Development of quality indicators for palliative care in intensive care units and pilot testing them via electronic medical record review.

BACKGROUND: Patients in intensive care units (ICUs) often require quality palliative care for relief from various types of suffering. To achieve quality palliative care, specific goals need to be identified, measured, and reported. The present study aimed to develop quality indicators (QIs) for palliative care in ICUs, based on a systematic review and modified Delphi method, and test their feasibility by reviewing electronic medical record (EMR) data. METHODS: The current study was performed in two phases: the development of QIs using the modified Delphi method, and pilot-testing the quality of palliative care in ICUs based on EMR review. The pilot test included 262 patients admitted to the general or emergency ICU at a university hospital from January 1, 2019, to June 30, 2019. RESULTS: A 28-item QI set for palliative care in ICUs was developed based on the consensus of 16 experts. The Delphi process resulted in low measurability ratings for two items: "Assessment of the patient's psychological distress" and "Assessment of the patient's spiritual and cultural practices." However, these items were determined to be important for quality care from the perspective of holistic assessment of distress and were adopted in the final version of the QI set. While the pilot test results indicated the feasibility of the developed QIs, they suggested that the frequency of care performance varied, and certain aspects of palliative care in ICUs needed to be improved, namely (1) regular pain assessment, (2) identification of the patient's advance directive and advance care planning for treatment, (3) conducting an interdisciplinary family conference on palliative care, and (4) assessment of psychological distress of family members. CONCLUSIONS: The QI set, developed using the modified Delphi method and tested using EMR data, provided a tool for assessing the quality of palliative care in ICUs. In the two ICUs considered in this study, aspects of the palliative care process with a low performance frequency were identified, and further national surveys were recommended. It is necessary to conduct ongoing surveys at more facilities to improve the quality of palliative care in ICUs.

One-Year Functional Outcomes After Invasive Mechanical Ventilation for Older Adults With Preexisting Long-Term Care-Needs.

OBJECTIVES: To examine 1-year functional outcomes after invasive mechanical ventilation for adults greater than or equal to 65 years with preexisting long-term care-needs. DESIGN: We used medical and long-term care administrative databases. The database included data on functional and cognitive impairments that were assessed with the national standardized care-needs certification system and were categorized into seven care-needs levels based on the total daily estimated care minutes. Primary outcome was mortality and care-needs at 1 year after invasive mechanical ventilation. Outcome was stratified by preexisting care-needs at the time of invasive mechanical ventilation: no care-needs, support level 1-2 and care-needs level 1 (estimated care time 25-49 min), care-needs level 2-3 (50-89 min), and care-needs level 4-5 (≥90 min). SETTING: A population-based cohort study in Tochigi Prefecture, one of 47 prefectures in Japan. PATIENTS: Among people greater than or equal to 65 years old registered between June 2014 and February 2018, patients who received invasive mechanical ventilation were identified. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 593,990 eligible people, 4,198 (0.7%) received invasive mechanical ventilation. The mean age was 81.2 years, and 55.5% were male. The 1-year mortality rates after invasive mechanical ventilation in patients with no care-needs, support level 1-2 and care-needs level 1, care-needs level 2-3, and care-needs level 4-5 at the time of invasive mechanical ventilation were 43.4%, 54.9%, 67.8%, and 74.1%, respectively. Similarly, those with worsened care-needs were 22.8%, 24.2%, 11.4%, and 1.9%, respectively. CONCLUSIONS: Among patients in preexisting care-needs levels 2-5 who received invasive mechanical ventilation, 76.0-79.2% died or had worsened care-needs within 1 year. These findings may aid shared decision-making among patients, their families, and heath care professionals on the appropriateness of starting invasive mechanical ventilation for people with poor functional and cognitive status at baseline.

Five Key Papers About Emergency Department Fall Evaluation: A Curated Collection for Emergency Physicians.

The evaluation of patients who have experienced a fall has been an integral part of geriatric emergency care. All physicians who engage in the care of the geriatric population in acute settings need to familiarize themselves with the current literature on this topic. However, it can be challenging to navigate the large body of literature on this topic. The purpose of this article is to identify and summarize the key studies that can be helpful for faculty interested in an evidence-based fall evaluation. The authors compiled a list of key papers on emergency department (ED) based upon a structured literature search supplemented with suggestions by key informants and an open call on social media; 32 studies on ED evaluation were identified. Our authorship group then engaged in a modified Delphi technique to develop consensus on the most important studies about fall evaluation for emergency physicians. This process eventually resulted in the selection of the top five articles on fall evaluation. Additionally, we summarize these studies with regard to their relevance to emergency medicine (EM) trainees and junior faculty. Evaluation of older patients with a history of falls is a challenging but crucial component of EM training. We believe our review will be educational for junior and senior EM faculty to better understand these patients' care and to design an evidence-based practice.

Association of the Number of a Simulation Faculty With the Implementation of Simulation-Based Education.

INTRODUCTION: Although the implementation of simulation-based education (SBE) is essential for emergency medicine residency programs (EMRPs), little is known about the factors associated with its degree of SBE implementation in EMRPs. Therefore, this study aimed to investigate factors associated with SBE implementation in EMRPs. We hypothesized that the number of the simulation faculty was associated with the degree of SBE implementation. METHODS: We conducted a multicenter, cross-sectional survey on SBE implementation in emergency medicine resident education, in accredited EMRPs in the Greater Tokyo area, Japan. Survey question themes included institutional characteristics and the status of simulation education in them. For analyzing factors associated with SBE implementation, we defined EMRPs with a robust SBE implementation as those having an annual simulation time exceeding 10 hours. RESULTS: The survey response rate was 73% (115/158). Of the EMRPs that responded, 32% reported that their annual simulation time was more than 10 hours. In the unadjusted analysis, possession of a simulator in the emergency department was significantly associated with nonrobust SBE implementation, but the number of the simulation faculty was significantly associated. On adjusting for possession of a simulator in the emergency department, presence of simulation curriculum, and presence of simulation-based formative or comprehensive assessment, we observed an association of robust SBE implementation with a number of the simulation faculty (unit odds ratio = 1.33; 95% confidence interval = 1.10-1.60). CONCLUSIONS: To our knowledge, this is the first Japanese study to demonstrate that the number of the simulation faculty at a program is independently associated with a robust SBE implementation.