Exploration of delirium assessment and management in a hospice inpatient unit.

Background: Delirium is common across all palliative care settings. Guidelines exist to support the care of terminally ill people who develop delirium; yet the evidence base is limited. Recent surveys of palliative care specialists have suggested clinical practice is variable. Aim: To explore delirium assessment and management in a hospice inpatient setting. Methods: A mixed-methods study comprising a retrospective case note review of 21 patients admitted to a hospice inpatient unit and semi-structured interviews with seven hospice inpatient doctors and nurses. Results: A total of 62% of patients were screened for delirium on admission using the 4 As tool (4AT). The period prevalence of delirium was 76% during the 2-week study period. The term 'delirium' was documented infrequently in case notes, compared to other more ambiguous terms. Interview data suggested that nurses were unfamiliar with delirium screening tools. Conclusion: Lack of awareness about delirium screening tools and the infrequent use of the term 'delirium' may suggest that delirium goes under-recognised and under-treated. Further education and research are required to support the care of terminally ill people with delirium.

The Iowa less aggressive protocol: A mixed-methods study on the novel treatment protocol of atrial fibrillation.

OBJECTIVES: Atrial fibrillation is the most common cardiac dysrhythmia in the United States. Our aim was to determine if a novel protocol for management of atrial fibrillation was feasible to implement in an emergency department (ED). Interviews were conducted with ED physicians and physician assistants to identify themes in relation to the clinical use and impleon of the protocol. METHODS: A novel protocol was developed by a multi-disciplinary team and implemented in an academic ED. The protocol used cardiac computed tomography (CT) to rule out left atrial thrombus in patients with greater than 12 h of symptoms and high risk of thromboembolism, or any patient with greater than 48 h of symptoms. Patients who underwent cardiac CT or electrical cardioversion were followed up at 30 days via telephone to monitor for recurrence or adverse thromboembolic events. Providers were interviewed to identify themes regarding protocol usage, barriers to its use, and future changes to increase utilization. RESULTS: Patients with atrial fibrillation in the ED were eligible for inclusion. Twenty-nine patients were treated using the protocol. Seven patients (24%) underwent cardiac CT prior to electrical cardioversion. Cardioversion success rate was 83%, with 69% of patients discharged home. Thirty-day follow-up was completed on 25 patients (86%). Six patients (24%) had reoccurrence of atrial fibrillation requiring subsequent cardioversion. No patients experienced stroke or thromboembolic event. Interviews were conducted with 14 providers. Usage barriers included time, availability, and additional work-up. Six subthemes were identified for future changes including EMR order set, frequent reminders, increased education, increased awareness, activation energy, and EMR pop-ups. CONCLUSION: The Iowa Less Aggressive Protocol is a novel treatment protocol for the ED management of atrial fibrillation that was feasible to implement and use. Providers viewed the protocol favorably and identified areas of improvement for future use.

Telemedicine Physical Examination Utilizing a Consumer Device Demonstrates Poor Concordance with In-Person Physical Examination in Emergency Department Patients with Sore Throat: A Prospective Blinded Study.

BACKGROUND: Telemedicine allows patients to connect with healthcare providers remotely. It has recently expanded to evaluate low-acuity illnesses such as pharyngitis by using patients' personal communication devices. The purpose of our study was to compare the telemedicine-facilitated physical examination with an in-person examination in emergency department (ED) patients with sore throat. MATERIALS AND METHODS: This was a prospective, observational, blinded diagnostic concordance study of patients being seen for sore throat in a 60,000-visit Midwestern academic ED. A telemedicine and a face-to-face examination were performed independently by two advanced practice providers (APP), blinded to the results of the other evaluator. The primary outcome was agreement on pharyngeal redness between the evaluators, with secondary outcomes of agreement and inter-rater reliability on 14 other aspects of the pharyngeal physical examination. We also conducted a survey of patients and providers to evaluate perceptions and preferences for sore throat evaluation using telemedicine. RESULTS: Sixty-two patients were enrolled, with a median tonsil size of 1.0. Inter-rater agreement (kappa) for tonsil size was 0.394, which was worse than our predetermined concordance threshold. Other kappa values ranged from 0 to 0.434, and telemedicine was best for detecting abnormal coloration of the palate and tender superficial cervical lymph nodes (anterior structures), but poor for detecting abnormal submandibular lymph nodes or asymmetry of the posterior pharynx (posterior structures). In survey responses, telemedicine was judged easier to use and more comfortable for providers than patients; however, neither patients nor providers preferred in-person to telemedicine evaluation. CONCLUSION: Telemedicine exhibited poor agreement with the in-person physical examination on the primary outcome of tonsil size, but exhibited moderate agreement on coloration of the palate and cervical lymphadenopathy. Future work should better characterize the importance of the physical examination in treatment decisions for patients with sore throat and the use of telemedicine in avoiding in-person healthcare visits.