Developing a set of emergency department performance measures to evaluate delirium care quality for older adults: a modified e-Delphi study.

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.

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.

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.

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.

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.

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.

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 .

The Metrics of Acute Care Reentry and Emergency Department Visits by Recently Discharged Inpatients.

Research on acute care reentry by recently discharged inpatients has generally focused on hospital readmissions, with less attention given to presentations to the emergency department (ED). This omission results in underestimation of the extent of reentry and its impact on ED patient volumes and flow. This project involved an analysis of administrative data to examine the rate of ED presentations by recently discharged inpatients using 3 time metrics-within 0-3 days, 0-7 days, and 0-30 days of discharge. Descriptive-correlational analyses were conducted to examine the rates of reentry and ability to predict ED presentations using patient demographic (age and sex) and clinical profile (length of hospital stay and day of presentation). Approximately 12% of hospital discharges to home involved patients who presented to the ED within 30 days, and almost half occurred within the first week. Results of multivariable analyses suggest that the influences of ED presentations differ depending on the time metric examined. Emergency department presentations within 3 and 7 days of discharge compared with 30 days were not predicted by patient age or sex but were more likely to involve those with shorter hospital stays. A weekend presentation was also more likely among case patients presenting within 3 days of discharge. Only about one third of ED presentations resulted in readmission. Emergency department presentations are an important component of acute care reentry. Establishment of a common reentry metric for ED presentations would facilitate efforts to determine the impact of these events. Emergency nurses working in advanced practice roles are ideally positioned to assume a leadership role in addressing the needs of recently discharged inpatients who present to the ED. By reviewing these cases and collaborating with the inpatient unit staff, it may be possible to identify strategies for augmenting discharge planning and the provision of transitional care.

Patterns of patient coping following hospital discharge from medical and surgical units: A pilot study.

A pilot study was conducted to determine the feasibility of a longitudinal investigation of patients' coping during the early postdischarge period. Recruitment was conducted on a general medical unit and a surgical orthopedic unit. Forty-four participants were recruited with 95% retention. Demographic characteristics plus measures of discharge risk and perceived readiness (expected coping) were collected before discharge. Measures of coping (experienced) and the use of supports and services were collected on the first day postdischarge, the end of the first week, and during weeks 3 and 5. Considerable variability was evident in coping scores, and not all participants exhibited improvement over time. Four patterns of coping were identified: ongoing recovery, initial shock, bumpy road, and progressive decline. Further investigation is required to validate the observed coping patterns. A better understanding of conditions affecting patient coping during the transition from hospital to home will support efforts to reduce unplanned use of acute care services.

An umbrella review of clinical practice guidelines for the management of patients with hip fractures and a synthesis of recommendations for the pre-operative period.

AIM: The aim of this review was to locate, retrieve and critically appraise practice guidelines for the management of hip fractures. Given increasing evidence that the early recognition and management of these fractures is integral to achieving optimal outcomes, recommendations for the pre-operative period were synthesized and compared. BACKGROUND: Hip fractures are associated with high rates of adverse outcomes and high healthcare costs which has resulted in the development of multiple practice guidelines to inform clinical decision-making. DESIGN: An umbrella review of practice guidelines was conducted which included a critical appraisal using the Appraisal of Guidelines, Research and Evaluation-II instrument and a synthesis of pre-operative management recommendations. DATA SOURCES: Multi-phased search for practice guidelines published in English using three bibliographic databases; three guideline network websites and three healthcare safety and quality organization websites with no date limit applied. Search was supplemented by contacting front-line knowledge users and content experts. REVIEW METHODS: Steps for evidence-informed practice were followed: form question then search for, appraise and synthesize the evidence. RESULTS: Five practice guidelines were appraised revealing significant variability in quality. The largest variability was in "rigour of development". Recommendations for pre-operative management were grouped into six categories: timing of surgery, expedited patient management, identification and treatment of correctable co-morbidities, pain management, preventative measures and multidisciplinary management. CONCLUSION: Results of this review illustrate that not all practice guidelines are of equal quality. Given the costs associated with the development and maintenance of high-quality practice guidelines, such work may be more efficiently completed through international collaborations and then adapted for national and regional healthcare contexts.