Understanding why delirium is often missed in older emergency department patients: a qualitative descriptive study.

OBJECTIVES: Unrecognized delirium is associated with significant adverse outcomes. Despite decades of effort and educational initiatives, validated screening tools have not improved delirium recognition in the emergency department (ED). There remains a fundamental knowledge gap of why it is consistently missed. The objective of this study was to explore the perceptions of ED physicians and nurses regarding factors contributing to missed delirium in older ED patients. METHODS: We conducted a qualitative descriptive study at two academic tertiary care EDs in Toronto, Canada. Emergency physicians and nurses were interviewed by a trained qualitative researcher using a semi-structured interview guide. We coded transcripts with an iteratively developed codebook. Interviews were conducted until thematic saturation occurred. Thematic data analysis occurred in conjunction with data collection to continuously monitor emerging themes and areas for further exploration. RESULTS: We interviewed 26 ED physicians and nurses. We identified key themes at four levels: clinical practice, provider attitudes, systematic processes, and education. The four themes include: (1) there are varied approaches to delirium recognition and infrequent use of screening tools; (2) delirium assessment is perceived as overly time consuming and of lower priority than other symptoms and syndromes; (3) it is unclear whose responsibility it is to recognize delirium; and (4) there is a need for a deeper or "functional" understanding of delirium that includes its consequences. CONCLUSIONS: Our findings demonstrate a need for ED leadership to identify clear team roles for delirium recognition, standardize use of delirium screening tools, and prioritize delirium as a symptom of an acute medical emergency.

RéSUMé: OBJECTIFS: Le délire non reconnu est associé à des résultats négatifs importants. Malgré des décennies d'efforts et d'initiatives éducatives, les outils de dépistage validés n'ont pas amélioré la reconnaissance du délire au service des urgences (SU). Il reste une lacune fondamentale dans la connaissance des raisons pour lesquelles elle est systématiquement manquée. L'objectif de cette étude était d'explorer les perceptions des médecins et des infirmières de l'urgence au sujet des facteurs contribuant au délire manqué chez les patients âgés des urgences. MéTHODES: Nous avons mené une étude qualitative descriptive dans deux urgences universitaires de soins tertiaires à Toronto, au Canada. Les médecins et les infirmières des urgences ont été interrogés par un chercheur qualitatif formé à l'aide d'un guide d'entretien semi-structuré. Nous avons codé les transcriptions à l'aide d'un livre de codes développé de manière itérative. Les entretiens ont été menés jusqu'à saturation thématique. L'analyse thématique des données s'est déroulée conjointement avec la collecte des données afin de surveiller continuellement les thèmes émergents et les domaines à explorer davantage. RéSULTATS: Nous avons interrogé 26 médecins et infirmières des urgences. Nous avons identifié des thèmes clés à quatre niveaux : la pratique clinique, les attitudes des prestataires, les processus systématiques et l'éducation. Les quatre thèmes abordés sont les suivants : 1) les approches de la reconnaissance du délire sont variées et les outils de dépistage peu utilisés ; 2) l'évaluation du délire est perçue comme prenant trop de temps et moins prioritaire que d'autres symptômes et syndromes ; 3) il n'est pas clair à qui revient la responsabilité de reconnaître le délire ; et 4) il est nécessaire d'avoir une compréhension plus profonde ou "fonctionnelle" du délire, qui inclut ses conséquences. CONCLUSIONS: Nos résultats démontrent la nécessité pour les responsables des urgences de définir clairement les rôles de l'équipe pour la reconnaissance du delirium, de normaliser l'utilisation des outils de dépistage du delirium et d'accorder la priorité au delirium en tant que symptôme d'une urgence médicale aiguë.

Exploring Health Care Providers' Experiences of Providing Collaborative Palliative Care for Patients With Advanced Heart Failure At Home: A Qualitative Study.

Background The HeartFull Collaborative is a regionally organized model of care which involves specialist palliative care and cardiology health care providers (HCPs) in a collaborative, home-based palliative care approach for patients with advanced heart failure (AHF). We evaluated HCP perspectives of barriers and facilitators to providing coordinated palliative care for patients with AHF at home. Methods and Results We conducted a qualitative study with 17 HCPs (11 palliative care and 6 cardiology) who were involved in the HeartFull Collaborative from April 2013 to March 2020. Individual, semi-structured interviews were held with each practitioner from November 2019 to March 2020. We used an interpretivist and inductive thematic analysis approach. We identified facilitators at 2 levels: (1) individual HCP level (on-going professional education to expand competency) and (2) interpersonal level (shared care between specialties, effective communication within the care team). Ongoing barriers were identified at 2 levels: (1) individual HCP level (e.g. apprehension of cardiology practitioners to introduce palliative care) and (2) system level (e.g. lack of availability of personal support worker hours). Conclusions Our results suggest that a collaborative shared model of care delivery between palliative care and cardiology improves knowledge exchange, collaboration and communication between specialties, and leads to more comprehensive patient care. Addressing ongoing barriers will help improve care delivery. Findings emphasize the acceptability of the program from a provider perspective, which is encouraging for future implementation. Further research is needed to improve prognostication, assess patient and caregiver perspectives regarding this model of care, and assess the economic feasibility and impact of this model of care.

Procedural Skills Training in Emergency Medicine Physicians Within the Edmonton Zone: A Needs Assessment.

OBJECTIVES: The objectives were to describe the current procedural skill practices, attitudes toward procedural skill competency, and the role for educational skills training sessions among emergency medicine (EM) physicians within a geographic health zone. METHODS: This is a multicenter descriptive cross-sectional survey of all EM physicians working at 12 emergency departments (EDs) within the Edmonton Zone in 2019. Survey items addressed current procedural skill performance frequency; perceived importance and confidence; current methods to maintain competence; barriers and facilitating factors to participation in a curriculum; preferred teaching methods; and desired frequency of practice for each procedural skill. RESULTS: Survey response rate was 53.6%. Variability in frequency of performed procedures was seen across the type of hospital sites. For the majority of skills, there was a significantly positive correlation between the frequency at which a skill was performed and the perceived confidence performing said skill. There was inconsistency and no significant correlation with perceived importance, perceived confidence or frequency performing a given skill, and the desired frequency of training for that skill. Course availability (76.2%) and time (72.8%) are the most common identified barriers to participation in procedural skills training. CONCLUSIONS: This study summarized the current ED procedural skill practices among EM physicians in the Edmonton Zone and attitudes toward an educational curriculum for procedural skill competency. This represents a step toward targeted continuing professional development in staff physicians.

Prevalence of and factors associated with head impact during falls in older adults in long-term care.

BACKGROUND: Falls cause more than 60% of head injuries in older adults. Lack of objective evidence on the circumstances of these events is a barrier to prevention. We analyzed video footage to determine the frequency of and risk factors for head impact during falls in older adults in 2 long-term care facilities. METHODS: Over 39 months, we captured on video 227 falls involving 133 residents. We used a validated questionnaire to analyze the mechanisms of each fall. We then examined whether the probability for head impact was associated with upper-limb protective responses (hand impact) and fall direction. RESULTS: Head impact occurred in 37% of falls, usually onto a vinyl or linoleum floor. Hand impact occurred in 74% of falls but had no significant effect on the probability of head impact (p = 0.3). An increased probability of head impact was associated with a forward initial fall direction, compared with backward falls (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.3-5.9) or sideways falls (OR 2.8, 95% CI 1.2-6.3). In 36% of sideways falls, residents rotated to land backwards, which reduced the probability of head impact (OR 0.2, 95% CI 0.04-0.8). INTERPRETATION: Head impact was common in observed falls in older adults living in long-term care facilities, particularly in forward falls. Backward rotation during descent appeared to be protective, but hand impact was not. Attention to upper-limb strength and teaching rotational falling techniques (as in martial arts training) may reduce fall-related head injuries in older adults.

Development and validation of a questionnaire for analyzing real-life falls in long-term care captured on video.

BACKGROUND: Falls are the number one cause of injuries in older adults, and are particularly common in long-term care (LTC). Lack of objective evidence on the mechanisms of falls in this setting is a major barrier to prevention. Video capture of real-life falls can help to address this barrier, if valid tools are available for data analysis. To address this need, we developed a 24-item fall video analysis questionnaire (FVAQ) to probe key biomechanical, behavioural, situational, and environmental aspects of the initiation, descent, and impact stages of falls. We then tested the reliability of this tool using video footage of falls collected in LTC. METHODS: Over three years, we video-captured 221 falls experienced by 130 individuals in common areas (e.g., dining rooms, hallways, and lounges) of two LTC facilities. The FVAQ was developed through literature review and an iterative process to ensure our responses captured the most common behaviours observed in preliminary review of fall videos. Inter-rater reliability was assessed by comparing responses from two teams, each having three members, who reviewed 15 randomly-selected videos. Intra-rater reliability was measured by comparing responses from one team at baseline and 12 months later. RESULTS: In 17 of the 24 questions, the percentage of inter- and intra-rater agreement was over 80% and the Cohen's Kappa was greater than 0.60, reflecting good reliability. These included questions on the cause of imbalance, activity at the time of the fall, fall direction, stepping responses, and impact to specific body sites. Poorer agreement was observed for footwear, contribution of clutter, reach-to-grasp responses, and perceived site of injury risk. CONCLUSIONS: Our results provide strong evidence of the reliability of the FVAQ for classifying biomechanical, behavioural, situational, and environmental aspects of falls captured on video in common areas in LTC. Application of this tool should reveal new and important strategies for the prevention and treatment of falls and fall-related injuries in this setting.

Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study.

BACKGROUND: Falls in elderly people are a major health burden, especially in the long-term care environment. Yet little objective evidence is available for how and why falls occur in this population. We aimed to provide such evidence by analysing real-life falls in long-term care captured on video. METHODS: We did this observational study between April 20, 2007, and June 23, 2010, in two long-term care facilities in British Columbia, Canada. Digital video cameras were installed in common areas (dining rooms, lounges, hallways). When a fall occurred, facility staff completed an incident report and contacted our teams so that we could collect video footage. A team reviewed each fall video with a validated questionnaire that probed the cause of imbalance and activity at the time of falling. We then tested whether differences existed in the proportion of participants falling due to the various causes, and while engaging in various activities, with generalised linear models, repeated measures logistic regression, and log-linear Poisson regression. FINDINGS: We captured 227 falls from 130 individuals (mean age 78 years, SD 10). The most frequent cause of falling was incorrect weight shifting, which accounted for 41% (93 of 227) of falls, followed by trip or stumble (48, 21%), hit or bump (25, 11%), loss of support (25, 11%), and collapse (24, 11%). Slipping accounted for only 3% (six) of falls. The three activities associated with the highest proportion of falls were forward walking (54 of 227 falls, 24%), standing quietly (29 falls, 13%), and sitting down (28 falls, 12%). Compared with previous reports from the long-term care setting, we identified a higher occurrence of falls during standing and transferring, a lower occurrence during walking, and a larger proportion due to centre-of-mass perturbations than base-of-support perturbations. INTERPRETATION: By providing insight into the sequences of events that most commonly lead to falls, our results should lead to more valid and effective approaches for balance assessment and fall prevention in long-term care. FUNDING: Canadian Institutes for Health Research.