[Conflicts between persons with opioid dependency and professionals in an acute hospital: A qualitative document analysis]. / Konflikte zwischen Personen mit Opioidabhängigkeit und Fachpersonen im Akutspital.

Conflicts between persons with opioid dependency and professionals in an acute hospital: A qualitative document analysis Abstract: Background: Opioid dependency is a chronic disease with severe health and social consequences. Patients often suffer from chronic infectious diseases, the consequences of which require treatment in an acute care hospital. On hospital wards, conflicts between patients with opioid dependency and professionals can be observed frequently. Aim: This study explores in which situations and for which reasons conflicts arise. Methods: Entries of professionals in patient charts were analysed qualitatively according to the Thematic Analysis. Results: Entries of 177 cases were analysed and three themes were identified. "Different priorities in the context of an acute hospital" showed that patients and professional teams often had divergent views on what is important during hospitalisation. "Self-medicating" provided evidence that patients suffered from symptoms that were inadequately treated and therefore self-medicated. The basic need "to be perceived as a human being" was not always met in the acute care hospital. Conclusions: Our results show causes and types of conflicts. Divergent values, under-treatment of addiction-specific symptoms and pain, and incomplete expertise among professionals appear to be causal, as does the lack of implementation of harm reduction.

The challenge of interprofessional collaboration in emergency department team triage - An interpretive description.

AIMS: To explore emergency nurses' and physicians' experience of collaboration and collective decision-making when triaging older Emergency Department patients within the interprofessional team triage system. DESIGN: Qualitative. METHODS: Semi-structured interviews were conducted with seven nurses and five physicians. Transcripts were analysed via Interpretive Description between September 2016-May 2017. RESULTS: 'Negotiating collaboration' was developed as the main theme. Three subthemes influenced the negotiation process: Participants described divergent opinions on how an optimal triage system should work ('preferences for triage systems'); they had conflicting perceptions of each profession's role ('role perceptions'); and they expressed different coping strategies regarding 'perceived time pressure'. The compatibility of participants' views on these sub-themes determined whether the nurse and physician were able to successfully negotiate their collaboration. These themes became more evident when the team triaged older ED patients. CONCLUSION: Improving interprofessional team triage requires working with the involved nurses' and physicians' values and beliefs. The strengths of both professions need to be considered and a flexible approach to collaboration established according to the patients' situations. IMPACT: Emergency Department leaders need to consider nurses' and physicians' values and beliefs to promote interprofessional collaboration in team triage.

COVID-19 driven care changes in high risk patients from an outpatient to a community setting - A cross-sectional study.

Background: COVID-19 has led to a change in care for patients with chronic conditions, involving a transfer of drug administration from an outpatient to a community setting. AIM: To investigate patient preferences for treatment settings in the light of the current pandemic. METHODS: Patients, who prior to the pandemic had attended two different outpatient clinics in a university hospital for their infusions or injections, were interviewed by telephone. The semi-structured interviews were analyzed using qualitative and quantitative methods. RESULTS: Out of 49 patients with either anti-inflammatory or immunoglobulin treatments (response rate: 83 %), 24 (49.0 %) switched from subcutaneous (sc) injections in the hospital to the community setting, 18 (36.7 %) from intravenous infusions (iv) in the hospital to sc administration at home and 7 (14.3 %) moved to iv at home. During the pandemic 38 (80.9 %) wanted to continue their treatment at home, but after the pandemic 22 (46.8 %) would opt to go back to the hospital. Satisfaction was high with both settings, slightly favoring drug administration in hospital. Qualitative data shows that patients while emphasizing the importance of the relationship with the healthcare team, had increased concerns about safety as a result of COVID-19. CONCLUSIONS: The experience during the COVID-19 pandemic has increased self-management-skills in some patients, but long-term follow-up is needed. It has repercussions for future shared decision making for patients and their healthcare teams.

Optimizing the month of the year backwards test for delirium screening of older patients in the emergency department.

INTRODUCTION: Different scoring methods exist for the Month of the Year Backward Test (MBT), which is designed to detect inattention, the core feature of delirium. When used as a part of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED), each error in the MBT scores one point. Because this scoring procedure is complex, we aimed to simplify the scoring method of the MBT. METHODS: This is a secondary analysis of a single center prospective validation study of the mCAM-ED comprising a sample of Emergency Department (ED) patients aged 65 or older presenting to our ED. DATA COLLECTION: Research assistants (RAs) who were trained nurses conducted the MBT. Geriatricians conducted the reference standard delirium assessment within 1 h of the RA. RESULTS: For the scoring method "number of errors", optimal performance according the Youden index was achieved when 8 or more errors were reached resulting in an overall sensitivity of 0.95 and overall specificity of 0.94. The scoring method "number of errors in combination with time needed" resulted in a comparable result with minimally lower positive likelihood ratios. For the scoring method "last month in correct order", optimal performance according the Youden index was achieved with the month of September resulting in an overall sensitivity of 0.90 and an overall specificity of 0.89. DISCUSSION: We suggest omitting the factor time and using a more practical scoring method with good performance: "last month in correct order" with the requirement to reach September to rule out delirium.

Screening and detection of delirium in older ED patients: performance of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). A two-step tool.

Delirium is frequent in older Emergency Department (ED) patients, but detection rates for delirium in the ED are low. To aid in identifying delirium, we developed and implemented a two-step systematic delirium screening and assessment tool in our ED: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Components of the mCAM-ED include: (1) screening for inattention, the main feature of delirium, which was performed with the Months Backwards Test (MBT); (2) delirium assessment based on a structured interview with questions from the Mental Status Questionnaire by Kahn et al. and the Comprehension Test by Hart et al. The aims of our study are (1) to investigate the performance criteria of the mCAM-ED tool in a consecutive sample of older ED patients, (2) to evaluate the performance of the mCAM-ED in patients with and without dementia and (3) to test whether this tool is efficient in keeping evaluation time to a minimum and reducing screening and assessment burden on the patient. For this prospective validation study, we recruited a consecutive sample of ED patients aged 65 and older during an 11-day period in November 2015. Trained nurses assessed patients with the mCAM-ED. Results were compared to the reference standard [i.e. the geriatricians' delirium diagnosis based on the criteria of the Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)]. Performance criteria were computed. We included 286 consecutive ED patients aged 65 and older. The median age was 80.02 (Q1 = 72.15; Q3 = 86.76), 58.7% of included patients were female, 14.3% had dementia. We found a delirium prevalence of 7.0%. In patients with dementia, specificity and positive likelihood ratio were lower. When compared to the reference standard, delirium assessment with the mCAM-ED has a 0.98 specificity and a 39.9 positive likelihood ratio. In 80.0% of all cases, the first step of the mCAM-ED, i.e. screening for inattention with the MBT, took less than 30 s. On average, the complete mCAM-ED assessment required 3.2 (SD 2.0), 5.6 (SD 3.2), and 6.2 (SD 2.3) minutes in cognitively unimpaired patients, patients with dementia and patients with dementia or delirium, respectively. The mCAM-ED is able to efficiently rule out delirium as well as confirm the diagnosis of delirium in elderly patients with and without dementia and applies minimal screening and assessment burden on the patient.

Performance of the modified Richmond Agitation Sedation Scale in identifying delirium in older ED patients.

BACKGROUND: Delirium in older emergency department (ED) patients is associated with severe negative patient outcomes and its detection is challenging for ED clinicians. ED clinicians need easy tools for delirium detection. We aimed to test the performance criteria of the modified Richmond Agitation Sedation Scale (mRASS) in identifying delirium in older ED patients. METHODS: The mRASS was applied to a sample of consecutive ED patients aged 65 or older by specially trained nurses during an 11-day period in November 2015. Reference standard delirium diagnosis was based on Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) criteria, and was established by geriatricians. Performance criteria were computed. Analyses were repeated in the subsamples of patients with and without dementia. RESULTS: Of 285 patients, 20 (7.0%) had delirium and 41 (14.4%) had dementia. The sensitivity of an mRASS other than 0 to detect delirium was 0.70 (95% confidence interval, CI, 0.48; 0.85), specificity 0.93 (95% CI 0.90; 0.96), positive likelihood ratio 10.31 (95% CI 6.06; 17.51), negative likelihood ratio 0.32 (95% CI 0.16; 0.63). In the sub-sample of patients with dementia, sensitivity was 0.55 (95% CI 0.28; 0.79), specificity 0.83 (95% CI 0.66; 0.93), positive likelihood ratio 3.27 (95% CI 1.25; 8.59), negative likelihood ratio 0.55 (95% CI 0.28; 1.06). CONCLUSION: The sensitivity of the mRASS to detect delirium in older ED patients was low, especially in patients with dementia. Therefore its usefulness as a stand-alone screening tool is limited.

Undertriage in older emergency department patients--tilting against windmills?

OBJECTIVES: The aim of this study was to investigate the long-term effect of a teaching intervention designed to reduce undertriage rates in older ED patients. Further, to test the hypothesis that non-adherence to the Emergency Severity Index (ESI) triage algorithm is associated with undertriage. Additionally, to detect patient related risk factors for undertriage. METHODS: Pre-post-test design. The study sample consisted of all patients aged 65 years or older presenting to the ED of an urban tertiary and primary care center in the study periods. A teaching intervention designed to increase adherence to the triage algorithm. To assess, if the intervention resulted in an increase of factual knowledge, nurses took a test before and immediately after the teaching intervention. Undertriage rates were assessed one year after the intervention and compared to the pre-test period. RESULTS: In the pre-test group 519 patients were included, and 394 in the post-test-group. Factual knowledge among triage nurses was high already before the teaching intervention. Prevalence of undertriaged patients before (22.5%) and one year after the intervention (24.2%) was not significantly different (χ2 = 0.248, df = 1, p = 0.619). Sex, age, mode of arrival, and type of complaint were not identified as independent risk factors for undertriage. However, undertriage rates increased with advancing age. Adherence to the ESI algorithm is associated with correct triage decisions. CONCLUSIONS: Undertriage of older ED patients remained unchanged over time. Reasons for undertriage seem to be more complex than anticipated. Therefore, additional contributing factors should be addressed.

Screening, detection and management of delirium in the emergency department - a pilot study on the feasibility of a new algorithm for use in older emergency department patients: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED).

BACKGROUND: Delirium in emergency department (ED) patients occurs frequently and often remains unrecognized. Most instruments for delirium detection are complex and therefore unfeasible for the ED. The aims of this pilot study were first, to confirm our hypothesis that there is an unmet need for formal delirium assessment by comparing informal delirium ratings of ED staff with formal delirium assessments performed by trained research assistants. Second, to test the feasibility of an algorithm for delirium screening, detection and management, which includes the newly developed modified Confusion Assessment Method for the Emergency Department (mCAM-ED) at the ED bedside. Third, to test interrater reliability of the mCAM-ED. METHODS: This was a pilot study with a pre-post-test design with two data collection periods before and after the implementation of the algorithm. Consecutive ED patients aged 65 years and older were screened and assessed in the ED of a tertiary care center by trained research assistants. The delirium detection rate of informal ratings by nurses and physicians was compared with the standardized mCAM-ED assessment performed by the research assistants. To show the feasibility at the ED bedside, defined as adherence of ED staff to the algorithm, only post-test data were used. Additionally, the ED nurses' assessments were analyzed qualitatively. To investigate the agreement between research assistants and the reference standard, the two data sets were combined. RESULTS: In total, 207 patients were included in this study. We found that informal delirium assessment was inappropriate, even after a teaching intervention: Sensitivity of nurses to detect delirium without formal assessment was 0.27 pretest and 0.40 post-test, whilst sensitivity of physicians' informal rating was 0.45 pre-test and 0.6 post-test. ED staff demonstrated high adherence to the algorithm (76.5%). Research assistants assessing delirium with the mCAM-ED demonstrated a high agreement compared to the reference standard (kappa = 0.729). CONCLUSIONS: Informal assessment of delirium is inadequate. The mCAM-ED proved to be useful at the ED bedside. Performance criteria need to be tested in further studies. The mCAM-ED may contribute to early identification of delirious ED patients.

At risk of undertriage? Testing the performance and accuracy of the emergency severity index in older emergency department patients.

STUDY OBJECTIVE: We test predictive validity, interrater reliability, and diagnostic accuracy of the Emergency Severity Index in older emergency department (ED) patients and identify reasons for inadequate triage. METHODS: We analyzed data of patients aged 65 years or older who were included in a prospective, single-center cohort study. Predictive validity was assessed by investigating associations of resources, disposition, length of stay, and mortality with Emergency Severity Index levels. Diagnostic accuracy was tested by calculating sensitivity and specificity of Emergency Severity Index level 1 for the prediction of a lifesaving intervention. For the assessment of interrater reliability, 2 experts independently reviewed the triage nurses' notes. Agreement was estimated as raw agreement and as Cohen's weighted κ. RESULTS: In total, 519 older patients were included. Emergency Severity Index level was associated with resource consumption (Spearman's ρ=-0.449; 95% confidence interval [CI] -0.519 to -0.379), disposition (Kendall's τ=-0.452; 95% CI -0.516 to -0.387), ED length of stay (Kruskal-Wallis χ(2)=92.5; df=4; P<.001), and mortality (log-rank χ(2)=37.04; df=3; P<.001). The sensitivity of the Emergency Severity Index to predict lifesaving interventions was 0.462 (95% CI 0.232 to 0.709), and the specificity was 0.998 (95% CI 0.989 to 1.000). Interrater reliability between experts was high (raw agreement 0.917, 95% CI 0.894 to 0.944; Cohen's weighted κ(w)=0.934, 95% CI 0.913 to 0.954). Undertriage occurred in 117 cases. Main reasons were neglect of high-risk situations and failure to appropriately interpret vital signs. CONCLUSION: In our study, older patients were at risk for undertriage. However, our results suggest that the Emergency Severity Index is reliable and valid for triage of older patients.

Self-reported cardiovascular risk factors in immigrants and Swiss nationals.

OBJECTIVE: The purpose of this study was to investigate whether the prevalence of self-reported cardiovascular risk factors differs between immigrants and Swiss nationals. DESIGN AND SAMPLE: This study is a secondary data analysis of the Swiss Health Survey 2002, a cross-sectional survey. In total, 19,249 individuals living in Switzerland were included. MEASURES: The prevalence of hypertension, high cholesterol level, smoking, diabetes, overweight, low fruit and vegetable intake, and physical inactivity were calculated for major immigrant groups and Swiss nationals. Demographic data were used to control for age and socioeconomic status. RESULTS: Major immigrant groups were people from Italy, Germany, former Yugoslavia, Spain, Portugal, France, and Turkey. Compared with Swiss women, women from former Yugoslavia were more likely to have hypertension, and women from Germany were more likely to have high cholesterol levels. Women from Italy, former Yugoslavia, Spain, Portugal, and Turkey were more likely to show physical inactivity and (except Turkish women) to be overweight. Men from these countries (except Spanish men) were more likely to be overweight than Swiss men. CONCLUSIONS: Differences exist in the prevalence of modifiable cardiovascular risk factors between Swiss nationals and many of the immigrant groups. Age and socioeconomic status could only partly explain the differences.

Transporting clinical tools to new settings: cultural adaptation and validation of the Emergency Severity Index in German.

STUDY OBJECTIVE: To date, no German triage tool with proven reliability and validity exists. The goal of this project is to translate and culturally adapt the Emergency Severity Index (ESI) and to assess reliability and validity of the German version. METHODS: The ESI was translated following principles recommended for the translation and cultural adaptation of instruments. We performed a prospective, single-center cohort study. Reliability was assessed by calculating Cohen's weighted κ for agreement of 2 experts who reviewed the triage nurses' notes. To assess validity, associations of the number of resources, hospitalization, admission to intensive care, length of stay, and mortality with the assigned ESI level were investigated. RESULTS: Only small cultural adaptations had to be made during the translation process. Interrater agreement was high (κ(w) = 0.985) in a sample of 125 patients. For the assessment of validity, a sample of 2,114 patients was used. Spearman's rank correlation coefficient between ESI category and number of resources was ρ = -0.567. The association (Kendall's τ) between ESI category and disposition, and hospitalization was τ = -0.429 and τ = -0.453, respectively. The areas under the curves for the predictive ability of the ESI for hospitalization in general and hospitalization to an ICU were 0.788 and 0.856, respectively. The association between emergency department length of stay and ESI category was also significant (Kruskal-Wallis χ² = 450.8; df = 4; P < .001). Furthermore, the association between ESI category and survival probability was significant (log-rank χ² = 36.06; df = 3; P < .001). CONCLUSION: Translation of the ESI following guidelines was feasible and resulted in a reliable and valid German version.

[Impact of patient education on self-care behaviour in patients with heart failure: a review of the literature]. / Schulung von Patienten mit Herzinsuffizienz - Effekte auf das Selbstpflegeverhalten. Eine Literaturrecherche.

Heart failure is a highly prevalent chronic condition. Nurse-led patient education has been described in the literature as a key component of disease management programs. This literature review investigates the impact of patient education on self-care behaviour in patients with heart failure. Seven randomised controlled trials could be included in the review. Medication taking, daily weighing, salt and fluid restriction and taking action in case of worsening symptoms are cornerstones in patient education programs. All seven studies revealed that interventions comprising patient education were associated with improved self-care behaviour in patients with heart failure. The education has to be individualized and family members should be included. Nurses play an important role in patient education interventions and must be well trained and skilled for example in clinical assessment. To date, the dose and the length of the patient education interventions necessary to improve self-care behaviour and sustain these behaviours remain unclear and need more research.