Improving Delirium Screening and Detection for Older Adults Presenting to the Emergency Department (ED): A Novel ED Delirium Screening and Detection Program

改善急诊科 (ED) 老年人的谵妄筛查和检测：一种新颖的 ED 谵妄筛查和检测计划

• 批准号: 10524537
• 负责人: Liron Danay Sinvani
• 金额: $ 25.13万
• 依托单位: FEINSTEIN INSTITUTE FOR MEDICAL RESEARCH
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-09-15 至 2024-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10524537
• 关键词: Accident and Emergency department; Address; Adherence; Adoption; Affect; Chemicals; Clinical; Clinical Management; Cluster randomized trial; Complex; Data; Delirium; Dementia; Detection; Discipline of Nursing; Documentation; Educational workshop; Elderly; Electronic Health Record; Emergency Medicine; Enrollment; Ensure; Environment; Failure; Goals; Health system; Hospitals; Impaired cognition; Intensive Care Units; Intervention; Interview; Knowledge; Leadership; Maintenance; Methods; Modeling; Nurses; Outcome; Outcome Assessment; Patients; Physical Restraint; Prevention; Psychological reinforcement; Randomized; Reach Effectiveness Adoption Implementation and Maintenance; Research; Screening procedure; Site; Standardization; Structure; Testing; Time; Trainers Training; Training; Training Programs; United States; Validation; base; clinical practice; confusion assessment method; demographics; emergency settings; experience; implementation evaluation; implementation fidelity; implementation outcomes; implementation science; improved; improved outcome; innovation; mortality; multimodality; novel; prevent; primary outcome; programs; recruit; response; restraint; retention rate; screening; secondary outcome; standard of care; success; telehealth

Over 23 million older adults present to the Emergency Department (ED) each year in the United States, and up to 20% will experience delirium while in the ED. Yet, it is estimated that over 75% of ED delirium cases are missed. Failure to systematically screen and detect ED delirium affects clinical management (e.g., use of chemical and physical restraints) and outcomes (e.g., increased mortality and dementia). Barriers to ED delirium detection consist of a lack in screening tool use, competing priorities, and wide-ranging knowledge deficits. Even when validated screening tools (e.g., brief confusion assessment method, bCAM) are prioritized and integrated into nursing workflow, they are rarely used consistently or accurately in clinical practice, leading to lack of delirium detection. Our long-term goal is to implement and disseminate a comprehensive ED Delirium Detection Program (ED-DDP) that will improve screening, detection, and management of ED delirium in older adults. Our group has previously developed and tested the innovative DDP in the intensive care unit (ICU- DDP). The ICU-DDP utilizes a “train-the-trainer” model, and consists of: 1) a multicomponent one-day delirium champion workshop; 2) real-time direct observation, training, and reinforcement via telehealth (tele-delirium training); and 3) training of nurses by champions. The ICU-DDP improved delirium detection from 9.1% to 30.1% (p = 0.005). Subsequently, we refined the ICU-DDP for the ED (ED-DDP) through semi-structured interviews with ED stakeholders and a pilot of ED tele-delirium training. ED stakeholder interviews revealed that participation in the ED-DDP was of high priority, acceptable, and feasible. The overarching aim of this proposal is to determine the preliminary efficacy of the ED-DDP for improving ED delirium screening, detection, and management in older adults, while also evaluating implementation outcomes of the ED-DDP for champions and nurses. We propose to: 1) conduct a pilot stepped wedge cluster randomized trial (SW-CRT) of the ED-DDP across 3 diverse EDs to determine preliminary efficacy of the ED-DDP; and 2) use a mixed- methods approach to assess RE-AIM implementation outcomes (Reach, Efficacy, Adoption, Implementation, and Maintenance) of the ED-DDP. Our team with expertise in delirium, emergency medicine, hospital-based interventions, and implementation science, is well-poised to complete the following 2 Specific Aims: 1) Conduct a pilot SW-CRT across 3 ED sites to determine the preliminary efficacy of the ED-DDP for improving delirium screening, detection, and management in older adults presenting to the ED; and 2) Grounded in the RE-AIM framework, we will use mixed methods to conduct implementation outcome assessments of the ED-DDP for champions and nurses. The proposal addresses a critical need for improving ED delirium screening, detection, and management, which will improve outcomes for the millions of older adults presenting to the ED each year. Our findings will: inform approaches to ensure program fidelity; enable validation and refinement of the ED- DDP; and estimate effect sizes for a subsequent full-scale SW-CRT of the ED-DDP.

在美国，每年有超过2300万老年人到急诊部就诊，甚至更多 到20%的人在急诊室时会经历精神错乱。然而，据估计，超过75%的勃起功能障碍病例是 打偏了。未能系统地筛查和检测勃起功能障碍会影响临床治疗(例如，使用 化学和物理限制)和结果(例如，增加死亡率和痴呆症)。边缘的障碍 精神错乱的检测包括缺乏筛查工具的使用，相互竞争的优先事项，以及广泛的知识 赤字。即使在对有效的筛选工具(例如，简单混淆评估方法，BCAM)进行优先排序时 并集成到护理工作流程中，在临床实践中很少始终如一或准确使用，导致 缺乏精神错乱的检测。我们的长期目标是实施和传播全面的ED Delirium 检测计划(ED-DDP)将改善老年人勃起功能障碍的筛查、检测和管理 成年人。我们小组之前曾在重症监护病房(ICU)开发和测试创新的DDP- DDP)。ICU-DDP采用“教练员培训”模式，包括：1)一天多成分的精神错乱 冠军研讨会；2)通过远程医疗(远程精神错乱)进行实时直接观察、培训和增援 培训)；以及3)冠军对护士的培训。ICU-DDP将妄想的检测率从9.1%提高到 30.1%(p=0.005)。随后，我们通过半结构化的方式对ED的ICU-DDP(ED-DDP)进行细化 采访ED的利益相关者和一名ED远程妄想训练的飞行员。ED利益相关者访谈揭示 参加ED-DDP是高度优先的、可接受的和可行的。这样做的首要目标是 建议确定ED-DDP在改善勃起功能障碍筛查、检测、 和老年人的管理，同时也评估ED-DDP的实施结果 冠军和护士。我们建议：1)进行试点阶梯楔形群随机试验(SWCRT) ED-DDP跨越3个不同的ED，以确定ED-DDP的初步疗效；和2)使用混合的- 评估RE-AIM实施结果的方法(REACH、有效性、采用、实施、 和维护)。我们的团队在精神错乱、急救医学方面拥有专业知识，以医院为基础 干预和实施科学已做好准备，以完成以下两个具体目标：1)开展 一项覆盖ED三个部位的中试短波CRT，以确定ED-DDP改善妄想的初步疗效 向急诊室提交的老年人的筛查、检测和管理；2)以RE-AIM为基础 框架内，我们会采用混合方法，为以下计划进行推行成效评估 冠军和护士。该提案解决了改善ED精神错乱筛查、检测、 和管理，这将改善每年向教育署提交报告的数百万老年人的结果。 我们的发现将：为确保计划保真度的方法提供信息；使ED- 并估计ED-DDP随后的全尺寸SWCRT的效应大小。