Use of a Multimodal Implementation Strategy to Improve Delirium Screening by Nurses on an Acute Care for Elders Unit.

This column shares the best evidence-based strategies and innovative ideas on how to facilitate the learning of EBP principles and processes by clinicians as well as nursing and interprofessional students. Guidelines for submission are available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1741-6787.

Identification of seniors at risk (ISAR) screening tool in the emergency department: implementation using the plan-do-study-act model and validation results.

INTRODUCTION: To better meet the needs of older adults in the emergency department, Senior Friendly care processes, such as high-risk screening are recommended. The identification of Seniors at Risk (ISAR) tool is a 6-item validated screening tool for identifying elderly patients at risk of the adverse outcomes post-ED visit. This paper describes the implementation of the tool in the Mount Sinai Hospital emergency department using a Plan-Do-Study-Act model; and demonstrates whether the tool predicts adverse outcomes. METHODS: An observational study tracked tool implementation. A retrospective chart audit was completed to collect data about elderly ED patients during 2 time periods in 2010 and 2011. Data analysis compared the characteristics of patients with positive and negative screening tool results. RESULTS: The identification of Seniors at Risk tool was completed for 51.6% of eligible patients, with 61.2% of patients having a positive result. Patients with positive screening results were more likely to be over age 79 (P = .003); be admitted to hospital (P < .001); have a longer mean ED length of stay (P < .001). For patients admitted to hospital, those with positive screening results had a longer mean inpatient stay (P = .012). DISCUSSION: Implementing the Idenfitication of Seniors at Risk tool was challenged by problematic compliance with tool completion. Strategies to address this included tool adaptation; and providing staff with knowledge of ED and inpatient geriatric resources and feedback on completion rates. Positive screening results predicted adverse outcomes in elderly Mount Sinai Hospital ED patients.

Randomized trial of personalized psychological feedback from a longitudinal online survey and simultaneous evaluation of randomized stepped wedge availability of in-person peer support for hospital staff during the COVID-19 pandemic.

OBJECTIVE: We tested if automated Personalized Self-Awareness Feedback (PSAF) from an online survey or in-person Peer Resilience Champion support (PRC) reduced emotional exhaustion among hospital workers during the COVID-19 pandemic. METHOD: Among a single cohort of participating staff from one hospital organization, each intervention was evaluated against a control condition with repeated measures of emotional exhaustion at quarterly intervals for 18 months. PSAF was tested in a randomized controlled trial compared to a no-feedback condition. PRC was tested in a group-randomized stepped-wedge design, comparing individual-level emotional exhaustion before and after availability of the intervention. Main and interactive effects on emotional exhaustion were tested in a linear mixed model. RESULTS: Among 538 staff, there was a small but significant beneficial effect of PSAF over time (p = .01); the difference at individual timepoints was only significant at timepoint three (month six). The effect of PRC over time was non-significant with a trend in the opposite direction to a treatment effect (p = .06). CONCLUSIONS: In a longitudinal assessment, automated feedback about psychological characteristics buffered emotional exhaustion significantly at six months, whereas in-person peer support did not. Providing automated feedback is not resource-intensive and merits further investigation as a method of support.

Trends in burnout and psychological distress in hospital staff over 12 months of the COVID-19 pandemic: a prospective longitudinal survey.

BACKGROUND: The mental health effects of healthcare work during the COVID-19 pandemic have been substantial, but it is not known how long they will persist. This study aimed to determine if hospital workers' burnout and psychological distress increased monotonically over 1 year, during which waves of case numbers and hospitalizations waxed and waned, or followed some other pattern. METHODS: A prospective longitudinal survey was conducted at four time-points over 1 year in a cohort of 538 hospital workers and learners, which included validated measures of burnout (emotional exhaustion scale of Maslach Burnout Inventory) and psychological distress (K6). Repeated measures ANOVA tested changes over time and differences between subjects by occupational role, age and ethnic group. The direction and magnitude of changes over time were investigated by plotting rates of high scores (using cut-offs) at each time-point compared to case rates of COVID-19 in the city in which the study took place. RESULTS: There were significant effects of occupational role (F = 11.2, p < .001) and age (F = 12.8, p < .001) on emotional exhaustion. The rate of high burnout was highest in nurses, followed by other healthcare professionals, other clinical staff, and lowest in non-clinical staff. Peak rates of high burnout occurred at the second or third measurement point for each occupational group, with lower rates at the fourth measurement point. Similarly to the results for emotional exhaustion, rates of high psychological distress peaked at the spring 2021 measurement point for most occupational groups and were higher in nurses than in other healthcare professionals. CONCLUSIONS: Neither emotional exhaustion nor psychological distress was rising monotonically. Burnout and psychological distress were consistently related to occupational role and were highest in nurses. Although emotional exhaustion improved as the case rate of COVID-19 decreased, rates of high emotional exhaustion in nurses and other healthcare professionals remained higher than was typically measured in hospital-based healthcare workers prior to the pandemic. Ongoing monitoring of healthcare workers' mental health is warranted. Organizational and individual interventions to support healthcare workers continue to be important.

Psychological impact of the COVID-19 pandemic on hospital workers over time: Relationship to occupational role, living with children and elders, and modifiable factors.

OBJECTIVE: The COVID-19 pandemic is expected to have a sustained psychological impact on healthcare workers. We assessed individual characteristics related to changes in emotional exhaustion and psychological distress over time. METHODS: A survey of diverse hospital staff measured emotional exhaustion (Maslach Burnout Inventory) and psychological distress (K6) in Fall 2020 (T1) and Winter 2021 (T2). Relationships between occupational, personal, and psychological variables were assessed using repeated measures ANOVA. RESULTS: Of 539 T1 participants, 484 (89.9%) completed T2. Emotional exhaustion differed by occupational role (F = 7.3, p < .001; greatest in nurses), with increases over time in those with children (F = 8.5, p = .004) or elders (F = 4.0, p = .047). Psychological distress was inversely related to pandemic self-efficacy (F = 110.0, p < .001), with increases over time in those with children (F = 7.0, p = .008). Severe emotional exhaustion occurred in 41.1% (95%CI 36.6-45.4) at T1 and 49.8% (95%CI 45.4-54.2) at T2 (McNemar test p < .001). Psychological distress occurred in 9.7% (95%CI 7.1-12.2) at T1 and 11.6% (95%CI 8.8-14.4) at T2 (McNemar test p = .33). CONCLUSIONS: Healthcare workers' psychological burden is high and rising as the pandemic persists. Ongoing support is warranted, especially for nurses and those with children and elders at home. Modifiable protective factors, restorative sleep and self-efficacy, merit special attention.

A Hospital Partnership with a Nursing Home Experiencing a COVID-19 Outbreak: Description of a Multiphase Emergency Response in Toronto, Canada.

Nursing homes have become "ground zero" for the coronavirus disease 2019 (COVID-19) epidemic in North America, with homes experiencing widespread outbreaks, resulting in severe morbidity and mortality among their residents. This article describes a 371-bed acute-care hospital's emergency response to a 126-bed nursing home experiencing a COVID-19 outbreak in Toronto, Canada. Like other healthcare system responses to COVID-19 outbreaks in nursing homes, this hospital-nursing home partnership can be characterized in several phases: (1) engagement, relationship, and trust building; (2) environmental scan, team building, and immediate response; (3) early-phase response; and (4) stabilization and transition period. J Am Geriatr Soc 68:1376-1381, 2020.

Proactive Psychiatry Intervention Using a Nurse-Led Behavioral Response Model for Hospitalized Patients With Behavioral Disturbances.

BACKGROUND: The health care sector has one of the highest rates of workplace violence, putting staff at risk and impeding care. To deliver quality health care, staff need targeted resources. This article describes a program to improve staff safety and reduce barriers to care for patients with behavioral disturbances. PROGRAM DESCRIPTION: A nurse-led behavioral response team was created to identify high-risk patients and offer prompt targeted interventions. The Behavioral Optimization and Outcomes Support Team (BOOST) was implemented in November 2012, in conjunction with a proactive model of care, enabling psychiatric intervention. Advanced practice nurses in psychiatry respond to requests from staff on medical/surgical units to assist with management of behavioral disturbances. METHODS: Consultation and intervention data were reviewed, and staff satisfaction surveys were completed to evaluate the program. RESULTS: The program has contributed to staff feeling more supported and safer at work. There has also been a reduction in staff's experience of perceived burden in the care of patients with behavioral disturbances although they are caring for more of these patients. CONCLUSIONS: Although violence risk in health care continues to be a significant issue, programs to intervene early can be effective in supporting staff to minimize these risks.

Geriatric Delirium Care: Using Chart Audits to Target Improvement Strategies.

BACKGROUND: Our hospital identified delirium care as a quality improvement target. Baseline characterization of our delirium care and deficits was needed to guide improvement efforts. METHODS: Two inpatient units were selected: 1) A general internal medicine unit with a focus on geriatrics, and 2) a surgical unit. Retrospective chart audits were conducted for all patients over age 50 admitted during a one-month period to compare delirium care with best practice guideline (BPG) recommendations, and to determine the incidence of missed cases of delirium and negative outcomes in patients with delirium. The aim was to gather local data to prioritize improvement efforts and mobilize stakeholders. RESULTS: 186 charts were reviewed: 17 patients had physician-diagnosed delirium, 21 patients had missed delirium, and 148 patients had no delirium. Compliance with delirium BPGs was variable, but generally poor. There was a trend towards missed delirium and physician-diagnosed delirium being associated with greater odds of having above-median length of stay and lower odds of discharge home compared to no delirium diagnosis. CONCLUSION: Overall, the chart audits confirmed delirium underrecognition and poor adherence to best practices in delirium management. Granular analysis of this data was used to mobilize stakeholders and prioritize improvement plans.