Managing Delirium in the Emergency Department: An Updated Narrative Review.

Purpose of Review: Emergency departments (EDs) are facing an epidemic of overcrowding and ED boarding, particularly of older adults who often present with, or develop, delirium in the ED. Delirium is associated with increased complications, longer hospital length of stay, mortality, and costs to the healthcare system. However, we only have limited knowledge of how to successfully prevent and treat delirium in the ED in a pragmatic, sustainable, and cost-effective way. We present a narrative review of recent literature of delirium prevention and treatment programs in the ED. We aim to describe the components of successful delirium management strategies to be used by EDs in building delirium management programs. Recent Findings: We reviewed 10 studies (2005-2023) that report delirium interventions in the ED, and describe the different components of these interventions that have been studied. These interventions included: optimizing hemodynamics and oxygenation, treating pain, hydration and nutrition support, avoiding sedative hypnotics, antipsychotics and anticholinergics, promoting sleep, sensory stimulation, limiting the time spent in the ED, educating providers and staff, and developing multidisciplinary delirium protocols integrated into the electronic health record. Summary: Through our narrative review of the recent literature on delirium prevention and treatment programs in the ED, we have identified nine components of successful delirium prevention strategies in the ED. We also discuss three high priority areas for further research including identification of most effective components of delirium prevention strategies, conduct of additional high-quality trials in non-hip.

Validation of the Self-Reported Edmonton Frail Scale - Acute Care in Patients ≥ 65 Years Undergoing Surgery.

BACKGROUND: Frailty is common in geriatric emergency surgery and associated with increased risk for poor postoperative outcomes. Frailty screening is challenging in emergency settings. The Edmonton Frail Scale (EFS) is a valid tool to screen for patients at high risk for poor postoperative outcomes. Recently, the EFS was modified to decrease dependence on staff to perform physical measures. This modification, the EFS-Acute Care (EFS-AC), has not been validated. We wish to assess the agreement between the EFS and the EFS-AC. STUDY DESIGN: We performed a prospective cohort study from 10/2021 - 10/2022 screening 688 patients ≥ 65 years with both the EFS and EFS-AC preoperatively. We assessed the ability of the EFS-AC to discriminate frailty identified by the EFS and compared the association of both scales with loss of independence (LOI), hospital length of stay (LOS), ICU admissions, and ICU LOS. Receiver Operator Curves were used to estimate the discriminatory thresholds for LOI. RESULTS: 688 patients with a median age 73 (IQR 68, 77) were enrolled. The EFS-AC was able to discriminate individuals' frailty status by the EFS with excellent agreement (AUC 0.971 [0.958, 0.983]). An EFS-AC threshold score of ≥ 6 points lead to 93.60% of individuals being correctly identified (77.87% sensitivity and 97.00% specificity). Both EFS and EFS-AC ≥ 6 were similarly associated with a higher risk for all clinical outcomes assessed and demonstrated similar ability to predict LOI. CONCLUSIONS: The EFS-AC is a valid preoperative frailty screen, and due to its self-reported nature, can be administered in the acute care setting, during virtual visits, or through digital health apps. Real-time screening can assist with better understanding patient needs and lead to interventions to prevent poor hospital outcomes.

Implementation of a Multispecialty Geriatric Surgery Pathway Reduces Inpatient Cost for Frail Patients.

OBJECTIVE: The objective of this study was to evaluate the effect of geriatric surgical pathway (GSP) implementation on inpatient cost of care. BACKGROUND: Achieving high-value care for older patients is the goal of the American College of Surgeons Geriatric Verification Program (ACS-GSV). We have previously shown that implementation of our geriatric surgery pathway, which aligns with the ACS-GSV standards, resulted in a reduction in loss of independence and complications. METHODS: Patients ≥65 years who underwent an inpatient elective surgical procedure included in the American College of Surgeons National Quality Improvement Program (ACS NSQIP) registry from July 2016 through December 2017 were compared with those patients from February 2018 to December 2019 who were cared for on our GSP. An amalgamation of Clinformatics DataMart, the electronic health record, and the ACS NSQIP registry produced the analytical dataset. We compared mean total and direct costs of care for the entire cohort as well as through propensity matching of frail surgical patients to account for differences in clinical characteristics. RESULTS: The total mean cost of health care services during hospitalization was significantly lower in the cohort on our GSP ($23,361±$1110) as compared with the precohort ($25,452±$1723), P <0.001. On propensity-matched analysis, cost savings was more evident in our frail geriatric surgery patients. CONCLUSIONS: This study shows that high-value care can be achieved with the implementation of a GSP that aligns with the ACS-GSV program.

Validation of the self-reported domains of the Edmonton Frail Scale in patients 65 years of age and older.

INTRODUCTION: In the era of virtual care, self-reported tools are beneficial for preoperative assessments and facilitating postoperative planning. We have previously reported the use of the Edmonton Frailty Scale (EFS) as a valid preoperative assessment tool. OBJECTIVE: We wished to validate the self-reported domains of the EFS (srEFS) by examining its association with loss of independence (LOI) and mortality. METHODS: This is a post-hoc analysis of a single-institution observational study of patients 65 years of age or older undergoing multi-specialty surgical procedures and assessed with the EFS in the preoperative setting. Exploratory data analysis was used to determine the threshold for identifying frailty using the srEFS. Procedures were classified using the Operative Stress Score (OSS) scored 1 to 5 (lowest to highest). Hierarchical Condition Category (HCC) was utilized to risk-adjust. LOI was described as requiring more support at discharge and mortality was defined as death occurring up to 30 days following surgery. Receiver operating characteristic (ROC) curves were used to determine the ability of the srEFS to predict the outcomes of interest in relation to the EFS. RESULTS: Five hundred thirty-five patients were included. Exploratory analysis confirmed best positive predictive value for srEFS was greater or equal to 5. Overall, 113 (21 percent) patients were considered high risk for frailty (HRF) and 179 (33 percent) patients had an OSS greater or equal to 5. LOI occurred in 7 percent (38 patients) and the mortality rate was 4 percent (21 patients). ROC analysis showed that the srEFS performed similar to the standard EFS with no difference in discriminatory thresholds for predicting LOI and mortality. Examination of the domains of the EFS not included in the srEFS demonstrated a lack of association between cognitive decline and the outcomes of interest. However, functional status assessed with either the Get up and Go (EFS only) or self-reported ADLs was independently associated with increased risk for LOI. CONCLUSION: This study shows that self-reported EFS may be an optional preoperative tool that can be used in the virtual setting to identify patients at HRF. Early identification of patients at risk for LOI and mortality provides an opportunity to implement targeted strategies to improve patient care.

Early Outcomes Following Implementation of a Multispecialty Geriatric Surgery Pathway.

OBJECTIVE: To examine geriatric-specific outcomes following implementation of a multispecialty geriatric surgical pathway (GSP). BACKGROUND: In 2018, we implemented a GSP in accordance with the proposed 32 standards of American College of Surgeons' Geriatric Surgery Verification Program. METHODS: This observational study combined data from the electronic health record system (EHR) and ACS-National Surgery Quality Improvement Program (NSQIP) to identify patients ≥65 years undergoing inpatient procedures from 2016 to 2020. GSP patients (2018-2020) were identified by preoperative high-risk screening. Frailty was measured with the modified frailty index. Surgical procedures were ranked according to the operative stress score (1-5). Loss of independence (LOI), length of stay, major complications (CD II-IV), and 30-day all-cause unplanned readmissions were measured in the pre/postpatient populations and by propensity score matching of patients by operative procedure and frailty. RESULTS: A total of 533 (300 pre-GSP, 233 GSP) patients similar by demographics (age and race) and clinical profile (frailty) were included. On multivariable analysis, GSP patients showed decreased risk for LOI [odds ratio (OR) 0.26 (0.23, 0.29) P <0.001] and major complications [OR: 0.63 (0.50, 0.78) P <0.001]. Propensity matching demonstrated similar findings. Examining frail patients alone, GSP showed decreased risk for LOI [OR: 0.30 (0.25, 0.37) P <0.001], major complications [OR: 0.31 (0.24, 0.40) P <0.001], and was independently associated with a reduction in length of stay [incidence rate ratios: 0.97 (0.96, 0.98), P <0.001]. CONCLUSIONS: In our diverse patient population, implementation of a GSP led to improved geriatric-specific surgical outcomes. Future studies to examine pathway compliance would promote the identification of further interventions.

Preoperative Evaluation of the Frail Patient.

Perioperative management of older adults is a complex field that is heavily influenced by the clinical heterogeneity of older adults. Frailty-a geriatric syndrome in which a patient is more vulnerable to stressors due to decreases in physical function and reserve-has been indicative of adverse postoperative outcomes. Many tools have been developed to measure frailty that incorporate a variety of factors including physical and cognitive function, comorbidities, self-reported measures of health, and clinical judgment. Most of these frailty assessment tools are able to identify a subset of patients at risk of adverse outcomes including postoperative complications, longer hospital length of stay, discharge to a higher level of care, and mortality. Frailty assessment before surgical interventions can also guide discussions among patients, their families, anesthesiologists, and surgeons to tailor operative plans for patients to mitigate this increased risk. Studies are ongoing to identify interventions in frail patients that can improve postoperative outcomes, but high-quality data in the form of randomized controlled trials are lacking at this time.

Alternate biosynthesis of valerenadiene and related sesquiterpenes.

It is proposed that the biosynthesis of the sesquiterpene valerenadiene, a key intermediate in the biosynthesis of a sedative in valerian, involves cyclopropane and not cyclobutane intermediates and includes as a key step a cyclopropylcarbinylcation-cyclopropylcarbinylcation rearrangement analogous to the one observed in the conversion of presqualene to squalene in triterpene and steroid biosynthesis. Similar mechanisms are proposed for the biosynthesis of the related sesquiterpenes pacifigorgiol, tamariscene and (+)-pacifigorgia-1,10-diene.