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Seidenfeld J, Lee S, Ragsdale L, Nickel CH, Liu SW, Kennedy M. Risk factors and risk stratification approaches for delirium screening: A Geriatric Emergency Department Guidelines 2.0 systematic review. Acad Emerg Med 2024; 31:969-984. [PMID: 38847070 DOI: 10.1111/acem.14939] [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: 02/14/2024] [Revised: 04/08/2024] [Accepted: 04/27/2024] [Indexed: 10/18/2024]
Abstract
OBJECTIVE As part of the Geriatric Emergency Department (ED) Guidelines 2.0 project, we conducted a systematic review to find risk factors or risk stratification approaches that can be used to identify subsets of older adults who may benefit from targeted ED delirium screening. METHODS An electronic search strategy was developed with a medical librarian, conducted in April 2021 and November 2022. Full-text studies of patients ≥65 years assessed for prevalent delirium in the ED were included. Risk of bias was assessed using the McMaster University Clarity Group tool. Outcomes measures pertained to the risk stratification method used. Due to heterogeneity of patient populations, risk stratification methods, and outcomes, a meta-analysis was not conducted. RESULTS Our search yielded 1878 unique citations, of which 13 were included. Six studies developed a novel delirium risk score with or without evaluation of specific risk factors, six studies evaluated specific risk factors only, and one study evaluated an existing nondelirium risk score for association with delirium. The most common risk factor was history of dementia, with odds ratios ranging from 3.3 (95% confidence interval [CI] 1.2-8.9) to 18.33 (95% CI 8.08-43.64). Other risk factors that were consistently associated with increased risk of delirium included older age, use of certain medications (such as antipsychotics, antidepressants, and opioids, among others), and functional impairments. Of the studies that developed novel risk scores, the reported area under the curve ranged from 0.77 to 0.90. Only two studies reported potential impact of the risk stratification tool on screening burden. CONCLUSIONS There is significant heterogeneity, but results suggest that factors such as dementia, age over 75, and functional impairments should be used to identify older adults who are at highest risk for ED delirium. No studies evaluated implementation of a risk stratification method for delirium screening or evaluated patient-oriented outcomes.
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Affiliation(s)
- Justine Seidenfeld
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
- Department of Emergency Medicine, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Luna Ragsdale
- Department of Emergency Medicine, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Cox R, Kyle G, Suzuki A, Wishart L, McCusker M, McConnell A, Ward EC, Ross L, Webb C. Patient and multidisciplinary health professional perceptions of an Australian geriatric evaluation and management and rehabilitation hospital in the home service. J Health Serv Res Policy 2024; 29:31-41. [PMID: 37897739 DOI: 10.1177/13558196231193863] [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: 10/30/2023]
Abstract
OBJECTIVES Hospital in the Home models are rapidly expanding in response to increasing bed pressures. This study examined patient and multidisciplinary health professional perceptions of a new geriatric evaluation and management and rehabilitation hospital in the home service in Australia. The service was unique, as adults of all ages with a variety of rehabilitation or geriatric evaluation and management needs were within scope. METHODS A qualitative descriptive approach was used with a consumer co-researcher and a consumer advisor being integral to decision-making. Patient feedback was collected via a paper-based patient satisfaction survey between August 2020 and February 2022. Additionally, interviews with current and past staff were conducted from July to November 2021. Reflexive thematic analysis was conducted for qualitative data and descriptive statistics used for quantitative data. RESULTS Patient surveys were analysed (n = 199, 42.2% response rate) with 60.8% of participants aged 75 years or over and 26.6% speaking a language other than English. High satisfaction was expressed. Feelings of comfort, familiarity, convenience, and reassurance were voiced. A person-centred approach enhanced involvement in care. Challenges included carer burden and clear communication. Sixteen staff (33% response rate) were interviewed. In general, staff said the service was inclusive and responsive, and the home environment beneficial, particularly for patients from culturally diverse backgrounds. A strong hospital partnership and comprehensive multidisciplinary approach were vital. Challenges included fragmentation due to part-time roles and combining with a pre-existing acute hospital in the home service. CONCLUSIONS This qualitative exploration of staff and patients' perceptions of a geriatrician-led, multidisciplinary geriatric evaluation and management and rehabilitation hospital in the home service demonstrated that it was person-centred and optimised patients' control and ownership of care. The inclusive service parameters ensured responsiveness to diverse needs whilst allowing earlier return home from hospital, both of which are vital for quality patient care.
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Affiliation(s)
- Ruth Cox
- Occupational Therapy Department, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Greg Kyle
- Centre for Functioning and Health Research, Metro South Health, Brisbane, QLD, Australia
| | - Anya Suzuki
- Occupational Therapy Department, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Laurelie Wishart
- Centre for Functioning and Health Research, Metro South Health, Brisbane, QLD, Australia
| | - Melissa McCusker
- Community and Oral Health, Metro South Health, Brisbane, QLD, Australia
| | - Alexander McConnell
- Consumer Partner, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Elizabeth C Ward
- Centre for Functioning and Health Research, Metro South Health, Brisbane, QLD, Australia
- School of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Leo Ross
- Division of Allied Health, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Clare Webb
- Occupational Therapy Department, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
- Division of Allied Health, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
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Ouchi K, Liu S, Tonellato D, Keschner YG, Kennedy M, Levine DM. Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities. J Am Coll Emerg Physicians Open 2021; 2:e12517. [PMID: 34322684 PMCID: PMC8295243 DOI: 10.1002/emp2.12517] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/27/2021] [Accepted: 07/01/2021] [Indexed: 12/03/2022] Open
Abstract
The $1 trillion industry of acute hospital care in the United States is shifting from inside the walls of the hospital to patient homes. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services announced that the acute hospital care at home waiver would reimburse for "home hospital" services. A "home hospital" is the home-based provision of acute services usually associated with the traditional inpatient hospital setting. Prior work suggests that home hospital care can reduce costs, maintain quality and safety, and improve patient experiences for select acutely ill adults who require hospital-level care. However, most emergency physicians are unfamiliar with the evidence of benefits demonstrated by home hospital services, especially for older adults. Therefore, the lead author solicited narrative inputs on this topic from selected experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then we sought to identify information most relevant to the practice of emergency medicine. We outline the proven and potential benefits of home hospital services specific to older adults compared to traditional acute care hospitalization with a focus on the emergency department.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Shan Liu
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Daniel Tonellato
- Department of Emergency MedicineMedStar Georgetown University HospitalWashingtonDistrict of ColumbiaUSA
- Department of Emergency MedicineGeorgetown University School of MedicineWashingtonDistrict of ColumbiaUSA
| | - Yonatan G. Keschner
- Department of Emergency MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Maura Kennedy
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - David M. Levine
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of General Internal Medicine and Primary CareBrigham and Women's HospitalBostonMassachusettsUSA
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Manni B, Federzoni L, Zucchi P, Mussi C, Inzitari M, Carda CA, Fabbo A, Morandi A. Prevalence and management of delirium in community dwelling older people with dementia referred to a memory clinic. Aging Clin Exp Res 2021; 33:2243-2250. [PMID: 33211247 DOI: 10.1007/s40520-020-01753-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/30/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Our aim was to measure the prevalence of delirium, its clinical features, and outcomes in older patients referred to a memory clinic. METHODS A retrospective cohort study of 109 older outpatients with delirium referred to a memory clinic with a home care service. Delirium was diagnosed using the confusion assessment method and dementia with the DSM-5 criteria. We collected information on cognitive and functional status, mortality, institutionalization, and hospitalization during 6 months following the delirium episode. RESULTS Delirium prevalence was 3.6%, mostly of hyperactive type. Delirium worsened functional (ADL 2.95 ± 1.95 vs. 2.16 ± 1.84) and cognitive (MMSE 13.88 ± 8.96 vs.11.0 ± 9.49) status after 6 months compared to the baseline. The mortality rate was 29.4%, and 28.3% were admitted to a long-term facility after the episode of delirium. Of these patients, more than half were hospitalized during the follow-up. Of the 109 patients with delirium, 85 were managed at home and 24 were hospitalized. Patients who were hospitalized had more severe behavioral symptoms during the delirium episode. There was no difference in mortality and institutionalization according to the home or hospital management. CONCLUSIONS This retrospective cohort study adds novel information to the existing literature of an understudied setting and population. The study supports the need to further investigate the feasibility and efficacy of the hospital at home models for the prevention and management of delirium in a high-risk population.
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Affiliation(s)
- Barbara Manni
- Cognitive Disorders and Dementia Unit, Modena Health Authority and Services, Primary Care, Modena, Italy
| | - Lucia Federzoni
- Cognitive Disorders and Dementia Unit, Modena Health Authority and Services, Primary Care, Modena, Italy
| | - Patrizia Zucchi
- Cognitive Disorders and Dementia Unit, Modena Health Authority and Services, Primary Care, Modena, Italy
| | - Chiara Mussi
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Inzitari
- REFiT Bcn Research Group, ParcSanitari Pere Virgili and Valld'Hebrón Institute of Research, Barcelona, Spain
| | - Cristina Arnal Carda
- REFiT Bcn Research Group, ParcSanitari Pere Virgili and Valld'Hebrón Institute of Research, Barcelona, Spain
| | - Andrea Fabbo
- Cognitive Disorders and Dementia Unit, Modena Health Authority and Services, Primary Care, Modena, Italy
| | - Alessandro Morandi
- REFiT Bcn Research Group, ParcSanitari Pere Virgili and Valld'Hebrón Institute of Research, Barcelona, Spain.
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Hospital Ancelle, Via Aselli 14, 26100, Cremona, Italy.
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Docherty T, Schneider JJ, Cooper J. Clinic- and Hospital-Based Home Care, Outpatient Parenteral Antimicrobial Therapy (OPAT) and the Evolving Clinical Responsibilities of the Pharmacist. PHARMACY 2020; 8:E233. [PMID: 33297356 PMCID: PMC7768382 DOI: 10.3390/pharmacy8040233] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 11/26/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022] Open
Abstract
Clinic- and hospital-based home care describes models of care where services commonly associated with hospital inpatient care are provided at the patient's home or in an outpatient or community-based clinic. Hospital in the Home (HITH), also termed Hospital at Home (HaH) in parts of Europe and America, is a common and important example of this type of care. Other examples include infusion centers, skilled nursing facilities (particularly in the USA), self-administration models (including home infusion services) and administration through outpatient or community clinics. Different models of HITH care are used internationally and these encompass a wide range of services. Medication administration, particularly outpatient parenteral antimicrobial therapy (OPAT), is an important element in many of these models of care. There is a key role for pharmacists since the provision of medication is integral in this model of patient care outside the hospital setting. Data on the growing importance of HITH and OPAT as well as the administration of medications suited to clinic- and hospital-based home care, including subcutaneous and intramuscular injectables, immunoglobulins and other blood fractions, cancer chemotherapy, total parenteral nutrition, biologicals/biosimilars, vasopressors and enzymes, using differing service models, are described. The pharmacist's role is evolving from that involved primarily with dose preparation and supply of medications. Their clinical expertise in medication management ensures that they are an integral member and leader in these models of care. Their role ensures the safe and quality use of medicines, particularly across transitions of care, with the pharmacist taking on the roles of educator and consultant to patients and health professional colleagues. Activities such as antimicrobial stewardship and ongoing monitoring of patients and outcomes is fundamental to ensure quality patient outcomes in these settings.
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Affiliation(s)
- Toni Docherty
- Central Coast Local Health District, Gosford, NSW 2250, Australia;
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia;
| | - Jennifer J. Schneider
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia;
| | - Joyce Cooper
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia;
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