Implementing Delirium Prevention in the Era of COVID-19

Patients admitted with COVID-19 can develop delirium due to predisposing factors, isolation, and the illness itself. Standard delirium prevention methods focus on interaction and stimulation. It can be challenging to deliver these methods of care in COVID settings where it is necessary to increase patient isolation. This paper presents a typical clinical vignette of representative patients in a tertiary care hospital and how a medical team modified an evidence-based delirium prevention model to deliver high-quality care to COVID-19 patients. The implemented model focuses on four areas of delirium-prevention: Mobility, Sleep, Cognitive Stimulation, and Nutrition. Future studies will be needed to track quantitative outcome measures.

Under-coding of dementia and other conditions indicates scope for improved patient management: A longitudinal retrospective study of dementia patients in Australia

BACKGROUND

Under-coding of dementia during hospitalisation results in an inability to identify all patients with dementia using hospital administrative data. Clinical coding can be viewed as a proxy for management; therefore, under-coding indicates dementia was not considered in the patient's management. While under-coding of dementia is well established, there is sparse evidence on whether dementia is coded in subsequent hospitalisations among patients with a known diagnosis.

OBJECTIVE

(a) To describe patterns of dementia coding over 5 years after a first-coded (i.e. index) admission for dementia; (b) to identify factors associated with clinical coding of dementia; and (c) to identify patient subgroups at risk of not being coded to inform future interventions to improve hospital identification and management of dementia.

METHOD

Retrospective study of longitudinal hospital data from 1 July 2006 to 30 June 2015 for 7919 patients hospitalised during the 5 years' post-index admission for dementia in a regional local health district of New South Wales, Australia.

RESULTS

Dementia was coded in 63.9% of admissions in the 12 months following index admission for dementia; this decreased to 53.7% after 5 years. Patients were 20% more likely to have dementia actively managed when it co-occurred with delirium. Under-coding varied across conditions, with dementia more likely to be coded in admissions for falls and pneumonitis, and less likely for heart failure, pneumonia and urinary tract infection (UTI).

CONCLUSION

The frequency with which dementia was not coded highlights opportunities to improve identification and management of dementia through dementia-specific care, enhanced clinical protocols, and interventions focused around heart failure, pneumonia and UTI admissions.

Turning education into action: Impact of a collective social education approach to improve nurses' ability to recognize and accurately assess delirium in hospitalized older patients

BACKGROUND

Although cognitive impairment including dementia and delirium is common in older hospital patients, it is not well recognized or managed by hospital staff, potentially resulting in adverse events. This paper describes, and reports on the impact of a collective social education approach to improving both nurses' knowledge of, and screening for delirium.

METHODS

Thirty-four experienced nurses from six hospital wards, became Cognition Champions (CogChamps) to lead their wards in a collective social education process about cognitive impairment and the assessment of delirium. At the outset, the CogChamps were provided with comprehensive education about dementia and delirium from a multidisciplinary team of clinicians. Their knowledge was assessed to ascertain they had the requisite understanding to engage in education as a collective social process, namely, with each other and their local teams. Following this, they developed ward specific Action Plans in collaboration with their teams aimed at educating and evaluating ward nurses' ability to accurately assess and care for patients for delirium. The plans were implemented over five months. The broader nursing teams' knowledge was assessed, together with their ability to accurately assess patients for delirium.

RESULTS

Each ward implemented their Action Plan to varying degrees and key achievements included the education of a majority of ward nurses about delirium and the certification of the majority as competent to assess patients for delirium using the Confusion Assessment Method. Two wards collected pre-and post-audit data that demonstrated a substantial improvement in delirium screening rates.

CONCLUSION

The education process led by CogChamps and supported by educators and clinical experts provides an example of successfully educating nurses about delirium and improving screening rates of patients for delirium.

TRIAL REGISTRATION

ACTRN 12617000563369.

Nurses' perceptions of preventing falls for patients with dementia in the acute hospital setting

OBJECTIVES

Safe and high-quality care for patients with dementia is a key priority area of the Australian Commission on Safety and Quality in Health Care; however, caring for patients with dementia in the acute hospital setting is perceived as challenging. The aim of this analysis was to explore nurses' perspectives regarding fall prevention for patients with dementia in an acute care setting.

METHODS

Secondary analysis of focus group data. Focus groups were conducted with nurses (n = 96) across six hospitals in New South Wales and Victoria.

RESULTS

Nurses frequently reported issues relating to the physical environment of the acute care setting, competing priorities in a complex care setting and the need for one-on-one supervision for patients with dementia.

CONCLUSION

Nurses report that one-on-one supervision is required to keep patients safe. Future research examining the acceptability and cost-effectiveness of volunteers providing this supervision is warranted in Australian hospitals.

A qualitative study of new graduates' readiness to use nursing informatics in acute care settings: clinical nurse educators' perspectives

BACKGROUND

There is an increase in demand for newly graduated nurses who are ready to use nursing informatics (NI) efficiently in technology-rich healthcare environments. However, the progress of embedding NI into curricula has been slow worldwide, and literature reports graduates are not ready to use NI tools effectively in the workplace, posing potential threats to patient safety. In the absence of National Standards for NI competencies, graduates' NI needs on entering the workplace need to be explored.

AIM

To identify graduates' NI needs on entering the workplace in acute care settings from the perspectives of clinical nurse educators.

METHODS

A qualitative study using interpretive description with one focus group of six clinical nurse educators was conducted. Clinical nurse educators who are significantly involved in supporting graduates from their first day in the workplace were purposively recruited. The focus group was audiotaped, transcribed verbatim and analysed using thematic analysis.

RESULTS

Graduates were found to be inadequately prepared to use NI tools on entering the workplace. Inefficient hospital systems and a ward culture that was discouraging graduates' NI practice were identified as major barriers to the implementation of NI practice. Lack of exposure to specific hospital systems as undergraduates was also identified as a significant barrier to NI practice among graduates.

CONCLUSIONS

As well as supporting the pre-existing studies on NI skills in graduates and barriers to graduates' NI practice, this current study identified the need for nursing schools to further integrate NI into formal curricula and increased opportunity for exposure to hospital systems as undergraduates. Further studies in multiple settings across Australia are recommended to ensure the transferability of the findings of this study.

CogChamps - a model of implementing evidence-based care in hospitals: study protocol

BACKGROUND

Delirium and dementia (cognitive impairment; CI), are common in older hospital patients, and both are associated with serious adverse outcomes. Despite delirium often being preventable, it is frequently not recognized in hospital settings, which may be because hospital nurses have not received adequate education or training in recognizing or caring for those with CI. However, the most effective way of increasing nurses' awareness about delirium and dementia, and initiating regular patient screening and monitoring to guide best practices for these patients in hospital settings is not known. Hence this current project, conducted in 2015-2017, aims to redress this situation by implementing a multi-component non-pharmacological evidence-based intervention for patients with CI, through educating and mentoring hospital nurses to change their practice.

METHODS

The development of the practice change component is informed by recent findings from implementation science that focuses on facilitation as the active ingredient in knowledge uptake and utilization. This component focuses on educating and empowering experienced nurses to become Cognition Champions (CogChamps) across six wards in a large Australian tertiary referral hospital. The CogChamps will, in turn, educate other nursing team members to more effectively care for patients with CI. The hospital leadership team are supportive of the project and are directly involved in selecting the CogChamps. CogChamps will be provided with comprehensive education in evidence-based delirium assessment, prevention and management, and practice change management skills. They will receive continuing support from research and education staff about raising awareness, upskilling other staff in delirium assessment and in the adoption of best practices for preventing and managing delirium. Both qualitative and quantitative data are being collected at multiple time-points to evaluate process, impact and outcome, and to provide clarity regarding the most effective aspects of the intervention.

DISCUSSION

This paper describes the study protocol for the implementation of multi-component evidence-based non-pharmacological practices designed to improve the care of older hospital patients with CI. Findings will inform subsequent initiatives directed towards enhancing the capacity of the nursing workforce to implement best practices for providing high quality care for this growing patient population throughout their acute care hospital stay.

The relationship between in-hospital location and outcomes of care in patients diagnosed with dementia and/or delirium diagnoses: analysis of patient journey

Background

The discrepancy between the number of admissions and the allocation of hospital beds means that many patients admitted to hospital can be placed in units or wards other than that which specialise in the patient’s primary health issue (home-ward). These patients are called ‘outlier’ patients. Risk factors and health system outcomes of hospital care for ‘outlier’ patients diagnosed with dementia and/or delirium are unknown. Therefore, the aim of this research was to examine patient journeys of people with dementia and/or delirium diagnoses, to identify risk factors for ‘inlier’ or ‘outlier’ status and patient or health system outcomes (consequences) of this status.

Methods

A retrospective, descriptive study compared patients who had dementia and/or delirium according to the proportion of time spent on the home ward i.e. ‘inliers’ or ‘outliers’. Data from the patient journey database at Flinders Medical Centre (FMC), a public hospital in South Australia from 2007 and 2014 were extracted and analysed. The analysis was carried out on the patient journeys of people with a dementia and/or delirium diagnosis.

Results

When 6367 inpatient journeys with dementia and/or delirium within FMC were examined, the Emergency Department (ED) Length of Stay (LOS) after being admitted as inpatient was prolonged for ‘outlier’ patients compared to ‘inlier’ patients (OR: 1.068, 95% CI: 1.057–1.079, p = 0.000). However, the inpatient LOS for’outlier’ patients was only marginally shorter than that of the ‘inlier’ patients (OR: 0.998, 95% CI: 0.998–0.998, p = 0.000). The chances of dying within 48 h of admission increased for ‘outlier’ patients (OR: 1.973, 95% CI: 1.158–3.359, p = 0.012) and their Charlson co-morbidity Index was higher (OR: 1.059, 95% CI: 1.021–1.10, p = 0.002). Completion of discharge summaries within 2 days post-discharge for ‘outlier’ patients was compromised (OR: 1.754, 95% CI: 1.492–2.061, p = 0.000).Additionally, ‘outlier’ patients were more likely to be discharged to another hospital for other care types not offered at FMC (OR: 1.931, 95% CI: 1.559–2.391, p = 0.000).

Conclusion

An examination of the patient journeys at FMC has determined that the health system outcomes for patients with dementia and/or delirium who are admitted outside of their home-ward are affected by in-hospital location despite the homogenous nature of the study population.

6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial

OBJECTIVE

To evaluate the effect of the 6-PACK programme on falls and fall injuries in acute wards.

DESIGN

Cluster randomised controlled trial.

SETTING

Six Australian hospitals.

PARTICIPANTS

All patients admitted to 24 acute wards during the trial period.

INTERVENTIONS

Participating wards were randomly assigned to receive either the nurse led 6-PACK programme or usual care over 12 months. The 6-PACK programme included a fall risk tool and individualised use of one or more of six interventions: "falls alert" sign, supervision of patients in the bathroom, ensuring patients' walking aids are within reach, a toileting regimen, use of a low-low bed, and use of a bed/chair alarm.

MAIN OUTCOME MEASURES

The co-primary outcomes were falls and fall injuries per 1000 occupied bed days.

RESULTS

During the trial, 46 245 admissions to 16 medical and eight surgical wards occurred. As many people were admitted more than once, this represented 31 411 individual patients. Patients' characteristics and length of stay were similar for intervention and control wards. Use of 6-PACK programme components was higher on intervention wards than on control wards (incidence rate ratio 3.05, 95% confidence interval 2.14 to 4.34; P<0.001). In all, 1831 falls and 613 fall injuries occurred, and the rates of falls (incidence rate ratio 1.04, 0.78 to 1.37; P=0.796) and fall injuries (0.96, 0.72 to 1.27; P=0.766) were similar in intervention and control wards.

CONCLUSIONS

Positive changes in falls prevention practice occurred following the introduction of the 6-PACK programme. However, no difference was seen in falls or fall injuries between groups. High quality evidence showing the effectiveness of falls prevention interventions in acute wards remains absent. Novel solutions to the problem of in-hospital falls are urgently needed.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12611000332921.

The influence of dementia on injury-related hospitalisations and outcomes in older adults

INTRODUCTION

Injury is the most common reason for admission to hospital in people with dementia in Australia. However relatively little is known about the temporal trends and the hospital experience of people with dementia hospitalised for an injury. This population-based data linkage study compared the causes, temporal trends and health outcomes for injury-related hospitalisations in people with and without dementia.

METHODS

Hospitalisation and death data for 235,612 individuals aged 65 years and over admitted to hospital for an injury over the ten year period (2003-2012) in New South Wales, Australia were probabilistically linked. Descriptive statistics including chi square tests, observed and age-standardised admission rates and rate ratios (RRs) were calculated. Trends over time were analysed using negative binomial regression.

RESULTS

There were 331,432 injury-related hospitalisations over the study period. Both the observed (RR 3.16; 95% CI 3.13-3.19) and age-standardised admission rate ratios (RR 1.78; 95% CI 1.77-1.79) were higher for people with dementia. Age-standardised rates increased by 3.5% (95% CI 3.1-3.9) per annum over the study period for people without dementia. In contrast, for people with dementia, rates increased by 2.4% (95% CI 1.8-3.1) per annum until 2007 and then decreased by 3.1% (95% CI -4.4 to -1.7) per annum from 2007 onwards. Compared to people without dementia, a higher proportion of people with dementia were hospitalised as a result of a fall (90.9% vs 75.2%, p<0.0001), sustained a fracture (57.2% vs 52.1%, p<0.0001), notably hip fracture (30.7% vs 14.7%, p<0.0001), had longer mean hospital lengths of stay (LOS) (16.5 vs 13.6 days), and higher 30-day mortality (8.7% vs 3.6% p<0.0001), although this pattern was not consistent across all injury types.

CONCLUSIONS

People with dementia are disproportionately represented in injury-related hospitalisations, experience longer hospital LOS and have poorer outcomes. Ninety percent of hospitalisations for people with dementia were as a result of a fall, highlighting the importance of developing and implementing effective fall-related preventive strategies in this high risk population.

Prevalence and incidence of dementia among indigenous populations: a systematic review

BACKGROUND

Indigenous populations may be at increased risk, compared with majority populations, for the development of dementia due to lower education levels and socio-economic status, higher rates of diabetes, hypertension, cardiovascular disease and alcohol abuse, an aging population structure, and poorer overall health. This is the first systematic review investigating the prevalence and incidence of dementia in indigenous populations worldwide.

METHODS

This systematic review was conducted in accordance with PRISMA guidelines. We searched MEDLINE, Embase, and PsycInfo for relevant papers published up to April 2015. Studies were included if they reported prevalence or incidence, the disease typically occurred after the age of 45, the study population included indigenous people, and the study was conducted in the general population.

RESULTS

Fifteen studies representing five countries (Canada, Australia, the USA, Guam, Brazil) met the inclusion criteria. Dementia prevalence ranged from 0.5% to 20%. Retrospective studies relying on medical records for diagnoses had much lower prevalence rates and a higher risk of bias than population-based prospective studies performing their own diagnoses with culturally appropriate cognitive assessment methods.

CONCLUSIONS

The prevalence of dementia among indigenous populations appears to be higher than it is for non-indigenous populations. Despite a building body of evidence supporting the need for dementia research among indigenous populations, there is a paucity of epidemiological research, none of which is of high quality.

Fall-related hip fracture hospitalisations and the prevalence of dementia within older people in New South Wales, Australia: an analysis of linked data

INTRODUCTION

Dementia and fall-related hip fractures both contribute significantly to the burden of illness within elderly populations in Australia and elsewhere. The research presented here uses a large probabilistically linked dataset from NSW, Australia to estimate the prevalence of dementia within hip fracture patients and investigate the impact of dementia on hospitalisation length of stay (LOS) and survival.

METHOD

The cases considered were NSW residents aged 65 years and above who experienced a fall related hip fracture between 1 July 2000 and 30 June 2009. The prevalence of dementia was calculated for the incident hip fracture using two methods to infer dementia status. Cox proportional hazards regression modelling was used to estimate the relative rate of discharge from a hospitalisation episode, and the relative mortality rate of hip fracture patients suffering dementia versus those who were cognitively intact. Additional covariates used in the models included sex, age group at admission, the Charlson Comorbidity Index and separation mode.

RESULTS

Of the 44,143 fall-related incident hip fracture cases considered, between 24% (observed diagnosis) to 29% (inferred diagnosis) of these people had dementia. The median LOS for patients with dementia was shorter than those without dementia, but there was a strong interaction with age. The rate of discharge from the fracture-related hospitalisation episode of the cases with dementia was 40% greater (95% CI 1.4-1.5) than the non-demented group. Similarly, the relative mortality rate of those with dementia was greater (2.4, 95% CI 2.3-2.6) than the non-demented group. Both Cox analyses indicated evidence for main effects of age at admission and comorbidity, as well as interaction effects between age group and dementia status.

CONCLUSION

The use of linked datasets with tens of thousands of cases enables the calculation of precise estimates of various parameters. People with dementia constitute a significant proportion of the total population of elderly hip fracture patients in hospitals (up to 29%). Their mortality rate is greater than those without a diagnosis of dementia and their hospital length of stay is shorter, particularly if they are discharged to a residential aged care facility.