Implementation of delirium screening in the emergency department: A qualitative study with early adopters.

INTRODUCTION: Delirium affects 15% of older adults presenting to emergency departments (EDs) but is detected in only one-third of cases. Evidence-based guidelines for ED delirium screening exist, but are underutilized. Frontline staff perceptions about delirium and time and resource constraints are known barriers to ED delirium screening uptake. Early adopters of ED delirium screening can offer valuable lessons about successful implementation. METHODS: We conducted semi-structured interviews with clinician-administrators leading ED delirium screening initiatives from 20 EDs in the United States and Canada. Interviews focused on experiences of planning and implementing ED delirium screening. Interviews lasted 15 to 50 minutes and were digitally recorded and transcribed. To identify factors that commonly impacted implementation of ED delirium screening, we used constructs from the Consolidated Framework for Implementation Research (CFIR), an Implementation Science framework widely used to evaluate healthcare improvement initiatives. RESULTS: Overall, notable facilitators of successful implementation were having institutional and ED leadership support and designated clinical champions to longitudinally engage and educate frontline staff. We found specific examples of factors affecting implementation drawn from the following seven CFIR constructs: (1) intervention complexity, (2) intervention adaptability, (3) external policies and incentives, (4) peer pressure from other institutions, (5) the implementation climate of the ED, (6) staff knowledge and beliefs, and (7) engaging deliverers of intervention, that is, frontline ED staff. CONCLUSION: Implementing ED delirium screening is complex and requires institutional resources as well as clinical champions to engage frontline staff in a sustained fashion.

A scoping review of geriatric emergency medicine research transparency in diversity, equity, and inclusion reporting.

INTRODUCTION: The intersection of ageism and racism is underexplored in geriatric emergency medicine (GEM) research. METHODS: We performed a scoping review of research published between January 2016 and December 2021. We included original emergency department-based research focused on falls, delirium/dementia, medication safety, and elder abuse. We excluded manuscripts that did not include (1) original research data pertaining to the four core topics, (2) older adults, (3) subjects from the United States, and (4) for which full text publication could not be obtained. The primary objective was to qualitatively describe reporting about older adults' social identities in GEM research. Secondary objectives were to describe (1) the extent of inclusion of minoritized older adults in GEM research, (2) GEM research about health equity, and (3) feasible approaches to improve the status quo of GEM research reporting. RESULTS: After duplicates were removed, 3277 citations remained and 883 full-text articles were reviewed, of which 222 met inclusion criteria. Four findings emerged. First, race and ethnicity reporting was inconsistent. Second, research rarely provided a rationale for an age threshold used to define geriatric patients. Third, GEM research more commonly reported sex than gender. Fourth, research commonly excluded older adults with cognitive impairment and speakers of non-English primary languages. CONCLUSION: Meaningful assessment of GEM research inclusivity is limited by inconsistent reporting of sociodemographic characteristics, specifically race and ethnicity. Reporting of sociodemographic characteristics should be standardized across different study designs. Strategies are needed to include in GEM research older adults with cognitive impairment and non-English primary languages.

Pragmatism and feasibility: A qualitative study of experiences implementing and upgrading care in geriatric emergency departments.

Objectives: Implementation and sustainability of new care processes in emergency departments (EDs) is difficult. We describe experiences of implementing geriatric care processes in EDs that upgraded their accreditation level for the Geriatric Emergency Department Accreditation (GEDA) program. These EDs can provide a model for adopting and sustaining guidelines for evidence-based geriatric care. Methods: We performed qualitative interviews with geriatric ED nurse and physician leaders overseeing their ED's geriatric accreditation processes. The interview guide was based on the Consolidated Framework for Implementation Research (CFIR), a framework consisting of a comprehensive set of factors that impact implementation of evidence-based interventions. We used inductive analysis to elucidate key themes from interviews and deductive analysis to map themes onto CFIR constructs. Results: Clinician leaders from 15 of 19 EDs that upgraded accreditation status by March 1, 2023 participated in interviews. Motivations to upgrade accreditation level centered on improving patient care (73%) and achieving recognition (56%). Rationales for choosing specific care processes were more commonly related to feasibility (40%) and ability to integrate the processes into the electronic health record (33%) than to site-specific patient needs (20%). Several common experiences in implementation were identified: (1) financing from the larger health system or philanthropy was crucial; (2) translating the Geriatric ED Guidelines into clinical practice was challenging for clinician leaders; (3) motivational barriers existed among frontline ED staff; (4) longitudinal staff education was needed given frontline ED staff attrition and turnover; and (5) the electronic health record facilitated implementation of geriatric screenings. Conclusions: Geriatric ED accreditation involves significant time, resource allocation, and longitudinal staff commitment. EDs pursuing geriatric accreditation balance aspirations to improve patient care with resource availability to implement new care processes and competing priorities.

A protocol to determine the acceptability and feasibility of a pilot intervention emergency department virtual observation unit fall prevention program.

BACKGROUND: As a third of all community dwellers aged 65+ fall each year, falls are common reasons for older adults to present to an Emergency Department (ED). Although EDs should assess patients' multifactorial fall risks to prevent future fall-related injuries, this frequently does not occur. We describe our protocol to determine the feasibility, acceptability, and safety of a pilot ED Virtual Observation Unit (VOU) Falls program. METHODS: To ensure standardized conduct and reporting, the Standard Protocol Items for Intervention Trials (SPIRIT) guidelines will be used. The VOU is a program where patients are sent home from the ED but are part of a virtual observation unit in that they can call on-call ED physicians while they are being treated for conditions such as cellulitis, congestive heart failure, or pneumonia. A paramedic conducts daily visits with the patient and facilitates a telemedicine consult with an ED physician. VOU nursing staff conduct daily assessments of patients via telemedicine. The ED VOU Falls program is one of the VOU pathways and is a multi-component fall prevention program for fall patients who present after an ED visit. The paramedic conducts a home safety evaluation, a Timed Up and Go Test (TUG). During the VOU visit, the ED physician conducts a telemedicine visit, while the paramedic is visiting the home, to review patients' fall-risk-increasing drugs and their TUG test. We will determine feasibility by calculating rates of patient enrollment refusal, and adherence to fall-risk prevention recommendations using information from 3-month follow-up telephone calls, as well as qualitative interviews with the paramedics. We will determine the acceptability of the ED VOU Falls program based on patient and provider surveys using a Likert scale. We will ask VOU nursing staff to report any safety issues encountered while the patient is in the ED VOU Falls program (e.g., tripping hazards). We will use the chi-square test or Fisher's exact test for categorical variables, Student's t-test for continuous variables, and Mann-Whitney for nonparametric data. We will review interview transcripts and generate codes. Codes will then be extracted and organized into concepts to generate an overall theme following grounded theory methods. This is a pilot study; hence, results cannot be extrapolated. However, a definite trial would be the next step in the future to determine if such a program could be implemented as part of fall prevention interventions. DISCUSSION: This study will provide insights into the feasibility and acceptability of a novel ED VOU Falls program with the aim of ultimately decreasing falls. In the future, such a program could be implemented as part of fall prevention interventions.

Emergency department communication with diverse caregivers and persons living with dementia: A qualitative study.

BACKGROUND: Research to date has detailed numerous challenges in emergency department (ED) communication with persons living with dementia (PLWD) and their caregivers. However, little is known about communication experiences of individuals belonging to minoritized racial and ethnic groups, who are disproportionately impacted by dementia and less likely to be included in dementia research. METHODS: We conducted semi-structured interviews with 29 caregivers of PLWD from two urban academic hospital EDs with distinct patient populations. The first site is an ED in the Northeast serving a majority White, English-speaking, and insured population. The second site is an ED in the South serving a majority Black and/or Hispanic, Spanish-speaking, and underinsured population. Interviews lasted an average of 25 min and were digitally recorded and transcribed. We used an inductive approach to analyze interview transcripts for dominant themes and compared themes between sites. RESULTS: Our sample included caregivers of diverse racial and ethnic backgrounds. Caregivers cared for PLWD who spoke English, Spanish, Arabic, Chinese, and Vietnamese. We identified three themes. First, caregiver advocacy was central to experiences of ED communication, particularly when PLWD primarily spoke a non-English language. Second, routine care plans did not address what mattered most to participants and PLWD. Participants felt that care arose from protocols and did not address what mattered most to them. Third, White English-speaking caregivers in Site 1 more commonly expected ED staff to engage them in care decision-making than Black, Hispanic, Asian, and Middle Eastern caregivers in Site 2. CONCLUSION: Language barriers amplify the higher intensity care needed by PLWD in the ED. Strategies should be developed for communicating with PLWD and caregivers about what matters most in their ED care.

Frailty assessment tools in the emergency department: A geriatric emergency department guidelines 2.0 scoping review.

Objective: Given the aging population and growing burden of frailty, we conducted this scoping review to describe the available literature regarding the use and impact of frailty assessment tools in the assessment and care of emergency department (ED) patients older than 60 years. Methods: A search was made of the available literature using the Covidence system using various search terms. Inclusion criteria comprised peer-reviewed literature focusing on frailty screening tools used for a geriatric population (60+ years of age) presenting to EDs. An additional search of PubMed, EBSCO, and CINAHL for articles published in the last 5 years was conducted toward the end of the review process (January 2023) to search specifically for literature describing interventions for frailty, yielding additional articles for review. Exclusion criteria comprised articles focusing on an age category other than geriatric and care environments outside the emergency care setting. Results: A total of 135 articles were screened for inclusion and 48 duplicates were removed. Of the 87 remaining articles, 20 were deemed irrelevant, leaving 67 articles for full-text review. Twenty-eight were excluded for not meeting inclusion criteria, leaving 39 full-text studies. Use of frailty screening tools were reported in the triage, care, and discharge decision-making phases of the ED care trajectory, with varying reports of usefulness for clinical decision-making. Conclusion: The literature reports tools, scales, and instruments for identifying frailty in older patients at ED triage; multiple frailty scores or tools exist with varying levels of utilization. Interventions for frailty directed at the ED environment were scant. Further research is needed to determine the usefulness of frailty identification in the context of emergency care, the effects of care delivery interventions or educational initiatives for front-line medical professionals on patient-oriented outcomes, and to ensure these initiatives are acceptable for patients.

The differences in code status conversation approaches reported by emergency medicine and palliative care clinicians: A mixed-method study.

BACKGROUND: During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different. METHODS: We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians' self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale ("very unlikely" to "very likely") was used to assess the likelihood of asking about medical procedures (procedure based) and patients' values (value based) during code status conversations, followed by semistructured interviews. RESULTS: Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patient's acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients' goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies. CONCLUSIONS: Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.

Perceptions of Acute Care Telemedicine Among Caregivers for Persons Living with Dementia: A Qualitative Study.

Persons living with dementia (PLWD) have high emergency department (ED) utilization. Little is known about using telemedicine with PLWD and caregivers as an alternative to ED visits for minor acute health problems. This qualitative interview-based study elicited caregivers' perspectives about the acceptability of telemedicine for acute complaints. We performed telephone interviews with 28 caregivers of PLWD from two academic EDs, one in the Northeast and another in the South. Using a combined deductive-inductive approach, we coded interview transcripts and elucidated common themes by consensus. All caregivers reported they would need to participate in the telemedicine visit to help overcome communication and digital literacy challenges. People from racial/ethnic minority groups reported lower comfort with the virtual format. In both sites, participants expressed uncertainty about illness severity that could preclude using telemedicine for acute complaints. Overall, respondents deemed acute care telemedicine acceptable, but caregivers describe specific roles as crucial intermediaries to facilitate virtual care.

Diversity, Equity, and Inclusion: Considerations in the Geriatric Emergency Department Patient.

This article introduces core topics in health equity scholarship and provides examples of how diversity, equity, and inclusion impact the aging population and emergency care of older adults. It offers strategies for promoting diversity, equity, and inclusion to both strengthen the patient-clinician therapeutic relationship and to address operations and systems that impact care of the geriatric emergency department patient.

Adults' Experiences with Type 2 Diabetes in Rural Guatemala: A Qualitative Study.

BACKGROUND: Given that the diabetes burden is rising rapidly in low- and middle-income countries, it is critical to understand perspectives of people living with diabetes in these settings. This qualitative study examines perceptions of causality and treatment among adults with type 2 diabetes in rural Indigenous communities of Guatemala. METHODS: We conducted semi-structured interviews with 29 people living with type 2 diabetes from a population survey in two majority Indigenous Guatemalan towns. Data were coded inductively and themes were elucidated by consensus. RESULTS: Participants emphasized strong emotional experiences and stress as perceived causes of diabetes, as well as diet and heritability. All participants took biopharmaceutical treatments, but many also endorsed diet, exercise, herbal remedies, and naturopathic products as important remedies. CONCLUSION: Perspectives from people living with diabetes in two rural Indigenous towns in Guatemala differ from the biomedical model of disease and have implications for clinical practice and program development.

The development of an educational workshop to reframe and manage professional conflict via a sex and gender lens.

Background: Conflict is inevitable in the emergency department, and conflict resolution is an essential skill for emergency providers to master. Effective conflict management can optimize patient care and enhance professional satisfaction. To communicate effectively in high-stress, high-impact situations, sex- and gender-based differences need to be considered. Methods: Nine resident, fellow, junior, and senior faculty members of the Academy for Women in Academic Emergency Medicine collaborated to design a 4-h workshop. The focus was on professional communication and conflict resolution in emergency medicine (EM), with special attention on how sex and gender can influence these processes. Results: The final educational workshop utilized a variety of formats focused on communication and effective conflict resolution including: traditional didactics, facilitated small groups with case-based learning, expert panel discussion, and an experiential learning session. The consideration of how sex- and gender-associated factors might contribute additional complexity or challenges to conflictual interactions were interwoven into each session to highlight alternative vantage points. Conclusions: Effective conflict resolution is an important skill for success in EM. We developed a workshop that went beyond typical communication-based programming to consider how sex- and gender-related factors influence communication and conflict resolution.

"I'd rather see action": Application and recruitment experiences of underrepresented in emergency medicine trainees.

Objectives: The emergency medicine (EM) physician workforce is largely composed of white men. Despite recruitment efforts over the past decade, there has not been a significant increase of trainees with underrepresented racial and ethnic identities in EM (URM). Prior studies have focused on institutional strategies to improve diversity, equity, and inclusion (DEI) in EM residency recruitment but have been limited in describing URM trainees' perspectives. We sought to assess URM trainees' perspectives on DEI in the EM residency application and selection process. Methods: This study was conducted at an urban academic medical center in the United States from November 2021 to March 2022. Junior residents were invited to participate in individual semistructured interviews. We used a combined deductive-inductive approach to categorize responses in predetermined areas of interest then elicit dominant themes within each category through consensus discussions. Thematic saturation was reached after eight interviews, indicating adequate sample size. Results: Ten residents participated in semistructured interviews. All identified as racial or ethnic minorities. Three dominant themes emerged relating to authenticity, representation, and being treated as a learner first. Participants assessed the authenticity of a program's DEI efforts by evaluating the time frame and scope of DEI efforts. Participants reported a desire for representation of other URM colleagues in a residency program and training environment. While participants wanted their lived experience as URM trainees acknowledged, they were wary of being viewed solely through the lens of future DEI leaders rather than as learners first. Conclusions: URM residents value multifaceted commitment to DEI efforts, representation, and being seen as learners first when assessing residency programs. Programs seeking to recruit URM residents should develop a department-wide, multipronged, comprehensive DEI plan and showcase how their program will contribute to an applicant's professional development.

Physical therapy consultation in the emergency department for older adults with falls: A qualitative study.

Objectives: Little is known about current practices in consulting physical therapy (PT) in the emergency department (ED) for older adults with falls, a practice that can reduce fall-related ED revisits. This qualitative study aimed to understand perspectives of ED staff about ED PT consultation for older adults with falls and fall-related complaints, specifically regarding perceived value and associated challenges and strategies. Methods: We performed focus groups and key informant interviews with emergency physicians, advanced practice clinicians, nurses, physical therapists, occupational therapists, and technicians who perform ED geriatric screenings. We used rapid qualitative analysis to identify common themes related to decisions to consult PT from the ED, perceived value of PT, and common challenges and strategies in ED PT consultation. Results: Twenty-five participants in 4 focus groups and 3 interviews represented 22 distinct institutions with ED PT consultation available for older adults with falls. About two thirds of EDs represented relied on clinician gestalt to request PT consultation (n = 15, 68%), whereas one third used formal consultation pathways (n = 7, 32%). Participants valued physical therapists' expertise, time, and facilitation of hospital throughput by developing safe discharge plans and contact with patients to improve outpatient follow-up. Common challenges included limited ED PT staffing and space for PT evaluations; strategies to promote ED PT consultation included advocating for leadership buy-in and using ED observation units to monitor patients and avoid admission until PT consultation was available. Conclusion: ED PT consultation for older adults with falls may benefit patients, ED staff, and hospital throughput. Uncertainty remains over whether geriatric screening-triggered consultation versus emergency clinician gestalt successfully identifies patients likeliest to benefit from ED PT evaluation. Leadership buy-in, designated consultation space, and formalized consultation pathways are strategies to address current challenges in ED PT consultation.

Leveraging the Electronic Health Record to Implement Emergency Department Delirium Screening.

OBJECTIVE: The aim of this study is to understand how emergency departments (EDs) use health information technology (HIT), and specifically the electronic health record (EHR), to support implementation of delirium screening. METHODS: We conducted semi-structured interviews with 23 ED clinician-administrators, representing 20 EDs, about how they used HIT resources to implement delirium screening. Interviews focused on challenges participants experienced when implementing ED delirium screening and EHR-based strategies they used to overcome them. We coded interview transcripts using dimensions from the Singh and Sittig sociotechnical model, which addresses use of HIT in complex adaptive health care systems. Subsequently, we analyzed data for common themes across dimensions of the sociotechnical model. RESULTS: Three themes emerged about how the EHR could be used to address challenges in implementation of delirium screening: (1) staff adherence to screening, (2) communication among ED team members about a positive screen, and (3) linking positive screening to delirium management. Participants described several HIT-based strategies including visual nudges, icons, hard stop alerts, order sets, and automated communications that facilitated implementation of delirium screening. An additional theme emerged about challenges related to the availability of HIT resources. CONCLUSION: Our findings provide practical HIT-based strategies for health care institutions planning to adopt geriatric screenings. Building delirium screening tools and reminders to perform screening into the EHR may prompt adherence to screening. Automating related workflows, team communication, and management of patients who screen positive for delirium may help save staff members' time. Staff education, engagement, and access to HIT resources may support successful screening implementation.

Qualitative study of pathways to care among adults with diabetes in rural Guatemala.

OBJECTIVE: The burden of diabetes mellitus is increasing in low-income and middle-income countries (LMICs). Few studies have explored pathways to care among individuals with diabetes in LMICs. This study evaluates care trajectories among adults with diabetes in rural Guatemala. DESIGN: A qualitative investigation was conducted as part of a population-based study assessing incidence and risk factors for chronic kidney disease in two rural sites in Guatemala. A random sample of 807 individuals had haemoglobin A1c (HbA1c) screening for diabetes in both sites. Based on results from the first 6 months of the population study, semistructured interviews were performed with 29 adults found to have an HbA1c≥6.5% and who reported a previous diagnosis of diabetes. Interviews explored pathways to and experiences of diabetes care. Detailed interview notes were coded using NVivo and used to construct diagrams depicting each participant's pathway to care and use of distinct healthcare sectors. RESULTS: Participants experienced fragmented care across multiple health sectors (97%), including government, private and non-governmental sectors. The majority of participants sought care with multiple providers for diabetes (90%), at times simultaneously and at times sequentially, and did not have longitudinal continuity of care with a single provider. Many participants experienced financial burden from out-of-pocket costs associated with diabetes care (66%) despite availability of free government sector care. Participants perceived government diabetes care as low-quality due to resource limitations and poor communication with providers, leading some to seek care in other health sectors. CONCLUSIONS: This study highlights the fragmented, discontinuous nature of diabetes care in Guatemala across public, private and non-governmental health sectors. Strategies to improve diabetes care access in Guatemala and other LMICs should be multisectorial and occur through strengthened government primary care and innovative private and non-governmental organisation care models.