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Marcomini I, Pisoni L, Mellino A, Labaran R, Milani L. Evaluation of Delirium Among Elders in the Emergency Department: A Cross-Sectional Study. Dimens Crit Care Nurs 2024; 43:130-135. [PMID: 38564455 DOI: 10.1097/dcc.0000000000000636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Health care professionals underestimate the recognition of delirium in emergency departments (EDs). In these settings, between 57% and 83% of cases of delirium go undetected. When delirium occurs, it causes an increase in the length of hospitalization, readmissions within 30 days, and mortality. No studies were carried out in Italy to assess the prevalence of delirium among elders in EDs. OBJECTIVES The primary goal of the study was to evaluate the prevalence of the risk of delirium in people 65 years and older hospitalized in the ED for a minimum of 8 hours. The study's secondary goal was to identify the variables that influenced the risk of delirium. METHOD A multicenter cross-sectional study was conducted in 2 EDs. The risk of delirium was assessed using the delirium screening tool 4 A's test. One hundred patients were enrolled. Data collection took place from June 28 to August 31, 2022. RESULTS The risk of delirium was detected in 29% of the sample, whereas the risk of cognitive impairment was 13%. The use of psychotropic drugs increased the risk of delirium by 11.8 times (odds ratio [OR], 11.80; P = .003). Bed confinement increased the risk by 4.3 times (OR, 4.31; P = .009). Being dehydrated increased the risk of onset by 4.6 times (OR, 4.62; P = .010). Having dementia increased the risk of delirium manifestation by 4.4 times (OR, 4.35; P = .021). DISCUSSION The risk of delirium was detected in a considerable portion of the sample. The results of this study can be used by health care professionals to implement preventive measures as well as support clinical judgment and establish priorities of care for patients at risk of developing delirium.
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Filiatreault S, Kreindler SA, Grimshaw JM, Chochinov A, Doupe MB. Developing a set of emergency department performance measures to evaluate delirium care quality for older adults: a modified e-Delphi study. BMC Emerg Med 2024; 24:28. [PMID: 38360551 PMCID: PMC10868025 DOI: 10.1186/s12873-024-00947-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/05/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Older adults are at high risk of developing delirium in the emergency department (ED); however, it is under-recognized in routine clinical care. Lack of detection and treatment is associated with poor outcomes, such as mortality. Performance measures (PMs) are needed to identify variations in quality care to help guide improvement strategies. The purpose of this study is to gain consensus on a set of quality statements and PMs that can be used to evaluate delirium care quality for older ED patients. METHODS A 3-round modified e-Delphi study was conducted with ED clinical experts. In each round, participants rated quality statements according to the concepts of importance and actionability, then their associated PMs according to the concept of necessity (1-9 Likert scales), with the ability to comment on each. Consensus and stability were evaluated using a priori criteria using descriptive statistics. Qualitative data was examined to identify themes within and across quality statements and PMs, which went through a participant validation exercise in the final round. RESULTS Twenty-two experts participated, 95.5% were from west or central Canada. From 10 quality statements and 24 PMs, consensus was achieved for six quality statements and 22 PMs. Qualitative data supported justification for including three quality statements and one PM that achieved consensus slightly below a priori criteria. Three overarching themes emerged from the qualitative data related to quality statement actionability. Nine quality statements, nine structure PMs, and 14 process PMs are included in the final set, addressing four areas of delirium care: screening, diagnosis, risk reduction and management. CONCLUSION Results provide a set of quality statements and PMs that are important, actionable, and necessary to a diverse group of clinical experts. To our knowledge, this is the first known study to develop a de novo set of guideline-based quality statements and PMs to evaluate the quality of delirium care older adults receive in the ED setting.
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Affiliation(s)
- Sarah Filiatreault
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada.
| | - Sara A Kreindler
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, K1H8L6, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
| | - Alecs Chochinov
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
- Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Malcolm B Doupe
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
- Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
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Jones A, Watt JA, Maclagan LC, Swayze S, Jaakkimainen L, Schull MJ, Bronskill SE. Factors associated with recurrent emergency department visits among people living with dementia: A retrospective cohort study. J Am Geriatr Soc 2023; 71:3731-3743. [PMID: 37314108 DOI: 10.1111/jgs.18457] [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: 02/17/2023] [Revised: 04/12/2023] [Accepted: 05/14/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Research on factors associated with recurrent emergency department (ED) visits and their implications for improving dementia care is lacking. The objective of this study was to examine associations between the individual characteristics of older adults living with dementia and recurrent ED visits. METHODS We used health administrative databases to conduct a population-based retrospective cohort study among older adults with dementia in Ontario, Canada. We included community-dwelling adults 66 years and older who visited the ED between April 1, 2010, and March 31, 2019 and were discharged home. We recorded all ED visits within one year after the baseline visit. We used recurrent event Cox regression to examine associations between repeat ED visits and individual clinical, demographic, and health service use characteristics. We fit conditional inference trees to identify the most important factors and define subgroups of varying risk. RESULTS Our cohort included 175,863 older adults with dementia. ED use in the year prior to baseline had the strongest association with recurrent visits (3+ vs.0 adjusted hazard ratio (aHR): 1.92 (1.89, 1.94), 2vs.0 aHR: 1.45 (1.43, 1.47), 1vs.0 aHR: 1.23 (1.21, 1.24)). The conditional inference tree utilized history of ED visits and comorbidity count to define 12 subgroups with ED revisit rates ranging from 0.79 to 7.27 per year. Older adults in higher risk groups were more likely to live in rural and low-income areas and had higher use of anticonvulsants, antipsychotics, and benzodiazepines. CONCLUSIONS History of ED visits may be a useful measure to identify older adults with dementia who would benefit from additional interventions and supports. A substantial proportion of older adults with dementia have a pattern of recurrent visits and may benefit from dementia-friendly and geriatric-focused EDs. Collaborative medication review in the ED and closer follow-up and engagement with community supports could improve patient care and experience.
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Affiliation(s)
- Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Jennifer A Watt
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Liisa Jaakkimainen
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael J Schull
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Susan E Bronskill
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
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Lee S, Howard MA, Han JH. Delirium and Delirium Prevention in the Emergency Department. Clin Geriatr Med 2023; 39:535-551. [PMID: 37798064 DOI: 10.1016/j.cger.2023.05.006] [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] [Indexed: 10/07/2023]
Abstract
This article covers the epidemiology of delirium and the overlapping condition of altered mental status and encephalopathy that is relevant to those who practice in the emergency department.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, 312 Oxford House, Nashville, TN 37232-4700, USA; Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, 1310 24th Avenue South, Nashville, TN 37212-2637, USA
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Filiatreault S, Grimshaw JM, Kreindler SA, Chochinov A, Linton J, Chatterjee R, Azeez R, Doupe MB. A critical appraisal and recommendation synthesis of delirium clinical practice guidelines relevant to the care of older adults in the emergency department: An umbrella review. J Eval Clin Pract 2023; 29:1039-1053. [PMID: 37316463 DOI: 10.1111/jep.13883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/16/2023]
Abstract
RATIONALE Older adults are at high risk of developing delirium in the emergency department (ED); however, it is often missed or undertreated. Improving ED delirium care is challenging in part due to a lack of standards to guide best practice. Clinical practice guidelines (CPGs) translate evidence into recommendations to improve practice. AIM To critically appraise and synthesize CPG recommendations for delirium care relevant to older ED patients. METHODS We conducted an umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations were critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II; and Appraisal of Guidelines Research and Evaluation-Recommendations Excellence (AGREE-REX) instruments. A threshold of 70% or greater in the AGREE-II Rigour of Development domain was used to define high-quality CPGs. Delirium recommendations from CPGs meeting this threshold were included in the synthesis and narrative analysis. RESULTS AGREE-II Rigour of Development scores ranged from 37% to 83%, with 5 of 10 CPGs meeting the predefined threshold. AGREE-REX overall calculated scores ranged from 44% to 80%. Recommendations were grouped into screening, diagnosis, risk reduction, and management. Although none of the included CPGs were ED-specific, many recommendations incorporated evidence from this setting. There was agreement that screening for nonmodifiable risk factors is important to define high-risk populations, and those at risk should be screened for delirium. The '4A's Test' was the recommended tool to use in the ED specifically. Multicomponent strategies were recommended for delirium risk reduction, and for its management if it occurs. The only area of disagreement was for the short-term use of antipsychotic medication in urgent situations. CONCLUSION This is the first known review of delirium CPGs including a critical appraisal and synthesis of recommendations. Researchers and policymakers can use this synthesis to inform future improvement efforts and research in the ED. REGISTRATION This study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6OSF.IO/TG7S6.
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Affiliation(s)
- Sarah Filiatreault
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sara A Kreindler
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alecs Chochinov
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Janice Linton
- Neil John Maclean Health Sciences Library, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rashmita Chatterjee
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rilwan Azeez
- Department of Immunology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Malcolm B Doupe
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre for Care Research, Western University of Applied Sciences, Bergen, Norway
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Filiatreault S, Kreindler S, Grimshaw J, Chochinov A, Doupe M. Protocol for developing a set of performance measures to monitor and evaluate delirium care quality for older adults in the emergency department using a modified e-Delphi process. BMJ Open 2023; 13:e074730. [PMID: 37607798 PMCID: PMC10445345 DOI: 10.1136/bmjopen-2023-074730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/10/2023] [Indexed: 08/24/2023] Open
Abstract
INTRODUCTION Older adults are at high risk of developing delirium in the emergency department (ED). Delirium associated with an ED visit is independently linked to poorer outcomes such as increased length of hospital stay and mortality. Performance measures (PMs) are needed to identify variations in the quality of delirium care to help focus improvement efforts where they are most needed. A preliminary list of 11 quality statements and 24 PMs was developed based on a synthesis of high-quality clinical practice guidelines. The purpose of this study is to gain consensus on a subset of PMs that can be used to evaluate delirium care quality for older ED patients. METHODS AND ANALYSIS This protocol for a modified e-Delphi study is informed by the Guidance on Conducting and REporting DElphi Studies. Clinical experts from across Canada and internationally will be recruited through peer referral, professional organisations and social media calls for expressions of interest. A minimum of 17 participants will be recruited. The primary survey for each round will consist of closed-ended questions with the opportunity to provide comments to justify decisions and clarify understanding. Using 9-point Likert scales, participants will rate each quality statement according to the concepts of importance and actionability, then its associated PMs according to the concept of necessity. Results will be fed back to participants in subsequent rounds. A priori stopping criteria have been defined in terms of consensus and stability. A minimum of three rounds will be undertaken to allow participants to have feedback, revise previous responses, then stabilise responses. ETHICS AND DISSEMINATION Ethical approval was provided at the University of Manitoba Health Research Ethics Board (ID HS25728 (H2022:340)). Informed consent will be obtained electronically using the Research Electronic Data Capture secure online platform. Knowledge translation and dissemination will be done through traditional (eg, conference presentations, peer-reviewed publications) and non-traditional (eg, ED Grand Rounds) strategies.
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Affiliation(s)
- Sarah Filiatreault
- Community Health Sciences, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Sara Kreindler
- Community Health Sciences, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Alecs Chochinov
- Community Health Sciences, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Emergency Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Malcolm Doupe
- Community Health Sciences, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Emergency Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
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Effects of delay to stroke unit admission in patients with ischemic and hemorrhagic stroke. Can J Neurol Sci 2023; 50:10-16. [PMID: 35094743 DOI: 10.1017/cjn.2021.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the association between delay in transfer to a central stroke unit from peripheral institutions and outcomes. METHODS We conducted a retrospective cohort study of all patients with acute stroke, admitted to a comprehensive stroke center (CSC) from three emergency departments (EDs), between 2016 and 2018. The primary outcomes were length of stay, functional status at 3 months, discharge destination, and time to stroke investigations. RESULTS One thousand four hundred thirty-five patients were included, with a mean age of 72.9 years, and 92.4% ischemic stroke; 663 (46.2%) patients were female. Each additional day of delay was associated with 2.0 days of increase in length of stay (95% confidence interval [CI] 0.8-3.2, p = 0.001), 11.5 h of delay to vascular imaging (95% CI 9.6-13.4, p < 0.0001), 24.2 h of delay to Holter monitoring (95% CI 7.9-40.6, p = 0.004), and reduced odds of nondisabled functional status at 3 months (odds ratio 0.98, 95% CI 0.96-1.00, p = 0.01). Factors affecting delay included stroke onset within 6 h of ED arrival (605.9 min decrease in delay, 95% CI 407.9-803.9, p < 0.0001), delay to brain imaging (59.4 min increase in delay for each additional hour, 95% CI 48.0-71.4, p < 0.0001), admission from an alternative service (3918.7 min increase in delay, 95% CI 3621.2-4079.9, p < 0.0001), and transfer from a primary stroke center (PSC; 740.2 min increase in delay, 95% CI 456.2-1019.9, p < 0.0001). CONCLUSION Delay to stroke unit admission in a system involving transfer from PSCs to a CSC was associated with longer hospital stay and poorer functional outcomes.
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Filiatreault S, Grimshaw JM, Kreindler SA, Chochinov A, Linton J, Doupe MB. A critical appraisal of delirium clinical practice guidelines relevant to the care of older adults in the emergency department with a synthesis of recommendations: an umbrella review protocol. Syst Rev 2022; 11:262. [PMID: 36464728 PMCID: PMC9720973 DOI: 10.1186/s13643-022-02145-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 11/25/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Up to 35% of older adults present to the emergency department (ED) with delirium or develop the condition during their ED stay. Delirium associated with an ED visit is independently linked to poorer outcomes such as loss of independence, increased length of hospital stay, and mortality. Improving the quality of delirium care for older ED patients is hindered by a lack of knowledge and standards to guide best practice. High-quality clinical practice guidelines (CPGs) have the power to translate the complexity of scientific evidence into recommendations to improve and standardize practice. This study will identify and synthesize recommendations from high-quality delirium CPGs relevant to the care of older ED patients. METHODS We will conduct a multi-phase umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations will be critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II; and Appraisal of Guidelines Research and Evaluation - Recommendations Excellence (AGREE-REX) instruments, respectively. We will also synthesize and conduct a narrative analysis of high-quality CPG recommendations. DISCUSSION This review will be the first known evidence synthesis of delirium CPGs including a critical appraisal and synthesis of recommendations. Recommendations will be categorized according to target population and setting as a means to define the bredth of knowledge in this area. Future research will use consensus building methods to identify which are most relevant to older ED patients. TRIAL REGISTRATION This study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6 .
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Affiliation(s)
- Sarah Filiatreault
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada.
| | - Jeremy M Grimshaw
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, K1H8L6, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, K1H 8M5, Canada
| | - Sara A Kreindler
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Alecs Chochinov
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada.,Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Janice Linton
- Neil John Maclean Health Sciences Library, University of Manitoba, 727 McDermot Ave, Winnipeg, MB, R3E 3P5, Canada
| | - Malcolm B Doupe
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada.,Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
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Immobilität als Grund der Vorstellung in einer Krankenhausnotaufnahme? Notf Rett Med 2022. [DOI: 10.1007/s10049-022-01019-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Zusammenfassung
Hintergrund
Die zunehmende Belastung von Krankenhausnotaufnahmen (KHN) durch wenig dringliche Patienten wirft Fragen nach Fehlsteuerungen bzw. Versorgungsdefiziten in anderen Bereichen auf.
Methode
Retrospektive Datenanalyse einer Zufallsstichprobe aus allen Fällen des Jahres 2019 zweier KHN in einer Metropolregion. Wir untersuchten Patienten, die ambulant versorgt, aber mit einem Krankentransportmittel (KT) wieder aus der Notaufnahme abtransportiert wurden.
Ergebnisse
1500 Patienten (767 [51,1 %] weiblich; Alter 56 ± 22,7 Jahre) aus einer Grundgesamtheit von 80.845 Patienten wurden analysiert. 888 (59,2 %) wurden ambulant versorgt. Jeweils 9 (0,5 %), 193 (12,9 %), 684 (45,6 %), 508 (33,9 %) und 48 (3,2 %) waren den Manchester-Triage-System-Kategorien Rot, Orange, Gelb, Grün bzw. Blau zugeordnet. Von 880 ambulanten Patienten wurden 731 (83,2 %) selbstständig und 149 (16,8 %) mit einem KT entlassen. Über die Hälfte der per KT entlassenen Patienten war mit urologischen Problemen, Extremitätenproblemen und nach Stürzen vorgestellt worden. Die liegend transportierten ambulant versorgten Patienten hatten ein höheres Alter (76,2 ± 16,2 vs. 45,1 ± 20,5 Jahre; p < 0,001), einen höheren Charlson Comorbidity Index (5 [3–6] vs. 0 [0–2]; p < 0,001), erhielten seltener eine CT-Diagnostik und häufiger lediglich eine einfache medizinische Maßnahme ohne diagnostischen Aufwand (24,8 % vs. 4,6 %; p < 0,001). Sie wurden zu einem größeren Anteil mehrfach vorgestellt (28,9 % vs. 8,5 %; p < 0,001). Der Anteil an Heimbewohnern war höher (59,5 % vs. 0 %; p < 0,001).
Schlussfolgerung
Etwa ein Zehntel der insgesamt in den KHN versorgten Patienten blieb ambulant und wurde mit einem KT entlassen. Mehr als die Hälfte wurde aus stationären Pflegeeinrichtungen vorgestellt. Ein Großteil erhielt einfache Leistungen und kaum Diagnostik und hatte eine niedrige Triagedringlichkeit.
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Oliveira J. e Silva L, Stanich JA, Jeffery MM, Lindroth HL, Miller DM, Campbell RL, Rabinstein AA, Pignolo RJ, Bellolio F. Association between emergency department modifiable risk factors and subsequent delirium among hospitalized older adults. Am J Emerg Med 2022; 53:201-207. [DOI: 10.1016/j.ajem.2021.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 10/19/2022] Open
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Saario EL, Mäkinen MT, Jämsen ERK, Nikander P, Castrén MK. Screening of community-dwelling older patients by the emergency medical services: An observational retrospective registry study. Int Emerg Nurs 2021; 59:101078. [PMID: 34571450 DOI: 10.1016/j.ienj.2021.101078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 08/16/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inadequate nutrition, falls, and cognitive impairment are common problems among acutely ill older people and are associated with complicated and prolonged health problems and mortality. OBJECTIVES To assess if the emergency medical services can identify patients with nutritional risk, falls risk, and cognitive impairment by using simple screening tools and to assess the prevalence of risks and rate they are reported to the emergency department. SETTING The study was carried out in Espoo, Finland to patients over the age of 70 requiring non-urgent ambulance transfer to the emergency department. OUTCOME MEASURES A set of validated electronic screening tools was used to identify patients at nutritional risk, risk of falling and having cognitive impairment. MAIN RESULTS A total of 488 (8%) out of 5792 patients were screened. Of the patients 60%, (n = 292) had at least one risk: 17% (n = 81) had nutritional risk, 43% (n = 209) falls risk, and 28% (n = 137) cognitive impairment. Twenty-two (5%) were screened positive in all three categories. The observed risk was reported to the emergency department staff in 59% (n = 173) of the patients. CONCLUSION The emergency medical services can be used in preventive health care to identify patients having nutritional risk, falls risk, or cognitive impairment.
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Affiliation(s)
- Eeva L Saario
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland; Satasairaala, Centre of Emergency Medicine, Satakunta Hospital District, Pori, Finland.
| | - Marja T Mäkinen
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Esa R K Jämsen
- Tampere University Hospital, Centre of Geriatrics and Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland.
| | - Pia Nikander
- Internal Medicine and Rehabilitation, Clinical Nutrition Unit, Helsinki University Hospital, Helsinki, Finland
| | - Maaret K Castrén
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
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de Wit K, Mercuri M, Clayton N, Worster A, Mercier E, Emond M, Varner C, McLeod SL, Eagles D, Stiell I, Barbic D, Morris J, Jeanmonod R, Kagoma Y, Shoamanesh A, Engels PT, Sharma S, Kearon C, Papaioannou A, Parpia S. Which older emergency patients are at risk of intracranial bleeding after a fall? A protocol to derive a clinical decision rule for the emergency department. BMJ Open 2021; 11:e044800. [PMID: 34215600 PMCID: PMC8256748 DOI: 10.1136/bmjopen-2020-044800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Falling on level ground is now the most common cause of traumatic intracranial bleeding worldwide. Older adults frequently present to the emergency department (ED) after falling. It can be challenging for clinicians to determine who requires brain imaging to rule out traumatic intracranial bleeding, and often head injury decision rules do not apply to older adults who fall. The goal of our study is to derive a clinical decision rule, which will identify older adults who present to the ED after a fall who do not have clinically important intracranial bleeding. METHODS AND ANALYSIS This is a prospective cohort study enrolling patients aged 65 years or older, who present to the ED of 11 hospitals in Canada and the USA within 48 hours of having a fall. Patients are included if they fall on level ground, off a chair, toilet seat or out of bed. The primary outcome is the diagnosis of clinically important intracranial bleeding within 42 days of the index ED visit. An independent adjudication committee will determine the primary outcome, blinded to all other data. We are collecting data on 17 potential predictor variables. The treating physician completes a study data form at the time of initial assessment, prior to brain imaging. Data extraction is supplemented by an independent, structured electronic medical record review. We will perform binary recursive partitioning using Classification and Regression Trees to derive a clinical decision rule. ETHICS AND DISSEMINATION The study was initially approved by the Hamilton Integrated Research Ethics Committee and subsequently approved by the research ethics boards governing all participating sites. We will disseminate our results by journal publication, presentation at international meetings and social media. TRIAL REGISTRATION NUMBER NCT03745755.
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Affiliation(s)
- Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mathew Mercuri
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Natasha Clayton
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Emergency Department, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Andrew Worster
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Eric Mercier
- Centre de recherche du CHU de Québec, Université Laval, Québec, Quebec, Canada
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Québec, Québec, Canada
| | - Marcel Emond
- Centre de recherche du CHU de Québec, Université Laval, Québec, Quebec, Canada
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Québec, Québec, Canada
| | - Catherine Varner
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Family and community medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Family and community medicine, University of Toronto, Toronto, Ontario, Canada
| | - Debra Eagles
- Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Heath, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - David Barbic
- Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation Outcome Sciences, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Judy Morris
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Québec, Québec, Canada
| | - Rebecca Jeanmonod
- Emergency Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Yoan Kagoma
- Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Ashkan Shoamanesh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Paul T Engels
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Clive Kearon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Sameer Parpia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Ontario Clinical Oncology Group, McMaster University, Hamilton, Ontario, Canada
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Oliveira J E Silva L, Berning MJ, Stanich JA, Gerberi DJ, Murad MH, Han JH, Bellolio F. Risk Factors for Delirium in Older Adults in the Emergency Department: A Systematic Review and Meta-Analysis. Ann Emerg Med 2021; 78:549-565. [PMID: 34127307 DOI: 10.1016/j.annemergmed.2021.03.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/17/2021] [Accepted: 03/02/2021] [Indexed: 12/19/2022]
Abstract
We conducted a systematic review and meta-analysis to identify risk factors for delirium in geriatric patients in the emergency department and to identify emergency department (ED)-based modifiable risk factors for developing delirium during hospitalization. We searched evidence based medicine reviews, EMBASE, MEDLINE, Scopus, and Web of Science for observational studies from the time of their inception to July 2020. We included studies that evaluated potential risk factors for either prevalent or incident delirium among older adults (age ≥ 60 years) presenting to the ED. When appropriate, we meta-analyzed estimates for risk factors using a random-effects model. The certainty of evidence was evaluated using the grading of recommendations assessment, development and evaluation approach. The study's protocol was registered in PROSPERO (CDR42020175261). A total of 4,513 citations were reviewed, and 34 studies met the criteria for inclusion: 27 evaluating risk factors for ED delirium (13,412 patients) and 7 evaluating ED-based risk factors for developing delirium during hospitalization (2,238 patients). The prevalence of ED delirium ranged from 7% to 35%. Four factors had strong associations with ED delirium and were graded as high-certainty evidence, including nursing home residence (4 studies; odds ratio [OR], 3.45; 95% confidence interval [CI], 2.17 to 5.48), cognitive impairment (7 studies; OR, 4.46; 95% CI, 3.38 to 5.89), hearing impairment (3 studies, OR, 2.57; 95% CI, 1.03 to 6.41), and a history of stroke (3 studies; OR, 3.20; 95% CI, 1.17 to 8.75). The rate of developing delirium during hospitalization ranged from 11% to 27%. A length of stay of more than 10 hours in ED was associated with a higher risk of delirium (1 study; OR, 2.23; 95% CI, 1.13 to 4.41). One study reported that severe pain, rather than the use of opioids, was associated with the development of delirium. These findings can be used to prioritize delirium screening in the ED and develop novel ED delirium risk scores or prevention interventions.
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Affiliation(s)
| | - Michelle J Berning
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN; University of Minnesota Medical School, Minneapolis, MN
| | | | | | - Mohammad Hassan Murad
- Department of Internal Medicine, Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, MN
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN; Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
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van Loveren K, Singla A, Sinvani L, Calandrella C, Perera T, Brave M, Becker L, Li T. Increased Emergency Department Hallway Length of Stay is Associated with Development of Delirium. West J Emerg Med 2021; 22:726-735. [PMID: 34125053 PMCID: PMC8202999 DOI: 10.5811/westjem.2021.1.49320] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 01/14/2021] [Indexed: 12/19/2022] Open
Abstract
Introduction Our study aimed to determine 1) the association between time spent in the emergency department (ED) hallway and the development of delirium and 2) the hospital location of delirium development. Methods This single-center, retrospective chart review included patients 18+ years old admitted to the hospital after presenting, without baseline cognitive impairment, to the ED in 2018. We identified the Delirium group by the following: key words describing delirium; orders for psychotropics, special observation, and restraints; or documented positive Confusion Assessment Method (CAM) screen. The Control group included patients not meeting delirium criteria. We used a multivariable logistic regression model, while adjusting for confounders, to assess the odds of delirium development associated with percentage of ED LOS spent in the hallway. Results A total of 25,156 patients met inclusion criteria with 1920 (7.6%) meeting delirium criteria. Delirium group vs. Control group patients spent a greater percentage of time in the ED hallway (median 50.5% vs 10.8%, P<0.001); had longer ED LOS (median 11.94 vs 8.12 hours, P<0.001); had more ED room transfers (median 5 vs 4, P<0.001); and had longer hospital LOS (median 5.0 vs 4.6 days, P<0.001). Patients more frequently developed delirium in the ED (77.5%) than on inpatient units (22.5%). The relative odds of a patient developing delirium increased by 3.31 times for each percent increase in ED hallway time (95% confidence interval, 2.85, 3.83). Conclusion Patients with delirium had more ED hallway exposure, longer ED LOS, and more ED room transfers. Understanding delirium in the ED has substantial implications for improving patient safety.
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Affiliation(s)
- Kate van Loveren
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
| | - Arnav Singla
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
| | - Liron Sinvani
- Center for Health Innovations and Outcomes Research, Feinstein Institutes of Medical Research, Northwell Health, Manhasset, New York.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Medicine, Division of Hospital Medicine, Manhasset, New York
| | - Christopher Calandrella
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Emergency Medicine, Manhasset, New York
| | - Thomas Perera
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Emergency Medicine, Manhasset, New York
| | - Martina Brave
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
| | - Lance Becker
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Emergency Medicine, Manhasset, New York
| | - Timmy Li
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Emergency Medicine, Manhasset, New York
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15
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Lee S, Angel C, Han JH. Succinct Approach to Delirium in the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2021; 9:11-18. [PMID: 33758677 PMCID: PMC7971395 DOI: 10.1007/s40138-021-00226-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 11/25/2022]
Abstract
Purpose of Review This study aims to provide a concise delirium review for practicing emergency medicine providers using the Assess, Diagnose, Evaluate, Prevent, and Treat (ADEPT) framework. Recent Findings Delirium is a form of acute brain dysfunction that results in significant mortality and morbidity for older emergency department (ED) patients. Delirium is frequently missed by healthcare providers, but monitoring for this syndrome using brief delirium assessments may improve recognition. Once delirium is diagnosed, emergency medicine providers' primary goal is to perform a comprehensive history and physical examination to uncover the underlying etiology for delirium. This includes obtaining history from a collateral historian and obtaining an accurate medication history. If posssible, emergency physicians (EPs) should treat the medical etiology that precipitated the delirium. If agitated, non-pharmacologic interventions such that minimize the use of tethers are preferred. Pharmacologic agents such as antipsychotic medications should be used as a last resort. Summary Delirium is a common geriatric emergency and requires the EP to assess, diagnose, evaluate, prevent, and treat. Delirium is a key geriatric syndrome that geriatric ED providers should routinely screen for. A strong emphasis is on the widespread use of delirium screening, followed by prevention and treatment efforts.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA USA
| | - Clay Angel
- Department of Hospital Medicine, Kaiser Permanente San Jose Medical Center, San Jose, CA USA
| | - Jin H. Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN USA
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN USA
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16
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Predictors of delirium in older patients at the emergency department: a prospective multicentre derivation study. CAN J EMERG MED 2021; 23:330-336. [PMID: 33959922 DOI: 10.1007/s43678-020-00004-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/14/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The objective of this study was to identify the predictors of incident delirium in this high-risk population. METHODS This study was a planned sub-analysis of the INDEED multicentre cohort study. We recruited patients aged ≥ 65, independent/semi-independent, with an emergency department (ED) length of stay ≥ 8 h and admitted to any hospital ward. Patients were followed up during their ED stay up to 24 h after ward admission. Sociodemographic characteristics, comorbidities, functional status (OARS), illness severity, level of frailty, cognitive status (TICS-m) and ED/patient environment evaluation were collected during initial interview. Patients were screened for delirium twice a day using the Confusion Assessment Method. Multivariate logistic regression was performed to identify the predictors of delirium. RESULTS Incident delirium was detected in 68 patients of the 612 patients included (11%). Initially, seven candidate predictors were included in a regression model, of which four were retained using a stepwise selection procedure. Presence of cognitive impairment at baseline (OR 3.6, p < 0.001), absence of mobilization during the whole ED length of stay (OR 3.3, p = 0.002), longer ED length of stay (OR 1.02, p = 0.006) were associated with a higher risk of incident delirium while higher functional status was associated with a lower risk (OR 0.8, p < 0.001). CONCLUSION More work is needed to determine which tool(s) are most appropriate for the ED use to increase delirium screening compliance among health professionals working in this department. It is really the first step to be able to suggest interventions to decrease delirium incidence.
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17
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Jones A, Bronskill SE, Schumacher C, Seow H, Feeny D, Costa AP. Effect of Access to After-Hours Primary Care on the Association Between Home Nursing Visits and Same-Day Emergency Department Use. Ann Fam Med 2020; 18:406-412. [PMID: 32928756 PMCID: PMC7489957 DOI: 10.1370/afm.2571] [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: 09/25/2019] [Revised: 01/29/2020] [Accepted: 02/05/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Previous work has demonstrated that home care patients have an increased risk of visiting the emergency department after a home nursing visit on the same day. We investigated whether this association is modified by greater access to after-hours primary care. METHODS We conducted a population-based case-crossover study of home care patients in Ontario, Canada in 2014-2016. Emergency department visits after 5:00 pm were selected as case periods and matched, within the same patient, to control periods within the previous week. The association between home nursing visits and same-day emergency department visits was estimated with conditional logistic regression. Access to after-hours primary care, measured on the patient and practice level, was tested for effect modification using an interaction term approach. Analysis was performed separately for all emergency department visits and a less urgent subset not admitted to hospital. RESULTS A total of 11,840 patients contributed cases to the analysis. Patients with a history of after-hours primary care use had a smaller increased risk of a same-day after-hours emergency department visit (OR = 1.18; 95% CI, 1.06-1.30) compared with patients with no after-hours care (OR = 1.31; 95% CI, 1.25-1.39). The modifying effect was stronger among emergency department visits not admitted to hospital (OR = 1.11; 95% CI, 0.97-1.28 vs OR = 1.41; 95% CI, 1.31-1.51). CONCLUSION Greater access to after-hours primary care reduced the risk of less-urgent emergency department use associated with home nursing visits. These findings suggest increasing access to after-hours primary care could prevent some less-urgent emergency department visits.
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Affiliation(s)
- Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Susan E Bronskill
- ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto
| | - Connie Schumacher
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Hsien Seow
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - David Feeny
- Department of Economics, McMaster University, Hamilton, Ontario, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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18
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Daoust R, Paquet J, Boucher V, Pelletier M, Gouin É, Émond M. Relationship Between Pain, Opioid Treatment, and Delirium in Older Emergency Department Patients. Acad Emerg Med 2020; 27:708-716. [PMID: 32441414 DOI: 10.1111/acem.14033] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/12/2020] [Accepted: 05/18/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Emergency department (ED) stay and its associated conditions (immobility, inadequate hydration and nutrition, lack of stimulation) increase the risk of delirium in older patients. Poorly controlled pain and paradoxically opioid pain treatment have also been identified as triggers for delirium. The aim of this study was to assess the relationship between pain, opioid treatment, and delirium in older ED patients. METHODS A multicenter prospective cohort study was conducted in four hospitals across the province of Québec (Canada). Patients aged ≥ 65 years old, waiting for hospital admission between March and July 2015, who were nondelirious upon ED arrival, who were independent or semi-independent in their daily living activities, and who had an ED stay of at least 8 hours were included. Delirium assessments were conducted twice a day during the patient's entire ED stay and their first 24 hours on the hospital ward using the Confusion Assessment Method. Pain intensity was evaluated using a visual analog scale (VAS = 0-100) during the initial interview, and all opioid treatments were documented. RESULTS A total of 338 patients were included; 51% were female, and mean (±SD) age was 77 (±8) years. Forty-one patients (12%) experienced delirium during their hospital stay occurring within a mean (±SD) delay of 47 (±19) hours after ED admission. Among patients with pain intensity ≥ 65 from VAS (0-100), 26% experienced delirium compared to 11% for patients with pain < 65 (p < 0.01), and no significant association was found between opioid consumption and delirium (p = 0.31). Logistic regression controlling for confounding factors showed that patients with pain intensity ≥ 65 are 3.3 (95% confidence interval = 1.4 to 7.9) times more likely to develop delirium than patients who had pain intensity of <65. CONCLUSIONS Severe pain, not opioids, is associated with the development of delirium during ED stay. Adequate pain control during the hospital stay may contribute to a decrease in delirium episodes.
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Affiliation(s)
- Raoul Daoust
- From the Centre d’Étude en Médecine d’Urgence Hôpital du Sacré‐Cœur de Montréal Montréal Québec Canada
- the Faculté de Médecine Département Médecine Familiale et Médecine d’Urgence Université de Montréal Montréal Québec Canada
| | - Jean Paquet
- the Faculté de Médecine Département Médecine Familiale et Médecine d’Urgence Université de Montréal Montréal Québec Canada
| | - Valérie Boucher
- CHU de Québec–Université Laval Québec Québec Canada
- the Centre d’Excellence du Vieillissement de Québec Québec Québec Canada
| | - Mathieu Pelletier
- the Faculté de Médecine Université Laval Québec Québec Canada
- the Centre Intégré de Santé et de Services Sociaux de Lanaudière Joliette Québec Canada
| | - Émilie Gouin
- and the Centre Hospitalier Régional de Trois‐Rivières Trois‐Rivières Québec Canada
| | - Marcel Émond
- CHU de Québec–Université Laval Québec Québec Canada
- the Centre d’Excellence du Vieillissement de Québec Québec Québec Canada
- the Faculté de Médecine Université Laval Québec Québec Canada
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Sunner C, Giles MT, Parker V, Dilworth S, Bantawa K, Kable A, Oldmeadow C, Foureur M. PACE-IT study protocol: a stepped wedge cluster randomised controlled trial evaluating the implementation of telehealth visual assessment in emergency care for people living in residential aged-care facilities. BMC Health Serv Res 2020; 20:672. [PMID: 32690008 PMCID: PMC7372753 DOI: 10.1186/s12913-020-05539-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022] Open
Abstract
Background Transfer of residential aged-care facility (RACF) residents to Emergency Departments (ED) is common, risky and expensive. RACF residents who present to ED are more likely to have hospital readmissions, longer stays and face major risks related to hospital acquired complications. Aged Care Emergency services (ACE) is a nurse led, protocol- guided, telephone RACF/ED outreach model that has been shown to be effective in reducing hospitalisation and length of hospital stay for RACF residents in the Hunter New England Local Health District, New South Wales (NSW). The Partnerships in Aged-Care Emergency services using Interactive Telehealth (PACE-IT) project enhances ACE by incorporating interactive video assessment and consultation. The PACE-IT project’s primary aim is to assess whether augmentation of ACE services through the addition of protocol-guided interactive Visual Telehealth Consultation (VTC) for clinical decision-making, plus telephone follow-up, reduces RACF resident transfers to ED. Methods A stepped-wedge cluster randomised controlled trial will be conducted. The intervention will be delivered sequentially to 8 clusters; each cluster comprises one ED and two RACFs in NSW, Australia. The 16 RACFs in the study will be selected for order of implementation using a computer-generated randomisation sequence. A 2-step randomisation process will be undertaken, randomising the hospital EDs first and then randomising the RACFs aligned with each hospital. The PACE-IT intervention comprises: an initial phone call by RACFs to the ACE service in the ED; the ACE service in ED responds with a protocol-guided VTC, a management plan agreed between all participants; an automated consultation summary letter to the General Practitioner and the RACF; a post VTC 24 h follow-up phone call to the RACF. Discussion If shown to be effective, the intervention has the potential to improve the clinical care and quality of life for residents. Findings will provide high level evidence that will inform sustainable change and broad translation into practice across NSW. It will show how the change has been achieved and highlight success factors for scalability and sustainability. It will inform review of processes, the development of policy and guidelines that will integrate PACE-IT into existing service models in NSW. Trial registration The trial is registered with the Australian New Zealand Clinical Trials Registry (Trial ID ACTR N12619001692123) 02/12/2020.)
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Affiliation(s)
- Carla Sunner
- Hunter New England Nursing and Midwifery Research Centre, James Fletcher Campus, 72 Watt Street, Newcastle, NSW, 2300, Australia. .,School of Nursing and Midwifery, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - Michelle Therese Giles
- Hunter New England Nursing and Midwifery Research Centre, James Fletcher Campus, 72 Watt Street, Newcastle, NSW, 2300, Australia.,School of Nursing and Midwifery, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Vicki Parker
- Hunter New England Nursing and Midwifery Research Centre, James Fletcher Campus, 72 Watt Street, Newcastle, NSW, 2300, Australia.,University of New England, Madgwick Drive, Armidale, NSW, 2351, Australia
| | - Sophie Dilworth
- Dementia Advisory Service Community Aged Care Services, Hunter New England Local Health District, Locked Bay 119, Wallsend, NSW, 2287, Australia
| | - Kamana Bantawa
- Hunter New England Nursing and Midwifery Research Centre, James Fletcher Campus, 72 Watt Street, Newcastle, NSW, 2300, Australia
| | - Ashley Kable
- School of Nursing and Midwifery, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Chris Oldmeadow
- Hunter Medical Research Institute, Locked Bag 1000, Kookaburra Circuit, New Lambton, NSW, 2305, Australia
| | - Maralyn Foureur
- Hunter New England Nursing and Midwifery Research Centre, James Fletcher Campus, 72 Watt Street, Newcastle, NSW, 2300, Australia.,School of Nursing and Midwifery, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
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20
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Jones A, Bronskill SE, Seow H, Feeny D, Lapointe-Shaw L, Mowbray F, Costa AP. Physician Home Visit Patterns and Hospital Use Among Older Adults with Functional Impairments. J Am Geriatr Soc 2020; 68:2074-2081. [PMID: 32579727 DOI: 10.1111/jgs.16639] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/07/2020] [Accepted: 05/09/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Home-based primary care has been associated with reductions in hospital use among homebound older adults, but population-based studies on the general home visit patterns of primary care physicians are lacking. OBJECTIVE We examined the association between the provision of home visits by primary care physicians and subsequent use of hospital-based care among their older adult patients with extensive functional impairments. DESIGN Population-based retrospective cohort study. SETTING The setting was Ontario, Canada, from October 2014 to September 2016. PARTICIPANTS Older adults (aged ≥65 years) with extensive functional impairments receiving publicly funded home care. MEASUREMENTS We measured the provision of home visits by a patient's most responsible primary care physician during the year before a comprehensive home care assessment. Physician home visit patterns were measured as the proportion of the total outpatient visits in a year that were home visits, categorized with quartiles. Multivariable, multilevel negative binomial regression models examined the associations between physician-level home visit provision and patient emergency department visits and hospital admissions over the 6 months following the home care assessment. RESULTS There were 49,613 patients in the cohort who were linked to 8,096 unique primary care physicians. A total of 69.1% of physicians provided at least one home visit in a year, with the median proportion of home visits to total visits ranging from 0.057% to 3.19% across quartiles. Patients whose physicians were in the highest home visit provision quartile had lower rates of emergency department visits (incidence rate ratio [IRR] = 0.93; 95% confidence interval [CI] = 0.90-0.96) and hospital admissions (IRR = 0.89; 95% CI = 0.85-0.93) compared with patients whose physician did not do home visits. CONCLUSION Home care patients with extensive functional impairments whose physicians provided higher levels of home visits had fewer emergency department visits and hospital admissions. Expanding home visits by primary care physicians could reduce hospital use by older adults living with functional impairments in the community.
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Affiliation(s)
- Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Susan E Bronskill
- ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Hsien Seow
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - David Feeny
- Department of Economics, McMaster University, Hamilton, Ontario, Canada
| | - Lauren Lapointe-Shaw
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,University Health Network, Toronto, Ontario, Canada
| | - Fabrice Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Jones A, Bronskill SE, Seow H, Junek M, Feeny D, Costa AP. Associations between continuity of primary and specialty physician care and use of hospital-based care among community-dwelling older adults with complex care needs. PLoS One 2020; 15:e0234205. [PMID: 32559214 PMCID: PMC7304563 DOI: 10.1371/journal.pone.0234205] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 05/20/2020] [Indexed: 12/21/2022] Open
Abstract
Objective While research suggests that higher continuity of primary and specialty physician care can improve patient outcomes, their effects have rarely been examined and compared concurrently. We investigated associations between continuity of primary and specialty physician care and emergency department visits and hospital admissions among community-dwelling older adults with complex care needs. Methods We conducted a retrospective cohort study of home care patients in Ontario, Canada, from October 2014 to September 2016. We measured continuity of primary and specialty physician care over the two years prior to a home care assessment and categorized them into low, medium, and high groups using terciles of the distribution. We used Cox regression models to concurrently test the associations between continuity of primary and specialty care and risk of an emergency department visit and hospital admission within six months of assessment, controlling for potential confounders. We examined interactions between continuity of care and count of chronic conditions, count of physician specialties seen, functional impairment, and cognitive impairment. Results Of 178,686 participants, 49% had an emergency department visit during follow-up and 27% had a hospital admission. High vs. low continuity of primary care was associated with a reduced risk of an emergency department visit (HR = 0.90 (0.89–0.92)) as was continuity of specialty care (HR = 0.93 (0.91–0.95)). High vs. low continuity of primary care was associated also with a reduced risk of a hospital admission (HR = 0.94 (0.92–0.96)) as was continuity of specialty care (HR = 0.92 (0.90–0.94)). The effect of continuity of specialty care was moderately stronger among patients who saw four or more physician specialties. Conclusion Higher continuity of primary physician and specialty physician care had independent, protective effects of similar magnitude against emergency department use and hospital admissions. Improving continuity of specialty care should be a priority alongside improving continuity of primary care in complex, older adult populations with significant specialist use.
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Affiliation(s)
- Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- * E-mail:
| | - Susan E. Bronskill
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Hsien Seow
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Mats Junek
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - David Feeny
- Department of Economics, McMaster University, Hamilton, Ontario, Canada
| | - Andrew P. Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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22
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Mowbray F, Zargoush M, Jones A, de Wit K, Costa A. Predicting hospital admission for older emergency department patients: Insights from machine learning. Int J Med Inform 2020; 140:104163. [PMID: 32474393 DOI: 10.1016/j.ijmedinf.2020.104163] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/26/2020] [Accepted: 04/28/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Emergency departments (ED) are a portal of entry into the hospital and are uniquely positioned to influence the health care trajectories of older adults seeking medical attention. Older adults present to the ED with distinct needs and complex medical histories, which can make disposition planning more challenging. Machine learning (ML) approaches have been previously used to inform decision-making surrounding ED disposition in the general population. However, little is known about the performance and utility of ML methods in predicting hospital admission among older ED patients. We applied a series of ML algorithms to predict ED admission in older adults and discuss their clinical and policy implications. MATERIALS AND METHODS We analyzed the Canadian data from the interRAI multinational ED study, the largest prospective cohort study of older ED patients to date. The data included 2274 ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Data were extracted from the interRAI ED Contact Assessment, with predictors including a series of geriatric syndromes, functional assessments, and baseline care needs. We applied a total of five ML algorithms. Models were trained, assessed, and analyzed using 10-fold cross-validation. The performance of predictive models was measured using the area under the receiver operating characteristic curve (AUC). We also report the accuracy, sensitivity, and specificity of each model to supplement performance interpretation. RESULTS Gradient boosted trees was the most accurate model to predict older ED patients who would require hospitalization (AUC = 0.80). The five most informative features include home intravenous therapy, time of ED presentation, a requirement for formal support services, independence in walking, and the presence of an unstable medical condition. CONCLUSION To the best of our knowledge, this is the first study to predict hospital admission in older ED patients using a series of geriatric syndromes and functional assessments. We were able to predict hospital admission in older ED patients with good accuracy using the items available in the interRAI ED Contact Assessment. This information can be used to inform decision-making about ED disposition and may expedite admission processes and proactive discharge planning.
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Affiliation(s)
- Fabrice Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Big Data and Geriatric Models of Care (BDG) Cluster, McMaster University, Hamilton, Ontario, Canada
| | - Manaf Zargoush
- Health Policy and Management, DeGroote School of Business, McMaster University, Hamilton, Ontario, Canada.
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Big Data and Geriatric Models of Care (BDG) Cluster, McMaster University, Hamilton, Ontario, Canada
| | - Kerstin de Wit
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Big Data and Geriatric Models of Care (BDG) Cluster, McMaster University, Hamilton, Ontario, Canada
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23
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O'Brien T, Mitra B, Le Sage N, Tardif PA, Emond M, D'Astous M, Mercier E. Clinically significant traumatic intracranial hemorrhage following minor head trauma in older adults: a retrospective cohort study. Brain Inj 2020; 34:834-839. [PMID: 32286890 DOI: 10.1080/02699052.2020.1753242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The primary objective of this study was to determine the incidence of clinically significant traumatic intracranial hemorrhage (T-ICH) following minor head trauma in older adults. Secondary objective was to investigate the impact of anticoagulant and antiplatelet therapies on T-ICH incidence. METHODS This retrospective cohort study extracted data from electronic patient records. The cohort consisted of patients presenting after a fall and/or head injury and presented to one of five ED between 1st March 2010 and 31st July 2017. Inclusion criteria were age ≥ 65 years old and a minor head trauma defined as an impact to the head without fulfilling criteria for traumatic brain injury. RESULTS From the 1,000 electronic medical records evaluated, 311 cases were included. The mean age was 80.1 (SD 7.9) years. One hundred and eighty-nine (189) patients (60.8%) were on an anticoagulant (n = 69), antiplatelet (n = 130) or both (n = 16). Twenty patients (6.4%) developed a clinically significant T-ICH. Anticoagulation and/or antiplatelets therapies were not associated with an increased risk of clinically significant T-ICH in this cohort (Odds ratio (OR) 2.7, 95% CI 0.9-8.3). CONCLUSIONS In this cohort of older adults presenting to the ED following minor head trauma, the incidence of clinically significant T-ICH was 6.4%.
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Affiliation(s)
- Toby O'Brien
- Axe Santé Des Populations Et Pratiques Optimales En Santé, Unité De Recherche En Traumatologie - Urgence - Soins Intensifs, Centre De Recherche Du CHU De Québec, Université Laval , Québec, Canada.,National Trauma Research Institute, Alfred Hospital , Melbourne, Australia
| | - Biswadev Mitra
- National Trauma Research Institute, Alfred Hospital , Melbourne, Australia.,Canada Département De Médecine Familiale Et Médecine d'Urgence, Faculté De Médecine, Université Laval , Québec, Canada
| | - Natalie Le Sage
- Axe Santé Des Populations Et Pratiques Optimales En Santé, Unité De Recherche En Traumatologie - Urgence - Soins Intensifs, Centre De Recherche Du CHU De Québec, Université Laval , Québec, Canada.,School of Public Health and Preventive Medicine, Monash University , Melbourne, Australia
| | - Pier-Alexandre Tardif
- Axe Santé Des Populations Et Pratiques Optimales En Santé, Unité De Recherche En Traumatologie - Urgence - Soins Intensifs, Centre De Recherche Du CHU De Québec, Université Laval , Québec, Canada
| | - Marcel Emond
- Axe Santé Des Populations Et Pratiques Optimales En Santé, Unité De Recherche En Traumatologie - Urgence - Soins Intensifs, Centre De Recherche Du CHU De Québec, Université Laval , Québec, Canada.,School of Public Health and Preventive Medicine, Monash University , Melbourne, Australia.,Centre De Recherche Sur Les Soins Et Les Services De Première Ligne De l'Université Laval , Quebec, Canada
| | - Myreille D'Astous
- Service of Neurosurgery, Department of Surgery, CHU De Québec, Université Laval , Québec, Canada
| | - Eric Mercier
- Axe Santé Des Populations Et Pratiques Optimales En Santé, Unité De Recherche En Traumatologie - Urgence - Soins Intensifs, Centre De Recherche Du CHU De Québec, Université Laval , Québec, Canada.,School of Public Health and Preventive Medicine, Monash University , Melbourne, Australia.,Centre De Recherche Sur Les Soins Et Les Services De Première Ligne De l'Université Laval , Quebec, Canada
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24
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Lisk R, Yeong K, Enwere P, Jenkinson J, Robin J, Irvin-Sellers M, Fluck D, Osmani A, Sharmin R, Sharma P, Fry CH, Han TS. Associations of 4AT with mobility, length of stay and mortality in hospital and discharge destination among patients admitted with hip fractures. Age Ageing 2020; 49:411-417. [PMID: 31813951 DOI: 10.1093/ageing/afz161] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/07/2019] [Accepted: 11/18/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND the 4AT (Alertness, Abbreviated Mental Test-4, Attention and Acute change or fluctuating course), a tool to screen cognitive impairment and delirium, has recently been recommended by the Scottish Intercollegiate Guidelines Network. We examined its ability to predict health outcomes among patients admitted with hip fractures to a single hospital between January 2018 and June 2019. METHODS the 4AT was performed within 1 day after hip surgery. A 4AT score of 0 means unlikely delirium or severe cognitive impairment (reference group); a score of 1-3 suggests possible chronic cognitive impairment, without excluding possibility of delirium; a score ≥ 4 suggests delirium with or without chronic cognitive impairment. Logistic regression, adjusted for: age; sex; nutritional status; co-morbidities; polypharmacy; and anticholinergic burden, used the 4AT to predict mobility, length of stay (LOS), mortality and discharge destination, compared with the reference group. RESULTS from 537 (392 women, 145 men: mean = 83.7 ± standard deviation [SD] = 8.8 years) consecutive patients, 522 completed the 4AT; 132 (25%) had prolonged LOS (>2 weeks) and 36 (6.8%) died in hospital. Risk of failure to mobilise within 1 day of surgery was increased with a 4AT score ≥ 4 (OR = 2.4, 95% confidence interval [CI] = 1.3-4.3). Prolonged LOS was increased with 4AT scores of 1-3 (OR = 2.4, 95%CI = 1.4-4.1) or ≥4 (OR = 3.1, 95%CI = 1.9-6.7). In-patient mortality was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.2-8.2) but not with a 4AT score of 1-3. Change of residence on discharge was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.4-6.8). These associations persisted after excluding patients with dementia. 4AT score = 1-3 and ≥ 4 associated with increased LOS by 3 and 6 days, respectively. CONCLUSIONS for older adults with hip fracture, the 4AT independently predicts immobility, prolonged LOS, death in hospital and change in residence on discharge.
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Affiliation(s)
- Radcliffe Lisk
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Keefai Yeong
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Peter Enwere
- Dementia Service, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | | | - Jonathan Robin
- Department of Acute Medicine, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Melanie Irvin-Sellers
- Department of Respiratory Medicine, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - David Fluck
- Department of Cardiology, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Ahmad Osmani
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Rifat Sharmin
- Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Surrey KT16 0PZ, UK
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway, University of London, Surrey TW20 0EX, UK
- Department of Clinical Neuroscience, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Christopher H Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol BS8 1TD, UK
| | - Thang S Han
- Institute of Cardiovascular Research, Royal Holloway, University of London, Surrey TW20 0EX, UK
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25
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Recognition, prevention, and treatment of delirium in emergency department: An evidence-based narrative review. Am J Emerg Med 2020; 38:349-357. [DOI: 10.1016/j.ajem.2019.158454] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 12/19/2022] Open
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26
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Incidence of intracranial bleeding in seniors presenting to the emergency department after a fall: A systematic review. Injury 2020; 51:157-163. [PMID: 31901331 DOI: 10.1016/j.injury.2019.12.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 12/24/2019] [Accepted: 12/26/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Seniors who fall are an increasing proportion of the patients who are treated in emergency departments (ED). Falling on level-ground is the most common cause of traumatic intracranial bleeding. We aimed to determine the incidence of intracranial bleeding among all senior patients who present to ED after a fall. METHOD We performed a systematic review. Medline, EMBASE, Cochrane, and Database of Abstracts of Reviews of Effects databases, Google Scholar, bibliographies and conference abstracts were searched for articles relevant to senior ED patients who presented after a ground-level fall. Studies were included if they reported on patients aged 65 or older who had fallen. At least 80% of the population had to have suffered a ground-level fall. There were no language restrictions. We performed a meta-analysis (using the random effects model) to report the pooled incidence of intracranial bleeding within 6 weeks of the fall. RESULTS We identified eleven studies (including 11,102 patients) addressing this clinical question. Only three studies were prospective in design. The studies varied in their inclusion criteria, with two requiring evidence of head injury and four requiring the emergency physician to have ordered a head computed tomography (CT). One study excluded patients on therapeutic anticoagulation. Overall, there was a high risk of bias for eight out of eleven studies. The pooled incidence of intracranial bleeding was 5.2% (95% CI 3.2-8.2%). A sensitivity analysis excluding studies with a high risk of bias gave a pooled estimate of 5.1% (95% CI 3.6-7.2%). CONCLUSION We found a lack of high-quality evidence on senior ED patients who have fallen. The available literature suggests there is around a 5% incidence of intracranial bleeding in seniors who present to the ED after a fall.
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27
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Yadav K, Boucher V, Carmichael PH, Voyer P, Eagles D, Pelletier M, Gouin É, Daoust R, Vu TTM, Berthelot S, Émond M. Serial Ottawa 3DY assessments to detect delirium in older emergency department community dwellers. Age Ageing 2019; 49:130-134. [PMID: 31755527 DOI: 10.1093/ageing/afz144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/11/2019] [Accepted: 10/07/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND delirium is associated with increased morbidity and mortality among older emergency department (ED) patients. When using physician gestalt, delirium is missed in the majority of patients. The Ottawa 3DY (O3DY) has been validated to detect cognitive dysfunction among older ED patients. OBJECTIVES to determine the sensitivity and specificity of serial O3DY assessments to detect delirium in older ED patients. DESIGN a prospective observational multicenter cohort study. SETTING four Quebec EDs. PARTICIPANTS independent or semi-independent older patients (age ≥ 65 years) with an ED stay of at least 8 hours that required hospitalisation. MEASUREMENTS eligible patients were evaluated using serial O3DY assessments at least 6 hours apart. The primary outcome was delirium after at least 8 hours in the ED. The reference standard for delirium assessment was the confusion assessment method (CAM). The sensitivity and specificity of the serial O3DY to detect delirium were calculated. RESULTS we enrolled 301 patients (mean age 77 years, 49.5% male, 3.0% with a history of mild dementia). Thirty patients (10.0%) were CAM positive for delirium. Patients had a median of three O3DY assessments. Serial O3DY evaluations to detect delirium among patients with at least one abnormal O3DY had a sensitivity of 86.7% (95% confidence interval-CI 69.3-96.2%) and a specificity of 44.3% (95%; CI 38.3-50.4%). CONCLUSION serial O3DY testing demonstrates good sensitivity as a screening tool to detect delirium among older adult patients with prolonged ED lengths of stay. Emergency physicians should consider the use of the serial O3DY over clinician gestalt to improve delirium detection.
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Affiliation(s)
| | - Valérie Boucher
- Centre de recherche sur les soins et les services de première ligne de l’Université Laval, Québec, Canada
- Centre d'excellence sur le vieillissement de Québec, Québec, Canada
- Faculté de Médecine, Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
| | | | - Philippe Voyer
- Centre de recherche sur les soins et les services de première ligne de l’Université Laval, Québec, Canada
- Centre d'excellence sur le vieillissement de Québec, Québec, Canada
- Faculté des sciences infirmières, Université Laval, Québec, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Mathieu Pelletier
- Centre Intégré de Santé et de Services Sociaux de Lanaudière, Joliette, Canada
| | - Émilie Gouin
- Centre Hospitalier Régional de Trois-Rivières, Trois-Rivières, Canada
- CIUSSS, Trois-Rivières, Canada
| | - Raoul Daoust
- Centre de recherche de l’Hôpital du Sacré-Cœur de Montréal, Montréal, Canada
- Faculté de Médicine, Université de Montréal, Montréal, Canada
- Département Médecine d’Urgence, Hôpital Sacré-Cœur de Montréal, Montreal, Canada
| | - Thien Tuong Minh Vu
- Faculté de Médicine, Université de Montréal, Montréal, Canada
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montréal, Canada
| | - Simon Berthelot
- Faculté de Médecine, Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Département de Médicine d’Urgence, CHU de Québec-Université Laval, Québec, Canada
| | - Marcel Émond
- Centre de recherche sur les soins et les services de première ligne de l’Université Laval, Québec, Canada
- Centre d'excellence sur le vieillissement de Québec, Québec, Canada
- Faculté de Médecine, Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Département de Médicine d’Urgence, CHU de Québec-Université Laval, Québec, Canada
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Hughes JA, Brown NJ, Chiu J, Allwood B, Chu K. The relationship between time to analgesic administration and emergency department length of stay: A retrospective review. J Adv Nurs 2019; 76:183-190. [DOI: 10.1111/jan.14216] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/25/2019] [Accepted: 09/17/2019] [Indexed: 11/29/2022]
Affiliation(s)
- James A. Hughes
- Emergency and Trauma Centre Royal Brisbane and Women's Hospital Brisbane Qld. Australia
- School of Nursing Queensland University of Technology Brisbane Qld. Australia
| | - Nathan J. Brown
- Emergency and Trauma Centre Royal Brisbane and Women's Hospital Brisbane Qld. Australia
- Faculty of Medicine University of Queensland Brisbane Qld. Australia
| | - Jacqui Chiu
- Faculty of Medicine University of Queensland Brisbane Qld. Australia
| | - Brandon Allwood
- Emergency and Trauma Centre Royal Brisbane and Women's Hospital Brisbane Qld. Australia
| | - Kevin Chu
- Emergency and Trauma Centre Royal Brisbane and Women's Hospital Brisbane Qld. Australia
- Faculty of Medicine University of Queensland Brisbane Qld. Australia
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Pérez-Ros P, Martínez-Arnau FM. Delirium Assessment in Older People in Emergency Departments. A Literature Review. Diseases 2019; 7:E14. [PMID: 30704024 PMCID: PMC6473718 DOI: 10.3390/diseases7010014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/27/2019] [Accepted: 01/28/2019] [Indexed: 12/21/2022] Open
Abstract
Delirium is a neuropsychiatric syndrome often manifesting in acute disease conditions, and with a greater prevalence in the older generation. Delirium in the Emergency Department (ED) is a highly prevalent problem that typically goes unnoticed by healthcare providers. The onset of a delirium episode in the ED is associated with an increase in morbidity and mortality. Because delirium is a preventable syndrome, these statistics are unacceptable. Emergency Department staff therefore should strive to perform systematic screening in order to detect delirium. Different tools have been developed for the assessment of delirium by healthcare professionals other than psychiatrists or geriatricians. Emergency Departments require delirium assessment scales of high sensitivity and specificity, suited to the characteristics of the Department, since the time available is scarce. In addition, the presence of dementia in the assessment of delirium may induce sensitivity bias. Despite the existence of numerous delirium rating scales, scales taking less than three minutes to complete are recommended. The choice of the tool depends on the characteristics of the ED. The only scale affording high sensitivity and specificity in older people with and without dementia is the Four "A"s Test (4AT); it requires no training on the part of the rater, and can be performed in under two minutes.
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Affiliation(s)
- Pilar Pérez-Ros
- School of Nursing, Universidad Católica de Valencia San Vicente Mártir, Calle Espartero, 7, 46007 València, Spain.
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Ringer T, Dougherty M, McQuown C, Melady D, Ouchi K, Southerland LT, Hogan TM. White Paper-Geriatric Emergency Medicine Education: Current State, Challenges, and Recommendations to Enhance the Emergency Care of Older Adults. AEM EDUCATION AND TRAINING 2018; 2:S5-S16. [PMID: 30607374 PMCID: PMC6304282 DOI: 10.1002/aet2.10205] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 10/02/2018] [Indexed: 05/21/2023]
Abstract
Older adults account for 25% of all emergency department (ED) patient encounters. One in five Americans will be 65 or older by 2030. In response to this need, geriatric emergency medicine (GEM) has developed into a robust area of academic and clinical interest, with extensive evidence-based research and guidelines, including clear undergraduate and postgraduate GEM competencies. Despite these developments, GEM content remains underrepresented in curricula and licensing examinations. The complex reasons for these deficits include a perception that care of older adults is not a core emergency medicine (EM) competency, a disjunction between traditional definitions of expertise and the GEM perspective, and lack of curricular capacity. This White Paper, prepared on behalf of the Academy of Geriatric Emergency Medicine, describes the state of GEM education, identifies the challenges it faces, and reviews innovations, including research presented at the 2018 Society for Academic Emergency Medicine (SAEM) Annual Scientific Meeting. The authors propose a number of recommendations. These include recognizing GEM as a core educational priority in EM, enhancing academic support for GEM clinician-educators, using social learning and practical problem solving to teach GEM concepts, emphasizing a whole-person multisystem approach to care of older adults, and identifying ageist attitudes as a hurdle to safe and effective GEM care.
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Affiliation(s)
- Thom Ringer
- Mount Sinai Academic Family Health TeamTorontoOntarioCanada
| | | | - Colleen McQuown
- Northeast Ohio Medical UniversityRootstownOH
- Academic & Community Emergency SpecialistsLLCUniontownOH
| | - Don Melady
- Schwarz/Reisman Emergency Medicine InstituteDepartment of Family and Community MedicineSinai Health SystemUniversity of TorontoTorontoOntarioCanada
| | - Kei Ouchi
- Brigham and Women's HospitalHarvard Medical SchoolBostonMA
| | - Lauren T. Southerland
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOH
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Performance of the French version of the 4AT for screening the elderly for delirium in the emergency department. CAN J EMERG MED 2018; 20:903-910. [PMID: 29769154 DOI: 10.1017/cem.2018.367] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Delirium is very frequent in older patients presenting to the emergency department (ED), but is often undetected. The purpose of this study was to evaluate the performance of the French version of the 4 A’s Test (4AT-F) for the detection of delirium and cognitive impairment in older patients. METHODS The study was conducted in four Canadian ED. Participants (n= 320) were independent or semi-independent patients (able to perform ≥5 activities of daily living) aged 65 and older and had an 8-hour exposure to the ED environment. The Telephone Interview for Cognitive Status (TICS-m), the Confusion Assessment Method (CAM) as well as the 4AT-F were administered to patients at the initial interview. The CAM and 4AT-F were then administered twice a day during the patients’ ED or hospital stay. The 4AT-F’s sensitivity and specificity were compared to those of the CAM (for delirium), and to that of the TICS (for cognitive impairment). RESULTS Our results suggest that the 4AT-F has a sensitivity of 84% (95% CI: [76, 93]) and a specificity of 74% (95% CI: [70, 78]) for delirium, as well as a sensitivity of 49% (95% CI: [34, 64]) and a specificity of 87% (95% CI: [82, 92]) for cognitive impairment. CONCLUSION The 4AT-F is a fast and reliable screening tool for delirium and cognitive impairment in ED. Due to its quick administration time, it allows a systematic screening of patients at risk of delirium, without significantly increasing the workload of the ED staff.
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Émond M, Boucher V, Carmichael PH, Voyer P, Pelletier M, Gouin É, Daoust R, Berthelot S, Lamontagne ME, Morin M, Lemire S, Minh Vu TT, Nadeau A, Rheault M, Juneau L, Le Sage N, Lee J. Incidence of delirium in the Canadian emergency department and its consequences on hospital length of stay: a prospective observational multicentre cohort study. BMJ Open 2018; 8:e018190. [PMID: 29523559 PMCID: PMC5855334 DOI: 10.1136/bmjopen-2017-018190] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE We aim to determine the incidence of delirium and describe its impacts on hospital length of stay (LOS) among non-delirious community-dwelling older adults with an 8-hour exposure to the emergency department (ED) environment. DESIGN This is a prospective observational multicentre cohort study (March-July 2015). Patients were assessed two times per day during their entire ED stay and up to 24 hours on hospital ward. SETTING The study took place in four Canadian EDs. PARTICIPANTS 338 included patients: (1) aged ≥65 years; (2) who had an ED stay ≥8 hours; (3) were admitted to hospital ward and (4) were independent/semi-independent. MAIN OUTCOMES AND MEASURES The primary outcomes of this study were incident delirium in the ED or within 24 hours of ward admission and ED and hospital LOS. Functional and cognitive status were assessed using validated Older Americans Resources and Services and the modified Telephone Interview for Cognitive Status tools. The Confusion Assessment Method was used to detect incident delirium. Univariate and multivariate analyses were conducted to evaluate outcomes. RESULTS Mean age was 76.8 (±8.1), 17.7% were aged >85 years old and 48.8% were men. The mean incidence of delirium was 12.1% (n=41). Median IQR ED LOS was 32.4 (24.5-47.9) hours and hospital LOS was 146.6 (75.2-267.8) hours. Adjusted mean hospital LOS was increased by 105.4 hours (4.4 days) (95% CI 25.1 to 162.0, P<0.001) for patients who developed an episode of delirium compared with non-delirious patient. CONCLUSIONS An incident delirium was observed in one of eight independent/semi-independent older adults after an 8-hour ED exposure. An episode of delirium increases hospital LOS by 4 days and therefore has important implications for patients and could contribute to ED overcrowding through a deleterious feedback loop.
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Affiliation(s)
- Marcel Émond
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Département de médecine d’urgence, CHU de Québec-Université Laval, Québec, Canada
- Medicine, Université Laval, Québec, Canada
- Centre d’excellence sur le vieillissement de Québec, Québec, Canada
- Centre de recherche sur les soins et les services de première ligne de l’Université Laval, Québec, Canada
| | - Valérie Boucher
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Medicine, Université Laval, Québec, Canada
- Centre d’excellence sur le vieillissement de Québec, Québec, Canada
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale, Québec, Canada
| | | | - Philippe Voyer
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Centre d’excellence sur le vieillissement de Québec, Québec, Canada
- Nursing, Université Laval, Québec, Canada
| | - Mathieu Pelletier
- Medicine, Université Laval, Québec, Canada
- Centre Intégré de Santé et de Services Sociaux de Lanaudière, Joliette, Canada
| | - Émilie Gouin
- Centre Hospitalier Régional de Trois-Rivières, Trois-Rivières, Canada
| | - Raoul Daoust
- Centre de recherche de l’Hôpital du Sacré-Cœur de Montréal, Montréal, Canada
- Medicine, Université de Montréal, Montréal, Canada
| | - Simon Berthelot
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Département de médecine d’urgence, CHU de Québec-Université Laval, Québec, Canada
- Medicine, Université Laval, Québec, Canada
| | - Marie-Eve Lamontagne
- Medicine, Université Laval, Québec, Canada
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale, Québec, Canada
| | - Michèle Morin
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Medicine, Université Laval, Québec, Canada
| | - Stéphane Lemire
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Medicine, Université Laval, Québec, Canada
- Centre d’excellence sur le vieillissement de Québec, Québec, Canada
| | - Thien Tuong Minh Vu
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montréal, Canada
- Centre hospitalier de l’Université de Montréal, Montréal, Canada
- Institut de gériatrie de l’Université de Montréal, Montréal, Canada
| | - Alexandra Nadeau
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Medicine, Université Laval, Québec, Canada
- Centre d’excellence sur le vieillissement de Québec, Québec, Canada
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale, Québec, Canada
| | | | - Lucille Juneau
- Centre Intégré Universitaire de Services Sociaux et de Santé de la Capitale-Nationale, Québec, Canada
| | - Natalie Le Sage
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
- Département de médecine d’urgence, CHU de Québec-Université Laval, Québec, Canada
- Medicine, Université Laval, Québec, Canada
| | - Jacques Lee
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Center, Toronto, Canada
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