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Carpenter CR, Lee S, Kennedy M, Arendts G, Schnitker L, Eagles D, Mooijaart S, Fowler S, Doering M, LaMantia MA, Han JH, Liu SW. Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments. Acad Emerg Med 2024. [PMID: 38757369 DOI: 10.1111/acem.14935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening. METHODS We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds. RESULTS Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%. CONCLUSIONS The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.
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Affiliation(s)
| | - Sangil Lee
- University of Iowa, Iowa City, Iowa, USA
| | - Maura Kennedy
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Glenn Arendts
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Linda Schnitker
- Bolton Clarke Research Institute, Bolton Clarke School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | | | - Simon Mooijaart
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, The Netherlands
| | - Susan Fowler
- University of Connecticut Health Sciences, Farmington, Connecticut, USA
| | - Michelle Doering
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | | | - Jin H Han
- Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Nothelle S, Slade E, Zhou J, Magidson PD, Chotrani T, Prichett L, Amjad H, Szanton S, Boyd CM, Wolff JL. Emergency Department Length of Stay for Older Adults With Dementia. Ann Emerg Med 2024; 83:446-456. [PMID: 38069967 PMCID: PMC11032237 DOI: 10.1016/j.annemergmed.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/11/2023] [Accepted: 09/28/2023] [Indexed: 01/11/2024]
Abstract
STUDY OBJECTIVE The emergency department (ED) poses unique challenges and risks to persons living with dementia. A longer ED length of stay is associated with the risk of death, delirium, and medication errors. We sought to determine whether ED length of stay differed by dementia status and trends in ED length of stay for persons living with dementia from 2014 to 2018 and whether persons living with dementia were at a higher risk for prolonged ED length of stay (defined as a length of stay > 90th percentile). METHODS In this observational study, we used data from the Healthcare Cost and Utilization Project State Emergency Department Database from Massachusetts, Arkansas, Arizona, and Florida. We included ED visits resulting in discharge for adults aged ≥65 years from 2014 to 2018. We used inverse probability weighting to create comparable groups of visits on the basis of dementia status. We used generalized linear models to estimate the mean difference in ED length of stay on the basis of dementia status and logistic regression to determine the odds of prolonged ED length of stay. RESULTS We included 1,039,497 ED visits (mean age: 83.5 years; 64% women; 78% White, 12% Hispanic). Compared with visits by persons without dementia, ED length of stay was 3.1 hours longer (95% confidence interval [CI] 3.0 to 3.3 hours) for persons living with dementia. Among the visits resulting in transfer, ED length of stay was on average 4.1 hours longer (95% CI 3.6 to 4.5 hours) for persons living with dementia. Visits by persons living with dementia were more likely to have a prolonged length of stay (risk difference 4.1%, 95% CI 3.9 to 4.4). CONCLUSION ED visits were more than 3 hours longer for persons living with versus without dementia. Initiatives focused on optimizing ED care for persons living with dementia are needed.
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Affiliation(s)
- Stephanie Nothelle
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Eric Slade
- Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Junyi Zhou
- Biostatistics Epidemiology and Data Management Core, Johns Hopkins University, Baltimore, Maryland
| | - Phillip D Magidson
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tanya Chotrani
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Laura Prichett
- Biostatistics Epidemiology and Data Management Core, Johns Hopkins University, Baltimore, Maryland
| | - Halima Amjad
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah Szanton
- Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jennifer L Wolff
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Filiatreault S, Kreindler SA, Grimshaw JM, Chochinov A, Doupe MB. Developing a set of emergency department performance measures to evaluate delirium care quality for older adults: a modified e-Delphi study. BMC Emerg Med 2024; 24:28. [PMID: 38360551 PMCID: PMC10868025 DOI: 10.1186/s12873-024-00947-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/05/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Older adults are at high risk of developing delirium in the emergency department (ED); however, it is under-recognized in routine clinical care. Lack of detection and treatment is associated with poor outcomes, such as mortality. Performance measures (PMs) are needed to identify variations in quality care to help guide improvement strategies. The purpose of this study is to gain consensus on a set of quality statements and PMs that can be used to evaluate delirium care quality for older ED patients. METHODS A 3-round modified e-Delphi study was conducted with ED clinical experts. In each round, participants rated quality statements according to the concepts of importance and actionability, then their associated PMs according to the concept of necessity (1-9 Likert scales), with the ability to comment on each. Consensus and stability were evaluated using a priori criteria using descriptive statistics. Qualitative data was examined to identify themes within and across quality statements and PMs, which went through a participant validation exercise in the final round. RESULTS Twenty-two experts participated, 95.5% were from west or central Canada. From 10 quality statements and 24 PMs, consensus was achieved for six quality statements and 22 PMs. Qualitative data supported justification for including three quality statements and one PM that achieved consensus slightly below a priori criteria. Three overarching themes emerged from the qualitative data related to quality statement actionability. Nine quality statements, nine structure PMs, and 14 process PMs are included in the final set, addressing four areas of delirium care: screening, diagnosis, risk reduction and management. CONCLUSION Results provide a set of quality statements and PMs that are important, actionable, and necessary to a diverse group of clinical experts. To our knowledge, this is the first known study to develop a de novo set of guideline-based quality statements and PMs to evaluate the quality of delirium care older adults receive in the ED setting.
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Affiliation(s)
- Sarah Filiatreault
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada.
| | - Sara A Kreindler
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, K1H8L6, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
| | - Alecs Chochinov
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
- Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Malcolm B Doupe
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
- Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
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Dombrowski W, Mims A, Kremer I, Cano Desandes P, Rodrigo-Herrero S, Epps F, Snow T, Gutierrez M, Nasta A, Epperly MB, Manaloto K, Hansen JC. Dementia Ideal Care: Ecosystem Map of Best Practices and Care Pathways Enhanced by Technology and Community. J Alzheimers Dis 2024; 100:87-117. [PMID: 38848182 PMCID: PMC11307099 DOI: 10.3233/jad-231491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 06/09/2024]
Abstract
Background Globally, much work has been done by nonprofit, private, and academic groups to develop best practices for the care of people living with dementia (PLWD), including Alzheimer's disease. However, these best practices reside in disparate repositories and tend to focus on one phase of the patient journey or one relevant group. Objective To fill this gap, we developed a Dementia Ideal Care Map that everyone in the dementia ecosystem can use as an actionable tool for awareness, policy development, funding, research, training, service delivery, and technology design. The intended audience includes (and not limited to) policymakers, academia, industry, technology developers, health system leaders, clinicians, social service providers, patient advocates, PLWD, their families, and communities at large. Methods A search was conducted for published dementia care best practices and quality measures, which were then summarized in a visual diagram. The draft diagram was analyzed to identify barriers to ideal care. Then, additional processes, services, technologies, and quality measures to overcome those challenges were brainstormed. Feedback was then obtained from experts. Results The Dementia Ideal Care Map summarizes the ecosystem of over 200 best practices, nearly 100 technology enablers, other infrastructure, and enhanced care pathways in one comprehensive diagram. It includes psychosocial interventions, care partner support, community-based organizations; awareness, risk reduction; initial detection, diagnosis, ongoing medical care; governments, payers, health systems, businesses, data, research, and training. Conclusions Dementia Ideal Care Map is a practical tool for planning and coordinating dementia care. This visualized ecosystem approach can be applied to other conditions.
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Affiliation(s)
- Wen Dombrowski
- CATALAIZE, Chicago, IL, USA
- USC Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - Adrienne Mims
- Rainmakers Strategic Solutions, Atlanta, GA, USA
- National Committee for Quality Assurance – NCQA, Washington, DC, USA
- NAPA Advisory Council, Washington, DC, USA
| | - Ian Kremer
- Leaders Engaged on Alzheimer’s Disease – LEAD Coalition, Washington, DC, USA
| | - Pedro Cano Desandes
- Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Taulí – I3PT-CERCA, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Silvia Rodrigo-Herrero
- Memory Unit, Department of Neurology, Juan Ramon Jimenez University Hospital, Huelva, Spain
| | - Fayron Epps
- School of Nursing, University of Texas Health Science Center, San Antonio, TX, USA
| | - Teepa Snow
- Positive Approach, LLC, Efland, NC, USA
- Snow Approach, Inc., Hillsborough, NC, USA
| | | | - Anil Nasta
- Roche Diagnostics Corporation, Indianapolis, IN, USA
| | | | - Katrina Manaloto
- Neurotech Collider Lab, University of California, Berkeley, Berkeley, CA, USA
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Hauer K, Dutzi I, Werner C, Bauer J, Ullrich P. Delirium Prevention in Early Rehabilitation During Acute Hospitalization and Implementation of Programs Specifically Tailored to Older Patients with Cognitive Impairment: A Scoping Review with Meta-Analysis. J Alzheimers Dis 2024; 97:3-29. [PMID: 38073387 DOI: 10.3233/jad-230644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND No systematic review on delirium prevention within early, hospital-based rehabilitation on implementation of approaches specifically tailored for patients with cognitive impairment (PwCI), such as Alzheimer's disease or vascular dementia, has been published despite the high relevance of specific medical care in this vulnerable population. OBJECTIVE To document design and effectiveness of delirium prevention programs by early rehabilitation during acute, hospital-based medical care and implementation of programs specifically tailored to PwCI. METHODS In a three-step approach, we first identified published systematic reviews of hospital-based, early rehabilitation interventions for older persons (>65 years) in relevant databases. In a second step, we screened each single trial of included reviews according to predefined inclusion criteria. In a third step, we analyzed studies with focus on delirium prevention. RESULTS Among n = 25 studies identified, almost all intervention programs did not specifically target cognitive impairment (CI). Interventions were heterogeneous (modules: n = 2-19); almost all study samples were mixed/unspecified for cognitive status with more affected patients excluded. Only one study exclusively included delirium patients, and only one included CI patients. Results of random effect meta-analysis showed significant effects of generic programs to reduce delirium incidence during hospitalization by 41% (p < 0.001, odds ratio, 95% confidence interval: 0.59 [0.49, 0.71] with modest heterogeneity (I2: 30%). CONCLUSIONS Study results document a lack of implementation for delirium prevention programs specifically tailored to PwCI by early, hospital-based rehabilitation. Specifying existing rehab concepts or augmenting them by CI-specific modules may help to develop, optimize, and implement innovative delirium prevention in PwCI in acute medical care.
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Affiliation(s)
- Klaus Hauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
- Robert Bosch Gesellschaft für Medizinische Forschung mbH, Stuttgart, Germany
| | - Ilona Dutzi
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Christian Werner
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen Bauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Phoebe Ullrich
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Heidelberg, Germany
- Department of Thoracic Oncology, Thoraxklinik Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
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Filiatreault S, Kreindler S, Grimshaw J, Chochinov A, Doupe M. Protocol for developing a set of performance measures to monitor and evaluate delirium care quality for older adults in the emergency department using a modified e-Delphi process. BMJ Open 2023; 13:e074730. [PMID: 37607798 PMCID: PMC10445345 DOI: 10.1136/bmjopen-2023-074730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/10/2023] [Indexed: 08/24/2023] Open
Abstract
INTRODUCTION Older adults are at high risk of developing delirium in the emergency department (ED). Delirium associated with an ED visit is independently linked to poorer outcomes such as increased length of hospital stay and mortality. Performance measures (PMs) are needed to identify variations in the quality of delirium care to help focus improvement efforts where they are most needed. A preliminary list of 11 quality statements and 24 PMs was developed based on a synthesis of high-quality clinical practice guidelines. The purpose of this study is to gain consensus on a subset of PMs that can be used to evaluate delirium care quality for older ED patients. METHODS AND ANALYSIS This protocol for a modified e-Delphi study is informed by the Guidance on Conducting and REporting DElphi Studies. Clinical experts from across Canada and internationally will be recruited through peer referral, professional organisations and social media calls for expressions of interest. A minimum of 17 participants will be recruited. The primary survey for each round will consist of closed-ended questions with the opportunity to provide comments to justify decisions and clarify understanding. Using 9-point Likert scales, participants will rate each quality statement according to the concepts of importance and actionability, then its associated PMs according to the concept of necessity. Results will be fed back to participants in subsequent rounds. A priori stopping criteria have been defined in terms of consensus and stability. A minimum of three rounds will be undertaken to allow participants to have feedback, revise previous responses, then stabilise responses. ETHICS AND DISSEMINATION Ethical approval was provided at the University of Manitoba Health Research Ethics Board (ID HS25728 (H2022:340)). Informed consent will be obtained electronically using the Research Electronic Data Capture secure online platform. Knowledge translation and dissemination will be done through traditional (eg, conference presentations, peer-reviewed publications) and non-traditional (eg, ED Grand Rounds) strategies.
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Affiliation(s)
- Sarah Filiatreault
- Community Health Sciences, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Sara Kreindler
- Community Health Sciences, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Alecs Chochinov
- Community Health Sciences, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Emergency Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Malcolm Doupe
- Community Health Sciences, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Emergency Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
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Arendts G, Chenoweth L, Hayes BJ, Campbell E, Agar M, Etherton-Beer C, Spilsbury K, Howard K, Braitberg G, Cubitt M, Sheehan C, Magann L, Sudharshan T, Schnitker LM, Pearce J, Gilmore I, Cerra N, duPreez J, Jaworski R, Soh SC, Celenza A. CELPI: trial protocol for a randomised controlled trial of a Carer End of Life Planning Intervention in people dying with dementia. BMC Geriatr 2022; 22:869. [PMID: 36384478 PMCID: PMC9670369 DOI: 10.1186/s12877-022-03534-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background Dementia is a leading cause of death in developed nations. Despite an often distressing and symptom laden end of life, there are systematic barriers to accessing palliative care in older people dying of dementia. Evidence exists that 70% of people living with severe dementia attend an emergency department (ED) in their last year of life. The aim of this trial is to test whether a Carer End of Life Planning Intervention (CELPI), co-designed by consumers, clinicians and content specialists, improves access to end of life care for older people with severe dementia, using an ED visit as a catalyst for recognising unmet needs and specialist palliative care referral where indicated. Methods A randomised controlled trial (RCT) enrolling at six EDs across three states in Australia will be conducted, enrolling four hundred and forty dyads comprising a person with severe dementia aged ≥ 65 years, and their primary carer. Participants will be randomly allocated to CELPI or the control group. CELPI incorporates a structured carer needs assessment and referral to specialist palliative care services where indicated by patient symptom burden and needs assessment. The primary outcome measure is death of the person with dementia in the carer-nominated preferred location. Secondary outcomes include carer reported quality of life of the person dying of dementia, hospital bed day occupancy in the last 12 months of life, and carer stress. An economic evaluation from the perspective of a health funder will be conducted. Discussion CELPI seeks to support carers and provide optimal end of life care for the person dying of dementia. This trial will provide high level evidence as to the clinical and cost effectiveness of this intervention. Trial registration ACTRN12622000611729 registered 22/04/2022. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03534-1.
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Dresden SM, Taylor Z, Serina P, Kennedy M, Wescott AB, Hogan T, Shah MN, Hwang U. Optimal Emergency Department Care Practices for Persons Living With Dementia: A Scoping Review. J Am Med Dir Assoc 2022; 23:1314.e1-1314.e29. [PMID: 35940683 DOI: 10.1016/j.jamda.2022.05.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/23/2022] [Accepted: 05/26/2022] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To summarize research on optimal emergency department (ED) care practices for persons living with dementia (PLWDs) and develop research priorities. DESIGN Systematic scoping review. SETTINGS AND PARTICIPANTS PLWDs in the ED. METHODS 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. RESULTS 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. CONCLUSIONS AND IMPLICATIONS 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.
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Affiliation(s)
- Scott M Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Zachary Taylor
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Peter Serina
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
| | - Annie B Wescott
- Galter Library and Learning Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Teresita Hogan
- Section of Emergency Medicine, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA; Geriatric Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
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Gettel CJ, Falvey JR, Gifford A, Hoang L, Christensen LA, Hwang U, Shah MN. Emergency Department Care Transitions for Patients With Cognitive Impairment: A Scoping Review. J Am Med Dir Assoc 2022; 23:1313.e1-1313.e13. [PMID: 35247358 PMCID: PMC9378565 DOI: 10.1016/j.jamda.2022.01.076] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES 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. DESIGN Systematic scoping review. SETTING AND PARTICIPANTS ED patients with cognitive impairment and/or their care partners. METHODS 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. RESULTS 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. CONCLUSIONS AND IMPLICATIONS 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.
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Affiliation(s)
- Cameron J Gettel
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA.
| | - Jason R Falvey
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Angela Gifford
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Ly Hoang
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA; Department of Medicine (Geriatrics and Gerontology), University of Wisconsin-Madison, Madison, WI, USA; Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA; Center for Health Disparities Research, University of Wisconsin-Madison, Madison, WI, USA; Wisconsin Alzheimer's Disease Research Center, University of Wisconsin-Madison, Madison, WI, USA
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Shih RD, Carpenter CR, Tolia V, Binder EF, Ouslander JG. Balancing Vision With Pragmatism: The Geriatric Emergency Department Guidelines-Realistic Expectations From Emergency Medicine and Geriatric Medicine. J Emerg Med 2022; 62:585-589. [PMID: 35181186 DOI: 10.1016/j.jemermed.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 12/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND In 2014, the Geriatric Emergency Department (GED) Guidelines were published and endorsed by four major medical organizations. The multidisciplinary GED Guidelines characterized the complex needs of the older emergency department (ED) patient and current best practices, with the goal of promoting more cost-effective and patient-centered care. The recommendations are extensive and most EDs then and now have neither the resources nor the hospital administrative support to provide this additional service. DISCUSSION At the 2021 American Academy of Emergency Medicine's Scientific Assembly, a panel of emergency physicians and geriatricians discussed the GED Guidelines and the current realities of EDs' capacity to provide best practice and guideline-recommended care of GED patients. This article is a synthesis of the panel's presentation and discussion. With the substantial challenges in providing guideline-recommended care in EDs, this article will explore three high-impact GED clinical conditions to highlight guideline recommendations, challenges, and opportunities, and discuss realistically achievable expectations for non-GED-accredited institutions. CONCLUSIONS In 2014, the GED Guidelines were published, describing the current best practices for GED patients. Unfortunately, most of the EDs worldwide do not provide the level of service recommended by the GED Guidelines. The GED Guidelines can best be termed aspirational for U.S. EDs at the present time.
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Affiliation(s)
- Richard D Shih
- Department of Emergency Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida and Delray Medical Center, Delray Beach, Florida
| | - Christopher R Carpenter
- Department of Emergency Medicine, Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Vaishal Tolia
- University of California San Diego Health, San Diego, California
| | - Ellen F Binder
- Division of Geriatrics and Nutritional Science, Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | - Joseph G Ouslander
- Department of Integrated Medical Science, Charles E. Schmidt College of Medicine; Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida
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11
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Heenan MA, Randall GE, Evans JM. Selecting Performance Indicators and Targets in Health Care: An International Scoping Review and Standardized Process Framework. Healthc Policy 2022; 15:747-764. [PMID: 35478929 PMCID: PMC9038160 DOI: 10.2147/rmhp.s357561] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/04/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Health care organizations monitor hundreds of performance indicators. It is unclear what processes and criteria organizations use to identify the indicators they use, who is involved in these processes, how performance targets are set, and what the impacts of these processes are. The purpose of this study is to synthesize international approaches to indicator selection and develop a standardized process framework. Methods Using the PubMed and Web of Science search engines, a scoping review of peer reviewed and grey literature following PRISMA-ScR guidelines was conducted to identify documents describing indicator selection processes used by health systems. English-language papers from 11 countries published from 2010 to 2020 were included. Papers were thematically analyzed to develop a standardized process framework. Results The review included 33 peer-reviewed papers and 11 grey-literature documents. While there are common practices used in health care to select indicators, no single standardized process framework for indicator selection exists. Arbitrary or incomplete indicator selection processes risk over-measurement, lack of alignment with strategic and operational goals, lack of support by end-users, and paralyzed decision-making ability. By consolidating international practices, we developed the 5-P indicator selection process framework to mitigate process risks and support high-quality indicator selection processes. Conclusion The 5-P indicator selection process framework consists of five domains and 17 elements, and offers health care agencies a practical structure they can use to design indicator selection processes. The framework also provides researchers with a basis by which the implementation of these processes may be evaluated.
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Affiliation(s)
- Michael A Heenan
- DeGroote School of Business, McMaster University, Hamilton, Ontario, Canada
- Correspondence: Michael A Heenan, Email
| | - Glen E Randall
- DeGroote School of Business, McMaster University, Hamilton, Ontario, Canada
| | - Jenna M Evans
- DeGroote School of Business, McMaster University, Hamilton, Ontario, Canada
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12
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Shih RD, Carpenter CR, Tolia V, Binder EF, Ouslander JG. Balancing vision with pragmatism: The geriatric emergency department guidelines‐realistic expectations from emergency medicine and geriatric medicine. J Am Geriatr Soc 2022; 70:1368-1373. [DOI: 10.1111/jgs.17745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Richard D. Shih
- Charles E. Schmidt College of Medicine Boca Raton Florida USA
| | - Christopher R. Carpenter
- Department of Emergency Medicine, Emergency Care Research Core Washington University in St. Louis, School of Medicine St. Louis Missouri USA
| | - Vaishal Tolia
- University of California San Diego Health San Diego California USA
| | - Ellen F. Binder
- School of Medicine, Division of Geriatrics and Nutritional Science Washington University in St. Louis St. Louis Missouri USA
| | - Joseph G. Ouslander
- Christine E. Lynn College of Nursing, Florida Atlantic University Boca Raton Florida USA
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13
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Yorganci E, Sampson EL, Gillam J, Aworinde J, Leniz J, Williamson LE, Cripps RL, Stewart R, Sleeman KE. Quality indicators for dementia and older people nearing the end of life: A systematic review. J Am Geriatr Soc 2021; 69:3650-3660. [PMID: 34331704 DOI: 10.1111/jgs.17387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/09/2021] [Accepted: 07/09/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Robust quality indicators (QIs) are essential for monitoring and improving the quality of care and learning from good practice. We aimed to identify and assess QIs for the care of older people and people with dementia who are nearing the end of life and recommend QIs for use with routinely collected electronic data across care settings. METHODS A systematic review was conducted, including five databases and reference chaining. Studies describing the development of QIs for care of older people and those with dementia nearing the end of life were included. QIs were categorized as relating to processes or outcomes, and mapped against six care domains. The psychometric properties (acceptability, evidence base, definition, feasibility, reliability, and validity) of each QI were assessed; QIs were categorized as robust, moderate, or poor. RESULTS From 12,980 titles and abstracts screened, 37 papers and 976 QIs were included. Process and outcome QIs accounted for 780 (79.7%) and 196 (20.3%) of all QIs, respectively. Many of the QIs concerned physical aspects of care (n = 492, 50.4%), and very few concerned spiritual and cultural aspects of care (n = 19, 1.9%). Three hundred and fifteen (32.3%) QIs were robust and of those 220 were measurable using routinely collected electronic data. The final shortlist of 71 QIs came from seven studies. CONCLUSIONS Of the numerous QIs developed for care of older adults and those with dementia nearing the end of life, most had poor or moderate psychometric properties or were not designed for use with routinely collected electronic datasets. Infrastructure for data availability, combined with use of robust QIs, is important for enhancing understanding of care provided to this population, identifying unmet needs, and improving service provision.
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Affiliation(s)
- Emel Yorganci
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
| | - Juliet Gillam
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Jesutofunmi Aworinde
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Javiera Leniz
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Lesley E Williamson
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Rachel L Cripps
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Robert Stewart
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Katherine E Sleeman
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute, King's College London, London, UK
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Sweeny A, Keijzers G, O'Dwyer J, Arendts G, Crilly J. Predictors of a long length of stay in the emergency department for older people. Intern Med J 2021; 50:572-581. [PMID: 31336021 DOI: 10.1111/imj.14441] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 07/01/2019] [Accepted: 07/18/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Dedicated geriatric models of care are becoming more prevalent due to the complexity of, and increase in, acute healthcare presentations for older patients. For older people, a long stay in the emergency department (ED) may reflect the complexity of their presentation, or deficiencies in systems that manage these complexities. AIMS To identify predictors of a long ED length of stay (LLoS) for patients ≥65 years old. METHODS Linked hospital information systems data from a large, public Australian ED were analysed in this retrospective cohort study. LLoS was defined as the 75th percentile (617 min). Multivariate regression identified LLoS predictors for admissions and discharges separately. RESULTS Of 16 791 ED presentations made by older people, 4192 experienced a LLoS; 55% were admitted. Increasing age was associated with an increasing ED LoS. Factors most predictive of LLoS for both admitted and discharged patients included: investigations (both pathology and imaging), less urgent Australasian triage scale categories and after-hours arrival. Ambulance arrival did not increase the risk of a LLoS for patients eventually admitted, but conferred nearly a twofold increased risk for a LLoS for discharged older persons (adjusted odds ratios = 1.9; 95% confidence interval 1.5-2.4). CONCLUSIONS This study assists clinicians and decision-makers to identify reasons why older persons have a LLoS, whether admitted or discharged. Interventions to streamline care for older patients arriving after-hours and who require imaging and pathology are required. LoS targets should consider age distribution. The use of ED LoS as a quality of care indicator should be assessed for admissions and discharges, separately.
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Affiliation(s)
- Amy Sweeny
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,School of Medicine, Bond University, Gold Coast, Queensland, Australia
| | - John O'Dwyer
- The Australian e-Health Research Centre, Health and Biosecurity, Commonwealth Scientific and Industrial Research Organisation (CSIRO), Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Glenn Arendts
- Discipline of Emergency Medicine, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Julia Crilly
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
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Carpenter CR, Hammouda N, Linton EA, Doering M, Ohuabunwa UK, Ko KJ, Hung WW, Shah MN, Lindquist LA, Biese K, Wei D, Hoy L, Nerbonne L, Hwang U, Dresden SM. Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement. Acad Emerg Med 2021; 28:19-35. [PMID: 33135274 DOI: 10.1111/acem.14166] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions. METHODS GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci. RESULTS In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research. CONCLUSIONS Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.
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Affiliation(s)
- Christopher R. Carpenter
- From the Department of Emergency Medicine Washington University in St. Louis School of MedicineEmergency Care Research Core St. Louis MIUSA
| | - Nada Hammouda
- the Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
| | - Elizabeth A. Linton
- the Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
- the Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MDUSA
| | - Michelle Doering
- the Becker Medical Library Washington University in St. Louis School of Medicine St. Louis MOUSA
| | - Ugochi K. Ohuabunwa
- the Division of General Medicine and Geriatrics Emory University School of Medicine Atlanta GAUSA
| | - Kelly J. Ko
- Clinical Research West Health Institute La Jolla CAUSA
| | - William W. Hung
- James J. Peters VA Medical Center Bronx NYUSA
- and the Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai New York NYUSA
| | - Manish N. Shah
- the BerbeeWalsh Department of Emergency Medicine University of Wisconsin–Madison Madison WIUSA
| | - Lee A. Lindquist
- the Department of Medicine Northwestern University Feinberg School of Medicine Chicago ILUSA
| | - Kevin Biese
- the Departments of Emergency Medicine and Internal Medicine University of North Carolina at Chapel Hill Chapel Hill NCUSA
| | - Daniel Wei
- the BerbeeWalsh Department of Emergency Medicine University of Wisconsin–Madison Madison WIUSA
| | | | | | - Ula Hwang
- the Department of Emergency Medicine Yale School of Medicine New Haven CTUSA
| | - Scott M. Dresden
- and the Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago IL USA
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Schuster S, Singler K, Lim S, Machner M, Döbler K, Dormann H. Quality indicators for a geriatric emergency care (GeriQ-ED) - an evidence-based delphi consensus approach to improve the care of geriatric patients in the emergency department. Scand J Trauma Resusc Emerg Med 2020; 28:68. [PMID: 32678052 PMCID: PMC7364502 DOI: 10.1186/s13049-020-00756-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 06/22/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION In emergency care, geriatric requirements and risks are often not taken sufficiently into account. In addition, there are neither evidence-based recommendations nor scientifically developed quality indicators (QI) for geriatric emergency care in German emergency departments. As part of the GeriQ-ED© research project, quality indicators for geriatric emergency medicine in Germany have been developed using the QUALIFY-instruments. METHODS Using a triangulation methodology, a) clinical experience-based quality aspects were identified and verified, b) research-based quality statements were formulated and assessed for relevance, and c) preliminary quality indicators were operationalized and evaluated in order to recommend a feasible set of final quality indicators. RESULTS Initially, 41 quality statements were identified and assessed as relevant. Sixty-seven QI (33 process, 29 structure and 5 outcome indicators) were extrapolated and operationalised. In order to facilitate implementation into daily practice, the following five quality statements were defined as the GeriQ-ED© TOP 5: screening for delirium, taking a full medications history including an assessment of the indications, education of geriatric knowledge and skills to emergency staff, screening for patients with geriatric needs, and identification of patients with risk of falls/ recurrent falls. DISCUSSION QIs are regarded as gold standard to measure, benchmark and improve emergency care. GeriQ-ED© QI focused on clinical experience- and research-based recommendations and describe for the first time a standard for geriatric emergency care in Germany. GeriQ-ED© TOP 5 should be implemented as a minimum standard in geriatric emergency care.
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Affiliation(s)
- Susanne Schuster
- Faculty of Medicine, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Emergency Department, Klinikum Fürth, Fürth, Germany
- Institute for Nursing Research, Gerontology and Ethics, Lutheran University of Applied Sciences - Evangelische Hochschule Nürnberg, Nuremberg, Germany
| | - Katrin Singler
- Institute for Biomedicine of Ageing, Friedrich-Alexander Universität Erlangen-Nürnberg, Nuremberg, Germany
- Geriatric Department - Medizinische Klinik 2, Geriatrie, Klinikum Nürnberg, Paracelsus Private Medical University, Nuremberg, Germany
| | - Stephen Lim
- Academic Geriatric Medicine, University of Southampton, University Hospital Southampton NHS FT, Southampton, UK
| | - Mareen Machner
- Charité – University of Medicine, Public Health Academy, Berlin, Germany
- Charité – University of Medicine, Lernzentrum, Medical Skills Lab, Berlin, Germany
| | - Klaus Döbler
- Competence Center Quality Management in Health Care, MDK Baden-Württemberg, Stuttgart, Germany
| | - Harald Dormann
- Faculty of Medicine, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Emergency Department, Klinikum Fürth, Fürth, Germany
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Mailhot T, Darling C, Ela J, Malyuta Y, Inouye SK, Saczynski J. Family Identification of Delirium in the Emergency Department in Patients With and Without Dementia: Validity of the Family Confusion Assessment Method (FAM-CAM). J Am Geriatr Soc 2020; 68:983-990. [PMID: 32274799 PMCID: PMC7370702 DOI: 10.1111/jgs.16438] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 01/24/2020] [Accepted: 02/01/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To examine the ability of the family-rated Family Confusion Assessment Method (FAM-CAM) to identify delirium in the emergency department (ED) among patients with and without dementia, as compared to the reference-standard Confusion Assessment Method (CAM). DESIGN Validation study. SETTING Urban academic ED. PARTICIPANTS Dyads of ED patients, aged 70 years and older, and their family caregivers (N = 108 dyads). MEASUREMENTS A trained reference standard interviewer performed a cognitive screen, delirium symptom assessment, and scored the CAM. The caregiver self-administered the FAM-CAM. Dementia was assessed using the Informant Questionnaire on Cognitive Decline in the Elderly and the medical record. For concurrent validity, performance of the FAM-CAM was compared to the CAM. For predictive validity, clinical outcomes (ED visits, hospitalization, and mortality) over 6 months were compared in FAM-CAM positive and negative patients, controlling for age, sex, comorbidity, and cognitive status. RESULTS Among the 108 patients, 30 (28%) were CAM positive for delirium and 58 (54%) presented with dementia. The FAM-CAM had a specificity of 83% and a negative predictive value of 83%. Most false negatives (n = 9 of 13, 69%) were due to caregivers not identifying the inattention criteria for delirium on the FAM-CAM. In patients with dementia, sensitivity was higher than in patients without (61% vs 43%). In adjusted models, a hospitalization in the following 6 months was more than three times as likely in FAM-CAM positive compared to negative patients (odds ratio = 3.4; 95% confidence interval = 1.2-9.3). CONCLUSIONS Among patients with and without dementia, the FAM-CAM shows qualities that are important in the ED setting for identification of delirium. Using the FAM-CAM as part of a systematic screening strategy for the ED, in which families' assessments could supplement healthcare professionals' assessments, is promising. J Am Geriatr Soc 68:983-990, 2020.
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Affiliation(s)
- Tanya Mailhot
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA; Montreal Heart Institute, Montreal, Qc, Canada
| | - Chad Darling
- Department of Emergency Medicine, UMass Memorial Health Care, Worcester, MA USA
| | - Jillian Ela
- Neurological Associates of Albany, Albany, NY USA
| | - Yelena Malyuta
- Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Sharon K Inouye
- Aging Brain Center, Boston, MA USA; Harvard Medical School, Boston, MA, USA
| | - Jane Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
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Eagles D, Otal D, Wilding L, Sinha S, Thiruganasambandamoorthy V, Wells GA, Stiell IG. Evaluation of the Ottawa 3DY as a screening tool for cognitive impairment in older emergency department patients. Am J Emerg Med 2020; 38:2545-2551. [PMID: 31937444 DOI: 10.1016/j.ajem.2019.12.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 11/07/2019] [Accepted: 12/17/2019] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE This study sought to evaluate the implementation of the Ottawa 3DY Tool, a simple screening instrument for cognitive impairment, by front-line ED clinicians. METHODS We conducted a prospective cohort study in an academic ED. Patients ≥75 years underwent cognitive screening with the Ottawa 3DY by front-line nurses and physicians. Descriptive statistics were used to describe level of implementation and acceptability of the tool. Sensitivity and specificity was calculated using an Mini-Mental State Exam <25 as the cut-off for cognitive impairment. A weighted kappa was calculated to establish inter-rater agreement. RESULTS Cognitive screening was completed in 260/332 eligible patients (78.3%), who were 60% female and had a mean age of 83.7 years. Facilitators to screening: perceived importance and ownership of screening and feasibility of Ottawa 3DY. Barriers to screening were: over confidence in clinical judgement and perceived lack of patient benefit. Ottawa 3DY had a sensitivity of 84.6% (64.3-95.0) and specificity of 54.2% (39.3-68.4) when completed by nurses. When completed by emergency physicians, sensitivity was 78.9% (53.9-93.0) and specificity was 70.0% (45.7-87.2). Inter-rater agreement kappa score was 0.67. DISCUSSION This study demonstrated that incorporating the Ottawa 3DY tool into the routine evaluation of older ED patients by front-line ED clinicians is both feasible and effective. With its demonstrated good inter-rater reliability and moderate level of sensitivity and specificity when compared with the much longer MMSE, the routine adoption of this tool may help lead to improved recognition of cognitive impairment and ultimately patient and system outcomes.
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Affiliation(s)
- Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Damanjot Otal
- Department of Family Medicine, University of Western Ontario, London, Ontario, Canada
| | - Laura Wilding
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Samir Sinha
- Departments of Medicine and Family and Community Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - George A Wells
- School of Epidemiology and Public Health, Department of Medicine and Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Parke B, Hunter KF. The dementia-friendly emergency department: An innovation to reducing incompatibilities at the local level. Healthc Manage Forum 2019; 30:26-31. [PMID: 28929901 DOI: 10.1177/0840470416664532] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Emergency Departments (EDs) are an integral part of the Canadian healthcare system. Older people living with dementia challenge EDs. They have complex health profiles that pose multiple challenges for staff. The current one-size-fits-all approach that aids efficiency in a technologically dependent hospital setting may not always serve older people living with dementia, their caregivers, or staff well. The premise that older people living with dementia are a problem for Canadian EDs must be reconsidered. Understanding the complexity of the situation is aided by the dementia-friendly ED framework. We propose one way to enhance communication between those living with dementia who receive ED services and those providing the service.
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Affiliation(s)
- Belinda Parke
- 1 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alberta, Canada
| | - Kathleen F Hunter
- 1 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alberta, Canada
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Ho MH, Wang CH, Joo JY, Chang HC(R, Chang CC, Liu MF. Predictors of Emergency Department Use Among Community-Dwelling Older Adults. J Gerontol Nurs 2019; 45:31-38. [DOI: 10.3928/00989134-20190404-02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 03/19/2019] [Indexed: 11/20/2022]
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Amador S, Sampson EL, Goodman C, Robinson L. A systematic review and critical appraisal of quality indicators to assess optimal palliative care for older people with dementia. Palliat Med 2019; 33:415-429. [PMID: 30854933 PMCID: PMC6439949 DOI: 10.1177/0269216319834227] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND A challenge for commissioners and providers of end-of-life care in dementia is to translate recommendations for good or effective care into quality indicators that inform service development and evaluation. AIM To identify and critically evaluate quality indicators for end-of-life care in dementia. RESULTS We found 8657 references, after de-duplication. In all, 19 publications describing 10 new and 3 updated sets of indicators were included in this review. Ultimately, 246 individual indicators were identified as being relevant to dementia end-of-life care and mapped against EAPC guidelines. CONCLUSIONS We systematically derived and assessed a set of quality indicators using a robust framework that provides clear definitions of aspects of palliative care, which are dementia specific, and strengthens the theoretical underpinning of new complex interventions in end-of-life care in dementia.
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Affiliation(s)
- Sarah Amador
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Louise Robinson
- Institute for Ageing and Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
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Perry W, Lacritz L, Roebuck-Spencer T, Silver C, Denney RL, Meyers J, McConnel CE, Pliskin N, Adler D, Alban C, Bondi M, Braun M, Cagigas X, Daven M, Drozdick L, Foster NL, Hwang U, Ivey L, Iverson G, Kramer J, Lantz M, Latts L, Maria Lopez A, Malone M, Martin-Plank L, Maslow K, Melady D, Messer M, Most R, Norris MP, Shafer D, Thomas CM, Thornhill L, Tsai J, Vakharia N, Waters M, Golden T. Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients. Clin Neuropsychol 2018; 32:1193-1225. [DOI: 10.1080/13854046.2018.1517503] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- William Perry
- National Academy of Neuropsychology (NAN)
- NAN
- University of California, San Diego
| | - Laura Lacritz
- National Academy of Neuropsychology (NAN)
- UT Southwestern Medical Center
| | | | | | - Robert L. Denney
- National Academy of Neuropsychology (NAN)
- Missouri Memory Center, Citizens Memorial Healthcare
| | | | | | | | - Deb Adler
- Senior Vice President Network Strategy, Optum of United Health Group
| | | | - Mark Bondi
- Society for Clinical Neuropsychology (SCN)
| | | | | | | | | | - Norman L. Foster
- American Academy of Neurology (AAN)
- Center for Alzheimer’s Care, Imaging and Research, Department of Neurology, University of Utah
| | - Ula Hwang
- Geriatric EM Section, American College of Emergency Physicians (ACEP)
- Department of Emergency Medicine
- Icahn School of Medicine at Mount Sinai, Geriatric Research Education, and Clinical Center, James J. Peters VAMC Geriatric EM Section
- American College of Emergency Physicians (ACEP)
| | - Laurie Ivey
- Collaborative Family Healthcare Association (CFHA)
| | - Grant Iverson
- National Academy of Neuropsychology (NAN)
- Neuropsychology Outcome Assessment Laboratory and Director, Massachusetts General Hospital for Children Sports Concussion Program, Harvard Medical School
| | - Joel Kramer
- International Neuropsychological Society (INS)
| | | | | | - Ana Maria Lopez
- American College of Physicians (ACP)
- Health Equity and Inclusion, University of Utah Health Sciences Center
- Cancer Health Equity, Huntsman Cancer Institute
- University of Utah School of Medicine
| | - Michael Malone
- American Geriatrics Society
- Aurora Senior Services, Aurora Health Care
| | | | | | - Don Melady
- Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, University of Toronto
- Canadian Association of Emergency Physicians
- International Federation of Emergency Medicine
| | - Melissa Messer
- Research & Development, Psychological Assessment Resources, Inc. (PAR)
| | - Randi Most
- American Board of Professional Neuropsychology (ABN)
| | | | | | | | | | - Jean Tsai
- American Academy of Neurology (AAN)
- University of Colorado, Denver Health
| | | | - Martin Waters
- Clinical Innovation and Thought Leadership, Beacon Health Options
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Perry W, Lacritz L, Roebuck-Spencer T, Silver C, Denney RL, Meyers J, McConnel CE, Pliskin N, Adler D, Alban C, Bondi M, Braun M, Cagigas X, Daven M, Drozdick L, Foster NL, Hwang U, Ivey L, Iverson G, Kramer J, Lantz M, Latts L, Ling SM, Lopez AM, Malone M, Martin-Plank L, Maslow K, Melady D, Messer M, Most R, Norris MP, Shafer D, Silverberg N, Thomas CM, Thornhill L, Tsai J, Vakharia N, Waters M, Golden T. Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients. Arch Clin Neuropsychol 2018; 33:655-675. [PMID: 30339202 PMCID: PMC6201735 DOI: 10.1093/arclin/acy052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 06/08/2018] [Indexed: 12/17/2022] Open
Abstract
SUMMIT PARTICIPANTS ORGANIZATIONS REPRESENTED
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Affiliation(s)
- William Perry
- National Academy of Neuropsychology (NAN)
- NAN
- University of California, San Diego
| | - Laura Lacritz
- National Academy of Neuropsychology (NAN)
- UT Southwestern Medical Center
| | | | | | - Robert L Denney
- National Academy of Neuropsychology (NAN)
- Missouri Memory Center, Citizens Memorial Healthcare
| | | | | | | | - Deb Adler
- Senior Vice President Network Strategy, Optum of United Health Group
| | | | - Mark Bondi
- Society for Clinical Neuropsychology (SCN)
| | | | | | | | | | - Norman L Foster
- American Academy of Neurology (AAN)
- Center for Alzheimer's Care, Imaging and Research, Department of Neurology, University of Utah
| | - Ula Hwang
- Geriatric EM Section, American College of Emergency Physicians (ACEP)
- Department of Emergency Medicine
- Icahn School of Medicine at Mount Sinai, Geriatric Research Education, and Clinical Center, James J. Peters VAMC Geriatric EM Section
- American College of Emergency Physicians (ACEP)
| | - Laurie Ivey
- Collaborative Family Healthcare Association (CFHA)
| | - Grant Iverson
- National Academy of Neuropsychology (NAN)
- Neuropsychology Outcome Assessment Laboratory and Director, Massachusetts General Hospital for Children Sports Concussion Program, Harvard Medical School
| | - Joel Kramer
- International Neuropsychological Society (INS)
| | | | | | - Shari M Ling
- Centers for Medicare and Medicaid Services (CMS)
| | - Ana Maria Lopez
- American College of Physicians (ACP)
- Health Equity and Inclusion, University of Utah Health Sciences Center
- Cancer Health Equity, Huntsman Cancer Institute
- University of Utah School of Medicine
| | - Michael Malone
- American Geriatrics Society
- Aurora Senior Services, Aurora Health Care
| | | | | | - Don Melady
- Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, University of Toronto
- Canadian Association of Emergency Physicians
- International Federation of Emergency Medicine
| | - Melissa Messer
- Research & Development, Psychological Assessment Resources, Inc. (PAR)
| | - Randi Most
- American Board of Professional Neuropsychology (ABN)
| | | | | | - Nina Silverberg
- Alzheimer's Disease Centers (ADC) Program, National Institute on Aging (NIA)
| | | | | | - Jean Tsai
- American Academy of Neurology (AAN)
- University of Colorado, Denver Health
| | | | - Martin Waters
- Clinical Innovation and Thought Leadership, Beacon Health Options
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Abstract
This article reviews 10 best practices that integrate geriatric principles into emergency department processes of care. These best practices are grouped around ten words: complexity; clinician education; geriatric-specific; atypical; medication; variability; cognitive impairment; psychosocial issues; end-of-life care; and interdisciplinary.
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Perry W, Lacritz L, Roebuck-Spencer T, Silver C, Denney RL, Meyers J, McConnel CE, Pliskin N, Adler D, Alban C, Bondi M, Braun M, Cagigas X, Daven M, Drozdick L, Foster NL, Hwang U, Ivey L, Iverson G, Kramer J, Lantz M, Latts L, Ling SM, Maria Lopez A, Malone M, Martin-Plank L, Maslow K, Melady D, Messer M, Most R, Norris MP, Shafer D, Silverberg N, Thomas CM, Thornhill L, Tsai J, Vakharia N, Waters M, Golden T. Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients. Innov Aging 2018; 2:igy025. [PMID: 30480142 PMCID: PMC6183165 DOI: 10.1093/geroni/igy025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition;emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; andrecognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time.
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Affiliation(s)
- William Perry
- National Academy of Neuropsychology (NAN)
- University of California, San Diego
| | - Laura Lacritz
- National Academy of Neuropsychology (NAN)
- UT Southwestern Medical Center
| | | | - Cheryl Silver
- National Academy of Neuropsychology (NAN)
- UT Southwestern Medical Center
| | - Robert L Denney
- National Academy of Neuropsychology (NAN)
- Missouri Memory Center, Citizens Memorial Healthcare
| | | | | | | | - Deb Adler
- Senior Vice President Network Strategy, Optum of United Health Group
| | | | - Mark Bondi
- Society for Clinical Neuropsychology (SCN)
| | | | | | | | | | - Norman L Foster
- American Academy of Neurology (AAN)
- Center for Alzheimer's Care, Imaging and Research, Department of Neurology, University of Utah
| | - Ula Hwang
- Geriatric EM Section, American College of Emergency Physicians (ACEP)
- Department of Emergency Medicine
- Icahn School of Medicine at Mount Sinai, Geriatric Research Education, and Clinical Center, James J. Peters VAMC Geriatric EM Section
- American College of Emergency Physicians (ACEP)
| | - Laurie Ivey
- Collaborative Family Healthcare Association (CFHA)
| | - Grant Iverson
- National Academy of Neuropsychology (NAN)
- Neuropsychology Outcome Assessment Laboratory and Director, Massachusetts General Hospital for Children Sports Concussion Program, Harvard Medical School
| | - Joel Kramer
- International Neuropsychological Society (INS)
| | | | | | - Shari M Ling
- Centers for Medicare and Medicaid Services (CMS)
| | - Ana Maria Lopez
- American College of Physicians (ACP)
- Health Equity and Inclusion, University of Utah Health Sciences Center
- Cancer Health Equity, Huntsman Cancer Institute
- University of Utah School of Medicine
| | - Michael Malone
- American Geriatrics Society
- Aurora Senior Services, Aurora Health Care
| | | | | | - Don Melady
- Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, University of Toronto
- Canadian Association of Emergency Physicians
- International Federation of Emergency Medicine
| | - Melissa Messer
- Research & Development, Psychological Assessment Resources, Inc. (PAR)
| | - Randi Most
- American Board of Professional Neuropsychology (ABN)
| | | | | | - Nina Silverberg
- Alzheimer's Disease Centers (ADC) Program, National Institute on Aging (NIA)
| | | | | | - Jean Tsai
- American Academy of Neurology (AAN)
- University of Colorado, Denver Health
| | | | - Martin Waters
- Clinical Innovation and Thought Leadership, Beacon Health Options
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Barbic D, Kim B, Salehmohamed Q, Kemplin K, Carpenter CR, Barbic SP. Diagnostic accuracy of the Ottawa 3DY and Short Blessed Test to detect cognitive dysfunction in geriatric patients presenting to the emergency department. BMJ Open 2018; 8:e019652. [PMID: 29549205 PMCID: PMC5857706 DOI: 10.1136/bmjopen-2017-019652] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES Cognitive dysfunction (CD) is a common finding in geriatric patients presenting to the emergency department (ED). Our primary objective was to determine the diagnostic accuracy of the Ottawa 3DY (O3DY) and Short Blessed Test (SBT) as screening tools for the detection of CD in the ED. Our secondary objective was to estimate the inter-rater reliability of these instruments. METHODS We conducted a prospective cross-sectional comparative study at an inner-city academic medical centre (annual ED visit census 86 000). Patients aged 75 years or greater were evaluated for inclusion, 163 were screened, 150 were deemed eligible and 117 were enrolled. The research team completed the O3DY, SBT and Mini-Mental State Exam (MMSE) for each participant. Descriptive statistics were calculated. Sensitivity and specificity of the O3DY and SBT were calculated in STATA V.11.2 using the MMSE as our criterion standard. RESULTS We enrolled 117 patients from June to November 2016. The median ED length of stay at the time of completion of all tests was 1:40 (IQR 1:34-1:46). The sensitivity of the O3DY was 71.4% (95% CI 47.8 to 95.1), and specificity was 56.3% (46.7-65.9). Sensitivity of the SBT was 85.7% (67.4-99.9) and specificity was 58.3% (48.7-67.8). The receiver operating characteristic area under the curve was calculated for the O3DY (0.51; 95% CI 0.42 to 0.61) and SBT (0.52; 95% CI 0.43 to 0.61) relative to the MMSE. Inter-rater reliability for the O3DY (k=0.64) and SBT (k=0.63) were good. CONCLUSION In a cohort of geriatric patients presenting to an inner-city academic ED, the O3DY and SBT tools demonstrate moderate sensitivity and specificity for the detection of CD. Inter-rater reliability for the O3DY and SBT were good. Future research on this topic should attempt to derive and validate ED-specific screening tools, which will hopefully result in more robust likelihood ratios for the screening of CD in ED geriatric patients.
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Affiliation(s)
- David Barbic
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian Kim
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Qadeem Salehmohamed
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kate Kemplin
- School of Nursing, University of Tennessee Chattanooga, Chattanooga, Tennessee, USA
| | | | - Skye Pamela Barbic
- Department of Occupational Therapy and Occupational Science, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation Outcome Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Jones J, Sim TF, Hughes J. Pain Assessment of Elderly Patients with Cognitive Impairment in the Emergency Department: Implications for Pain Management-A Narrative Review of Current Practices. PHARMACY 2017; 5:E30. [PMID: 28970442 PMCID: PMC5597155 DOI: 10.3390/pharmacy5020030] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/05/2017] [Accepted: 05/26/2017] [Indexed: 01/08/2023] Open
Abstract
Elderly people are susceptible to both falls and cognitive impairment making them a particularly vulnerable group of patients when it comes to pain assessment and management in the emergency department (ED). Pain assessment is often difficult in patients who present to the ED with a cognitive impairment as they are frequently unable to self-report their level of pain, which can have a negative impact on pain management. This paper aims to review how cognitive impairment influences pain assessment in elderly adults who present to the ED with an injury due to a fall. A literature search of EMBASE, ProQuest, PubMed, Science Direct, SciFinder and the Curtin University Library database was conducted using keyword searches to generate lists of articles which were then screened for relevance by title and then abstract to give a final list of articles for full-text review. Further articles were identified by snowballing from the reference lists of the full-text articles. The literature reports that ED staff commonly use visual or verbal analogue scales to assess pain, but resort to their own intuition or physiological parameters rather than using standardised observational pain assessment tools when self-report of pain is not attainable due to cognitive impairment. While studies have found that the use of pain assessment tools improves the recognition and management of pain, pain scores are often not recorded for elderly patients with a cognitive impairment in the ED, leading to poorer pain management in this patient group in terms of time to analgesic administration and the use of strong opioids. All healthcare professionals involved in the care of such patients, including pharmacists, need to be aware of this and strive to ensure analgesic use is guided by appropriate and accurate pain assessment in the ED.
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Affiliation(s)
- Joshua Jones
- School of Pharmacy, Curtin University, Western Australia 6102, Australia.
| | - Tin Fei Sim
- School of Pharmacy, Curtin University, Western Australia 6102, Australia.
| | - Jeff Hughes
- School of Pharmacy, Curtin University, Western Australia 6102, Australia.
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Prusaczyk B, Cherney SM, Carpenter CR, DuBois JM. Informed Consent to Research with Cognitively Impaired Adults: Transdisciplinary Challenges and Opportunities. Clin Gerontol 2017; 40:63-73. [PMID: 28452628 PMCID: PMC5911394 DOI: 10.1080/07317115.2016.1201714] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Due to issues related to informed research consent, older adults with cognitive impairments are often excluded from high-quality studies that are not directly related to cognitive impairment, which has led to a dearth of evidence for this population. The challenges to including cognitively impaired older adults in research and the implications of their exclusion are a transdisciplinary issue. The ethical challenges and logistical barriers to conducting research with cognitively impaired older adults are addressed from the perspectives of three different fields-social work, emergency medicine, and orthopaedic surgery. Issues related to funding, study design, intervention components, and outcomes are discussed through the unique experiences of three different providers. A fourth perspective-medical research ethics-provides alternatives to exclusion when conducting research with cognitively impaired older adults such as timing, corrective feedback and plain language, and capacity assessment and proxy appointments. Given the increasing aging population and the lack of evidence on cognitively impaired older adults, it is critical that researchers, funders, and institutional review boards not be dissuaded from including this population in research studies.
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Affiliation(s)
- Beth Prusaczyk
- a Washington University School of Medicine , St. Louis , Missouri , USA
| | - Steven M Cherney
- a Washington University School of Medicine , St. Louis , Missouri , USA
| | | | - James M DuBois
- a Washington University School of Medicine , St. Louis , Missouri , USA
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Singler K, Dormann H, Dodt C, Heppner HJ, Püllen R, Burkhardt M, Swoboda W, Roller-Wirnsberger RE, Pinter G, Mrak P, Münzer T. Der geriatrische Patient in der Notaufnahme. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0216-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Schnitker LM, Beattie ERA, Martin-Khan M, Burkett E, Gray LC. Characteristics of older people with cognitive impairment attending emergency departments: A descriptive study. ACTA ACUST UNITED AC 2016; 19:118-26. [PMID: 27173359 DOI: 10.1016/j.aenj.2016.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 04/10/2016] [Accepted: 04/11/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The objective of this paper is to describe the profile of older people with cognitive impairment (CI) presenting to emergency departments (EDs). METHODS This was a multi-centre (n=8) observational study of a convenience sample of older (≥70y) ED patients (n=579). Participants were prospectively assessed for CI and surveyed for the duration of their ED stay (n=191). A picture of patients' health status and ED responses to care needs was obtained through application of standardised assessment tools. Additionally, observations of care processes in ED were undertaken. Demographic data were collected through both ED's information system and survey. Outcome data were collected 28 days post-ED visit using follow-up telephone interviews. RESULTS Of 579 older persons, 191 (33%) persons met criteria for CI. The majority of older ED patients with CI in ED lived in the community (157/177, 88.7%), arrived by ambulance (116/172, 67%), were accompanied by a support person (94/149, 63%), were triaged as urgent to semi-urgent (157/191, 82%), and were hospitalised (108/172, 57%). The median ED length of stay was 6h. In ED, 53% of the sample experienced pain (92/173). Older ED patients with CI pose the following characteristics: prior hospital admissions (43/129, 33%), incontinence (61/178, 34%), dependence in activities in daily living (81/190, 43%), issues in nutrition (73/182, 40%), vision and hearing impairment (93% (160/172) and 26% (44/171) respectively). CONCLUSION Increased understanding of these presenting characteristics and their impacts on patient risk facilitates tailoring the quality of emergency care to better suit the needs and improve outcomes of this increasing ED population.
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Affiliation(s)
- Linda M Schnitker
- School of Nursing, Queensland University of Technology, Brisbane, Australia; The Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, Australia.
| | | | - Melinda Martin-Khan
- The Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, Australia; Centre for Online Health, The University of Queensland, Brisbane, Australia
| | - Ellen Burkett
- The Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, Australia; Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, Australia
| | - Leonard C Gray
- The Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, Australia; Centre for Online Health, The University of Queensland, Brisbane, Australia
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32
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A national survey of Canadian emergency medicine residents' comfort with geriatric emergency medicine. CAN J EMERG MED 2016; 19:9-17. [PMID: 27086864 DOI: 10.1017/cem.2016.27] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Geriatric patients represent a large and complex subgroup seen in emergency departments (EDs). Competencies in geriatric emergency medicine (EM) training have been established. Our objectives were to examine Canadian postgraduate year (PGY)-5 EM residents' comfort with the geriatric EM competency domains, assess whether Canadian EM residents become more comfortable through residency, and determine whether geriatric educational exposures are correlated with resident comfort with geriatric EM. METHODS A national, cross-sectional study of PGY-1 and PGY-5 Royal College EM residents was conducted to determine their comfort in geriatric EM clinical competency domains. Residents reported their level of comfort in satisfying each competency domain using a seven-point Likert scale. Residents were also asked about the location of their medical education as well as the type and number of different geriatric exposures that they had received to date. RESULTS Of the 141 eligible residents from across Canada, 77% (109) consented to participate. None of the PGY-1 EM residents and 34% (14) of PGY-5 EM residents reported that they were comfortable with all eight geriatric EM competency domains. PGY-5 EM residents were significantly more comfortable than PGY-1 EM residents. Residents reported a highly variable range of geriatric educational exposures obtained during training. No relationship was found between resident-reported comfort and the nature or number of geriatric exposures that they had received. CONCLUSION Current Royal College EM residency training in Canada may not be adequately preparing graduates to be comfortable with defined competencies for the care of older ED patients.
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Wilding L, Eagles D, Molnar F, O'Brien JA, Dalziel WB, Moors J, Stiell I. Prospective Validation of the Ottawa 3DY Scale by Geriatric Emergency Management Nurses to Identify Impaired Cognition in Older Emergency Department Patients. Ann Emerg Med 2015; 67:157-63. [PMID: 26607333 DOI: 10.1016/j.annemergmed.2015.09.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 08/19/2015] [Accepted: 09/02/2015] [Indexed: 01/12/2023]
Abstract
STUDY OBJECTIVE Assessment of older emergency department (ED) patients with cognitive impairment is challenging because few tools exist that can be quickly administered by front-line practitioners. Our objective is to validate the Ottawa 3DY Scale, a 4-question screening tool for cognitive impairment, in older ED patients and compare its performance with that of the Animal Fluency Test. METHODS We conducted a prospective cohort study in 2 EDs and enrolled a convenience sample of patients aged 75 years or older with no history of cognitive impairment. Eligible patients were assessed by geriatric emergency management nurses who administered the Mini-Mental State Examination, ordered with the Ottawa 3DY Scale questions first, followed by the Animal Fluency Test. Mini-Mental State Examination score less than 25 was our criterion standard for cognitive impairment. RESULTS Study patients (N=238) had a mean age of 81.9 years and were 60.1% women, and 26.5% were admitted to the hospital. The Ottawa 3DY Scale and Mini-Mental State Examination were in agreement for 75.6% of cases, with a sensitivity of 93.8% (95% confidence interval [CI] 77.8% to 98.9%) and specificity of 72.8% (95% CI 66.1% to 78.7%). The Animal Fluency Test score less than 15 and Mini-Mental State Examination score were in agreement for 46.2% of cases, with sensitivity 90.6% (95% CI 73.8% to 97.5%) and specificity 39.3% (95% CI 32.7% to 46.4%). CONCLUSION Both the Ottawa 3DY Scale and the Animal Fluency Test demonstrated excellent sensitivity versus the Mini-Mental State Examination; however, the Animal Fluency Test exhibited poor specificity. The Ottawa 3DY Scale is an effective tool to screen for cognitive impairment in older ED patients, and its use may facilitate improved care in this vulnerable population.
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Affiliation(s)
- Laura Wilding
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Frank Molnar
- Regional Geriatric Program of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada; Division of Geriatric Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jo-Anne O'Brien
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - William B Dalziel
- Division of Geriatric Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joy Moors
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Melady D, Banerjee J. Is your department's quality good enough for your grandmother? Quality indicators for patients with dementia and delirium. Acad Emerg Med 2015; 22:362-4. [PMID: 25716708 DOI: 10.1111/acem.12619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Don Melady
- Emergency Medicine, University of Toronto, Toronto, Ontario, Canada.
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