Supervisory knowing in practice across medical specialities.

Clinical supervisors play key roles in facilitating trainee learning. Yet combining that role with patient care complicates both roles. So, we need to know how both roles can effectively co-occur. When facilitating their trainees' learning through practice, supervisors draw on their skills - clinical and supervisory - and available opportunities in their practice. This process can be conceptualised as supervisory knowing in practice (or contextual knowing) and offers ways to elaborate on how facilitating trainees' learning can be optimised. The practice-based study presented and discussed here examined clinical supervisors' knowing in practice related to facilitating trainee learning, across three medical specialities. Nineteen clinical supervisors from emergency medicine, internal medicine and surgery, were interviewed about their roles and engagement with trainees. Interview transcripts were analysed in two stages. Firstly, a framework analysis, informed by interdependent learning theory was conducted, focussing on affordances and individual engagement. Secondly, drawing on practice theory, a further layer of analysis was undertaken interrogating supervisors' knowing in practice. We identified two common domains of supervisor practice used to facilitate trainee learning: (1) orientating and assessing trainees' readiness (or capabilities), (2) sequencing and enriching pedagogic practices. Yet across the speciality groups the supervisors' knowing in practice differed and were shaped by a trio of: (i) disciplinary practices, (ii) situational requirements and (iii) clinician preference. Overall, we offer a new reading of clinical supervision as practice differences generated distinct supervisory knowing in practice. These findings emphasise clinical supervision as fundamentally entwined in the speciality's practice; and reinforce alignments with patient care.

A narrative review of the development and performance characteristics of electronic delirium-screening tools.

BACKGROUND: Electronic delirium-screening tools are an emergent area of research. OBJECTIVE: The objective of this study was to summarise the development and performance characteristics of electronic screening tools in delirium. METHODS: Searches were conducted in Pubmed, Embase, and CINAHL Complete databases to identify electronic delirium-screening tools. RESULTS: Five electronic delirium-screening tools were identified and reviewed. Two were designed for and tested within a medical setting, and three were applied to intensive care. Adaptive design features, such as skip function to reduce test burden, were variably integrated into instrument design. All tools were shown to have acceptable psychometric properties, but validation studies were largely incomplete. CONCLUSIONS: Electronic delirium-screening tools are an exciting area of development and may offer hope for improved uptake of delirium screening.

Modifiable risk factors for post-operative delirium in older adults undergoing major non-cardiac elective surgery: a multi-centre, trainee delivered observational cohort feasibility study and trainee survey.

BACKGROUND: Post-operative delirium (POD) is an acute brain failure which may occur following major surgery, with serious implications for participants and caregivers. Evidence regarding optimal anaesthetic management for older participants at higher risk of POD is conflicting. We conducted a feasibility study of our protocol in 5 centres to guide sample size estimation and inform future recruitment strategies for a larger cohort study. METHODS: Participants aged over 65 and scheduled for major surgery were recruited. They were assessed pre-operatively for delirium, cognitive impairment, depression, comorbidity, activity levels and alcohol use. Details of management during surgery, all medications and complications were recorded by a trainee-led research team. Participants were assessed for delirium in the immediate recovery period and then on post-operative days 1-4 using the 4 question attention test (4AT) with complications assessed at day 4 using the post-operative morbidity survey (POMS). Primary outcomes were the incident rates of POD. Secondary outcomes were number of eligible patients, recruitment rates and retention rates throughout the study, time required for data collection, preoperative risk factors assessment and daily postoperative delirium assessments. Also to assess the added value of employing the regional trainee research network (INCARNNET) to deliver the study. Specifically, what proportion of patient consent, data collection and post-operative testing is performed by anaesthesia trainees from this group, especially the success of weekend delirium assessment by trainees? A survey was completed at the end of the study by the trainees involved regarding their involvement in the study. RESULTS: Ninety-five participants were recruited, of whom 93 completed the study. Overall, POD occurred in 9 patients. Of these, three were detected in recovery and six on post-op days 1-4. Median length of stay was 6 days. Recruitment rates were high in all but one site. 59 (62%) participants were consented by trainees and 189 (63%) of post op delirium assessments were performed by trainees. A total of six patients declined the study (in a follow up survey of trainees). Pre-existing cognitive impairment, depression and problem drinking were detected in 4(4.3%), 3(3.2%) and 5(5.37%) participants, respectively. Co-morbidity was common with 55(59%) in class three or four of the geriatric index of morbidity. Overall, from a total of 641 data points, levels of missing data were as follows, site A = 9.3%, B = 13.5%, C = 15.4%, D = 10.9%, E = 11.1% (data could not be completed retrospectively). CONCLUSIONS: A multi-centre observational cohort study of delirium carried out by UK trainee anaesthetists is feasible. Patients are content to undergo day of surgery consent and multiple short questionnaires pre-operatively. Proposed data, especially pharmacological, should be carefully considered for their relevance to modifiable mechanisms that can lead to POD. Future research to enable prognostic modelling of POD should involve large scale cohort studies of enriched populations to capture a higher POD incidence. POD remains a common complication in older persons undergoing major surgery in the UK and studies of interventions are urgently needed. TRIAL REGISTRATION: All methods were carried out in accordance with relevant guidelines and regulations. The study was retrospectively registered with ISRCTN94663125 on 07/02/2018.

'It's tough. It is hard': A qualitative interview study of staff and volunteers caring for hospice in-patients with delirium.

BACKGROUND: Delirium is a distressing condition often experienced by hospice in-patients. Increased understanding of current multidisciplinary care of delirium is needed to develop interventions in this setting. AIM(S): To explore hospice staff and volunteers' practice, its influences and what may need to change to improve hospice delirium care. DESIGN: Qualitative interview study using behaviour change theory from a critical realist stance. SETTING/PARTICIPANTS: Thirty-seven staff, including different professional groups and roles, and volunteers were purposively sampled from two in-patient hospices. RESULTS: We found that participants' practice focus was on managing hyperactive symptoms of delirium, through medication use and non-pharmacological strategies. Delirium prevention, early recognition and hypoactive delirium received less attention. Our theoretically-informed analysis identified this focus was influenced by staff and volunteers' emotional responses to the distress associated with hyperactive symptoms of delirium as well as understanding of delirium prevention, recognition and care, which varied between staff groups. Non-pharmacological delirium management was supported by adequate staffing levels, supportive team working and a culture of person-centred and family-centred care, although behaviours that disrupted the calm hospice environment challenged this. CONCLUSIONS: Our findings can inform hospice-tailored behaviour change interventions that develop a shared team understanding and engage staff's emotional responses to improve delirium care. Reflective learning opportunities are needed that increase understanding of the potential to reduce patient distress through prevention and early recognition of delirium, as well as person-centred management. Organisational support for adequate, flexible staffing levels and supportive team working is required to support person-centred delirium care.

A systematic review of modified electroconvulsive therapy (ECT) to treat delirium.

BACKGROUND: Delirium is costly for patients, carers, and healthcare systems. In addition, non-pharmacological and pharmacological management of delirium is challenging. Electroconvulsive therapy (ECT) has been proposed and used as an anecdotal treatment of delirium in clinical practice. However, the efficacy and safety of this approach are not well understood. OBJECTIVE: To synthesise and review the evidence relating to the safety and efficacy of ECT as a treatment for delirium. METHODS: A systematic review was completed according to PRISMA guidelines using the PubMed, CINAHL, Cochrane Library, and PsycINFO databases. Studies were eligible for inclusion if modified ECT was used to treat delirium symptoms. ECT for delirium in people with neuroleptic malignant syndrome, catatonia, or confusional states associated with acute primary psychiatric conditions were excluded. All included records were first ranked using the hierarchy of evidence-based medicine; quality was then assessed using the Joanna Briggs critical appraisal checklists. Pooled data across the cases identified were analysed using descriptive statistics. RESULTS: Of 1226 records screened, 10 studies met inclusion criteria: six case reports, three case series, and one quasi-experimental study. The literature base was of mixed quality. A single quasi-experimental study was assessed to be of 'fair' quality, the remainder of the case series and case reports were rated as 'poor' to 'fair' quality. A total of only 40 individual people with delirium who were treated with ECT were identified. In 33/40 cases, the aetiology of delirium was substance withdrawal. The number of ECT treatments administered ranged from 1 to 13. ECT was reported to positively contribute towards treatment of delirium in all cases, although objective measures of improvement were reported in only 6/13 patient cases from case reports and case series (46%). The singular quasi-experimental study reported a statistically significant decrease in duration of delirium, time spent in physical restraint, and in benzodiazepine requirement when ECT was used as an adjunct in benzodiazepine withdrawal delirium. When adverse events were described these included mild confusion and memory deficits; all were reported as time limited and reversible. Considerable limitations in the quality of the evidence base were identified, including the risk of selection, publication and reporting bias. Much data reporting on safety and efficacy of ECT in delirium was missing. CONCLUSION: There is insufficient literature to support modified ECT as a clinical treatment for delirium. The few studies identified were generally of weak evidence lacking important data on safety and objective outcome measures, and not including populations with broad delirium aetiologies. Further research using more robust methodologies and broader populations (age, aetiology) of people with delirium treated with ECT is needed.

An interdisciplinary statement of scientific societies for the advancement of delirium care across Europe (EDA, EANS, EUGMS, COTEC, IPTOP/WCPT).

BACKGROUND: Delirium is a geriatric syndrome that presents in 1 out of 5 hospitalized older patients. It is also common in the community, in hospices, and in nursing homes. Delirium prevalence varies according to clinical setting, with rates of under 5% in minor elective surgery but up to 80% in intensive care unit patients. Delirium has severe adverse consequences, but despite this and its high prevalence, it remains undetected in the majority of cases. Optimal delirium care requires an interdisciplinary, multi-dimensional diagnostic and therapeutic approach involving doctors, nurses, physiotherapists, and occupational therapists. However, there are still important gaps in the knowledge and management of this syndrome. MAIN BODY: The objective of this paper is to promote the interdisciplinary approach in the prevention and management of delirium as endorsed by a delirium society (European Delirium Association, EDA), a geriatrics society (European Geriatric Medicine Society, EuGMS), a nursing society (European Academy of Nursing Science, EANS), an occupational therapy society (Council of Occupational Therapists for European Countries, COTEC), and a physiotherapy society (International Association of Physical Therapists working with Older People of the World Confederation for Physical Therapy, IPTOP/WCPT). SHORT CONCLUSION: In this paper we have strongly promoted and supported interdisciplinary collaboration underlying the necessity of increasing communication among scientific societies. We have also provided suggestions on how to fill the current gaps via improvements in undergraduate and postgraduate delirium education among European Countries.

Debate article: Antipsychotic medications are clinically useful for the treatment of delirium.

Prescribing of antipsychotic medications for patients with delirium remains controversial. Concerns exist that these vulnerable and frail patients may be prescribed antipsychotics inappropriately as a substitute for non-pharmacological approaches when identifiable causes are not found or they challenge ward processes. Moreover, recent evidence suggests that antipsychotics may cause more harm than good in the palliative care patient group with delirium. On the other hand, guidelines in the United Kingdom and the Netherlands support prescribing of antipsychotics in certain circumstances, and a large European survey has revealed that antipsychotics tend to be prescribed first line for hyperactive delirium. Never before, therefore, is there a greater need to examine whether indeed these medications are clinically useful for the treatment of delirium. With this in mind, evidence-based arguments for and against prescribing antipsychotics for the treatment of delirium are presented in this debate article. The paper concludes with a moderation piece to help guide clinical practice.

Evaluation of the delirium early monitoring system (DEMS).

BACKGROUND: Despite awareness of the negative health and financial outcomes of delirium, systems to routinely assess and manage the condition are absent in clinical practice. We report the development and pilot evaluation of a Delirium Early Monitoring System (DEMS), designed to be completed by non-medical staff to influence clinical processes within inpatient settings. Two versions of the DEMS are described based on a modified Confusion Assessment Method (DEMS-CAM) and Delirium Observation Screening Scale (DEMS-DOSS). METHODS: Both versions of DEMS were piloted on a 20-bedded Psychogeriatric ward over 6 weeks. Training was administered to ward staff on the use of each version of the DEMS and data were collected via electronic medical records and completed assessment sheets. The primary outcome was patterns of DEMS use and the secondary outcome was the initiation of delirium management protocols. Data regarding the use of the DEMS DOSS and DEMS CAMS were analyzed using χ 2 tests. RESULTS: Completion rates for the DEMS CAM and DEMS DOSS were 79% and 68%, respectively. Non-medical staff were significantly more likely to use the DEMS-CAM as part of daily practice as opposed to the DEMS-DOSS (p<0.001). However, there was no difference between the use of the DEMS-CAM and DEMS-DOSS in triggering related actions such as documentation of assessment scores in patients' medical records and implementation of delirium management protocols. CONCLUSIONS: This real world evaluation revealed that non-medical staff were able to incorporate delirium monitoring into their practice, on the majority of occasions, as part of their daily working routine. Further research is necessary to determine if the routine use of the DEMS can lead to improved understandings and practice of non-medical staff regarding delirium detection.