Managing "socially admitted" patients in hospital: a qualitative study of health care providers' perceptions.

BACKGROUND: Emergency departments are a last resort for some socially vulnerable patients without an acute medical illness (colloquially known as "socially admitted" patients), resulting in their occupation of hospital beds typically designated for patients requiring acute medical care. In this study, we aimed to explore the perceptions of health care providers regarding patients admitted as "social admissions." METHODS: This qualitative study was informed by grounded theory and involved semistructured interviews at a Nova Scotia tertiary care centre. From October 2022 to July 2023, we interviewed eligible participants, including any health care clinician or administrator who worked directly with "socially admitted" patients. Virtual or in-person individual interviews were audio-recorded and transcribed, then independently and iteratively coded. We mapped themes on the 5 domains of the Quintuple Aim conceptual framework. RESULTS: We interviewed 20 nurses, physicians, administrators, and social workers. Most identified as female (n = 11) and White (n = 13), and were in their mid to late career (n = 13). We categorized 9 themes into 5 domains: patient experience (patient description, provision of care); care team well-being (moral distress, hierarchy of care); health equity (stigma and missed opportunities, prejudices); cost of care (wait-lists and scarcity of alternatives); and population health (factors leading to vulnerability, system changes). Participants described experiences caring for "socially admitted" patients, perceptions and assumptions underlying "social" presentations, system barriers to care delivery, and suggestions of potential solutions. INTERPRETATION: Health care providers viewed "socially admitted" patients as needing enhanced care but identified individual, institutional, and system challenges that impeded its realization. Examining perceptions of the people who care for "socially admitted" patients offers insights to guide clinicians and policy-makers in caring for socially vulnerable patients.

Translating Delirium Prevention Strategies for Elderly Adults with Hip Fracture into Routine Clinical Care: A Pragmatic Clinical Trial.

OBJECTIVES: To compare the feasibility (adherence) and effectiveness (prevalence of delirium, length of stay, mortality, discharge site) of delirium-friendly preprinted postoperative orders (PPOs) for individuals with hip fracture, administered by regular orthopedic nurses, with routine postoperative orders. DESIGN: Pragmatic clinical trial to evaluate a quality improvement intervention. SETTING: Tertiary care hospital. PARTICIPANTS: Individuals aged 65 and older admitted for hip fracture repair (N = 283). INTERVENTION: PPOs with delirium-friendly options and doses for nighttime sedation, analgesia, and nausea and attention to catheter removal and bowel movements. MEASUREMENTS: Adherence to PPO was compared with adherence to routine orders. Drug doses were recorded. Presence of delirium was documented using the Confusion Assessment Method and the Mini-Mental State Examination on postoperative Days 1, 3, and 5. Length of stay, discharge site, and in-hospital mortality were recorded. RESULTS: Orthopedic nurses adhered reasonably well with delirium-friendly PPOs. Of 283 participants, 42% developed postoperative delirium, with significantly less delirium in the intervention group (intervention 33%, control 51%, P = .001). The effect of the intervention was stronger in individuals with preexisting dementia (intervention 60%, control 97%, P < .001). Participants with postoperative delirium had longer hospital stays and were more likely to die or be discharged to a nursing home, but there was no significant between-group difference in these outcomes. CONCLUSION: It is possible to introduce delirium-friendly PPOs into routine post-hip fracture care in a representative elderly population including individuals with dementia. Delirium-friendly PPOs executed by regular nursing staff resulted in a significant reduction in postoperative delirium but no difference in other outcomes.

Prevalence and Characteristics of Pre-Operative Delirium in Hip Fracture Patients.

BACKGROUND: Delirium is a common complication of hip fracture and is associated with negative outcomes. Previous studies document risk factors for post-operative delirium but have frequently excluded patients with pre-operative delirium. OBJECTIVE: This study endeavours to document prevalence and risk factors for pre-operative delirium in hip fracture patients and compares risk factor profiles and outcomes between pre- and post-operative delirium. METHODS: 283 hip fracture patients were assessed pre-operatively with the Delirium Elderly At Risk (DEAR) instrument, Mini-Mental State Examination (MMSE), and Confusion Assessment Method (CAM). They were followed on post-operative days 1, 3, and 5 for the presence of delirium. Doses of opioids were recorded. Wait time to surgery, length of stay, and discharge site were noted. RESULTS: Delirium was present in 57.6% patients pre-operatively and 41.7% post-surgery. Not all patients (62%) with pre-operative delirium also had post-operative delirium. There was a considerable overlap in risk factors, with some differences. Wait time to surgery, number of comorbidities, and total pre-operative opioid and lorazepam doses were associated with pre- but not post-operative delirium. Negative outcomes were more closely associated with post-operative delirium. CONCLUSION: Delirium is common in pre-hip fracture surgery patients, and not all patients with pre-operative delirium go on to have post-operative delirium. Risk factor profiles are not identical, raising the possibility of identifying and intervening in patients at high risk of delirium pre-operatively.

End of Life Care in Frailty.

The increasing prevalence of frailty within the aging population poses challenges to current models of chronic disease management and end-of-life care delivery. As frailty progresses, individuals face an increasing frequency of acute health issues requiring medical attention. The ability of health care systems to recognize and respond to acute health issues in frail patients using a holistic understanding of health and prognosis will play a central role in ensuring their effective and appropriate care, including that at the end of their lives. This chapter reviews the history of palliative care and the elements of frailty that require the modification of current models of palliative care. In addition, tools and models for recognition of end of life in frailty and considerations for symptom management are introduced.

Risk of Pre-and Post-Operative Delirium and the Delirium Elderly At Risk (DEAR) Tool in Hip Fracture Patients.

BACKGROUND AND PURPOSE: Delirium is common after hip fracture. Previous work has shown that a simple delirium risk factor tool, the Delirium Elderly At Risk instrument (DEAR), has a high inter-rater reliability in this population. Little research has looked at the ability of risk factor screening tools to identify patients at high risk of pre-operative delirium. This study investigates the ability of the DEAR to identify patients at high risk of pre-operative delirium, as well as reporting its performance in a post-operative validation sample. Associations between delirium risk factors and pre-operative delirium are explored. METHODS: This prospective cohort study took place on an orthopedic in-patient service at a University-affiliated tertiary care hospital. Patients aged 65 and older who were admitted for surgical repair of hip fracture (N = 283) were assessed pre-operatively for 5 delirium risk factors (cognitive impairment, sensory impairment, functional dependence, substance use, age) using the DEAR. Patients were assessed for delirium using the Mini-Mental State Examination and the Confusion Assessment Method pre-operatively and on post-operative days 1, 3 and 5. Characteristics of patients who developed delirium were compared with the characteristics of those who did not. RESULTS: Delirium was present in 58% (95% CI = 52-63%) of patients pre-operatively and 42% (95% CI = 36-48%) post-operatively. Individually, sensory impairment (χ(2) = 21.7, p = .0001), functional dependence (χ(2) = 24.1, p = .0001), cognitive impairment (χ(2) = 55.5, p = .0001) and substance use (χ(2) = 7.5, p = .007) were significantly associated with pre-operative delirium, as was wait-time for surgery (t = 3.1, p = .003) and length of stay (t = 2.8, p =.03). In multivariate modeling, the strongest association with pre-operative delirium was cognitive impairment. CONCLUSIONS: The DEAR, a simple, delirium risk factor screening tool, can be used to identify hip fracture patients at risk of both pre-operative and post-operative delirium, which may allow targeted implementation of delirium prevention strategies.

Frailty in older adults: implications for end-of-life care.

Frailty has important implications for the care needs of older adults and how those needs are met. By recognizing frailty and measuring it objectively, clinicians can better engage patients and their loved ones in difficult discussions about treatment plans and prognosis, and ultimately deliver better palliative care.

Specialist physician approaches to discussing cardiopulmonary resuscitation for frail older adults: a qualitative study.

BACKGROUND: Despite the impact and importance of end-of-life discussions, little is known about how physicians discuss cardiopulmonary resuscitation (CPR) with patients and their families. The necessary components for successful communication about CPR are poorly understood and an established framework to structure these conversations is lacking. Here, we were motivated to understand how physicians approach resuscitation planning with families when older patients have limited life expectancy and a high burden of illness. METHOD: Qualitative analysis was conducted of semi-structured interviews of 28 physicians of varying medical sub-specialties in a tertiary care hospital. RESULTS: Most physicians explored the surrogates' goals and values, but few provided explicit information about the patients' overall health status or expected long-term health outcome related to CPR and underlying illnesses. CONCLUSION: There is considerable heterogeneity in physicians' approaches to CPR discussions. The principle of autonomy is dominant with less emphasis on providing adequate information for effective decision-making.