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Lee-Steere K, Mudge A, Liddle J, Bennett S. Understanding family carer experiences and perceptions of engagement in delirium prevention and care for adults in hospital: Qualitative systematic review. J Clin Nurs 2024; 33:1320-1345. [PMID: 38284503 DOI: 10.1111/jocn.16990] [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] [Received: 06/01/2023] [Revised: 09/29/2023] [Accepted: 11/01/2023] [Indexed: 01/30/2024]
Abstract
AIM To identify, describe and synthesise what is known about family carers' experiences and perspectives of engagement in delirium prevention and care for adults in hospital. DESIGN Systematic review and synthesis of qualitative evidence. DATA SOURCES Comprehensive literature search within PubMed, CINAHL, EMBASE, Scopus, Cochrane Central and PsycInfo databases to August 2022. Peer reviewed original qualitative research published in English. METHODS Data were extracted using Covidence systematic review software. Methodological quality was reviewed against the Critical Appraisal Skills Program (CASP) Qualitative Checklist. Thematic synthesis was used to develop analytical themes. Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) framework was applied to findings. RESULTS Of 3429 records identified, 29 met criteria for final inclusion. Studies included a range of settings (intensive care, medical and surgical wards) and family carer types (spouse, daughter, parent and friend). Three primary themes Shared Caregiving, Partnership and Support, Communication for Shared Understanding and three cross-cutting contextual themes Care Transitions, Family Carer Context and Hospital Context were identified. Family carers have mixed experiences of involvement in delirium care and prevention. Family carer engagement in care impacted perceptions of care quality and their own self-efficacy. Where person-centred care expectations were not met, some family carers adopted compensatory or care contingency strategies. Information sharing and timely support from hospital staff who understood the carer context supported carer involvement. Supportive physical environments and addressing power imbalances allowed greater engagement. CONCLUSION Family carers often wish to be involved in delirium prevention and care, but need to be recognised as individuals, listened to, informed and supported to optimise their contribution. IMPACT The review findings can guide health professional and decision makers to optimise family carer involvement in delirium care programs. PROTOCOL REGISTRATION PROSPERO [CRD42020221854]. REPORTING ENTREQ. No Patient or Public Contribution.
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Affiliation(s)
- Karen Lee-Steere
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
- Eat Walk Engage Program, Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Alison Mudge
- Eat Walk Engage Program, Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jacki Liddle
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
- Occupational Therapy Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Sally Bennett
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
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Garrido M, Álvarez E, Salech F, Rojas V, Jara N, Farías JI, de la Vega DP, Tobar E. Software-guided (PREVEDEL) cognitive stimulation to prevent delirium in hospitalised older adults: study protocol. BMC Geriatr 2023; 23:472. [PMID: 37543590 PMCID: PMC10403832 DOI: 10.1186/s12877-023-04189-2] [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: 07/29/2022] [Accepted: 07/20/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND Delirium is a clinical condition characterised by acute and fluctuating deterioration of the cognitive state, generally secondary to an acute pathology. Delirium is associated with negative outcomes in older adults, such as longer hospitalisations, higher mortality, and short and medium-term institutionalisation. Randomised clinical trials have shown that delirium is preventable through non-pharmacological prevention measures, decreasing its incidence by 30-50%. These interventions include promoting physical activity, facilitating the use of glasses and hearing aids, cognitive stimulation, and providing frequent reorientation of time and space, among others. These measures are currently seldom applied in hospitals in Chile and around the world for reasons including the heavy workload of clinical staff, the lack of trained personnel, and in general the absence of a systematic implementation processes. We developed a software called PREVEDEL, which includes non-pharmacological strategies such as cognitive stimulation, early mobilisation, orientation, and pain assessment. We propose a randomised clinical trial to evaluate whether cognitive stimulation guided by PREVEDEL software prevents delirium status (full/subsyndromal delirium) in hospitalised older adults. METHOD A randomised controlled trial, with parallel, multicentre groups. We will recruite patients 65 years or older who have been hospitalised for less than 48 h in the general ward or the intermediate care units of four hospitals in Santiago, Chile. The participants in the intervention group will use a tablet with cognitive stimulation software for delirium prevention for five continuous days versus the control group who will use the tablet without the software. We will evaluate the incidence, duration, density of delirium, subsyndromal delirium with the Confusion Assessment Method, cognitive with the Montreal Cognitive Assessment, and functional status with the Functional Independence Measure at discharge. Moreover, we will evaluate the adherence to prevention measures, as well as demographic variables of interest. DISCUSSION The use of cognitive PREVEDEL software could increase and improve the implementation of non-pharmacological prevention measures for delirium in hospitalised older adults, thus reducing its incidence and contributing to patients and health professionals. TRIAL REGISTRATION NCT05108207 ClinicalTrials.gov. Registered 4 November 2021.
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Affiliation(s)
- Maricel Garrido
- Departamento de Medicina, Servicio de Medicina Física y Rehabilitación, Hospital Clínico de La Universidad de Chile, Dr. Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
| | - Evelyn Álvarez
- Departamento de Terapia Ocupacional y Ciencia de La Ocupación, Facultad de Medicina, Universidad de Chile, Av. Independencia #1027, 8380453, Independencia-Santiago, Chile
- Centro de Estudios en Neurociencia Humana y Neuropsicología, Facultad de Psicología, Universidad Diego Portales, Vergara #275, 8320000, Santiago-Santiago, Chile
| | - Felipe Salech
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico de La Universidad de Chile, Dr. Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
- Sección de Geriatría, Hospital Clínico de La Universidad de Chile, Dr. Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
- Centro de Gerociencia, Salud Mental y Metabolismo, GERO, Las Palmeras #3425, 7800003, Ñuñoa, Santiago, Chile
| | - Verónica Rojas
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico de La Universidad de Chile, Dr. Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico de La Universidad de Chile, Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
- International Research Project for the Humanization of Intensive Care Units (HU-CI Project), Calle Cerceda #11, Collado -Villalba, 28400, Madrid, Spain
| | - Nicole Jara
- Departamento de Medicina, Servicio de Medicina Física y Rehabilitación, Hospital Clínico de La Universidad de Chile, Dr. Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
| | - José Ignacio Farías
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico de La Universidad de Chile, Dr. Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico de La Universidad de Chile, Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
| | - Daniela Ponce de la Vega
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico de La Universidad de Chile, Dr. Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile
| | - Eduardo Tobar
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico de La Universidad de Chile, Carlos Lorca Tobar #999, 8380456, Independencia-Santiago, Chile.
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3
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Martínez-García M, Sánchez-López E, Fernández-Trinidad M. Managing delirium in acute inpatient units: A cross-sectional study of nursing teams' knowledge and perceived limitations. Nurs Open 2023; 10:2213-2221. [PMID: 36379912 PMCID: PMC10006588 DOI: 10.1002/nop2.1471] [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: 11/08/2021] [Revised: 10/05/2022] [Accepted: 10/29/2022] [Indexed: 11/17/2022] Open
Abstract
AIM The aim of the study was to describe nursing teams' theoretical knowledge of delirium and their perceptions of the way in which it is handled in acute inpatient units. DESIGN This is a descriptive cross-sectional study using a questionnaire comprising ten questions on knowledge and seven on perception. METHODS The sample consisted of 216 professionals working at a hospital complex in Madrid, Spain. Descriptive and non-parametric bivariate analyses were performed for a p < .05. RESULTS Fifty-three point two per cent of staff possessed sufficient theoretical knowledge, and this figure rose significantly among professionals with more years of experience. Areas for improvement in theoretical knowledge included the use of therapeutic immobilization, screening scale, subtypes of delirium and precipitating factors. Sixty-eight point five per cent of staff perceived their knowledge as fair, 50% agreed that delirium was underdiagnosed and 48.1% agreed that preventive measures were only occasionally taken. Perceived barriers included lack of training, work overload, ineffective coordination and lack of standardized protocols.
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Affiliation(s)
- Marta Martínez-García
- Hospital Universitario Infanta Leonor, Madrid, Spain.,Facultad de Enfermería Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Miriam Fernández-Trinidad
- Hospital Universitario Infanta Leonor, Madrid, Spain.,Facultad de Enfermería Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, Spain
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Green A, Hosie A, Phillips JL, Kochovska S, Noble B, Brassil M, Cumming A, Lawlor PG, Bush SH, Davis JM, Edwards L, Hunt J, Wilcock J, Phillipson C, Wesley Ely E, Parr C, Lovell M, Agar M. Stakeholder perspectives of a pilot multicomponent delirium prevention intervention for adult patients with advanced cancer in palliative care units: A behaviour change theory-based qualitative study. Palliat Med 2022; 36:1273-1284. [PMID: 36062724 DOI: 10.1177/02692163221113163] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Theory-based and qualitative evaluations in pilot trials of complex clinical interventions help to understand quantitative results, as well as inform the feasibility and design of subsequent effectiveness and implementation trials. AIM To explore patient, family, clinician and volunteer ('stakeholder') perspectives of the feasibility and acceptability of a multicomponent non-pharmacological delirium prevention intervention for adult patients with advanced cancer in four Australian palliative care units that participated in a phase II trial, the 'PRESERVE pilot study'. DESIGN A trial-embedded qualitative study via semi-structured interviews and directed content analysis using Michie's Behaviour Change Wheel and the Theoretical Domains Framework. SETTING/PARTICIPANTS Thirty-nine people involved in the trial: nurses (n = 17), physicians (n = 6), patients (n = 6), family caregivers (n = 4), physiotherapists (n = 3), a social worker, a pastoral care worker and a volunteer. RESULTS Participants' perspectives aligned with the 'capability', 'opportunity' and 'motivation' domains of the applied frameworks. Of seven themes, three were around the alignment of the delirium prevention intervention with palliative care (intervention was considered routine care; intervention aligned with the compassionate and collaborative culture of palliative care; and differing views of palliative care priorities influenced perspectives of the intervention) and four were about study processes more directly related to adherence to the intervention (shared knowledge increased engagement with the intervention; impact of the intervention checklist on attention, delivery and documentation of the delirium prevention strategies; clinical roles and responsibilities; and addressing environmental barriers to delirium prevention). CONCLUSION This theory-informed qualitative study identified multiple influences on the delivery and documentation of a pilot multicomponent non-pharmacological delirium prevention intervention in four palliative care units. Findings inform future definitive studies of delirium prevention in palliative care.Australian New Zealand Clinical Trials Registry, ACTRN12617001070325; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373168.
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Affiliation(s)
- Anna Green
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Annmarie Hosie
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia.,School of Nursing & Midwifery, The University of Notre Dame Australia, Darlinghurst, NSW, Australia.,St Vincent's Health Network Sydney, Darlinghurst, NSW, Australia
| | - Jane L Phillips
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia.,Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, Australia
| | - Slavica Kochovska
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Beverly Noble
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Meg Brassil
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Anne Cumming
- Australian Commission on Safety and Quality in Health Care, Sydney, NSW, Australia
| | - Peter G Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Jan Maree Davis
- Department of Palliative Care, Calvary Health Care Kogarah, Kogarah, NSW, Australia
| | - Layla Edwards
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Jane Hunt
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Julie Wilcock
- Ingham Institute, Liverpool Hospital, Liverpool, NSW, Australia
| | - Carl Phillipson
- Central Adelaide Palliative Care Service, The Queen Elizabeth Hospital, Woodville South, SA, Australia
| | - Eugene Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - Cynthia Parr
- HammondCare, Greenwich Hospital, Greenwich, NSW, Australia
| | - Melanie Lovell
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia.,HammondCare, Greenwich Hospital, Greenwich, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Meera Agar
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia.,Ingham Institute, Liverpool Hospital, Liverpool, NSW, Australia.,South West Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia
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Zastrow I, Tohsche P, Loewen T, Vogt B, Feige M, Behnke M, Wolff A, Kiefmann R, Olotu C. Comparison of the '4-item assessment test' and 'nursing delirium screening scale' delirium screening tools on non-intensive care unit wards: A prospective mixed-method approach. Eur J Anaesthesiol 2021; 38:957-965. [PMID: 33606422 DOI: 10.1097/eja.0000000000001470] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In elderly patients following surgery, postoperative delirium (POD) is the most frequent complication and is associated with negative outcomes. The 2017 European Society of Anaesthesiology guideline on POD aims to improve patient care by implementing structured delirium prevention, diagnosis and treatment. However, these recommendations, especially systematic delirium screening, are still incompletely adopted in clinical practice. The aim of this study was to evaluate the feasibility and acceptance of validated delirium screening tools and to identify barriers to their implementation on nonintensive care unit wards. METHODS Screening rates, as well as practicability, acceptance and the interprofessional handling of positive results, were assessed for each group. Screening rates were calculated as a percentage of the total potential testing episodes completed (up to 15 per patient). Patients were considered eligible when aged 65 years and above. Barriers and motivating factors were assessed in a mixed method approach by utilising questionnaires and focus group discussions. INTERVENTION In a 3-month phase, a guideline-compliant screening protocol involving screening for POD three times daily for 5 days following surgery was introduced in five wards: both the 4-item assessment test (4AT) and the nursing delirium screening scale (NuDESC) were used. Before commencing the study and again after 6 weeks, medical staff of the respective wards underwent a 45 min training session. RESULTS Of a total of 3183 potential testing episodes, 999 (31.4%) were completed, with more NuDESC observational tests (43%) than 4AT bedside tests completed (20%). The 4AT was considered more difficult to integrate into daily working routines, it took longer to administer, and nurses felt uncomfortable conducting the screening (53 vs. 13%). Screening results indicating delirium were often not discussed within the team (47%), and nurses felt that often such results were not taken seriously by physicians (54%). CONCLUSION The observational NuDESC showed a higher completion rate than the bedside 4AT, although overall testing rates were low. The necessary time needed to conduct the screening, the negative reactions by patients, insufficient team communication and a lack of initiation of any therapy were identified as major barriers in the implementation of the guideline-compliant screening protocol. For all staff, further education and awareness of the importance of POD diagnosis and treatment might improve the screening rates. The NuDesc received better results concerning acceptance, practicability and introduction into daily work routine, leading to higher screening rates compared with the 4AT. The latter instrument, which was intended to be used rather selectively or when POD is suspected, might therefore not be suitable for guideline-compliant regular and repeated screening for POD.
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Affiliation(s)
- Inke Zastrow
- From the Department of Patient and Care Management (IZ, BV, MF), Department of Intensive Care Medicine (PT, AW) and Department of Anaesthesiology (TL, MB, RK, CO), Centre of Anaesthesiology and Intensive Care Medicine, University Medical Centre, Hamburg, Germany
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Sarti AJ, Zheng K, Herry CL, Sutherland S, Scales NB, Watpool I, Porteous R, Hickey M, Anstee C, Fazekas A, Ramsay T, Burns KE, Seely AJ. Feasibility of implementing Extubation Advisor, a clinical decision support tool to improve extubation decision-making in the ICU: a mixed-methods observational study. BMJ Open 2021; 11:e045674. [PMID: 34385234 PMCID: PMC8362728 DOI: 10.1136/bmjopen-2020-045674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES Although spontaneous breathing trials (SBTs) are standard of care to extubation readiness, no tool exists that optimises prediction and standardises assessment. In this study, we evaluated the feasibility and clinical impressions of Extubation Advisor (EA), a comprehensive clinical extubation decision support (CDS) tool. DESIGN Phase I mixed-methods observational study. SETTING Two Canadian intensive care units (ICUs). PARTICIPANTS We included patients on mechanical ventilation for ≥24 hours and clinicians (respiratory therapists and intensivists) responsible for extubation decisions. INTERVENTIONS Components included a predictive model assessment, feasibility evaluation, questionnaires and interviews with clinicians. RESULTS We enrolled 117 patients, totalling 151 SBTs and 80 extubations. The incidence of extubation failure was 11% in low-risk patients and 21% in high-risk patients stratified by the predictive model; 38% failed extubation when both the model and clinical impression were at high risk. The tool was well rated: 94% and 75% rated the data entry and EA report as average or better, respectively. Interviews (n=15) revealed favourable impressions regarding its user interface and functionality, but unexpectedly, also concerns regarding EA's potential impact on respiratory therapists' job security. CONCLUSIONS EA implementation was feasible, and users perceived it to have potential to support extubation decision-making. This study helps to understand bedside implementation of CDS tools in a multidisciplinary ICU. TRIAL REGISTRATION NUMBER NCT02988167.
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Affiliation(s)
- Aimee J Sarti
- Department of Critical Care, Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Katina Zheng
- Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | | | | | | | - Irene Watpool
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Michael Hickey
- Department of Medicine, Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Caitlin Anstee
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Anna Fazekas
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Karen Ea Burns
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Je Seely
- Department of Critical Care, Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- University of Ottawa, Ottawa, Ontario, Canada
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Garrido MA, Alvarez EA, Ponce DP, Salech F, Tobar DI, Tobar EA. Consolidated framework for advancing implementation science for the implementation process and adherence assessment of a non-pharmacological delirium prevention program. Int J Geriatr Psychiatry 2021; 36:302-313. [PMID: 32892410 DOI: 10.1002/gps.5425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 08/31/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the contribution of applying the theoretical framework of implementation science for adherence to non-pharmacological interventions to prevent delirium. METHODS A quasi-experimental prospective design was conducted from March 2017 to October 2018 in a teaching hospital. Participants included 149 healthcare staff and 72 elderly inpatients. A non-pharmacological delirium prevention program was designed, applied and evaluated in accordance with the consolidated framework for advancing implementation research (CFIR). The primary outcome was the global adherence rate to 12 predefined indicators, comparing measurements at baseline (O1), after training (O2) and at a 6-month follow-up (O3) assessed by an external reviewer. Staff knowledge and beliefs about delirium were assessed using a validated tool, and delirium incidence was evaluated using the confusion assessment method. RESULTS Overall adherence increased from 58.2% (O1) to 77.9% (O2) and 75.6% (O3) (O2 vs. O1: p < 0.001 and O3 vs. O1: p < 0.001). Staff perceptions regarding implementation of non-pharmacological interventions increased from 74.8% to 81.9% (p = 0.004). Delirium incidence was non-significantly reduced from 20% (O1) to 16% (O3) (p = 0.99). CONCLUSIONS Implementation of a delirium prevention program using a CFIR model was useful in improving adherence to activities included in this program, as well as improving the knowledge and beliefs regarding delirium by healthcare workers. The impact of this implementation strategy on the incidence of delirium should be evaluated in a larger scale multicenter trial.
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Affiliation(s)
- Maricel A Garrido
- Departamento de Medicina Interna Norte, Servicio Medicina Física y Rehabilitación, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Evelyn A Alvarez
- Escuela de Terapia Ocupacional, Facultad de Ciencias de la Salud, Universidad Central de Chile, Santiago, Chile.,Departamento de Ciencias de la Ocupación y Terapia Ocupacional, Universidad de Chile, Santiago, Chile
| | - Daniela P Ponce
- Centro de Investigación Clínica Avanzada (CICA), Universidad de Chile, Santiago, Chile
| | - Felipe Salech
- Centro de Investigación Clínica Avanzada (CICA), Universidad de Chile, Santiago, Chile.,Departamento de Medicina Interna Norte, Sección Geriatría, Hospital Clínico Universidad de Chile, Santiago, Chile.,Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Unidad de Cuidados Adulto Mayor, Clínica Las Condes, Santiago, Chile
| | - Daniel I Tobar
- Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Eduardo A Tobar
- Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Departamento de Medicina Interna Norte, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, Santiago, Chile
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Lee-Steere K, Liddle J, Mudge A, Bennett S, McRae P, Barrimore SE. "You've got to keep moving, keep going": Understanding older patients' experiences and perceptions of delirium and nonpharmacological delirium prevention strategies in the acute hospital setting. J Clin Nurs 2020; 29:2363-2377. [PMID: 32220101 DOI: 10.1111/jocn.15248] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/17/2020] [Accepted: 03/12/2020] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To explore older inpatients' experiences and perceptions of delirium and nonpharmacological delirium prevention strategies (NDPS). BACKGROUND Delirium is a distressing and serious complication in hospitalised older adults. NDPS (supporting nutrition, mobility and cognitive participation) have strong supporting evidence. Few studies have explored older inpatients' perspectives of these strategies. This information may assist staff to better support patient participation in NDPS. DESIGN Qualitative study using an interpretive descriptive (ID) methodological approach to explore older patient's experience of delirium and NDPS. METHODS Structured interviews of inpatients aged over 65 years across 6 medical and surgical wards explored patients' experiences and perceptions of delirium and prevention activities related to nutrition, mobility and cognition; and barriers and enablers to participation. Reporting used COREQ. RESULTS Twenty-three participants were included (12 male, 11 reported delirium experience). Participants reported a range of physiological, emotional and psychological responses to delirium, hearing about delirium was different to experiencing it. Most participants were aware of the benefits of maintaining nutrition and hydration, physical activity and cognitive engagement in hospital. Barriers included poor symptom control, inflexible routines and inconsistent communication, whilst enablers included access to equipment, family involvement, staff encouragement and individual goals. These were organised into themes: outlook, feeling well enough, hospital environment, feeling informed and listened to, and support networks. CONCLUSION A more patient-centred approach to delirium prevention requires consideration of older people's values, needs, preferences and fit within the hospital environment and routines. Feeling informed, listened to and receiving support from staff and family carers can improve older inpatients' engagement in NPDS to prevent delirium in hospital. RELEVANCE TO CLINICAL PRACTICE Nurses are ideally placed to improve patient participation in NDPS through holistic assessment and care, addressing symptoms, providing clear information about delirium and delirium prevention, and facilitating family carer support and patient interactions.
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Affiliation(s)
- Karen Lee-Steere
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia.,Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jacki Liddle
- ARC Centre of Excellence for the Dynamics of Language, School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, QLD, Australia
| | - Alison Mudge
- Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Queensland University of Technology, Brisbane, QLD, Australia.,School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Sally Bennett
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Prue McRae
- Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Sally E Barrimore
- Nutrition and Dietetics Department, The Prince Charles Hospital, Brisbane, QLD, Australia
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Wong AR, Sun V, George K, Liu J, Padam S, Chen BA, George T, Amini A, Li D, Sedrak MS. Barriers to Participation in Therapeutic Clinical Trials as Perceived by Community Oncologists. JCO Oncol Pract 2020; 16:e849-e858. [PMID: 32240068 DOI: 10.1200/jop.19.00662] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Despite considerable research on the barriers to enrollment in cancer therapeutic trials, few studies have elicited barriers from the perspective of community physicians, who provide the majority of cancer care. The purpose of this study was to characterize barriers to and facilitators of cancer therapeutic trials as perceived by oncologists in community practices. METHODS Twenty semistructured interviews were conducted with oncologists at six community sites affiliated with City of Hope National Medical Center from March to June 2018. Responses were recorded digitally and transcribed. Data were analyzed using qualitative content analysis. RESULTS Of the 20 participants, 4 (20%) were women, 13 (65%) had > 10 years of practice experience, and 16 (80%) reported that < 5% of their patients were enrolled in a therapeutic trial. Participants identified four system-level barriers: lack of appropriate trials for community-based settings, insufficient infrastructure support, restrictive eligibility criteria, and financial limitations; three physician-level barriers: lack of awareness of available trials, lack of knowledge of trial details, and lack of time; and two patient-level barriers: patient burden and negative beliefs/attitudes toward research. Efforts aimed to increase trial availability, clinical trial support personnel, and physician knowledge were identified as major facilitators. CONCLUSION Community oncologists face numerous complex, multifaceted barriers to cancer therapeutic trial enrollment. Although expanding clinical research beyond the academic setting allows access to a larger and more diverse patient population, increasing generalizability and relevance of trial findings, there remains a substantial need for new strategies to improve cancer research delivery in the community.
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Affiliation(s)
- Andrew R Wong
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Virginia Sun
- Department of Population Science, City of Hope, Duarte, CA
| | - Kevin George
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Jennifer Liu
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Simran Padam
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Brandon A Chen
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Thomas George
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Arya Amini
- Department of Radiation Oncology, City of Hope, Duarte, CA
| | - Daneng Li
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
| | - Mina S Sedrak
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA
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10
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Sanatinia R, Crawford MJ, Quirk A, Hood C, Gordon F, Crome P, Staniszewska S, Zafarani G, Hammond S, Burns A, Seers K. Identifying features associated with higher-quality hospital care and shorter length of admission for people with dementia: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Concerns have repeatedly been expressed about the quality of inpatient care that people with dementia receive. Policies and practices have been introduced that aim to improve this, but their impact is unclear.
Aims
To identify which aspects of the organisation and delivery of acute inpatient services for people with dementia are associated with higher-quality care and shorter length of stay.
Design
Mixed-methods study combining a secondary analysis of data from the third National Audit of Dementia (2016/17) and a nested qualitative exploration of the context, mechanism and outcomes of acute care for people with dementia.
Setting
Quantitative data from 200 general hospitals in England and Wales and qualitative data from six general hospitals in England that were purposively selected based on their performance in the audit.
Participants
Quantitative data from clinical records of 10,106 people with dementia who had an admission to hospital lasting ≥ 72 hours and 4688 carers who took part in a cross-sectional survey of carer experience. Qualitative data from interviews with 56 hospital staff and seven carers of people with dementia.
Main outcome measures
Length of stay, quality of assessment and carer-rated experience.
Results
People with dementia spent less time in hospital when discharge planning was initiated within 24 hours of admission. This is a challenging task when patients have complex needs, and requires named staff to take responsibility for co-ordinating the discharge and effective systems for escalating concerns when obstacles arise. When trust boards review delayed discharges, they can identify recurring problems and work with local stakeholders to try to resolve them. Carers of people with dementia play an important role in helping to ensure that hospital staff are aware of patient needs. When carers are present on the ward, they can reassure patients and help make sure that they eat and drink well, and adhere to treatment and care plans. Clear communication between staff and family carers can help ensure that they have realistic expectations about what the hospital staff can and cannot provide. Dementia-specific training can promote the delivery of person-centred care when it is made available to a wide range of staff and accompanied by ‘hands-on’ support from senior staff.
Limitations
The quantitative component of this research relied on audit data of variable quality. We relied on carers of people with dementia to explore aspects of service quality, rather than directly interviewing people with dementia.
Conclusions
If effective support is provided by senior managers, appropriately trained staff can work with carers of people with dementia to help ensure that patients receive timely and person-centred treatment, and that the amount of time they spend in hospital is minimised.
Future work
Future research could examine new ways to work with carers to co-produce aspects of inpatient care, and to explore the relationship between ethnicity and quality of care in patients with dementia.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 22. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Mike J Crawford
- Centre for Psychiatry, Imperial College London, London, UK
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Alan Quirk
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Chloe Hood
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Fabiana Gordon
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Peter Crome
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Sophie Staniszewska
- Warwick Research in Nursing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Gemma Zafarani
- Centre for Psychiatry, Imperial College London, London, UK
| | - Sara Hammond
- Centre for Psychiatry, Imperial College London, London, UK
| | - Alistair Burns
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Kate Seers
- Warwick Research in Nursing, Warwick Medical School, University of Warwick, Coventry, UK
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11
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Alvarez EA, Garrido M, Ponce DP, Pizarro G, Córdova AA, Vera F, Ruiz R, Fernández R, Velásquez JD, Tobar E, Salech F. A software to prevent delirium in hospitalised older adults: development and feasibility assessment. Age Ageing 2020; 49:239-245. [PMID: 31957783 DOI: 10.1093/ageing/afz166] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND non-pharmacological interventions to prevent delirium are useful in hospitalised older adults. However, they are poorly implemented in clinical practice. We aimed to develop a software for bedside use by hospitalised older adults and to improve their access to these interventions. METHODS a transdisciplinary team composed of healthcare professionals, designers, engineers and older adults participated in the development of the software. Scrum methodology was used to coordinate the work of the team, and the software was evaluated in a feasibility study. RESULTS a software for touchscreen mobile devices that supports Android 5.0 or later was produced, including modules for time-spatial re-orientation, cognitive stimulation, early mobilisation, sensorial support use promotion, sleep hygiene and pain management optimisation. Horizontal disposition, use of colour contrast and large interaction areas were used to improve accessibility. The software's usability and accessibility were evaluated in 34 older adults (average age 73.2 ± 9.1 years) showing that 91.1% of them got access to all the software functions without previous instructions. The clinical feasibility assessment showed that 83.3% of the 30 enrolled hospitalised patients (76 ± 8 years) completed the 5-day protocol of software usage during hospitalisation. Software use was associated with a decreased trend in delirium incidence of 5 of 32 (15.6%) at baseline to 2 of 30 (6.6%) after its implementation. CONCLUSION a highly accessible and implementable software, designed to improve access to non-pharmacological interventions to prevent delirium in hospitalised older adults, was developed. The effectiveness of the software will be evaluated in a randomised clinical trial.
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Affiliation(s)
- Evelyn A Alvarez
- Escuela de Terapia Ocupacional, Facultad de Ciencias de la Salud, Universidad Central de Chile, Santiago, Metropolitana, Chile
- Departamento de Terapia Ocupacional y Ciencia de la Ocupación, Facultad de Medicina, Universidad de Chile, Santiago, Metropolitana, Chile
| | - Maricel Garrido
- Departamento de Medicina Interna Norte, Servicio Medicina Física y Rehabilitación, Hospital Clínico Universidad de Chile, Santiago, Metropolitana, Chile
| | - Daniela P Ponce
- Centro de Investigación Clínica Avanzada (CICA), Universidad de Chile, Santiago, Metropolitana, Chile
| | - Gaspar Pizarro
- Web Intelligence Center, Facultad de Ciencias Físicas y Matemáticas, Universidad de Chile, Santiago, Metropolitana, Chile
| | - Andres A Córdova
- Web Intelligence Center, Facultad de Ciencias Físicas y Matemáticas, Universidad de Chile, Santiago, Metropolitana, Chile
| | - Felipe Vera
- Web Intelligence Center, Facultad de Ciencias Físicas y Matemáticas, Universidad de Chile, Santiago, Metropolitana, Chile
| | - Rocio Ruiz
- Web Intelligence Center, Facultad de Ciencias Físicas y Matemáticas, Universidad de Chile, Santiago, Metropolitana, Chile
| | - Raul Fernández
- Departamento de Medicina Interna Norte, Servicio Medicina Física y Rehabilitación, Hospital Clínico Universidad de Chile, Santiago, Metropolitana, Chile
- Departamento de Medicina Interna Norte, Sección Geriatría, Hospital Clínico Universidad de Chile, Santiago, Metropolitana, Chile
| | - Juan D Velásquez
- Web Intelligence Center, Facultad de Ciencias Físicas y Matemáticas, Universidad de Chile, Santiago, Metropolitana, Chile
- Instituto Sistemas Complejos de Ingeniería (ISCI), Universidad de Chile, Santiago, Metropolitana, Chile
| | - Eduardo Tobar
- Departamento de Medicina Interna Norte, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, Santiago, Metropolitana, Chile
- Facultad de Medicina, Universidad de Chile, Santiago, Metropolitana, Chile
| | - Felipe Salech
- Centro de Investigación Clínica Avanzada (CICA), Universidad de Chile, Santiago, Metropolitana, Chile
- Departamento de Medicina Interna Norte, Sección Geriatría, Hospital Clínico Universidad de Chile, Santiago, Metropolitana, Chile
- Facultad de Medicina, Universidad de Chile, Santiago, Metropolitana, Chile
- Unidad de Cuidados Adulto Mayor, Clínica Las Condes, Santiago, Chile
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12
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Choi M, DeGennaro R, Blevins C. Multimodal Education Program to Improve Nurses' Knowledge and Confidence on Delirium Recognition in a Surgical-Trauma Intermediate-Care Setting. J Dr Nurs Pract 2020; 13:31-41. [DOI: 10.1891/2380-9418.jdnp-d-19-00030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BackgroundHigh incidence of delirium in hospitalized patients has been reported in the United States and is significantly associated with increased morbidity and mortality. The lack of knowledge and confidence in performing delirium assessment (KCDA) has led to significant underrecognition of delirium by nurses regardless of evidence-based education intervention.ObjectiveThe purpose of this study was to determine the effectiveness of a multimodal educational program (MEP) to enhance nurses' KCDA.MethodsA MEP including an online didactic with a video-simulation and 1:1 bedside coaching with delirium screening (DS) was conducted in the surgical intermediate-care unit of an academic medical center. A quasi-experimental pre- and post-test design was used.ResultsOf 23 nurses, the majority were <41 years old (73.9%) and had at least a bachelor of science in nursing degree (78.3%) with <6 years of experience (60.9%). The overall KCDA scores and the performance of DS improved significantly after the MEP (p < .001). A positive correlation was noted between the changes of the KCDA scores (p = .009).ConclusionsThe MEP demonstrated improvement in nurses' KCDA. The MEP should focus on an individualized learning approach with a targeted patient population, using current delirium screening tools.Implications for NursingEducational programs are recommended in either an orientation or continuing education program on nursing units. This is also recommended for use in other academic centers that encompass similar clinical settings and could possibly be considered for use in other disease processes.
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13
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Garcez FB, Jacob-Filho W, Avelino-Silva TJ. Association Between Level of Arousal and 30-Day Survival in Acutely Ill Older Adults. J Am Med Dir Assoc 2020; 21:493-499. [PMID: 31974062 DOI: 10.1016/j.jamda.2019.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/29/2019] [Accepted: 11/22/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate the association between impaired arousal on admission and 30-day mortality in acutely ill older adults. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Patients age +65 years admitted to the geriatric ward of a tertiary university hospital from 2010 to 2018 in Sao Paulo, Brazil. METHODS Participants were evaluated on admission according to a standardized comprehensive geriatric assessment model. Delirium was detected using the short version of the Confusion Assessment Method (Short-CAM). We used 2 alternative criteria to define impaired arousal: lethargy, stupor, or coma according to the Short-CAM; and a Glasgow Coma Scale (GCS) score of ≤13. Our primary outcome was time-to-death in 30 days, and we used Cox proportional hazards models to explore the association between impaired arousal and decreased survival. RESULTS We included 1554 admissions with a mean age of 81 years and of whom 61% were women. Overall, prevalent delirium was observed in 28% of the cases. We found that in 33% of admissions, patients were lethargic, stuporous, or comatose, and that in 23%, they had GCS scores of ≤13. General 30-day mortality was 19% but reached 32% in patients with GCS scores of ≤13. Impaired arousal was independently associated with lower survival in 30 days, both when defined using Short-CAM criteria [lethargy + stupor + coma: hazard ratio (HR) 2.33, 95% confidence interval (CI) 1.66‒3.27] and GCS scores (GCS 12‒13: HR 1.62, 95% CI 1.13‒2.33; GCS ≤ 11: HR 2.53, 95% CI 1.68‒3.80). In interaction analyses, we confirmed our results in patients who had impaired arousal but were neither delirious (lethargy + stupor + coma: HR 2.16, 95% CI 1.44‒3.24; GCS ≤ 11: HR 3.07; 95% CI 1.50‒6.29) nor demented (lethargy + stupor + coma: HR 1.95, 95% CI 1.15‒3.28). CONCLUSIONS AND IMPLICATIONS Level of arousal on admission was an independent predictor of 30-day survival in acutely ill older adults, regardless of delirium or baseline dementia. Clinicians should be aware that even if unsure of whether a patient has delirium, arousal assessment can provide crucial clinical and prognostic insight.
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Affiliation(s)
| | - Wilson Jacob-Filho
- Division of Geriatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil; Medical Research Laboratory (LIM-66), Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Thiago Junqueira Avelino-Silva
- Division of Geriatrics, University of Sao Paulo Medical School, Sao Paulo, Brazil; Medical Research Laboratory (LIM-66), Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil; School of Medicine, Faculdade Israelita de Ciências da Saúde Albert Einstein, Sao Paulo, Brazil
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14
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Morandi A, Pozzi C, Milisen K, Hobbelen H, Bottomley JM, Lanzoni A, Tatzer VC, Carpena MG, Cherubini A, Ranhoff A, MacLullich AMJ, Teodorczuk A, Bellelli G. An interdisciplinary statement of scientific societies for the advancement of delirium care across Europe (EDA, EANS, EUGMS, COTEC, IPTOP/WCPT). BMC Geriatr 2019; 19:253. [PMID: 31510941 PMCID: PMC6739939 DOI: 10.1186/s12877-019-1264-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 08/29/2019] [Indexed: 01/12/2023] Open
Abstract
Background Delirium is a geriatric syndrome that presents in 1 out of 5 hospitalized older patients. It is also common in the community, in hospices, and in nursing homes. Delirium prevalence varies according to clinical setting, with rates of under 5% in minor elective surgery but up to 80% in intensive care unit patients. Delirium has severe adverse consequences, but despite this and its high prevalence, it remains undetected in the majority of cases. Optimal delirium care requires an interdisciplinary, multi-dimensional diagnostic and therapeutic approach involving doctors, nurses, physiotherapists, and occupational therapists. However, there are still important gaps in the knowledge and management of this syndrome. Main body The objective of this paper is to promote the interdisciplinary approach in the prevention and management of delirium as endorsed by a delirium society (European Delirium Association, EDA), a geriatrics society (European Geriatric Medicine Society, EuGMS), a nursing society (European Academy of Nursing Science, EANS), an occupational therapy society (Council of Occupational Therapists for European Countries, COTEC), and a physiotherapy society (International Association of Physical Therapists working with Older People of the World Confederation for Physical Therapy, IPTOP/WCPT). Short conclusion In this paper we have strongly promoted and supported interdisciplinary collaboration underlying the necessity of increasing communication among scientific societies. We have also provided suggestions on how to fill the current gaps via improvements in undergraduate and postgraduate delirium education among European Countries.
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Affiliation(s)
- Alessandro Morandi
- Department of Rehabilitation and Aged Care "Fondazione Camplani" Hospital, Cremona, Italy. .,Rehabilitation Hospital Ancelle di Cremona, Via Aselli 14, 26100, Cremona, CR, Italy.
| | - Christian Pozzi
- University of Applied Sciences and Arts of Southern Switzerland (SUPSI), Manno, Switzerland
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium.,Division of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Hans Hobbelen
- Healthy Lifestyle, Ageing and Healthcare Research group Healthy Ageing, Allied Health Care and Nursing Centre of Expertise Healthy Ageing Hanze University of Applied Sciences Groningen, Groningen, Netherlands.,International Physical Therapist Working with Older People, Subgroup of World Confederation for Physical Therapy, WCPT, London, UK
| | - Jennifer M Bottomley
- International Physical Therapist Working with Older People, Subgroup of World Confederation for Physical Therapy, WCPT, London, UK.,Simmons College, Boston, MA, USA
| | - Alessandro Lanzoni
- NODAIA Unit, Villa Igea, Modena, Italy.,University of Modena and Reggio Emilia, Modena, Italy
| | - Verena C Tatzer
- University of applied Sciences Wiener Neustadt, Neustadt, Austria
| | | | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Anette Ranhoff
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Division of Health Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK.,Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Andrew Teodorczuk
- School of Medicine, Gold Coast Campus, Griffith University, Mount Gravatt, QLD, Australia
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Geriatric Unit, S. Gerardo Hospital, Monza, Italy
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15
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Grealish L, Real B, Todd JA, Darch J, Soltau D, Phelan M, Lunn M, Brandis S, Cooke M, Chaboyer W. Implementing Evidence-Based Guidelines for Falls Prevention: Observations of Nursing Activities During the Care of Older People With Cognitive Impairment. Worldviews Evid Based Nurs 2019; 16:335-343. [PMID: 31155840 DOI: 10.1111/wvn.12376] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Evidence-based guidelines assist clinicians in practice, but how the guidelines are implemented is less established. AIM To describe the nurses' implementation of activities recommended in evidence-based guidelines for falls prevention and care of older people with cognitive impairment. METHODS Structured observation with a categorical checklist was used. Nursing personnel were recruited from one subacute and two acute wards in two hospitals in one tertiary-level health service in south-eastern Queensland, Australia. The data collection instrument identified 31 activities drawn directly from the evidence-based guidelines, which were categorized into six domains of nursing practice: clinical care, comfort, elimination, mobility, nutrition and hydration, and social engagement. Four-hour observation periods, timed to occur across the morning and evening shifts, were conducted over 2 months. RESULTS Nineteen registered nurses, six enrolled nurses, and 16 assistants in nursing (N = 41) were observed for 155 hr of observation. There was variability in adherence with specific activities, ranging from 21% to 100% adherence. Three categories with the highest adherence were nutrition and hydration, mobilization safety, and social engagement. The clinical care, comfort, and elimination categories had lower adherence, with lowest adherence in activities of education provision about falls risk, pain assessment, using a clock or calendar to reorient to time and place, and bowel care. LINKING EVIDENCE TO ACTION Nursing care is delivered within an interdisciplinary team. Therefore, responsibility for the everyday fundamental care activities known to prevent falls in older people with cognitive impairment requires localized negotiation. A practical guide for preventing in-hospital falls in older people with cognitive impairment addressing the interdisciplinary context of practice is required. Interdisciplinary teams should develop strategies to enhance the implementation of pain assessment and prevention of constipation in the context of regularly implemented hydration, nutrition, and mobilization care strategies.
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Affiliation(s)
- Laurie Grealish
- School of Nursing & Midwifery and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia.,Gold Coast Hospital and Health Service, Southport, QLD, Australia
| | - Belinda Real
- Gold Coast Hospital and Health Service, Southport, QLD, Australia
| | - Jo-Anne Todd
- School of Nursing & Midwifery, Griffith University, Southport, QLD, Australia
| | - Jacob Darch
- Cancer Access and Support Services Research Unit, Gold Coast Hospital and Health Service, Southport, QLD, Australia
| | - Dawn Soltau
- Gold Coast Hospital and Health Service, Southport, QLD, Australia
| | - Maggie Phelan
- Falls and Balance Clinic, Gold Coast Hospital and Health Service, Robina, QLD, Australia
| | - Matthew Lunn
- Gold Coast Hospital and Health Service, Southport, QLD, Australia
| | | | - Marie Cooke
- School of Nursing & Midwifery and Menzies Health Institute Queensland, Griffith University, Nathan, QLD, Australia
| | - Wendy Chaboyer
- School of Nursing & Midwifery and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
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16
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Miech EJ, Rattray NA, Flanagan ME, Damschroder L, Schmid AA, Damush TM. Inside help: An integrative review of champions in healthcare-related implementation. SAGE Open Med 2018; 6:2050312118773261. [PMID: 29796266 PMCID: PMC5960847 DOI: 10.1177/2050312118773261] [Citation(s) in RCA: 222] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 04/05/2018] [Indexed: 11/26/2022] Open
Abstract
Background/aims: The idea that champions are crucial to effective healthcare-related implementation has gained broad acceptance; yet the champion construct has been hampered by inconsistent use across the published literature. This integrative review sought to establish the current state of the literature on champions in healthcare settings and bring greater clarity to this important construct. Methods: This integrative review was limited to research articles in peer-reviewed, English-language journals published from 1980 to 2016. Searches were conducted on the online MEDLINE database via OVID and PubMed using the keyword “champion.” Several additional terms often describe champions and were also included as keywords: implementation leader, opinion leader, facilitator, and change agent. Bibliographies of full-text articles that met inclusion criteria were reviewed for additional references not yet identified via the main strategy of conducting keyword searches in MEDLINE. A five-member team abstracted all full-text articles meeting inclusion criteria. Results: The final dataset for the integrative review consisted of 199 unique articles. Use of the term champion varied widely across the articles with respect to topic, specific job positions, or broader organizational roles. The most common method for operationalizing champion for purposes of analysis was the use of a dichotomous variable designating champion presence or absence. Four studies randomly allocated of the presence or absence of champions. Conclusions: The number of published champion-related articles has markedly increased: more articles were published during the last two years of this review (i.e. 2015–2016) than during its first 30 years (i.e. 1980–2009). The number of champion-related articles has continued to increase sharply since the year 2000. Individual studies consistently found that champions were important positive influences on implementation effectiveness. Although few in number, the randomized trials of champions that have been conducted demonstrate the feasibility of using experimental design to study the effects of champions in healthcare.
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Affiliation(s)
- Edward J Miech
- VA Precision Monitoring (PRIS-M) QUERI, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA.,William M. Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, IN, USA.,Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas A Rattray
- VA Precision Monitoring (PRIS-M) QUERI, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Mindy E Flanagan
- VA Precision Monitoring (PRIS-M) QUERI, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Laura Damschroder
- VA Health Services Research & Development Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Arlene A Schmid
- Department of Occupational Therapy, Colorado State University, College of Health and Human Sciences, Fort Collins, CO, USA
| | - Teresa M Damush
- VA Precision Monitoring (PRIS-M) QUERI, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA.,William M. Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, IN, USA.,Department of Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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17
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Hutchinson M, Higson M, Jackson D. Mapping trends in the concept of nurse rounding: A bibliometric analysis and research agenda. Int J Nurs Pract 2017; 23. [DOI: 10.1111/ijn.12584] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 05/11/2017] [Accepted: 07/31/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Marie Hutchinson
- School of Health and Human Science; Southern Cross University; Coffs Harbour New South Wales Australia
- Faculty of Health & Life Sciences; Oxford Brookes University; Oxford UK
| | - Mary Higson
- School of Health and Human Science; Southern Cross University; Coffs Harbour New South Wales Australia
| | - Debra Jackson
- Faculty of Health & Life Sciences; Oxford Brookes University; Oxford UK
- Nursing Research; Oxford University Hospitals NHS Trust; Oxford UK
- School of Health; University of New England; Armidale NSW Australia
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18
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Oosterhouse KJ, Vincent C, Foreman MD, Gruss VA, Corte C, Berger B. Intensive Care Unit Nurses' Beliefs About Delirium Assessment and Management. AACN Adv Crit Care 2017; 27:379-393. [PMID: 27959294 DOI: 10.4037/aacnacc2016535] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Delirium, the most frequent complication of hospitalized older adults, particularly in intensive care units (ICUs), can result in increased mortality rates and length of stay. Nurses are neither consistently identifying nor managing delirium in these patients. The purpose of this study was to explore ICU nurses' identification of delirium, actions they would take for patients with signs or symptoms of delirium, and beliefs about delirium assessment and management. In this cross-sectional study using qualitative descriptive methods guided by the theory of planned behavior, 30 ICU nurses' responses to patient vignettes depicting different delirium subtypes were explored. Descriptive and content analyses revealed that nurses did not consistently identify delirium; their actions varied in different vignettes. Nurses believed that they needed adequate staffing, balanced workload, interprofessional collaboration, and established policy and protocols to identify and manage delirium successfully. Research is needed to determine if implementing these changes increases recognition and decreases consequences of delirium.
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Affiliation(s)
- Kimberly J Oosterhouse
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Catherine Vincent
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Marquis D Foreman
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Valerie A Gruss
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Colleen Corte
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Barbara Berger
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
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Friese CR, Mendelsohn-Victor K, Ginex P, McMahon CM, Fauer AJ, McCullagh MC. Lessons Learned From a Practice-Based, Multisite Intervention Study With Nurse Participants. J Nurs Scholarsh 2017; 49:194-201. [PMID: 28098951 PMCID: PMC5334367 DOI: 10.1111/jnu.12279] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2016] [Indexed: 01/06/2023]
Abstract
PURPOSE To identify challenges and solutions to the efficient conduct of a multisite, practice-based randomized controlled trial to improve nurses' adherence to personal protective equipment use in ambulatory oncology settings. DESIGN The Drug Exposure Feedback and Education for Nurses' Safety (DEFENS) study is a clustered, randomized, controlled trial. Participating sites are randomized to Web-based feedback on hazardous drug exposures in the sites plus tailored messages to address barriers versus a control intervention of a Web-based continuing education video. APPROACH The study principal investigator, the study coordinator, and two site leaders identified challenges to study implementation and potential solutions, plus potential methods to prevent logistical challenges in future studies. FINDINGS Noteworthy challenges included variation in human subjects' protection policies, grants and contracts budgeting, infrastructure for nursing-led research, and information technology variation. Successful strategies included scheduled Web conferences, site-based study champions, site visits by the principal investigator, and centrally based document preparation. Strategies to improve efficiency in future studies include early and continued engagement with contract personnel in sites, and proposed changes to the common rule concerning human subjects. The DEFENS study successfully recruited 393 nurses across 12 sites. To date, 369 have completed surveys and 174 nurses have viewed educational materials. CONCLUSIONS Multisite studies of nursing personnel are rare and challenging to the existing infrastructure. These barriers can be overcome with strong engagement and planning. CLINICAL RELEVANCE Leadership engagement, onsite staff support, and continuous communication can facilitate successful recruitment to a workplace-based randomized, controlled behavioral trial.
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Affiliation(s)
- Christopher R Friese
- Rho, Professor, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Kari Mendelsohn-Victor
- Clinical Research Coordinator, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Pamela Ginex
- Nurse Scientist, Department of Nursing, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Carol M McMahon
- Nurse Supervisor, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
| | - Alex J Fauer
- Rho, Undergraduate Student, University of Michigan School of Nursing and the Hillman Foundation Scholars in Nursing Innovation Program, Ann Arbor, MI, USA
| | - Marjorie C McCullagh
- Rho, Professor, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, MI, USA
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Zalon ML, Sandhaus S, Kovaleski M, Roe-Prior P. Hospitalized Older Adults With Established Delirium: Recognition, Documentation, and Reporting. J Gerontol Nurs 2017; 43:32-40. [PMID: 27845806 DOI: 10.3928/00989134-20161109-01] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 09/22/2016] [Indexed: 11/20/2022]
Abstract
Delirium, a life-threatening complication for hospitalized older adults associated with adverse outcomes, is often underrecognized and underreported. The purpose of the current study was to analyze delirium documentation for hospitalized older adults. Charts of 34 patients, aged 71 and older with documented delirium and referral to a Hospital Elder Life Program, were reviewed. With the exception of International Classification of Diseases-9 coding, delirium was only mentioned in 12 (35.3%) charts, although descriptors potentially indicative of delirium were usually recorded. Of these, the most frequently recorded were confusion (94.1%), mental status change (70.6%), and disorientation (61.8%). When nurses charted delirium descriptors, only 5.9% of their notes included physician referral. Physician responses were to order diagnostic tests and medications, usually antipsychotic or benzodiazepine agents. Of 28 patients requiring transfer to another facility after discharge, delirium was mentioned in only one transfer note. Commonly used delirium descriptors can be used for the development of natural language processing tools for clinical decision support. [Journal of Gerontological Nursing, 43(3), 32-40.].
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Mudge AM, Banks MD, Barnett AG, Blackberry I, Graves N, Green T, Harvey G, Hubbard RE, Inouye SK, Kurrle S, Lim K, McRae P, Peel NM, Suna J, Young AM. CHERISH (collaboration for hospitalised elders reducing the impact of stays in hospital): protocol for a multi-site improvement program to reduce geriatric syndromes in older inpatients. BMC Geriatr 2017; 17:11. [PMID: 28068906 PMCID: PMC5223473 DOI: 10.1186/s12877-016-0399-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 12/15/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Older inpatients are at risk of hospital-associated geriatric syndromes including delirium, functional decline, incontinence, falls and pressure injuries. These contribute to longer hospital stays, loss of independence, and death. Effective interventions to reduce geriatric syndromes remain poorly implemented due to their complexity, and require an organised approach to change care practices and systems. Eat Walk Engage is a complex multi-component intervention with structured implementation, which has shown reduced geriatric syndromes and length of stay in pilot studies at one hospital. This study will test effectiveness of implementing Eat Walk Engage using a multi-site cluster randomised trial to inform transferability of this intervention. METHODS A hybrid study design will evaluate the effectiveness and implementation strategy of Eat Walk Engage in a real-world setting. A multisite cluster randomised study will be conducted in 8 medical and surgical wards in 4 hospitals, with one ward in each site randomised to implement Eat Walk Engage (intervention) and one to continue usual care (control). Intervention wards will be supported to develop and implement locally tailored strategies to enhance early mobility, nutrition, and meaningful activities. Resources will include a trained, mentored facilitator, audit support, a trained healthcare assistant, and support by an expert facilitator team using the i-PARIHS implementation framework. Patient outcomes and process measures before and after intervention will be compared between intervention and control wards. Primary outcomes are any hospital-associated geriatric syndrome (delirium, functional decline, falls, pressure injuries, new incontinence) and length of stay. Secondary outcomes include discharge destination; 30-day mortality, function and quality of life; 6 month readmissions; and cost-effectiveness. Process measures including patient interviews, activity mapping and mealtime audits will inform interventions in each site and measure improvement progress. Factors influencing the trajectory of implementation success will be monitored on implementation wards. DISCUSSION Using a hybrid design and guided by an explicit implementation framework, the CHERISH study will establish the effectiveness, cost-effectiveness and transferability of a successful pilot program for improving care of older inpatients, and identify features that support successful implementation. TRIAL REGISTRATION ACTRN12615000879561 registered prospectively 21/8/2015.
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Affiliation(s)
- Alison M Mudge
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Australia.
| | - Merrilyn D Banks
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Australia
| | - Adrian G Barnett
- Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Irene Blackberry
- John Richards Initiative, Australian Institute of Primary Care and Ageing, La Trobe University, Albury-Wodonga, Australia
| | - Nicholas Graves
- Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Theresa Green
- School of Nursing, Queensland University of Technology, Brisbane, Australia
| | | | - Ruth E Hubbard
- Centre for Research in Geriatric Medicine, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Sharon K Inouye
- Harvard Medical School, Beth Israel Deaconess Medical Centre, Institute for Aging Research, Hebrew Senior Life, Boston, USA
| | - Sue Kurrle
- Cognitive Decline Partnership Centre, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Kwang Lim
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Prue McRae
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Australia
| | - Nancye M Peel
- Centre for Research in Geriatric Medicine, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Jessica Suna
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Australia
| | - Adrienne M Young
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Australia
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Drainoni ML, Koppelman EA, Feldman JA, Walley AY, Mitchell PM, Ellison J, Bernstein E. Why is it so hard to implement change? A qualitative examination of barriers and facilitators to distribution of naloxone for overdose prevention in a safety net environment. BMC Res Notes 2016; 9:465. [PMID: 27756427 PMCID: PMC5070095 DOI: 10.1186/s13104-016-2268-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 10/06/2016] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The increase in opioid overdose deaths has become a national public health crisis. Naloxone is an important tool in opioid overdose prevention. Distribution of nasal naloxone has been found to be a feasible, and effective intervention in community settings and may have potential high applicability in the emergency department, which is often the initial point of care for persons at high risk of overdose. One safety net hospital introduced an innovative policy to offer take-home nasal naloxone via a standing order to ensure distribution to patients at risk for overdose. The aims of this study were to examine acceptance and uptake of the policy and assess facilitators and barriers to implementation. METHODS After obtaining pre-post data on naloxone distribution, we conducted a qualitative study. The PARiHS framework steered development of the qualitative guide. We used theoretical sampling in order to include the range of types of emergency department staff (50 total). The constant comparative method was initially used to code the transcripts and identify themes; the themes that emerged from the coding were then mapped back to the evidence, context and facilitation constructs of the PARiHS framework. RESULTS Acceptance of the policy was good but uptake was low. Primary themes related to facilitators included: real-world driven intervention with philosophical, clinician and leadership support; basic education and training efforts; availability of resources; and ability to leave the ED with the naloxone kit in hand. Barriers fell into five general categories: protocol and policy; workflow and logistical; patient-related; staff roles and responsibilities; and education and training. CONCLUSIONS The actual implementation of a new innovation in healthcare delivery is largely driven by factors beyond acceptance. Despite support and resources, implementation was challenging, with low uptake. While the potential of this innovation is unknown, understanding the experience is important to improve uptake in this setting and offer possible solutions for other facilities to address the opioid overdose crisis. Use of the PARiHS framework allowed us to recognize and understand key evidence, contextual and facilitation barriers to the successful implementation of the policy and to identify areas for improvement.
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Affiliation(s)
- Mari-Lynn Drainoni
- Boston University School of Public Health, 715 Albany Street, T3 W, Boston, MA 02118 USA
- Boston University School of Medicine, Boston, MA USA
- Center for Healthcare Organization and Implementation Research, ENRM Veterans Administration Hospital, Bedford, MA USA
| | - Elisa A. Koppelman
- Boston University School of Public Health, 715 Albany Street, T3 W, Boston, MA 02118 USA
- Center for Healthcare Organization and Implementation Research, ENRM Veterans Administration Hospital, Bedford, MA USA
| | - James A. Feldman
- Boston University School of Medicine, Boston, MA USA
- Boston Medical Center, Boston, MA USA
| | - Alexander Y. Walley
- Boston University School of Medicine, Boston, MA USA
- Boston Medical Center, Boston, MA USA
| | - Patricia M. Mitchell
- Boston University School of Medicine, Boston, MA USA
- Boston Medical Center, Boston, MA USA
| | - Jacqueline Ellison
- Boston University School of Public Health, 715 Albany Street, T3 W, Boston, MA 02118 USA
| | - Edward Bernstein
- Boston University School of Public Health, 715 Albany Street, T3 W, Boston, MA 02118 USA
- Boston University School of Medicine, Boston, MA USA
- Boston Medical Center, Boston, MA USA
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Sommerbakk R, Haugen DF, Tjora A, Kaasa S, Hjermstad MJ. Barriers to and facilitators for implementing quality improvements in palliative care - results from a qualitative interview study in Norway. BMC Palliat Care 2016; 15:61. [PMID: 27422410 PMCID: PMC4947264 DOI: 10.1186/s12904-016-0132-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 07/06/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation of quality improvements in palliative care (PC) is challenging, and detailed knowledge about factors that may facilitate or hinder implementation is essential for success. One part of the EU-funded IMPACT project (IMplementation of quality indicators in PAlliative Care sTudy) aiming to increase the knowledge base, was to conduct national studies in PC services. This study aims to identify factors perceived as barriers or facilitators for improving PC in cancer and dementia settings in Norway. METHODS Individual, dual-participant and focus group interviews were conducted with 20 employees working in different health care services in Norway: two hospitals, one nursing home, and two local medical centers. Thematic analysis with a combined inductive and theoretical approach was applied. RESULTS Barriers and facilitators were connected to (1) the innovation (e.g. credibility, advantage, accessibility, attractiveness); (2) the individual professional (e.g. motivation, PC expertise, confidence); (3) the patient (e.g. compliance); (4) the social context (e.g. leadership, culture of change, face-to-face contact); (5) the organizational context (e.g. resources, structures/facilities, expertise); (6) the political and economic context (e.g. policy, legislation, financial arrangements) and (7) the implementation strategy (e.g. educational, meetings, reminders). Four barriers that were particular to PC were identified: the poor general condition of patients in need of PC, symptom assessment tools that were not validated in all patient groups, lack of PC expertise and changes perceived to be at odds with staff's philosophy of care. CONCLUSION When planning an improvement project in PC, services should pay particular attention to factors associated with their chosen implementation strategy. Leaders should also involve staff early in the improvement process, ensure that they have the necessary training in PC and that the change is consistent with the staff's philosophy of care. An important consideration when implementing a symptom assessment tool is whether or not the tool has been validated for the relevant patient group, and to what degree patients need to be involved when using the tool.
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Affiliation(s)
- Ragni Sommerbakk
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St. Olavs Hospital, Trondheim University Hospital, P.O. Box 8905, N-7491, Trondheim, Norway. .,Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Dagny Faksvåg Haugen
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St. Olavs Hospital, Trondheim University Hospital, P.O. Box 8905, N-7491, Trondheim, Norway.,Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
| | - Aksel Tjora
- Department of Sociology and Political Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St. Olavs Hospital, Trondheim University Hospital, P.O. Box 8905, N-7491, Trondheim, Norway.,Department of Oncology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marianne Jensen Hjermstad
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St. Olavs Hospital, Trondheim University Hospital, P.O. Box 8905, N-7491, Trondheim, Norway.,Regional Centre for Excellence in Palliative Care, Department of Oncology, Oslo University Hospital, Ullevål, Oslo, Norway
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Buck HG, Kolanowski A, Fick D, Baronner L. Improving Rural Geriatric Care Through Education: A Scalable, Collaborative Project. J Contin Educ Nurs 2016; 47:306-13. [DOI: 10.3928/00220124-20160616-06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 04/20/2016] [Indexed: 11/20/2022]
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Yevchak AM, Doherty K, Archambault EG, Kelly B, Fonda JR, Rudolph JL. The association between an ultrabrief cognitive screening in older adults and hospital outcomes. J Hosp Med 2015; 10:651-7. [PMID: 26374602 PMCID: PMC4594206 DOI: 10.1002/jhm.2450] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 07/31/2015] [Accepted: 08/02/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Though often recommended, hospital cognitive assessment is infrequently completed due to clinical and time constraints. OBJECTIVE This analysis aimed to evaluate the relationship between performance on ultrabrief cognitive screening instruments and hospital outcomes. DESIGN This is a secondary data analysis of a quality improvement project. SETTING Tertiary Veterans Administration hospital in New England. PATIENTS Patients, ≥ 60 years old, admitted to the hospital. INTERVENTION None. MEASUREMENTS Upon admission, patients were administered 2 cognitive screening tools. The modified Richmond Agitation and Sedation Scale (mRASS) is a measure of arousal that can be completed in 15 seconds. The months of the year backward (MOYB) is a measure of attention that can be administered in ≤1 minute. In-hospital outcomes included restraints and mortality, whereas discharge outcomes included length of stay, discharge not home, and variable direct costs. Risk ratios were calculated for dichotomous outcomes and unadjusted Poisson regression for continuous outcomes. RESULTS Patients (n = 3232) were screened. Altered arousal occurred in 15% of patients (n = 495); incorrect MOYB was recorded in 45% (n = 1457). Relative to those with normal arousal and attention, those with abnormal mRASS and incorrect MOYB had increased length of stay (incident rate ratio [IRR]: 1.23, 95% confidence interval [CI]: 1.17-1.30); restraint use (risk ratio [RR]: 5.05, 95% CI: 3.29-7.75), in-hospital mortality (RR: 3.46, 95% CI: 1.24-9.63), and decreased discharge home (RR: 2.97, 95% CI: 2.42-3.64). Hospital variable direct costs were slightly, but not significantly, higher (IRR: 1.02, 95% CI: 0.88-1.17). CONCLUSION Impaired performance on ultrabrief cognitive assessments of arousal and attention provide valuable insights regarding hospital outcomes.
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Affiliation(s)
| | - Kelly Doherty
- Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, MA
| | | | - Brittany Kelly
- Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, MA
- School of Nursing, Science and Health Professions, Regis College, Boston, MA
| | - Jennifer R. Fonda
- Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, MA
- Department of Epidemiology, Boston University, Boston MA
| | - James L. Rudolph
- Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, MA
- Division of Aging, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Fick DM, Inouye SK, Guess J, Ngo LH, Jones RN, Saczynski JS, Marcantonio ER. Preliminary development of an ultrabrief two-item bedside test for delirium. J Hosp Med 2015; 10:645-50. [PMID: 26369992 PMCID: PMC4665114 DOI: 10.1002/jhm.2418] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 06/04/2015] [Accepted: 06/09/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Delirium is common, morbid, and costly, yet is greatly under-recognized among hospitalized older adults. OBJECTIVE To identify the best single and pair of mental status test items that predict the presence of delirium. DESIGN, SETTING Diagnostic test evaluation study that enrolled medicine inpatients aged 75 years or older at an academic medical center. METHODS Patients underwent a clinical reference standard assessment involving a patient interview, medical record review, and interviews with family members and nurses to determine the presence or absence of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition defined delirium. Participants also underwent the three-dimensional Confusion Assessment Method (3D-CAM), a brief, validated assessment for delirium. Individual items and pairs of items from the 3D-CAM were evaluated to determine sensitivity and specificity relative to the reference standard delirium diagnosis. RESULTS Of the 201 participants (mean age 84 years, 62% female), 42 (21%) had delirium based on the clinical reference standard. The single item with the best test characteristics was "months of the year backwards" with a sensitivity of 83% (95% confidence interval [CI]: 69%-93%) and specificity of 69% (95% CI: 61%-76%). The best 2-item screen was the combination of "months of the year backwards" and "what is the day of the week?" with a sensitivity of 93% (95% CI: 81%-99%) and specificity of 64% (95% CI: 56%-70%). CONCLUSIONS We identified a single item with >80% and pair of items with >90% sensitivity for delirium. If validated prospectively, these items will serve as an initial innovative screening step for delirium identification in hospitalized older adults.
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Affiliation(s)
- Donna M. Fick
- College of Nursing, College of Medicine, Department of Psychiatry, Penn State University, University Park, Pennsylvania
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Address for correspondence and reprint requests: Donna M. Fick, PhD, Distinguished Professor, College of Nursing, Penn State University, Health and Human Development East, University Park, PA 16802; Telephone: 814-865-9325; Fax: 814-865-3779;
| | - Sharon K. Inouye
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jamey Guess
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Long H. Ngo
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Richard N. Jones
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Jane S. Saczynski
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Edward R. Marcantonio
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Is there a role for physician involvement in introducing research to surrogate decision makers in the intensive care unit? (The Approach trial: a pilot mixed methods study). Intensive Care Med 2014; 41:58-67. [DOI: 10.1007/s00134-014-3558-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 11/09/2014] [Indexed: 11/26/2022]
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Improving the organization of palliative care: identification of barriers and facilitators in five European countries. Implement Sci 2014; 9:130. [PMID: 25686479 PMCID: PMC4203898 DOI: 10.1186/s13012-014-0130-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 09/19/2014] [Indexed: 11/11/2022] Open
Abstract
Background Interventions to improve palliative care encounter challenges beyond the usual implementation problems because of palliative care’s complex and changing character. In this study, we explored barriers and facilitators faced by health-care professionals in five European countries (England, Germany, Italy, Norway and the Netherlands) with regard to improving the organization of their palliative care service. Methods Semi-structured individual and focus group interviews were conducted with purposefully selected health-care professionals. The constant comparative method was used to analyse the data. Results Professionals working in hospitals, hospices, nursing homes and primary care facilities who provide palliative care to adult patients were interviewed (n =40) or participated in ten focus group interviews (n =59). Barriers and facilitators were inductively grouped into 16 categories and arranged into five themes: innovation, individual professional level, group dynamics, organizational context and local political-economic context. Although the barriers and facilitators identified differed in scope, context, strength and provenance, they were shared by professionals from different European countries. Conclusion This study identified barriers and facilitators to organizational change in palliative care. Some of these barriers and facilitators were experienced by professionals in almost all countries and are therefore prerequisites to change. Understanding the barriers to and facilitators of change will help tailor organizational improvements to the needs of individuals and organizations. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0130-z) contains supplementary material, which is available to authorized users.
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Hill NL, Yevchak A, Gilmore-Bykovskyi A, Kolanowski AM. The Model of Care Partner Engagement: Use in delirium management. Geriatr Nurs 2014; 35:272-8. [DOI: 10.1016/j.gerinurse.2014.02.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 02/20/2014] [Accepted: 02/22/2014] [Indexed: 01/26/2023]
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Ettema R, Harten DV, Hoogerduijn J, Hoekstra T, Schuurmans M. Nurses Opinions Regarding Delirium Care in the Older General Hospital Population and in Older Cardiac Surgery Patients Specifically: A Multicentre Survey among Dutch Nurses. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ijcm.2014.521173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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