart (n = 815, 19.3%). After the infrequent flowchart 'major trauma' (n = 9, 13.8%), 'unwell adult' had the highest 30-day mortality (n = 88, 10.8%). When compared to all other flowcharts, patients assigned as 'unwell adult' have significantly higher 30-day mortality rates (OR 1.89 (95%CI 1.46-2.46), p =  < 0.001), also when adjusted for age, gender and triage priority (OR 1.75 (95%CI 1.32-2.31), p =  < 0.001). Patients from the 'unwell adult' flowchart had the highest hospital admission rate (n = 540, 66.3%), and had among the longest ED length of stay., Conclusions: Older ED patients are most commonly assigned the presentational flowchart 'unwell adult' when using the MTS. Patients in this category have the highest non-trauma mortality and highest hospital admission rates when compared to other presenting complaints., (© 2021. The Author(s), under exclusive licence to European Geriatric Medicine Society.)

Purpose: Despite the rapidly expanding knowledge in the field of Geriatric Emergency Medicine in Europe, widespread implementation of change is still lacking. Many opportunities in everyday clinical care are missed to improve care for this susceptible and growing patient group. The aim was to develop expert clinical recommendations on Geriatric Emergency Medicine to be disseminated across Europe., Methods: A group of multi-disciplinary experts in the field of Geriatric Emergency Medicine in Europe was assembled. Using a modified Delphi procedure, a prioritized list of topics related to Geriatric Emergency Medicine was created. Next, a multi-disciplinary group of nurses, geriatricians and emergency physicians performed a review of recent guidelines and literature to create recommendations. These recommendations were voted upon by a group of experts and placed on visually attractive posters. The expert group identified the following eight subject areas to develop expert recommendations on: Comprehensive Geriatric Assessment in the Emergency Department (ED), age/frailty adjusted risk stratification, delirium and cognitive impairment, medication reviews in the ED for older adults, family involvement, ED environment, silver trauma, end of life care in the acute setting., Results: Eight posters with expert clinical recommendations on the most important topics in Geriatric Emergency Medicine are now available through https://posters.geriemeurope.eu/ ., Conclusion: Expert clinical recommendations for Geriatric Emergency Medicine may help to improve care for older patients in the Emergency Department and are ready for dissemination across Europe., (© 2021. The Author(s), under exclusive licence to European Geriatric Medicine Society.)

Study Objective: To investigate how age affects the predictive performance of the National Early Warning Score (NEWS) at arrival to the emergency department (ED) regarding inhospital mortality and intensive care admission., Methods: International multicenter retrospective cohorts from 2 Danish and 3 Dutch ED. Development cohort: 14,809 Danish patients aged ≥18 years with at least systolic blood pressure or pulse measured from the Danish Multicenter Cohort. External validation cohort: 50,448 Dutch patients aged ≥18 years with all vital signs measured from the Netherlands Emergency Department Evaluation Database (NEED). Multivariable logistic regression was used for model building. Performance was evaluated overall and within age categories: 18 to 64 years, 65 to 80 years, and more than 80 years., Results: In the Danish Multicenter Cohort, a total of 2.5% died inhospital, and 2.8% were admitted to the ICU, compared with 2.8% and 1.6%, respectively, in the NEED. Age did not add information for the prediction of intensive care admission but was the strongest predictor for inhospital mortality. For NEWS alone, severe underestimation of risk was observed for persons above 80 while overall Area Under Receiver Operating Characteristic (AUROC) was 0.82 (confidence interval [CI] 0.80 to 0.84) in the Danish Multicenter Cohort versus 0.75 (CI 0.75 to 0.77) in the NEED. When combining NEWS with age, underestimation of risks was eliminated for persons above 80, and overall AUROC increased significantly to 0.86 (CI 0.85 to 0.88) in the Danish Multicenter Cohort versus 0.82 (CI 0.81 to 0.83) in the NEED., Conclusion: Combining NEWS with age improved the prediction performance regarding inhospital mortality, mostly for persons aged above 80, and can potentially improve decision policies at arrival to EDs., (Copyright © 2021 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Citizen science and models for public participation in health research share normative ideals of participation, inclusion, and public and patient engagement. Academic researchers collaborate in research with members of the public involved in an issue, maximizing all involved assets, competencies, and knowledge. In citizen science new ethical issues arise, such as who decides, who participates, who is excluded, what it means to share power equally, or whose knowledge counts. This article aims to present an ethics framework that offers a lens of understanding and heuristic guidelines to deal with ethical issues in citizen science., Methods: We conducted seven case studies between 2015 and 2021 to attune and validate the ethics framework for the context of citizen science. The cases related to studies with older adults, people with a psychiatric vulnerability, people dependent on community care, people who are unemployed or living in poverty or both, and young adults with respiratory disease., Results: Ethics in citizen science reaches beyond the ethical issues in traditional biomedical and health research. It entails more than following procedures about informed consent and privacy and submitting a proposal to a Medical Research Ethics Committee. Ethics in citizen science relates to everyday ethical issues during the study, including relational and moral complexities concerning collaboration, sharing power, and democratic decision-making. Dealing with these issues requires ethics work of researchers. This entails seeing ethically salient issues and reflecting on everyday ethical issues. Ethics work consists of seven features: framing work, role work, emotion work, identity work, reason work, relationship work, and performance work. All are relevant for researchers in citizen science., Conclusions: Ethical issues in citizen science often relate to power differentials, partnership, and collaboration between academics and non-academics. The ethics framework prepares researchers for the work needed in citizen science to act responsibly and offers a heuristic guide to reflect on ethics. Reflection on ethics is a pathway towards ethical citizen science, especially if researchers collaboratively reflect in partnership with non-academics who are subject to the moral issue., (© 2022. The Author(s).)

Over the previous years, the residential care sector has gone through a transition from a rather paternalistic approach towards a more democratic way of caregiving. Nevertheless, many care organizations still find it challenging to engage their residents in the process of care. In this study, we investigated the challenges regarding the engagement of older adults in residential care. As recent studies indicated the increasing opportunities of ICTs, we paid particular attention to this in the process of engagement. We followed a participatory action research approach among caregivers and older adults at a somatic care department in a care residence in the Netherlands. Methods used included 15 participants in two homogeneous group sessions, reflections on action in practice, and one mixed focus group. Our findings show that both caregivers and older adults acknowledge the importance of engagement in daily care. However, their different perspectives on how this should take place, made the actual engagement of older adults a challenge. We determined three dilemmas complicating this engagement in care, and labeled these (1) autonomy versus dependence; (2) personal experiences versus privacy; and (3) happiness versus honesty. We found different ways of how caregivers and older adults deal with these dilemma's in practice and defined these in terms of pitfalls and potentials. ICTs were shown to reinforce both the pitfalls and potentials. Paying attention to these challenges in residential care, including how caregivers and older adults deal with these challenges, will encourage a mutual understanding and actual engagement in decisions on daily care. Further research is recommended on the role of organizations' management, older adults' relatives, or older adults with cognitive impairments.

Health researchers increasingly work with patients in a participatory fashion. Active patient involvement throughout the research process can provide epistemic justice to patients who have often only had an informant role in traditional health research. This study aims to conduct participatory research on patient experiences to create a solid research agenda with patients and discuss it with relevant stakeholders. We followed a participatory research design in 18 sub-studies, including interviews and group sessions ( n = 404 patients), and dialogue sessions ( n = 367 professionals and directors in healthcare and social work, municipality civil servants, and funding agencies) on patient experiences with psychiatric care, community care, daycare, public health, and social work. Findings from the eight-year study show that four priorities stood out: attention for misuse of power and abuse; meaningful participation; non-human assistance, and peer support. Moreover, that: (1) patients, based on their experiences, prioritize different topics than experts; (2) most topics are trans-diagnostic and point to the value of a cross-disability approach; and (3) the priorities of patients are all too easily dismissed and require ethics work to prevent epistemic injustice. Long-term investment in a transdisciplinary community of practice offers a solid basis for addressing patient-centered topics and may impact the quality of life of people living with chronic illness, disability, or vulnerability.

Background and Importance: Although aging societies in Western Europe use presenting complaints (PCs) in emergency departments (EDs) triage systems to determine the urgency and severity of the care demand, it is unclear whether their prognostic value is age-dependent., Objective: To assess the frequency and association of PCs with hospitalization and mortality across age categories., Methods: An observational multicenter study using all consecutive visits of three EDs in the Netherlands Emergency department Evaluation Database. Patients were stratified by age category (0-18; 19-50; 51-65; 66-80; >80 years), in which the association between PCs and case-mix adjusted hospitalization and mortality was studied using multivariable logistic regression analysis (adjusting for demographics, hospital, disease severity, comorbidity and other PCs)., Results: We included 172  104 ED-visits. The most frequent PCs were 'extremity problems' [range across age categories (13.5-40.8%)], 'feeling unwell' (9.5-23.4%), 'abdominal pain' (6.0-13.9%), 'dyspnea' (4.5-13.3%) and 'chest pain' (0.6-10.7%). For most PCs, the observed and the case-mix-adjusted odds for hospitalization and mortality increased the higher the age category. The most common PCs with the highest adjusted odds ratios (AORs, 95% CI) for hospitalization were 'diarrhea and vomiting' [2.30 (2.02-2.62)] and 'feeling unwell' [1.60 (1.48-1.73)]. Low hospitalization risk was found for 'chest pain' [0.58 (0.53-0.63)] and 'palpitations' [0.64 (0.58-0.71)]., Conclusions: Frequency of PCs in ED patients varies with age, but the same PCs occur in all age categories. For most PCs, (case-mix adjusted) hospitalization and mortality vary across age categories. 'Chest pain' and 'palpitations,' usually triaged 'very urgent', carry a low risk for hospitalization and mortality., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Appropriate interpretation of blood tests is important for risk stratification and guidelines used in the Emergency Department (ED) (such as SIRS or CURB-65). The impact of abnormal blood test values on mortality may change with increasing age due to (patho)-physiologic changes. The aim of this study was therefore to assess the effect of age on the case-mix adjusted association between biomarkers of renal function and homeostasis, inflammation and circulation and in-hospital mortality. This observational multi-center cohort study has used the Netherlands Emergency department Evaluation Database (NEED), including all consecutive ED patients ≥ 18 years of three hospitals. A generalized additive logistic regression model was used to visualize the association between in-hospital mortality, age and five blood tests (creatinine, sodium, leukocytes, C-reactive Protein, and hemoglobin). Multivariable logistic regression analyses were used to assess the association between the number of abnormal blood test values and mortality per age category (18-50; 51-65; 66-80; > 80 years). Of the 94,974 included patients, 2550 (2.7%) patients died in-hospital. Mortality increased gradually for C-reactive Protein (CRP), and had a U-shaped association for creatinine, sodium, leukocytes, and hemoglobin. Age significantly affected the associations of all studied blood tests except in leukocytes. In addition, with increasing age categories, case-mix adjusted mortality increased with the number of abnormal blood tests. In summary, the association between blood tests and (adjusted) mortality depends on age. Mortality increases gradually or in a U-shaped manner with increasing blood test values. Age-adjusted numerical scores may improve risk stratification. Our results have implications for interpretation of blood tests and their use in risk stratification tools and acute care guidelines.Trial registration number Netherlands Trial Register (NTR) NL8422, 03/2020., (© 2022. The Author(s).)

Objective: The aim of this study was to investigate whether sex differences exist in disease presentations, disease severity and (case-mix adjusted) outcomes in the Emergency Department (ED)., Methods: Observational multicenter cohort study using the Netherlands Emergency Department Evaluation Database (NEED), including patients ≥ 18 years of three Dutch EDs. Multivariable logistic regression was used to study the associations between sex and outcome measures in-hospital mortality and Intensive Care Unit/Medium Care Unit (ICU/MCU) admission in ED patients and in subgroups triage categories and presenting complaints., Results: Of 148,825 patients, 72,554 (48.8%) were females. Patient characteristics at ED presentation and diagnoses (such as pneumonia, cerebral infarction, and fractures) were comparable between sexes at ED presentation. In-hospital mortality was 2.2% in males and 1.7% in females. ICU/MCU admission was 4.7% in males and 3.1% in females. Males had higher unadjusted (OR 1.34(1.25-1.45)) and adjusted (AOR 1.34(1.24-1.46)) risks for mortality, and unadjusted (OR 1.54(1.46-1.63)) and adjusted (AOR 1.46(1.37-1.56)) risks for ICU/MCU admission. Males had higher adjusted mortality and ICU/MCU admission for all triage categories, and with almost all presenting complaints except for headache., Conclusions: Although patient characteristics at ED presentation for both sexes are comparable, males are at higher unadjusted and adjusted risk for adverse outcomes. Males have higher risks in all triage categories and with almost all presenting complaints. Future studies should investigate reasons for higher risk in male ED patients., (Copyright © 2021. Published by Elsevier B.V.)

The recent advances in relative protein-ligand binding free energy calculations have shown the value of alchemical methods in drug discovery. Accurately assessing absolute binding free energies, although highly desired, remains a challenging endeavour, mostly limited to small model cases. Here, we demonstrate accurate first principles based absolute binding free energy estimates for 128 pharmaceutically relevant targets. We use a novel rigorous method to generate protein-ligand ensembles for the ligand in its decoupled state. Not only do the calculations deliver accurate protein-ligand binding affinity estimates, but they also provide detailed physical insight into the structural determinants of binding. We identify subtle rotamer rearrangements between apo and holo states of a protein that are crucial for binding. When compared to relative binding free energy calculations, obtaining absolute binding free energies is considerably more challenging in large part due to the need to explicitly account for the protein in its apo state. In this work we present several approaches to obtain apo state ensembles for accurate absolute Δ G calculations, thus outlining protocols for prospective application of the methods for drug discovery., Competing Interests: There are no conflicts to declare., (This journal is © The Royal Society of Chemistry.)

Poor patient knowledge about transplantation is a significant problem following kidney transplant. A video-based educational intervention was developed to supplement standard education provided by transplant teams., Methods: A multicenter randomized controlled trial tested the intervention delivered to patients undergoing assessment or waitlisted for kidney transplant. Adult participants were randomized to the control (standard education) or the intervention group, consisting of electronic access to the videos (or digital video disks if no internet) plus standard education. Differences between groups in changes in transplant knowledge (measured by the Kidney Transplant Understanding Tool), education satisfaction, self-efficacy, and quality of life (secondary outcomes) were evaluated by a preintervention and postintervention survey. Video viewing habits were tracked and described for patients in the intervention group., Results: One hundred sixty-two patients were enrolled, with 132 completing both questionnaires (n = 64 intervention and n = 68 control), with similar enrollment from 3 Canadian sites. Video viewing statistics in the complete cases indicated that 78% (50/64) watched the videos, with 70% (45/64) viewing them electronically, while 8% (5/64) received digital video disks and self-reported participation. Baseline knowledge scores in the intent-to-treat population were 55.4 ± 6.5 and 55.7 ± 7.1 in the intervention and control, respectively. The mean knowledge change in the intervention (2.1 ± 3.6) was significantly higher than in the control group (0.8 ± 3.4, P < 0.02). In the per-protocol analysis (patients with objective evidence of watching at least 80% of the videos), the knowledge improvements were 3.4 ± 3.8. Video group participants reported higher satisfaction with education ( P < 0.02) and expressed positive comments in open-ended feedback., Conclusions: Electronic video education in the pretransplant setting improved knowledge and satisfaction., Competing Interests: H.M., N.R., R.M., and A.S. developed the video intervention used in this project. The other authors declare no conflicts of interest., (Copyright © 2021 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.)

Emergency Departments (EDs) are increasingly seeing more seriously unwell older people living with frailty. In the context of limited resources and increasing demand it's the ED practitioner's challenge to unpick this constellation of physical, psychological, functional and social issues.To properly assess older people living with frailty at the ED it is crucial to use an holistic approach. This consists of triage with algorithms sensitive to the higher risk of older people living with frailty, a frailty assessment, and an assessment with the help of the principles of Comprehensive Geriatric Assessment. Multi-disciplinary care, a tailor-made treatment plan, based on what the person values most, will help the ED practitioner to deliver appropriate and valuable care during the ED stay, but also in transition from hospital to home., Competing Interests: Competing interests: JB reports personal fees from NHS Elect, England, personal fees from Jay Banerjee Consultancy Ltd, outside the submitted work; and I am the Chair of the Frailty/ Older Person’s Special Interest Group for the Royal College of Emergency Medicine, UK. SPC reports grants from National Institute of Health Research, UK, outside the submitted work. All other authors have nothing to disclose., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

An emerging body of research indicates that active arts engagement can enhance older adults' health and experienced well-being, but scientific evidence is still fragmented. There is a research gap in understanding arts engagement grounded in a multidimensional conceptualization of the value of health and well-being from older participants' perspectives. This Dutch nation-wide study aimed to explore the broader value of arts engagement on older people's perceived health and well-being in 18 participatory arts-based projects (dance, music, singing, theater, visual arts, video, and spoken word) for community-dwelling older adults and those living in long term care facilities. In this study, we followed a participatory design with narrative- and arts-based inquiry. We gathered micro-narratives from older people and their (in)formal caregivers ( n = 470). The findings demonstrate that arts engagement, according to participants, resulted in (1) positive feelings, (2) personal and artistic growth, and (3) increased meaningful social interactions. This study concludes that art-based practices promote older people's experienced well-being and increase the quality of life of older people. This study emphasizes the intrinsic value of arts engagement and has implications for research and evaluation of arts engagement.

Objective: Early identification of emergency department (ED) patients who need hospitalization is essential for quality of care and patient safety. We aimed to compare machine learning (ML) models predicting the hospitalization of ED patients and conventional regression techniques at three points in time after ED registration., Methods: We analyzed consecutive ED patients of three hospitals using the Netherlands Emergency Department Evaluation Database (NEED). We developed prediction models for hospitalization using an increasing number of data available at triage, ∼30 min (including vital signs) and ∼2 h (including laboratory tests) after ED registration, using ML (random forest, gradient boosted decision trees, deep neural networks) and multivariable logistic regression analysis (including spline transformations for continuous predictors). Demographics, urgency, presenting complaints, disease severity and proxies for comorbidity, and complexity were used as covariates. We compared the performance using the area under the ROC curve in independent validation sets from each hospital., Results: We included 172,104 ED patients of whom 66,782 (39 %) were hospitalized. The AUC of the multivariable logistic regression model was 0.82 (0.78-0.86) at triage, 0.84 (0.81-0.86) at ∼30 min and 0.83 (0.75-0.92) after ∼2 h. The best performing ML model over time was the gradient boosted decision trees model with an AUC of 0.84 (0.77-0.88) at triage, 0.86 (0.82-0.89) at ∼30 min and 0.86 (0.74-0.93) after ∼2 h., Conclusions: Our study showed that machine learning models had an excellent but similar predictive performance as the logistic regression model for predicting hospital admission. In comparison to the 30-min model, the 2-h model did not show a performance improvement. After further validation, these prediction models could support management decisions by real-time feedback to medical personal., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Participatory health research (PHR) is a research approach in which people, including hidden populations, share lived experiences about health inequities to improve their situation through collective action. Boundary objects are produced, using arts-based methods, to be heard by stakeholders. These can bring about dialogue, connection, and involvement in a mission for social justice. This study aims to gain insight into the value and ethical issues of boundary objects that address health inequalities. A qualitative evaluation is conducted on three different boundary objects, created in different participatory studies with marginalized populations (mothers in poverty, psychiatric patients, and unemployed people). A successful boundary object evokes emotions among those who created the objects and those encountering these objects. Such objects move people and create an impulse for change. The more provocative the object, the more people feel triggered to foster change. Boundary objects may cross personal boundaries and could provoke feelings of discomfort and ignorance. Therefore, it is necessary to pay attention to ethics work. Boundary objects that are made by people from hidden populations may spur actions and create influence by improving the understanding of the needs of hidden populations. A dialogue about these needs is an essential step towards social justice.

Aims: Syncope care is often fragmented and inefficient. Structuring syncope care through implementation of guidelines and Syncope Units has been shown to improve diagnostic yield, reduce costs and improve quality of life. We implemented the European Society of Cardiology (ESC) 2018 syncope guidelines at the Emergency Departments (ED) and established Syncope Units in five Dutch hospitals. We evaluated the implementation process by identifying factors that hinder ('barriers') and facilitate ('facilitators') the implementation., Methods and Results: We conducted, recorded and transcribed semi-structured interviews with 19 specialists and residents involved in syncope care from neurology, cardiology, internal medicine and emergency medicine. Two researchers independently classified the reported barriers and facilitators, according to the framework of qualitative research (Flottorp), which distinguished several separate fields ('levels'). Software package Atlas.ti was used for analysis. We identified 31 barriers and 22 facilitators. Most barriers occurred on the level of the individual health care professional (e.g. inexperienced residents having to work with the guideline at the ED) and the organizational context (e.g. specialists not relinquishing preceding procedures). Participants reported most facilitators at the level of innovation (e.g. structured work-flow at the ED). The multidisciplinary Syncope Unit was welcomed as useful solution to a perceived need in clinical practice., Conclusion: Implementing ESC syncope guidelines at the ED and establishing Syncope Units facilitated a structured multidisciplinary work-up for syncope patients. Most identified barriers related to the individual health care professional and the organizational context. Future implementation of the multidisciplinary guideline should be tailored to address these barriers., Competing Interests: Declaration of Competing Interest MG, LvBV, FJdL, ECAK, BdG and MB report no disclosures relevant to the manuscript. SYGP received lecture fees from Spaarne Gasthuis hospital and Medtronic. MEWH received speakers fees from Biotronik and Medtronic. JGvD has received lecture fees from Medtronic. RDT has received fees for lectures from Medtronic, UCB, and Novartis. RDT has received consultancy fees from Theravarance and Arvelle. RDT receives research support from the Dutch National Epilepsy Fund, The Netherlands Organisation for Health Research and Development (ZonMW), NUTS Ohra Fund, Medtronic, Christelijke Vereniging voor de Verpleging van Lijders aan Epilepsie, The Netherlands., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Background and Importance: Healthcare personnel working in the emergency department (ED) is at risk of acquiring severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2). So far, it is unknown if the reported variety in infection rates among healthcare personnel is related to the use of personal protective equipment (PPE) or other factors., Objective: The aim of this study was to investigate the association between PPE use and SARS-CoV-2 infections among ED personnel in the Netherlands., Design, Setting and Participants: A nationwide survey, consisting of 42 questions about PPE-usage, ED layout - and workflow and SARS-CoV-2 infection rates of permanent ED staff, was sent to members of the Dutch Society of Emergency Physicians. Members were asked to fill out one survey on behalf of the ED of their hospital. The association between PPE use and the infection rate was investigated using univariable and multivariable regression analyses, adjusting for potential confounders., Outcome Measures: Primary outcome was the incidence of confirmed SARS-CoV-2 infections among permanent ED staff between 1 March and 15 May 2020., Results: Surveys were sent to 64 EDs of which 45 responded (70.3%). In total, 164 ED staff workers [5.1 (3.2-7.0)%] tested positive for COVID-19 during the study period compared to 0.087% of the general population. There was significant clustering of infected ED staff in some hospitals (range: 0-23 infection). In 13 hospitals, an FFP2 (filtering facepiece particles >94% aerosol filtration) mask or equivalent and eye protection was worn for all contacts with patients with suspected or confirmed SARS-CoV-2 during the whole study period. The unadjusted staff infection rate was higher in these hospitals [7.3 (3.4-11.1) vs. 4.0 (1.9-6.1)%, absolute difference + 3.3%]. Hospital staff testing policy was identified as a potential confounder of the relation between PPE use and confirmed SARS-CoV-2 infections (collinearity statistic 0.95). After adjusting for hospital testing policy, type of PPE was not associated with incidence of COVID 19 infections among ED staff (P = 0.40)., Conclusion: In this cross-sectional study, the use of high-level PPE (FFP2 or equivalent and eye protection) by ED personnel during all contacts with patients with suspected or confirmed SARS-CoV-2 does not seem to be associated with a lower infection rate of ED staff compared to lower level PPE use. Attention should be paid to ED layout and social distancing to prevent cross-contamination of ED personnel., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: During the first wave of the coronavirus disease 2019 (COVID-19) pandemic, older patients had an increased risk of hospitalisation and death. Reports on the association of frailty with poor outcome have been conflicting., Objective: The aim of the present study was to investigate the independent association between frailty and in-hospital mortality in older hospitalised COVID-19 patients in the Netherlands., Methods: This was a multicentre retrospective cohort study in 15 hospitals in the Netherlands, including all patients aged ≥70 years, who were hospitalised with clinically confirmed COVID-19 between February and May 2020. Data were collected on demographics, co-morbidity, disease severity and Clinical Frailty Scale (CFS). Primary outcome was in-hospital mortality., Results: A total of 1,376 patients were included (median age 78 years (interquartile range 74-84), 60% male). In total, 499 (38%) patients died during hospital admission. Parameters indicating presence of frailty (CFS 6-9) were associated with more co-morbidities, shorter symptom duration upon presentation (median 4 versus 7 days), lower oxygen demand and lower levels of C-reactive protein. In multivariable analyses, the CFS was independently associated with in-hospital mortality: compared with patients with CFS 1-3, patients with CFS 4-5 had a two times higher risk (odds ratio (OR) 2.0 (95% confidence interval (CI) 1.3-3.0)) and patients with CFS 6-9 had a three times higher risk of in-hospital mortality (OR 2.8 (95% CI 1.8-4.3))., Conclusions: The in-hospital mortality of older hospitalised COVID-19 patients in the Netherlands was 38%. Frailty was independently associated with higher in-hospital mortality, even though COVID-19 patients with frailty presented earlier to the hospital with less severe symptoms., (© The Author(s) 2021. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Purpose: Geriatric Emergency Medicine (GEM) focuses on delivering optimal care to (sub)acutely ill older people. This involves a multidisciplinary approach throughout the whole healthcare chain. However, the underpinning evidence base is weak and it is unclear which research questions have the highest priority. The aim of this study was to provide an inventory and prioritisation of research questions among GEM professionals throughout Europe., Methods: A two-stage modified Delphi approach was used. In stage 1, an online survey was administered to various professionals working in GEM both in the Emergency Department (ED) and other healthcare settings throughout Europe to make an inventory of potential research questions. In the processing phase, research questions were screened, categorised, and validated by an expert panel. Subsequently, in stage 2, remaining research questions were ranked based on relevance using a second online survey administered to the same target population, to identify the top 10 prioritised research questions., Results: In response to the first survey, 145 respondents submitted 233 potential research questions. A total of 61 research questions were included in the second stage, which was completed by 176 respondents. The question with the highest priority was: Is implementation of elements of CGA (comprehensive geriatric assessment), such as screening for frailty and geriatric interventions, effective in improving outcomes for older patients in the ED?, Conclusion: This study presents a top 10 of high-priority research questions for a European Research Agenda for Geriatric Emergency Medicine. The list of research questions may serve as guidance for researchers, policymakers and funding bodies in prioritising future research projects.

Background: The patient perspective on the use of screening for high risks of adverse health outcomes in Emergency Department (ED) care is underexposed, although it is an important perspective influencing implementation in routine care. This study explores the experiences with, and attitudes towards geriatric screening in routine ED care among older people who visited the ED., Methods: This was a qualitative study using individual face-to-face semi-structured interviews. Interviews were conducted in older patients (≥70 years) who completed the 'Acutely Presenting Older Patient' screener while visiting the ED of a Dutch academic hospital. Purposive convenience sampling was used to select a heterogeneous sample of participants regarding age, disease severity and the result from screening. Transcripts were analyzed inductively using thematic analysis., Results: After 13 interviews (7 women, median age 82 years), data saturation was reached. The participants had noticed little of the screening administration during triage and screening was considered as a normal part of ED care. Most participants believed that geriatric screening contributes to assessing older patients holistically, recognizing geriatric problems early and comforting patients with communication and attention. None of the participants had a negative attitude towards screening or thought that screening is discrimination on age. Care providers should communicate respectfully with frail older patients and involve them in decision-making., Conclusions: Older patients experienced geriatric screening as a normal part of ED care and had predominantly positive attitudes towards its use in the ED. This qualitative study advocates for continuing the implementation of geriatric screening in routine ED practice.

Background: Falls in older Emergency Department (ED) patients may indicate underlying frailty. Geriatric follow-up might help improve outcomes in addition to managing the direct cause and consequence of the fall. We aimed to study whether fall characteristics and the result of geriatric screening in the ED are independently related to adverse outcomes in older patients with fall-related ED visits., Methods: This was a secondary analysis of the observational multicenter Acutely Presenting Older Patient (APOP) study, of which a subset of patients aged ≥70 years with fall-related ED visits were prospectively included in EDs of two Dutch hospitals. Fall characteristics (cause and location) were retrospectively collected. The APOP-screener was used as a geriatric screening tool. The outcome was 3- and 12-months functional decline and mortality. We assessed to what extent fall characteristics and the geriatric screening result were independent predictors of the outcome, using multivariable logistic regression analysis., Results: We included 393 patients (median age 80 (IQR 76-86) years) of whom 23.0% were high risk according to screening. The cause of the fall was extrinsic (49.6%), intrinsic (29.3%), unexplained (6.4%) or missing (14.8%). A high risk geriatric screening result was related to increased risk of adverse outcomes (3-months adjusted odds ratio (AOR) 2.27 (1.29-3.98), 12-months AOR 2.20 (1.25-3.89)). Independent of geriatric screening result, an intrinsic cause of the fall increased the risk of 3-months adverse outcomes (AOR 1.92 (1.13-3.26)) and a fall indoors increased the risk of 3-months (AOR 2.14 (1.22-3.74)) and 12-months adverse outcomes (AOR 1.78 (1.03-3.10))., Conclusions: A high risk geriatric screening result and fall characteristics were both independently associated with adverse outcomes in older ED patients, suggesting that information on both should be evaluated to guide follow-up geriatric assessment and interventions in clinical care.

Background: Personal protective equipment (PPE) used by healthcare workers was scarce during the COVID-19 pandemic . The aim of this study was to assess whether telemedicine (using iPads) reduced PPE use in emergency department (ED) patients who were treated in contact isolation, and whether telemedicine had a positive effect on patient anxiety and satisfaction., Methods: We conducted a prospective single centre before-and-after study including ED patients ≥18 years who were treated in contact isolation. PPE use, the Hospital Anxiety Scale and the 15-item Picker Patient Experience Questionnaire were compared between the control period (8 April to 14 April 2020) and intervention period (15 April to 24 April 2020)., Results: We included 25 patients in each period. PPE use per patient was higher for physicians in the control period (mean 1.7; 95% CI 1.5 to 1.9) compared with the intervention period (mean 1.2; 95% CI 1.0 to 1.3, p<0.01). Total PPE use per patient contact for ED physicians decreased from 42 out of 42 patient contacts in the control period, to 29 out of 66 patient contacts in the intervention period (difference 54.3%; 95% CI 50.1% to 58.6%, p<0.01). Reported anxiety and satisfaction were not significantly different., Conclusion: PPE use by physicians can successfully be reduced by using telemedicine in the ED without increasing anxiety or dissatisfaction. This study was a first step to gain experience with telemedicine in the ED which has the potential to reduce PPE use in future pandemics or other patients with an indication for contact isolation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) care shortly after implementation., Methods: We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate., Results: Two comparable groups of patients (median age 77 years) were included before (n = 920) and after (n = 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after; p = 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after; p = 0.152) or hospital admission rate (40% before vs. 39% after; p = 0.410)., Conclusion: Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.