Managing "socially admitted" patients in hospital: a qualitative study of health care providers' perceptions.

BACKGROUND: Emergency departments are a last resort for some socially vulnerable patients without an acute medical illness (colloquially known as "socially admitted" patients), resulting in their occupation of hospital beds typically designated for patients requiring acute medical care. In this study, we aimed to explore the perceptions of health care providers regarding patients admitted as "social admissions." METHODS: This qualitative study was informed by grounded theory and involved semistructured interviews at a Nova Scotia tertiary care centre. From October 2022 to July 2023, we interviewed eligible participants, including any health care clinician or administrator who worked directly with "socially admitted" patients. Virtual or in-person individual interviews were audio-recorded and transcribed, then independently and iteratively coded. We mapped themes on the 5 domains of the Quintuple Aim conceptual framework. RESULTS: We interviewed 20 nurses, physicians, administrators, and social workers. Most identified as female (n = 11) and White (n = 13), and were in their mid to late career (n = 13). We categorized 9 themes into 5 domains: patient experience (patient description, provision of care); care team well-being (moral distress, hierarchy of care); health equity (stigma and missed opportunities, prejudices); cost of care (wait-lists and scarcity of alternatives); and population health (factors leading to vulnerability, system changes). Participants described experiences caring for "socially admitted" patients, perceptions and assumptions underlying "social" presentations, system barriers to care delivery, and suggestions of potential solutions. INTERPRETATION: Health care providers viewed "socially admitted" patients as needing enhanced care but identified individual, institutional, and system challenges that impeded its realization. Examining perceptions of the people who care for "socially admitted" patients offers insights to guide clinicians and policy-makers in caring for socially vulnerable patients.

Adapting Geriatric Day Hospital Care From an In-House to Outreach Process.

Outpatient programs have been challenged to find ways to deliver services while adhering to coronavirus disease protocols. Our Geriatric Day Hospital (GDH) Falls Clinic changed from a 6-week in-house program to an outreach program incorporating telephone assessments and home visits. We evaluated whether the outreach program was effective in improving patient outcomes in 23 serially enrolled clients. Statistically significant gains were achieved with falls, Berg Balance Scale scores, functional reach measurements, and pain management scores. Access to social support from family or friends led to higher implementation of recommendations. There was an inability to predict which clients would improve from an outreach program, but it was evident that the program benefited some clients and provided a viable alternative to an in-person program. [Journal of Gerontological Nursing, 49(4), 33-38.].

Prevalence and Characteristics of Pre-Operative Delirium in Hip Fracture Patients.

BACKGROUND: Delirium is a common complication of hip fracture and is associated with negative outcomes. Previous studies document risk factors for post-operative delirium but have frequently excluded patients with pre-operative delirium. OBJECTIVE: This study endeavours to document prevalence and risk factors for pre-operative delirium in hip fracture patients and compares risk factor profiles and outcomes between pre- and post-operative delirium. METHODS: 283 hip fracture patients were assessed pre-operatively with the Delirium Elderly At Risk (DEAR) instrument, Mini-Mental State Examination (MMSE), and Confusion Assessment Method (CAM). They were followed on post-operative days 1, 3, and 5 for the presence of delirium. Doses of opioids were recorded. Wait time to surgery, length of stay, and discharge site were noted. RESULTS: Delirium was present in 57.6% patients pre-operatively and 41.7% post-surgery. Not all patients (62%) with pre-operative delirium also had post-operative delirium. There was a considerable overlap in risk factors, with some differences. Wait time to surgery, number of comorbidities, and total pre-operative opioid and lorazepam doses were associated with pre- but not post-operative delirium. Negative outcomes were more closely associated with post-operative delirium. CONCLUSION: Delirium is common in pre-hip fracture surgery patients, and not all patients with pre-operative delirium go on to have post-operative delirium. Risk factor profiles are not identical, raising the possibility of identifying and intervening in patients at high risk of delirium pre-operatively.

Translating Delirium Prevention Strategies for Elderly Adults with Hip Fracture into Routine Clinical Care: A Pragmatic Clinical Trial.

OBJECTIVES: To compare the feasibility (adherence) and effectiveness (prevalence of delirium, length of stay, mortality, discharge site) of delirium-friendly preprinted postoperative orders (PPOs) for individuals with hip fracture, administered by regular orthopedic nurses, with routine postoperative orders. DESIGN: Pragmatic clinical trial to evaluate a quality improvement intervention. SETTING: Tertiary care hospital. PARTICIPANTS: Individuals aged 65 and older admitted for hip fracture repair (N = 283). INTERVENTION: PPOs with delirium-friendly options and doses for nighttime sedation, analgesia, and nausea and attention to catheter removal and bowel movements. MEASUREMENTS: Adherence to PPO was compared with adherence to routine orders. Drug doses were recorded. Presence of delirium was documented using the Confusion Assessment Method and the Mini-Mental State Examination on postoperative Days 1, 3, and 5. Length of stay, discharge site, and in-hospital mortality were recorded. RESULTS: Orthopedic nurses adhered reasonably well with delirium-friendly PPOs. Of 283 participants, 42% developed postoperative delirium, with significantly less delirium in the intervention group (intervention 33%, control 51%, P = .001). The effect of the intervention was stronger in individuals with preexisting dementia (intervention 60%, control 97%, P < .001). Participants with postoperative delirium had longer hospital stays and were more likely to die or be discharged to a nursing home, but there was no significant between-group difference in these outcomes. CONCLUSION: It is possible to introduce delirium-friendly PPOs into routine post-hip fracture care in a representative elderly population including individuals with dementia. Delirium-friendly PPOs executed by regular nursing staff resulted in a significant reduction in postoperative delirium but no difference in other outcomes.

Multimodal Pain Management in Older Elective Arthroplasty Patients.

BACKGROUND: Pain management after elective arthroplasty in older adults is complicated due to the risk of undertreatment of postoperative pain and potential adverse effects from analgesics, notably opioids. Using combinations of analgesics has been proposed as potentially beneficial to achieve pain control with lower opioid doses. OBJECTIVE: We compared a multimodal pain protocol with a traditional one, in older elective arthroplasty patients, measuring self-rated pain, incidence of postoperative delirium, quantity and cost of opioid analgesics consumed. METHODS: One hundred fifty-eight patients, 70 years and older, admitted to tertiary care for elective arthroplasty were prospectively assessed postoperative days 1-3. Patients received either traditional postoperative analgesia (acetaminophen plus opioids) or a multimodal pain protocol (acetaminophen, opioids, gabapentin, celecoxib), depending on surgeon preference. Self-rated pain, postoperative delirium, and time to achieve standby-assist ambulation were compared, as were total opioid doses and analgesic costs. RESULTS: Despite receiving significantly more opioid analgesics (traditional: 166.4 mg morphine-equivalents; multimodal: 442 mg morphine equivalents; t = 10.64, P < .0001), there was no difference in self-rated pain, delirium, or mobility on postoperative days 1-3. Costs were significantly higher in the multimodal group (t = 9.15, P < .0001). Knee arthroplasty was associated with higher pain scores than hip arthroplasty, with no significant difference in opioid usage. CONCLUSION: A multimodal approach to pain control demonstrated no benefit over traditional postoperative analgesia in elective arthroplasty patients, but with significantly higher amounts of opioid consumed. This poses a potential risk regarding tolerability in frail older adults and results in increased drug costs.

Prevalence and outcomes of delirium in community and non-acute care settings in people without dementia: a report from the Canadian Study of Health and Aging.

BACKGROUND: While delirium is common among older adults in acute care hospitals, its prevalence in other settings has been less well studied. We examined delirium prevalence and outcomes in a large cohort of older Canadians living outside of acute care. METHODS: In this secondary analysis of the Canadian Study of Health and Aging, the prevalence of clinically diagnosed delirium was estimated and five-year survival was compared with that of individuals with dementia of graded severity. RESULTS: Delirium was very uncommon (prevalence <0.5%) and was associated with reduced survival, similar to that of moderate-to-severe dementia. CONCLUSION: In this cohort of older Canadians, delirium in non-demented people was associated with very low 5-year survival, at levels comparable with advanced dementia. Although it is common in hospital, delirium is uncommon among older adults in their usual place of residence, suggesting that it is a potent stimulus to seek medical care.

Incomplete functional recovery after delirium in elderly people: a prospective cohort study.

BACKGROUND: Delirium often has a poor outcome, but why some people have incomplete recovery is not well understood. Our objective was to identify factors associated with short-term (by discharge) and long-term (by 6 month) incomplete recovery of function following delirium. METHODS: In a prospective cohort study of elderly patients with delirium seen by geriatric medicine services, function was assessed at baseline, at hospital discharge and at six months. RESULTS: Of 77 patients, vital and functional status at 6 months was known for 71, of whom 21 (30%) had died. Incomplete functional recovery, defined as > or =10 point decline in the Barthel Index, compared to pre-morbid status, was present in 27 (54%) of the 50 survivors. Factors associated with death or loss of function at hospital discharge were frailty, absence of agitation (hypoactive delirium), a cardiac cause and poor recognition of delirium by the treating service. Frailty, causes other than medications, and poor recognition of delirium by the treating service were associated with death or poor functional recovery at 6 months. CONCLUSION: Pre-existing frailty, cardiac cause of delirium, and poor early recognition by treating physicians are associated with worse outcomes. Many physicians view the adverse outcomes of delirium as intractable. While in some measure this might be true, more skilled care is a potential remedy within their grasp.

Risk of Pre-and Post-Operative Delirium and the Delirium Elderly At Risk (DEAR) Tool in Hip Fracture Patients.

BACKGROUND AND PURPOSE: Delirium is common after hip fracture. Previous work has shown that a simple delirium risk factor tool, the Delirium Elderly At Risk instrument (DEAR), has a high inter-rater reliability in this population. Little research has looked at the ability of risk factor screening tools to identify patients at high risk of pre-operative delirium. This study investigates the ability of the DEAR to identify patients at high risk of pre-operative delirium, as well as reporting its performance in a post-operative validation sample. Associations between delirium risk factors and pre-operative delirium are explored. METHODS: This prospective cohort study took place on an orthopedic in-patient service at a University-affiliated tertiary care hospital. Patients aged 65 and older who were admitted for surgical repair of hip fracture (N = 283) were assessed pre-operatively for 5 delirium risk factors (cognitive impairment, sensory impairment, functional dependence, substance use, age) using the DEAR. Patients were assessed for delirium using the Mini-Mental State Examination and the Confusion Assessment Method pre-operatively and on post-operative days 1, 3 and 5. Characteristics of patients who developed delirium were compared with the characteristics of those who did not. RESULTS: Delirium was present in 58% (95% CI = 52-63%) of patients pre-operatively and 42% (95% CI = 36-48%) post-operatively. Individually, sensory impairment (χ(2) = 21.7, p = .0001), functional dependence (χ(2) = 24.1, p = .0001), cognitive impairment (χ(2) = 55.5, p = .0001) and substance use (χ(2) = 7.5, p = .007) were significantly associated with pre-operative delirium, as was wait-time for surgery (t = 3.1, p = .003) and length of stay (t = 2.8, p =.03). In multivariate modeling, the strongest association with pre-operative delirium was cognitive impairment. CONCLUSIONS: The DEAR, a simple, delirium risk factor screening tool, can be used to identify hip fracture patients at risk of both pre-operative and post-operative delirium, which may allow targeted implementation of delirium prevention strategies.

Development and Evaluation of a Mandatory Course in Geriatric Medicine for Fourth Year Medical Students.

BACKGROUND AND OBJECTIVES: As the population ages, older adults will make up an increasing proportion of the practices of most physicians. Because of this, education of medical students in Geriatric Medicine is essential, yet there is considerable variability in the amount, timing within the curriculum, and content of geriatric training in Medical Schools. Our goal was to develop and evaluate an integrated, mandatory 3-week geriatric medicine course for fourth year medical students with emphasis on knowledge acquisition. METHODS: All fourth year medical students at Dalhousie Medical School underwent 2 ½ days of didactic teaching on core geriatric topics and a 2-week clinical rotation. Pre-rotation knowledge testing occurred on the first day of the rotation. On the final examination, students were retested on the 15 pre-rotation questions, as well as 5 additional questions that they had not encountered previously. RESULTS: There was a statistically significant improvement in examination performance from 46.9% on the pretest to 78.6% on the final examination (t=24.7, p˂.001). It is unlikely that the significant improvement in scores is simply a result of repeat testing, as students tended to score better on the five additional questions that they had not seen before. DISCUSSION: We developed a geriatric medicine course for fourth year medical students, in one integrated 3-week block, using a combination of didactic teaching and clinical encounters. We used students as their own controls, using the same questions pre- and post-rotation, and demonstrated significant knowledge acquisition on a variety of topics pertaining to geriatric medicine and care of the older patient. Future research should address the issue of translating acquired knowledge in geriatric medicine into demonstrated clinical skills when caring for the elderly.

A 3 Week Geriatric Education Program for 4th Year Medical Students at Dalhousie University.

Purpose -Population demographics are shifting towards an increased average age. Yet, many medical schools still do not have mandatory comprehensive education in Geriatric Medicine. In 2001, the Division of Geriatric Medicine at Dalhousie University developed a required three-week geriatric course for fourth year medical students. This paper describes the details of the curriculum so that it can be reproduced in other settings. Results - The curriculum was successfully implemented. An examination, held at the end of each 3- week rotation, documented extensive learning of important concepts in Geriatric Medicine. The students gave positive feedback about the benefits of this training program. Conclusion -A well developed formal education program teaches students specific skills in Geriatric Medicine, which may improve the care of the growing elderly population. Key words: geriatric, geriatrics, elderly, curriculum, medical school education.