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The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation.The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research.Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics.Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC.There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.

To identify research and practice gaps to establish future research priorities to advance the detection of cognitive impairment and dementia in the emergency department (ED).Literature review and consensus-based rankings by a transdisciplinary, stakeholder task force of experts, persons living with dementia, and care partners.Scoping reviews focused on adult ED patients.Two systematic scoping reviews of 7 medical research databases focusing on best tools and approaches for detecting cognitive impairment and dementia in the ED in terms of (1) most accurate and (2) most pragmatic to implement. The results were screened, reviewed, and abstracted for relevant information and presented at the stakeholder consensus conference for discussion and ranked prioritization.We identified a total of 1464 publications and included 45 to review for accurate tools and approaches for detecting cognitive impairment and dementia. Twenty-seven different assessments and instruments have been studied in the ED setting to evaluate cognitive impairment and dementia, with many focusing on sensitivity and specificity of instruments to screen for cognitive impairment. For pragmatic tools, we identified a total of 2166 publications and included 66 in the review. Most extensively studied tools included the Ottawa 3DY and Six-Item Screener (SIS). The SIS was the shortest to administer (1 minute). Instruments with the highest negative predictive value were the SIS (vs MMSE) and the 4 A's Test (vs expert diagnosis). The GEAR 2.0 Advancing Dementia Care Consensus conference ranked research priorities that included the need for more approaches to recognize more effectively and efficiently persons who may be at risk for cognitive impairment and dementia, while balancing the importance of equitable screening, purpose, and consequences of differentiating various forms of cognitive impairment.The scoping review and consensus process identified gaps in clinical care that should be prioritized for research efforts to detect cognitive impairment and dementia in the ED setting. These gaps will be addressed as future GEAR 2.0 research funding priorities.

In response to the COVID-19 pandemic, many medical schools suspended clinical clerkships and implemented newly adapted curricula to facilitate continued educational progress. While the implementation of these new curricula has been described, an understanding of the impact on student learning outcomes is lacking. In 2020, the authors followed Kern's 6-step approach to curricular development to create and evaluate a novel COVID-19 curriculum for medical students at the University of California San Francisco School of Medicine and evaluate its learning outcomes. The primary goal of the curriculum was to provide third- and fourth-year medical students an opportunity for workplace learning in the absence of clinical clerkships, specifically for students to develop clerkship-level milestones in the competency domains of practice-based learning and improvement, professionalism, and systems-based practice. The curriculum was designed to match students with faculty-mentored projects occurring primarily in virtual formats. A total of 126 students enrolled in the curriculum and completed a survey about their learning outcomes (100% response rate). Of 35 possible clerkship-level milestones, there were 12 milestones for which over half of students reported development, in competency domains including practice-based learning and improvement, professionalism, and interpersonal and communication skills. Thematic analysis of students' qualitative survey responses demonstrated 2 central motivations for participating in the curriculum: identity as physicians-in-training, and patient engagement. Six central learning areas were developed during the curriculum: interprofessional teamwork, community resources, technology in medicine, skill-building, quality improvement, and specialty-specific learning. This analysis demonstrates that students can develop competencies and achieve rich workplace learning through project-based experiential learning, even in virtual clinical workplaces. Furthermore, knowledge of community resources, technology in medicine, and quality improvement were developed through the curriculum more readily than in traditional clerkships, and could be considered as integral learning objectives in future curricular design.

Supplemental Digital Content is available in the text., Background: Stakeholder involvement in health care research has been shown to improve research development, processes, and dissemination. The literature is developing on stakeholder engagement methods and preliminarily validated tools for evaluating stakeholder level of engagement have been proposed for specific stakeholder groups and settings. Objectives: This paper describes the methodology for engaging a Study Advisory Committee (SAC) in research and reports on the use of a stakeholder engagement survey for measuring level of engagement. Methods: Stakeholders with previous research connections were recruited to the SAC during the planning process for a multicenter randomized control clinical trial, which is ongoing at the time of this writing. All SAC meetings undergo qualitative analysis, while the Stakeholder Engagement Survey instrument developed by the Patient-Centered Outcomes Research Institute (PCORI) is distributed annually for quantitative evaluation. Results: The trial’s SAC is composed of 18 members from 3 stakeholder groups: patients and their caregivers; patient advocacy organizations; and health care payers. After an initial in-person meeting, the SAC meets quarterly by telephone and annually in-person. The SAC monitors research progress and provides feedback on all study processes. The stakeholder engagement survey reveals improved engagement over time as well as continued challenges. Conclusions: Stakeholder engagement in the research process has meaningfully contributed to the study design, patient recruitment, and preliminary analysis of findings.

To summarize research on optimal emergency department (ED) care practices for persons living with dementia (PLWDs) and develop research priorities.Systematic scoping review.PLWDs in the ED.The following Patient-Intervention-Comparison-Outcome (PICO) questions were developed: PICO 1, What components of emergency department care improve patient-centered outcomes for persons with dementia? PICO 2, How do emergency care needs for persons with dementia differ from other patients in the emergency department? A scoping review was conducted following PRISMA-ScR guidelines and presented to the Geriatric Emergency care Applied Research 2.0 Advancing Dementia Care network to inform research priorities.From the 6348 publications identified, 23 were abstracted for PICO 1 and 26 were abstracted for PICO 2. Emergency care considerations for PLWDs included functional dependence, behavioral and psychological symptoms of dementia, and identification of and management of pain. Concerns regarding ED care processes, the ED environment, and meeting a PWLD's basic needs were described. A comprehensive geriatric assessment and dedicated ED unit, a home hospital program, and a low-stimulation bed shade and contact-free monitor all showed improvement in patient-centered or health care use outcomes. However, all were single-site studies evaluating different outcomes. These results informed the following research priorities: (1) training and dementia care competencies; (2) patient-centric and care partner-centric evaluation interventions; (3) the impact of community- and identity-based factors on ED care for PLWDs; (4) economic or other implementation science measures to address viability; and (5) environmental, operational, personnel, system, or policy changes to improve ED care for PLWDs.A wide range of components of both ED care practices and ED care needs for PLWDs have been studied. Although many interventions show positive results, the lack of depth and reproducible results prevent specific recommendations on best practices in ED care for PLWDs.

To synthesize published research exploring emergency department (ED) communication strategies and decision-making with persons living with dementia (PLWD) and their care partners as the basis for a multistakeholder consensus conference to prioritize future research.Systematic scoping review.PLWD and their care partners in the ED setting.Informed by 2 Patient-Intervention-Comparison-Outcome (PICO) questions, we conducted systematic electronic searches of medical research databases for relevant publications following standardized methodological guidelines. The results were presented to interdisciplinary stakeholders, including dementia researchers, clinicians, PLWD, care partners, and advocacy organizations. The PICO questions included: How does communication differ for PLWD compared with persons without dementia? Are there specific communication strategies that improve the outcomes of ED care? Future research areas were prioritized.From 5451 studies identified for PICO-1, 21 were abstracted. From 2687 studies identified for PICO-2, 3 were abstracted. None of the included studies directly evaluated communication differences between PLWD and other populations, nor the effectiveness of specific communication strategies. General themes emerging from the scoping review included perceptions by PLWD/care partners of rushed ED communication, often exacerbated by inconsistent messages between providers. Care partners consistently reported limited engagement in medical decision-making. In order, the research priorities identified included: (1) Barriers/facilitators of effective communication; (2) valid outcome measures of effective communication; (3) best practices for care partner engagement; (4) defining how individual-, provider-, and system-level factors influence communication; and (5) understanding how each member of ED team can ensure high-quality communication.Research exploring ED communication with PLWD is sparse and does not directly evaluate specific communication strategies. Defining barriers and facilitators of effective communication was the highest-ranked research priority, followed by validating outcome measures associated with improved information exchange.

We aimed to describe emergency department (ED) care transition interventions delivered to older adults with cognitive impairment, identify relevant patient-centered outcomes, and determine priority research areas for future investigation.Systematic scoping review.ED patients with cognitive impairment and/or their care partners.Informed by the clinical questions, we conducted systematic electronic searches of medical research databases for relevant publications following published guidelines. The results were presented to a stakeholder group representing ED-based and non-ED-based clinicians, individuals living with cognitive impairment, care partners, and advocacy organizations. After discussion, they voted on potential research areas to prioritize for future investigations.From 3848 publications identified, 78 eligible studies underwent full text review, and 10 articles were abstracted. Common ED-to-community care transition interventions for older adults with cognitive impairment included interdisciplinary geriatric assessments, home visits from medical personnel, and telephone follow-ups. Intervention effects were mixed, with improvements observed in 30-day ED revisit rates but most largely ineffective at promoting connections to outpatient care or improving secondary outcomes such as physical function. Outcomes identified as important to adults with cognitive impairment and their care partners included care coordination between providers and inclusion of care partners in care management within the ED setting. The highest priority research area for future investigation identified by stakeholders was identifying strategies to tailor ED-to-community care transitions for adults living with cognitive impairment complicated by other vulnerabilities such as social isolation or economic disadvantage.This scoping review identified key gaps in ED-to-community care transition interventions delivered to older adults with cognitive impairment. Combined with a stakeholder assessment and prioritization, it identified relevant patient-centered outcomes and clarifies priority areas for future investigation to improve ED care for individuals with impaired cognition, an area of critical need given the current population trends.

Colleges and universities are critical components of the U.S. innovation ecosystem. These institutions are called upon to play ever-evolving roles in building talent for a changing workforce; achieving scientific breakthroughs; creating new technologies, products, and companies; and contributing to local economic development. Yet, as the pace of change accelerates across our economy, federal and state budget constraints have made meeting these expectations increasingly challenging. The federal commitment to research and development stands at a multidecadal low as a percentage of GDP ([ 1 ][1]). Now, the coronavirus disease 2019 (COVID-19) pandemic has disrupted almost all aspects of higher education, including the ability to keep laboratories open, conduct research in a timely manner, collect and process data, and collaborate with colleagues and students. As colleges and universities across the nation make difficult decisions to advance their vital missions this fall, the $55 billion in federal support for university-performed R&D (i.e., on-campus research) is at risk ([ 2 ][2]). Maintaining the strength of the U.S. research enterprise—the same research enterprise that has enabled the rapid sequencing of the COVID-19 genome and launched numerous treatment and vaccine studies—must be a national priority. Laboratories must remain open, and researchers must be allowed to continue data collection and analysis, with all the necessary health protocols in place. We cannot afford to shut down critical projects with long-term national benefits or to postpone projects that provide the hands-on graduate and undergraduate student research experiences necessary to train the next generation of scientists and engineers. In these difficult times, we call upon the federal government to provide the leadership, critical funding, and programmatic flexibility necessary to enable the nation's colleges and universities to continue the U.S. commitment to research, exploration, and new knowledge creation that will power our economy and provide opportunity for all. 1. [↵][3]AAAS, “Federal RD [www.aaas.org/sites/default/files/2020-07/RDGDP.png][4]. 2. [↵][5]AAAS, “RD [www.aaas.org/programs/r-d-budget-and-policy/rd-colleges-and-universities][6]. [1]: #ref-1 [2]: #ref-2 [3]: #xref-ref-1-1 "View reference 1 in text" [4]: http://www.aaas.org/sites/default/files/2020-07/RDGDP.png [5]: #xref-ref-2-1 "View reference 2 in text" [6]: http://www.aaas.org/programs/r-d-budget-and-policy/rd-colleges-and-universities

The growing palliative care needs of emergency department (ED) patients in the United States have motivated the development of ED primary palliative care principles. An expert panel convened to develop best practice guidelines for ED primary palliative care to help guide frontline ED clinicians based on available evidence and consensus opinion of the panel. Results include recommendations for screening and assessment of palliative care needs, ED management of palliative care needs, goals of care conversations, ED palliative care and hospice consults, and transitions of care.

Management of agitated patients presents a challenge with regard to balancing appropriate diagnostic plans and treatment aimed at controlling symptoms with an interest in prioritizing patient and staff safety and preserving patient dignity. This article will discuss a tiered approach to caring for the agitated patient, including early recognition of escalating behavior, verbal de-escalation techniques, the use and choice of medication and route for symptom control, and concepts related to physical restraint, special populations, and bias.

For patients' preferences to be honored, emergency department (ED) physicians must be able to find and use advance care planning (ACP) information in the electronic medical record (EMR). ED physicians' experiences with ACP EMR documentation and their documentation needs are unknown.We surveyed 70 ED physicians (81% response rate) from a tertiary and county ED. Our primary outcome was confidence finding and using ACP EMR documentation (percentage reporting very/extremely on a five-point Likert scale). Secondary outcomes included frequency of use and perceived usefulness of types of ACP documentation. Suggestions for improvement were analyzed using thematic content analysis.Participants' mean age was 36 years (± 9) and 54% were women. Thirty-one percent reported being very/extremely confident they could find ACP EMR documentation, and 55% felt very/extremely confident they could use it to care for patients. Yet 74% needed it ≥1 time/week and 43% ≥5 times/week. Participants reported code status orders (90%), Physician Orders for Life Sustaining Treatment (POLST) (86%), and durable power of attorney for health care (78%) as very/extremely useful, followed by values statements (31%), oral directives (34%), and living wills (37%). ED physicians wanted highly visible ACP information, "on the main screen."EMR systems are not optimized to provide critical ACP information to ED physicians who lack confidence finding or using ACP EMR documentation to care for patients. Dedicated ACP information on the EMR home screen and tailored training may be needed to help ED providers find, use, and discuss ACP documentation to provide care aligned with patients' goals.

Necrotizing fasciitis is a rare but serious disease, and early diagnosis is essential to reducing its substantial morbidity and mortality. The 2 cases presented show that the key clinical and radiographic features of necrotizing fasciitis exist along a continuum of severity at initial presentation; thus, this diagnosis should not be prematurely ruled out in cases that do not show the dramatic features familiar to most clinicians. Although computed tomography and magnetic resonance imaging are considered the most effective imaging modalities, the cases described here illustrate how sonography should be recommended as an initial imaging test to make a rapid diagnosis and initiate therapy.

Violent and agitated patients are high risk because they may pose a physical threat to the staff, may harm themselves, and may have dangerous comorbidities and illness that are causing the violence. The emergency physician must quickly control these behaviors, and thoroughly identify and treat their etiology, while simultaneously protecting the patients' rights and reducing the risks of injury to themselves, other patients, and medical staff. This article highlights potentially high-risk situations and describes corresponding mitigation tactics.

The emergency department visit for a patient with serious illness represents a sentinel event, signalling a change in the illness trajectory. By better understanding patient and family wishes, emergency physicians can reinforce advance care plans and ensure the hospital care provided matches the patient's values. Despite their importance in care at the end of life, emergency physicians have received little training on how to talk to seriously ill patients and their families about goals of care. To expand communication skills training to emergency medicine, we developed a programme to give emergency medicine physicians the ability to empathically deliver serious news and to talk about goals of care. We have built on lessons from prior studies to design an intervention employing the most effective pedagogical techniques, including the use of simulated patients/families, role-playing and small group learning with constructive feedback from master clinicians. Here, we describe our evidence-based communication skills training course EM Talk using simulation, reflective feedback and deliberate practice.

Study objective: Estimates of time intervals by bystanders are considered critical in cardiac arrest, and are often used in other disorders such as stroke and myocardial infarction. Because they have never been previously studied, we sought to determine their accuracy. Methods: This study was performed by prospective collection of bystander estimates (made at the time of the arrest) of the time from calling 911 to the arrival of urban fire department first responders, and comparison with actual measured response interval from computerized records, in all out-of-hospital cardiac arrests from January 1996 through June 1998. Results: The fire department responded to 1,015 patients in cardiac arrest during the study period. First responders arrived before advanced life support providers to 831 patients, who thus met study entry criteria. Bystander estimates were obtained in 497 of these 831 patients, who did not differ in key characteristics from those lacking estimates. The bystander's average estimated fire department response interval was 5.6 minutes (95% confidence interval [CI] 5.2 to 5.9 minutes) and the actual measured interval to the patient's side from computer records was 6.1 minutes (95% CI 5.9 to 6.4 minutes). However, the median error of the bystander estimate (1.3 minutes) was 32% of the median of the actual measured on-scene interval, and there was no correlation between the bystander estimates and the measured interval in individual cases ( R ≤0.14), regardless of which intervals were examined. Seventy-five percent of the bystander estimates erred by 20% or more. When bystanders estimated a response interval as excessively long, they were almost invariably wrong, but they also usually failed to identify intervals that actually were long. Conclusion: Although many diagnostic and research conclusions are based on interval estimates from laypersons, we found no correlation between estimates and actual measured intervals in cardiac arrest. Current methodology may not be developed well enough to provide reliable data for research or quality assurance, and other clinical time estimates by patients and bystanders may be equally unreliable. [Isaacs E, Callaham ML. Ability of laypersons to estimate short time intervals in cardiac arrest. Ann Emerg Med. February 2000;35:147-154.]

Pain is a ubiquitous problem, affecting more than 100 million individuals in the United States chronically and many more in the acute setting. Up to three-quarters of patients presenting to the emergency department (ED) report pain as a key component of their reasons for requiring acute care. While pain management is a fundamental component of emergency medicine (EM), there are numerous attitudinal and structural barriers that have been identified to effectively providing pain control in the ED. Coupled with public demands and administrative mandates, concerns surrounding ED pain management have reached a crisis level that should be considered an ethical issue in the profession of EM. In this article, the authors propose an ethical framework based on a combination of virtue, narrative, and relationship theories that can be used to address the clinical dilemmas that arise in managing pain in ED patients.

To the Editor: Determination of pregnancy status is vital in the workup of a patient presenting with vaginal bleeding or lower abdominal pain. We report a case of false negative results on urine and serum pregnancy tests as a result of the “high-dose hook effect.” A 26-year-old woman (gravida 1, para 1) presented to the emergency department, reporting lower abdominal pain, vomiting, and several weeks of irregular vaginal bleeding. On examination, she was anxious and in moderate discomfort, and her heart rate and blood pressure were elevated. Her abdomen was soft, with a tender lower abdominal mass. Pelvic examination revealed . . .