Implementation of geriatric screening in the emergency department using the Consolidated Framework for Implementation Research.

OBJECTIVE: Implementation of evidence-based care processes (EBP) into the emergency department (ED) is challenging and there are only a few studies of real-world use of theory-based implementation frameworks. We report final implementation results and sustainability of an EBP geriatric screening program in the ED using the Consolidated Framework for Implementation Research (CFIR). METHODS: The EBP involved nurses screening older patients for delirium (Delirium Triage Screen), fall risk (4-Stage Balance Test), and vulnerability (Identification of Seniors at Risk score) with subsequent appropriate referrals to physicians, therapy specialists, or social workers. The proportions of screened adults ≥65 years old were tracked monthly. Outcomes are reported January 2021-December 2022. Barriers encountered were classified according to CFIR. Implementation strategies were classified according to the CFIR-Expert Recommendations for Implementing Change (ERIC). RESULTS: Implementation strategies increased geriatric screening from 5% to 68%. This did not meet our prespecified goal of 80%. Change was sustained through several COVID-19 waves. Inner setting barriers included culture and implementation climate. Initially, the ED was treated as a single inner setting, but we found different cultures and uptake between ED units, including night versus day shifts. Characteristics of individuals barriers included high levels of staff turnover in both clinical and administrative roles and very low self-efficacy from stress and staff turnover. Initial attempts with individualized audit and feedback were not successful in improving self-efficacy and may have caused moral injury. Adjusting feedback to a team/unit level approach with unitwide stretch goals worked better. Identifying early adopters and conducting on-shift education increased uptake. Lessons learned regarding ED culture, implementation in interconnected health systems, and rapid cycle process improvement are reported. CONCLUSIONS: The pandemic exacerbated barriers to implementation in the ED. Cognizance of a large ED as a sum of smaller units and using the CFIR model resulted in improvements.

National opioid shortage is associated with increased use of ketamine infusion for analgosedation in the medical intensive care unit.

OBJECTIVE: To assess the impact of the national shortage of injectable opioids during the winter of 2017-2018 on the use of ketamine infusion for analgosedation in the medical intensive care unit (MICU). DESIGN: A retrospective cohort study. SETTING: Single-center tertiary care MICU at The Ohio State University Wexner Medical Center. PATIENTS: All patients who received continuous infusion of ketamine to facilitate mechanical ventilation between May 1, 2015 and September 1, 2018. MEASUREMENTS AND MAIN RESULTS: Seventy-seven patients were identified during the study time frame: 43 before and 19 during the opioid shortage. During the peak of the shortage, there was a sevenfold increase in orders for ketamine infusion (2.2 patients/week vs 0.32 patients/week; p < 0.001). Median time from the start of mechanical ventilation to initiation of ketamine infusion was significantly shorter during the shortage (14.1 hours) versus before (51.2 hours; p = 0.03). There was a trend toward adding ketamine into the sedation regimen earlier during the shortage (mean number of drips added prior to ketamine was 2.74 during the shortage vs 3.3 before; p = 0.06). There was also a trend toward increased use of ketamine infusion as monotherapy during (21.1 percent of patients) versus before the shortage (7 percent), though this did not reach statistical significance (p = 0.19). CONCLUSION: The national opioid shortage may have led to earlier and more frequent use of ketamine infusion for anaglosedation in mechanically ventilated MICU patients.