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Jackson C, Malia C, Zacharias H, Dyson J, Johnson MJ. Improving hospice delirium guideline adoption through an understanding of barriers and facilitators: A mixed-methods study. PLoS One 2024; 19:e0310704. [PMID: 39325715 DOI: 10.1371/journal.pone.0310704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 09/05/2024] [Indexed: 09/28/2024] Open
Abstract
OBJECTIVES This study seeks to understand and address barriers to practitioners' optimal assessment and management of people with delirium in hospices. METHODS Retrospective clinical record review to identify areas of low concordance with guideline-adherent delirium care; Survey of healthcare practitioners to identify barriers and facilitators to optimal care; Qualitative interviews with health care practitioners to explore and develop strategies to address barriers or optimise facilitators; Meeting with senior clinical staff to refine identified strategies. RESULTS Eighty clinical records were reviewed. Elements of poor guideline concordance were identified. Delirium screening on admission was conducted for 61% of admissions. Non-pharmacological management was documented for 59% of those we identified as having delirium from the clinical records. Survey and interview data identified key barriers to delirium assessment as competing priorities, poor knowledge and skills and lack of environmental resources (staff and guidelines, environment). Consultation with staff resulted in strategies to address barriers and enhance facilitators including champions, educational meetings, audit and feedback, and environmental changes (including careful consideration of the staff skills mix on shift and tools to support non-pharmacological management). CONCLUSIONS We conducted a theoretically underpinned, internationally relevant study in a hospice in England, UK. Implementation of strategies should result in greater guideline-adherent delirium care. Further work should test this in practice and include both process and clinical outcomes (e.g., reduction in delirium days).
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Affiliation(s)
- Catriona Jackson
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, East Yorkshire, United Kingdom
- Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, United Kingdom
| | | | | | - Judith Dyson
- Centre for Social, Health and Related Research, Birmingham City University, Birmingham, West Midlands, United Kingdom
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, East Yorkshire, United Kingdom
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Arnold E, Finucane AM, Taylor S, Spiller JA, O’Rourke S, Spenceley J, Carduff E, Tieges Z, MacLullich AMJ. The 4AT, a rapid delirium detection tool for use in hospice inpatient units: Findings from a validation study. Palliat Med 2024; 38:535-545. [PMID: 38767241 PMCID: PMC11170929 DOI: 10.1177/02692163241242648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Delirium is a serious neuropsychiatric syndrome with adverse outcomes, which is common but often undiagnosed in terminally ill people. The 4 'A's test or 4AT (www.the4AT.com), a brief delirium detection tool, is widely used in general settings, but validation studies in terminally ill people are lacking. AIM To determine the diagnostic accuracy of the 4AT in detecting delirium in terminally ill people, who are hospice inpatients. DESIGN A diagnostic test accuracy study in which participants underwent the 4AT and a reference standard based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The reference standard was informed by Delirium Rating Scale Revised-98 and tests assessing arousal and attention. Assessments were conducted in random order by pairs of independent raters, blinded to the results of the other assessment. SETTING/PARTICIPANTS Two hospice inpatient units in Scotland, UK. Participants were 148 hospice inpatients aged ⩾18 years. RESULTS A total of 137 participants completed both assessments. Three participants had an indeterminate reference standard diagnosis and were excluded, yielding a final sample of 134. Mean age was 70.3 (SD = 10.6) years. About 33% (44/134) had reference standard delirium. The 4AT had a sensitivity of 89% (95% CI 79%-98%) and a specificity of 94% (95% CI 90%-99%). The area under the receiver operating characteristic curve was 0.97 (95% CI 0.94-1). CONCLUSION The results of this validation study support use of the 4AT as a delirium detection tool in hospice inpatients, and add to the literature evaluating methods of delirium detection in palliative care settings. TRIAL REGISTRY ISCRTN 97417474.
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Affiliation(s)
| | - Anne M Finucane
- Marie Curie Hospice Edinburgh, Edinburgh, UK
- Clinical Psychology, University of Edinburgh, Edinburgh, UK
| | | | | | | | | | | | - Zoë Tieges
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Computing, School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Scotland, UK
| | - Alasdair MJ MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
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Pearson M, Jackson G, Jackson C, Boland J, Featherstone I, Huang C, Ogden M, Sartain K, Siddiqi N, Twiddy M, Johnson M. Improving the Detection, Assessment, Management and Prevention of Delirium in Hospices (the DAMPen-D study): protocol for a co-design and feasibility study of a flexible and scalable implementation strategy to deliver guideline-adherent delirium care. BMJ Open 2022; 12:e060450. [PMID: 35831039 PMCID: PMC9280901 DOI: 10.1136/bmjopen-2021-060450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/20/2022] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Delirium is a complex condition in which altered mental state and cognition causes severe distress and poor clinical outcomes for patients and families, anxiety and stress for the health professionals and support staff providing care, and higher care costs. Hospice patients are at high risk of developing delirium, but there is significant variation in care delivery. The primary objective of this study is to demonstrate the feasibility of an implementation strategy (designed to help deliver good practice delirium guidelines), participant recruitment and data collection. METHODS AND ANALYSIS Three work packages in three hospices in the UK with public involvement in codesign, study management and stakeholder groups: (1) experience-based codesign to adapt an existing theoretically-informed implementation strategy (Creating Learning Environments for Compassionate Care (CLECC)) to implement delirium guidelines in hospices; (2) feasibility study to explore ability to collect demographic, diagnostic and delirium management data from clinical records (n=300), explanatory process data (number of staff engaged in CLECC activities and reasons for non-engagement) and cost data (staff and volunteer hours and pay-grades engaged in implementation activities) and (3) realist process evaluation to assess the acceptability and flexibility of the implementation strategy (preimplementation and postimplementation surveys with hospice staff and management, n=30 at each time point; interviews with hospice staff and management, n=15). Descriptive statistics, rapid thematic analysis and a realist logic of analysis will be used be used to analyse quantitative and qualitative data, as appropriate. ETHICS AND DISSEMINATION Ethical approval obtained: Hull York Medical School Ethics Committee (Ref 21/23), Health Research Authority Research Ethics Committee Wales REC7 (Ref 21/WA/0180) and Health Research Authority Confidentiality Advisory Group (Ref 21/CAG/0071). Written informed consent will be obtained from interview participants. A results paper will be submitted to an open access peer-reviewed journal and a lay summary shared with study site staff and stakeholders. TRIAL REGISTRATION NUMBER ISRCTN55416525.
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Affiliation(s)
- Mark Pearson
- Hull York Medical School, University of Hull, Hull, UK
| | | | | | - Jason Boland
- Hull York Medical School, University of Hull, Hull, UK
| | | | - Chao Huang
- Hull York Medical School, University of Hull, Hull, UK
| | - Margaret Ogden
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Kathryn Sartain
- Hull York Medical School, University of Hull, Hull, UK
- York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Najma Siddiqi
- Department of Psychiatry, University of York, York, UK
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Featherstone I, Hosie A, Siddiqi N, Grassau P, Bush SH, Taylor J, Sheldon T, Johnson MJ. The experience of delirium in palliative care settings for patients, family, clinicians and volunteers: A qualitative systematic review and thematic synthesis. Palliat Med 2021; 35:988-1004. [PMID: 33784915 PMCID: PMC8189008 DOI: 10.1177/02692163211006313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Delirium is common in palliative care settings and is distressing for patients, their families and clinicians. To develop effective interventions, we need first to understand current delirium care in this setting. AIM To understand patient, family, clinicians' and volunteers' experience of delirium and its care in palliative care contexts. DESIGN Qualitative systematic review and thematic synthesis (PROSPERO 2018 CRD42018102417). DATA SOURCES The following databases were searched: CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Embase, MEDLINE and PsycINFO (2000-2020) for qualitative studies exploring experiences of delirium or its care in specialist palliative care services. Study selection and quality appraisal were independently conducted by two reviewers. RESULTS A total of 21 papers describing 16 studies were included. In quality appraisal, trustworthiness (rigour of methods used) was assessed as high (n = 5), medium (n = 8) or low (n = 3). Three major themes were identified: interpretations of delirium and their influence on care; clinicians' responses to the suffering of patients with delirium and the roles of the family in delirium care. Nursing staff and other clinicians had limited understanding of delirium as a medical condition with potentially modifiable causes. Practice focused on alleviating patient suffering through person-centred approaches, which could be challenging with delirious patients, and medication use. Treatment decisions were also influenced by the distress of family and clinicians and resource limitations. Family played vital roles in delirium care. CONCLUSIONS Increased understanding of non-pharmacological approaches to delirium prevention and management, as well as support for clinicians and families, are important to enable patients' multi-dimensional needs to be met.
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Affiliation(s)
| | - Annmarie Hosie
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
- The Cunningham Centre for Palliative Care, St Vincent’s Health Network, Sydney, NSW, Australia
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | - Pamela Grassau
- School of Social Work, Carleton University, Ottawa, ON, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Palliative Care, Bruyere Continuing Care, Ottawa, ON, Canada
| | - Johanna Taylor
- Department of Health Sciences, University of York, York, UK
| | - Trevor Sheldon
- Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Arnold E, Finucane AM, Spiller JA, Tieges Z, MacLullich AM. Validation of the 4AT tool for delirium assessment in specialist palliative care settings: protocol of a prospective diagnostic test accuracy study [version 1; peer review: 2 approved]. AMRC OPEN RESEARCH 2021; 3:16. [PMID: 35966135 PMCID: PMC7613285 DOI: 10.12688/amrcopenres.12973.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Delirium is a serious and distressing neuropsychiatric condition, which is prevalent across all palliative care settings. Hypoactive delirium is particularly common, but difficult to recognize, partly due to overlapping symptoms with depression and dementia. Delirium screening tools can lead to earlier identification and hence better management of patients. The 4AT (4 'A's Test) is a brief tool for delirium detection, designed for use in clinical practice. It has been validated in 17 studies in over 3,700 patients. The test is currently used in specialist palliative care units, but has not been validated in this setting. The aim of the study is to determine the diagnostic accuracy of the 4AT for delirium detection against a reference standard, in hospice inpatients. METHODS 240 participants will be recruited from the inpatient units of two hospices in Scotland. If a patient lacks capacity to consent, agreement will be sought from a legal proxy. Each participant will complete the 4AT and a reference standard assessment based on the diagnostic delirium criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This will be supplemented by tests of cognition and attention, including reverse days of the week, counting down from 20 to 1, Vigilance 'A', the Observational Scale for Level of Arousal, the modified Richmond Agitation Sedation Scale and the Delirium Rating Scale-Revised-98. The assessments will be conducted in a randomized order by two independent clinicians, who will be blinded to the results until both are complete. Primary outcomes will be the sensitivity and specificity of the 4AT in detecting delirium. DISCUSSION The findings will inform clinical practice regarding delirium assessment in palliative care settings. TRIAL REGISTRATION ISRCTN ISRCTN97417474 (21/02/2020).
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Affiliation(s)
- Elizabeth Arnold
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, Scotland, EH10 7DR, UK
| | - Anne M. Finucane
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, Scotland, EH10 7DR, UK
| | - Juliet A. Spiller
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, Scotland, EH10 7DR, UK
| | - Zoë Tieges
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland, EH16 4SA, UK
| | - Alasdair M.J. MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland, EH16 4SA, UK
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Watt CL, Scott M, Webber C, Sikora L, Bush SH, Kabir M, Boland JW, Woodhouse R, Sands MB, Lawlor PG. Delirium screening tools validated in the context of palliative care: A systematic review. Palliat Med 2021; 35:683-696. [PMID: 33588640 DOI: 10.1177/0269216321994730] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Delirium is a distressing neuropsychiatric disorder affecting patients in palliative care. Although many delirium screening tools exist, their utility, and validation within palliative care settings has not undergone systematic review. AIM To systematically review studies that validate delirium screening tools conducted in palliative care settings. DESIGN Systematic review with narrative synthesis (PROSPERO ID: CRD42019125481). A risk of bias assessment via Quality Assessment Tool for Diagnostic Accuracy Studies-2 was performed. DATA SOURCES Five electronic databases were systematically searched (January 1, 1982-May 3, 2020). Quantitative studies validating a screening tool in adult palliative care patient populations were included. Studies involving alcohol withdrawal, critical or perioperative care were excluded. RESULTS Dual-reviewer screening of 3749 unique titles and abstracts identified 95 studies for full-text review and of these, 17 studies of 14 screening tools were included (n = 3496 patients). Data analyses revealed substantial heterogeneity in patient demographics and variability in screening and diagnostic practices that limited generalizability between study populations and care settings. A risk of bias assessment revealed methodological and reporting deficits, with only 3/17 studies at low risk of bias. CONCLUSIONS The processes of selecting a delirium screening tool and determining optimal screening practices in palliative care are complex. One tool is unlikely to fit the needs of the entire palliative care population across all palliative care settings. Further research should be directed at evaluating and/or adapting screening tools and practices to fit the needs of specific palliative care settings and populations.
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Affiliation(s)
- Christine L Watt
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Mary Scott
- Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lindsey Sikora
- University of Ottawa, Health Sciences Library, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Rebecca Woodhouse
- Hull York Medical School and Department of Health Sciences, University of York, York, UK
| | - Megan B Sands
- University of New South Wales Prince of Wales Clinical School, Randwick, NSW, Australia
| | - Peter G Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
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