Comparative Implementation of a Brief App-Directed Protocol for Delirium Identification by Hospitalists, Nurses, and Nursing Assistants : A Cohort Study.

BACKGROUND: Systematic screening improves delirium identification among hospitalized older adults. Little data exist on how to implement such screening. OBJECTIVE: To test implementation of a brief app-directed protocol for delirium identification by physicians, nurses, and certified nursing assistants (CNAs) in real-world practice relative to a research reference standard delirium assessment (RSDA). DESIGN: Prospective cohort study. SETTING: Large urban academic medical center and small rural community hospital. PARTICIPANTS: 527 general medicine inpatients (mean age, 80 years; 35% with preexisting dementia) and 399 clinicians (53 hospitalists, 236 nurses, and 110 CNAs). MEASUREMENTS: On 2 study days, enrolled patients had an RSDA. Subsequently, CNAs performed an ultra-brief 2-item screen (UB-2) for delirium, whereas physicians and nurses performed a 2-step protocol consisting of the UB-2 followed in those with a positive screen result by the 3-Minute Diagnostic Assessment for the Confusion Assessment Method. RESULTS: Delirium was diagnosed in 154 of 924 RSDAs (17%) and in 114 of 527 patients (22%). The completion rate for clinician protocols exceeded 97%. The CNAs administered the UB-2 in a mean of 62 seconds (SD, 51). The 2-step protocols were administered in means of 104 seconds (SD, 99) by nurses and 106 seconds (SD, 105) by physicians. The UB-2 had sensitivities of 88% (95% CI, 72% to 96%), 87% (CI, 73% to 95%), and 82% (CI, 65% to 91%) when administered by CNAs, nurses, and physicians, respectively, with specificities of 64% to 70%. The 2-step protocol had overall accuracy of 89% (CI, 83% to 93%) and 87% (CI, 81% to 91%), with sensitivities of 65% (CI, 48% to 79%) and 63% (CI, 46% to 77%) and specificities of 93% (CI, 88% to 96%) and 91% (CI, 86% to 95%), for nurses and physicians, respectively. Two-step protocol sensitivity for moderate to severe delirium was 78% (CI, 54% to 91%). LIMITATION: Two sites; limited diversity. CONCLUSION: An app-directed protocol for delirium identification was feasible, brief, and accurate, and CNAs and nurses performed as well as hospitalists. PRIMARY FUNDING SOURCE: National Institute on Aging.

Nature as nurture: Rural older women's perspectives on the natural environment.

Rural older women are surrounded by nature, a dynamic context for human development. Informed by place attachment and attention restoration theory, and guided by a life course perspective, this qualitative study focused on the perceived influence of nature in the lives of 34 rural older women. Using grounded theory techniques to analyze in-depth interviews, two primary findings emerged: (a) nature was integral to the women's identity; and (b) interactions with nature were motivated by prior positive spiritual and psychological outcomes. Findings revealed the power of the natural environment as a resource for coping with the challenges associated with aging.

Factors associated with disagreement between clinician app-based ultra-brief Confusion Assessment Method and reference standard delirium assessments.

BACKGROUND: Recently, the Ultra-Brief Confusion Assessment Method (UB-CAM), designed to help physicians and nurses to recognize delirium, showed high, but imperfect, accuracy compared with Research Reference Standard Delirium Assessments (RRSDAs). The aim of this study is to identify factors associated with disagreement between clinicians' app-based UB-CAM assessments and RRSDAs. METHODS: This is a secondary analysis of a prospective diagnostic test study. The study was conducted at two hospitals and included 527 inpatients (≥70 years old) and 289 clinicians (53 physicians, 236 nurses). Trained research associates performed RRSDAs and determined delirium presence using the CAM. Clinicians administered the UB-CAM using an iPad app. Disagreement factors considered were clinician, patient, and delirium characteristics. We report odds ratios and 95% confidence intervals. RESULTS: One thousand seven hundred and ninety-five clinician UB-CAM assessments paired with RRSDAs were administered. The prevalence of delirium was 17%. The rate of disagreement between clinician UB-CAM assessments and RRSDAs was 12%. Significant factors associated with disagreement between clinician UB-CAM assessments and RRSDAs (OR [95% CI]) included: presence of dementia (2.7 [1.8-4.1]), patient education high school or less (1.9 [1.3-2.9]), psychomotor retardation (2.5 [1.4-4.2]), and the presence of mild delirium or subsyndromal delirium (5.5 [3.5-8.7]). Significant risk factors for false negatives were patient age less than 80 (2.2 [1.1-4.3]) and mild delirium (3.5 [1.6-7.4]). Significant risk factors for false positives were presence of dementia (4.0 [2.3-7.0]), subsyndromal delirium (5.1 [2.9-9.1]), and patient education high school or less (2.0 [1.2-3.6]). Clinician characteristics were not significantly associated with disagreement. CONCLUSIONS: The strongest factors associated with disagreement between clinician UB-CAM screens and RRSDAs were the presence of dementia and subsyndromal delirium as risk factors for false positives, and mild delirium and younger age as a risk factor for false negatives. These disagreement factors contrast with previous studies of risk factors for incorrect clinician delirium screening, and better align screening results with patient outcomes.

Usability of the 4Ms Worksheet in the Emergency Department for Older Patients: A Qualitative Study.

Introduction: Older adults often have multiple comorbidities; therefore, they are at high risk for adverse events after discharge. The 4Ms framework-what matters, medications, mentation, mobility-has been used in acute and ambulatory care settings to identify risk factors for adverse events in older adults, although it has not been used in the emergency department (ED). We aimed to determine whether 1) use of the 4Ms worksheet would help emergency clinicians understand older adult patients' goals of care and 2) use of the worksheet was feasible in the ED. Methods: We conducted a qualitative, descriptive study among patients aged ≥60 years and emergency clinicians from January-June 2022. Patients were asked to fill out a 4Ms worksheet; following this, semi-structured interviews were conducted with patients and clinicians separately. We analysed data to create codes, which were divided into categories and sub-categories. Results: A total of 20 older patients and 19 emergency clinicians were interviewed. We identified two categories based on our aims: understanding patient goals of care (sub-categories: clinician/ patient concordance; understanding underlying goals of care; underlying goals of care discrepancy) and use of 4Ms Worksheet (sub-categories: worksheet to discussion discrepancy; challenges using worksheet; challenge completing worksheet before discharge). Rates of concordance between patient and clinician on main concern/goal of care and underlying goals of care were 82.4% and 15.4%, respectively. Conclusion: We found that most patients and emergency clinicians agreed on the main goal of care, although clinicians often failed to elicit patients' underlying goal(s) of care. Additionally, many patients preferred to have the interviewer fill out the worksheet for them. There was often discrepancy between what was written and what was discussed with the interviewer. More research is needed to determine the best way to integrate the 4Ms framework within emergency care.

Collaborating toward equity in Pennsylvania: The Age-Friendly Care, PA project.

OBJECTIVE: To collaboratively implement the age-friendly health systems framework, known as the 4Ms: What Matters, Medication, Mentation, and Mobility, at The Primary Health Network (PHN), a federally qualified health center. DATA SOURCES: Data were collected from PHN electronic medical records (EMRs) for individuals over age 65 from December 30, 2019 to December 24, 2021 and from Project ECHO© attendance and evaluation surveys. STUDY DESIGN: The telementoring educational program, Project ECHO©, was used to engage PHN health care professionals working in rural areas of Pennsylvania to incorporate the 4Ms into their practice starting with the annual wellness visit (AWV). Project ECHO© was launched at three primary care sites. After 18 months, it was then disseminated to an additional 18 sites creating pilot and comparison groups. Outcomes included codesigned patient process metrics using EMR data and project ECHO© participant data. DATA COLLECTION METHODS: EMR data were generated by system reports created by PHN's quality assurance program manager. Project ECHO© data were collected and managed using REDCap electronic data capture tools. Outcomes were aggregated, analyzed for trends over time, and compared between groups. PRINCIPAL FINDINGS: All nine process outcomes increased from baseline to follow-up at the three initial sites, ranging from 4% to 43% g. At year two, the three initial sites had higher rates on AWVs (pilot 24%, comparison 12%; p < 0.0001), Advance Care Planning (New on file, pilot 8%, comparison 2%; Discussed with patient, pilot 18%, comparison 13%; Patient declined, pilot 0%, comparison 0%; p = 0.0001), Dementia Screening (pilot 24%, comparison 12%; p < 0.0001), Fall Risk Management (pilot 43%, comparison 10%; p < 0.0001), and Mobility Goal (pilot 19%, comparison 9%; p < 0.0001); and lower rates on High-Risk Medication Elimination (pilot 54%, comparison, 63%, p < 0.02). CONCLUSIONS: Access to high-quality geriatric care for rural older adults can be improved by increasing health care professionals' knowledge of the 4Ms, beginning with its incorporation into the AWV.

Older adults' goals of care in the emergency department setting: A qualitative study guided by the 4Ms framework.

Background: We sought to identify what matters to older adults (60 years and older) presenting to the emergency department (ED) and the challenges or concerns they identify related to medication, mobility, and mentation to inform how the 4Ms framework could improve care of older adults in the ED setting. Methods: A qualitative study was conducted using the 4Ms to identify what matters to older adults (≥60 years old) presenting to the ED and what challenges or concerns they identify related to medication, mobility, and mentation. We conducted semi-structured interviews with a convenience sample of patients in a single ED. Interview guide responses and interviewer field notes were entered into REDCap. Interviews were reviewed by the research team (2 coders per interview) who inductively assigned codes. A codebook was created through an iterative process and was used to group codes into themes and sub-themes within the 4Ms framework. Results: A total of 20 ED patients participated in the interviews lasting 30-60 minutes. Codes identified for "what matters" included problem-oriented expectation, coordination and continuity, staying engaged, being with family, and getting back home. Codes related to the other 4Ms (medication, mobility, and mentation) described challenges. Medication challenges included: non-adherence, side effects, polypharmacy, and knowledge. Mobility challenges included physical activity and independence. Last, mentation challenges included memory concerns, depressed mood, and stress and worry. Conclusions: Our study used the 4Ms to identify "what matters" to older adults presenting to the ED and the challenges they face regarding medication, mobility, and mentation. Understanding what matters to patients and the specific challenges they face can help shape and individualize a patient-centered approach to care to facilitate the goals of care discussion and handoff to the next care team.

Comparative salary-related costs of a brief app-directed delirium identification protocol by hospitalists, nurses, and nursing assistants.

BACKGROUND: Systematic screening can improve delirium identification among hospitalized older adults. Prior studies have shown clinicians and health system leaders may believe they do not have the time and resources for assessment. We conducted a comparative salary-related cost analysis of an adaptive delirium identification protocol directed by an iPad app. METHODS: We recruited 527 older adult medicine patients from an urban academic medical center (n = 269) and a rural community hospital (n = 258). Physicians and nurses completed the two-step Ultra-brief Confusion Assessment Method (UB-CAM) protocol (with or without a skip pattern), while certified nursing assistants completed only the UB-2 ultra-brief screen. The sample included 527 patients (average age 80, 57% women, 35% with dementia). Time required to administer the protocol was collected automatically by the iPad app. Salary-related costs of screening were determined by multiplying the time required by the hourly wage for the three disciplines, as obtained from national and regional published healthcare salary cost data. Cost estimates for entire hospital implementation were also calculated. RESULTS: Participants were screened on 924 hospital days by 399 clinicians (53 physicians, 236 nurses, 110 CNAs). For the UB-2, CNAs cost per screen was lower than the other clinician types ($0.37 per screen vs. $0.73 for nurses and $2.39 for hospitalists). For the UB-CAM with skip (UB-CAM), costs per protocol were $1.10 for nurses vs. $3.61 for physicians. The annual salary-related costs of hospital-wide implementation of a nurse-based UB-CAM protocol in a medium-sized (300-bed) hospital was $63,015 plus $4356 for initial and annual training. CONCLUSIONS: CNAs and nurses had the lowest salary-associated costs for app-directed CAM-based delirium screening and identification, respectively. Salary-related annual hospital costs for the most efficient protocols in a medium-sized hospital were less than the annual cost of hiring 1 FTE of the discipline performing the protocols.

Implementing a Rapid, Two-Step Delirium Screening Protocol in Acute Care: Barriers and Facilitators.

BACKGROUND/OBJECTIVES: An effective and efficient protocol for delirium identification is needed to improve health outcomes for older adults and reduce healthcare costs. This study describes the barriers and facilitators related to the implementation of the ultra-brief confusion assessment method (UB-CAM), a rapid two-step delirium identification protocol (ultra-brief screen, followed by CAM in positives), field tested with hospitalized older adults (70+). DESIGN: A qualitative descriptive design using observational data collection and brief semi-structured interviews. SETTINGS: An urban academic medical center and a community teaching hospital. PARTICIPANTS: Participants included 50 physician hospitalists, 189 registered nurses, and 83 nursing assistants (NAs). MEASUREMENTS: Field researchers guided by a modified multi-level implementation framework, collected observational data as participants administered the UB-CAM (n = 767). Thematic analysis was conducted on five observational categories: structural, organizational, patient, clinician, and innovation. Field notes and brief semi-structured interviews (n = 231) with clinicians, explored the utility, acceptability, and feasibility of the protocol, and supplemented the observations. RESULTS: The UB-CAM was generally positively received by all three clinician types. Six themes describe barriers and/or facilitators to implementing the UB-CAM: (1) physical setting and milieu; (2) practice environment; (3) integrating into role; (4) adaptive techniques; (5) patient responses; and (6) systematic assessment. The composition and interaction of the six themes determined if the theme was expressed as a barrier or facilitator, affirming the importance of context when implementing system-level delirium screening. CONCLUSION: This is one of the first studies to test a two-step process for delirium identification, and to involve NAs in screening, and the findings demonstrate overall support from clinicians for delirium identification, and describe the need for a multifaceted, contextualized, and systemic approach to implementation and evaluation of delirium screening.

A mobile app for delirium screening.

OBJECTIVE: The objective of this study is to describe the algorithm and technical implementation of a mobile app that uses adaptive testing to assess an efficient mobile app for the diagnosis of delirium. MATERIALS AND METHODS: The app was used as part of a NIH-funded project to assess the feasibility, effectiveness, administration time, and costs of the 2-step delirium identification protocol when performed by physicians and nurses, and certified nursing assistants (CNA). The cohort included 535 hospitalized patients aged 79.7 (SD = 6.6) years enrolled at 2 different sites. Each patient was assessed on 2 consecutive days by the research associate who performed the reference delirium assessment. Thereafter, physicians, nurses, and CNAs performed adaptive delirium assessments using the app. Qualitative data to assess the experience of administering the 2-step protocol, and the app usability were also collected and analyzed from 50 physicians, 189 nurses, and 83 CNAs. We used extensible hypertext markup language (XHTML) and JavaScript to develop the app for the iOS-based iPad. The App was linked to Research Electronic Data Capture (REDCap), a relational database system, via a REDCap application programming interface (API) that sent and received data from/to the app. The data from REDCap were sent to the Statistical Analysis System for statistical analysis. RESULTS: The app graphical interface was successfully implemented by XHTML and JavaScript. The API facilitated the instant updating and retrieval of delirium status data between REDCap and the app. Clinicians performed 881 delirium assessments using the app for 535 patients. The transmission of data between the app and the REDCap system showed no errors. Qualitative data indicated that the users were enthusiastic about using the app with no negative comments, 82% positive comments, and 18% suggestions of improvement. Delirium administration time for the 2-step protocol showed similar total time between nurses and physicians (103.9 vs 106.5 seconds). Weekly enrollment reports of the app data were generated for study tracking purposes, and the data are being used for statistical analyses for publications. DISCUSSION: The app developed using iOS could be easily converted to other operating systems such as Android and could be linked to other relational databases beside REDCap, such as electronic health records to facilitate better data retrieval and updating of patient's delirium status. CONCLUSION: Our app operationalizes an adaptive 2-step delirium screening protocol. Its algorithm and cross-plat formed code of XHTML and JavaScript can be easily exported to other operating systems and hardware platforms, thus enabling wider use of the efficient delirium screening protocol that we have developed. The app is currently implemented as a research tool, but with adaptation could be implemented in the clinical setting to facilitate widespread delirium screening in hospitalized older adults.

Comparative Accuracy and Efficiency of Four Delirium Screening Protocols.

BACKGROUND/OBJECTIVES: Systematic screening can improve detection of delirium, but lack of time is often cited as why such screening is not performed. We investigated the time required to implement four screening protocols that use the Ultra-Brief two-item screener for delirium (UB-2) and the 3-Minute Diagnostic Interview for Confusion Assessment Method (CAM)-defined Delirium (3D-CAM), with and without a skip pattern that can further shorten the assessment. Our objective was to compare the sensitivity, specificity, and time required to complete four protocols: (1) full 3D-CAM on all patients, (2) 3D-CAM with skip on all patients, (3) UB-2, followed by the full 3D-CAM in "positives," and (4) UB-2, followed by the 3D-CAM with skip in "positives." DESIGN: Comparative efficiency simulation study using secondary data. SETTING: Two studies (3D-CAM and Researching Efficient Approaches to Delirium Identification (READI)) conducted at a large academic medical center (3D-CAM and READI) and a small community hospital (READI only). PARTICIPANTS: General medicine inpatients, aged 70 years and older (3D-CAM, n = 201; READI, n = 330). MEASUREMENTS: We used 3D-CAM data to simulate the items administered under each protocol and READI data to calculate median administration time per item. We calculated sensitivity, specificity, and total administration time for each of the four protocols. RESULTS: The 3D-CAM and READI samples had similar characteristics, and all four protocols had similar simulated sensitivity and specificity. Mean administration times were 3 minutes 13 seconds for 3D-CAM, 2 minutes 19 seconds for 3D-CAM with skip, 1 minute 52 seconds for UB-2 + 3D-CAM in positives, and 1 minute 14 seconds for UB-2 + 3D-CAM with skip in positives, which was 1 minute 59 seconds faster than the 3D-CAM (P < .001). CONCLUSION: The UB-CAM, consisting of the UB-2, followed in positives by the 3D-CAM with skip pattern, is a time-efficient delirium screening protocol that holds promise for increasing systematic screening for delirium in hospitalized older adults.

Older women with cardiovascular disease: perceptions of initial experiences and long-term influences on daily life.

In 2004, we conducted qualitative interviews with 29 White women diagnosed with cardiovascular disease (CVD) living in Southwest Virginia, aged 69 to 92 years (M age = 79.2 years; SD = 6.8); time since diagnosis ranged from 1 to 50 years (M = 14.3; SD = 11.2). We explored the women's initial illness episode and the influence of CVD on their current daily functioning, family activities and relationships, and social engagement. The women were slow to seek help for CVD symptoms. Postrecovery, 62% of women perceived their heart disease as influencing change in their daily lives. The influence of CVD varied depending on how congruent behavior changes were with their sense of self.

Older women's experiences with multiple health conditions: daily challenges and care practices.

Guided by life-course theory and a trajectory model of chronic illness, we examined the health care practices and management strategies used by 17 older women with multiple chronic conditions. Qualitative analyses revealed that the women played an active role in shaping the course of their illness within their everyday lives. Pain and a decline in energy frequently interfered with completion of daily activities. To compensate, many women reduced and slowed down the pace of activities they performed while emphasizing the importance of maintaining independence and autonomy. Appreciative of support from family members, at times the women received more help and advice than they preferred.