Transitions of care for older adults discharged home from the emergency department: an inductive thematic content analysis of patient comments.

OBJECTIVE: Improving care transitions for older adults can reduce emergency department (ED) visits, adverse events, and empower community autonomy. We conducted an inductive qualitative content analysis to identify themes emerging from comments to better understand ED care transitions. METHODS: The LEARNING WISDOM prospective longitudinal observational cohort includes older adults (≥ 65 years) who experienced a care transition after an ED visit from both before and during COVID-19. Their comments on this transition were collected via phone interview and transcribed. We conducted an inductive qualitative content analysis with randomly selected comments until saturation. Themes that arose from comments were coded and organized into frequencies and proportions. We followed the Standards for Reporting Qualitative Research (SRQR). RESULTS: Comments from 690 patients (339 pre-COVID, 351 during COVID) composed of 351 women (50.9%) and 339 men (49.1%) were analyzed. Patients were satisfied with acute emergency care, and the proportion of patients with positive acute care experiences increased with the COVID-19 pandemic. Negative patient comments were most often related to communication between health providers across the care continuum and the professionalism of personnel in the ED. Comments concerning home care became more neutral with the COVID-19 pandemic. CONCLUSION: Patients were satisfied overall with acute care but reported gaps in professionalism and follow-up communication between providers. Comments may have changed in tone from positive to neutral regarding home care over the COVID-19 pandemic due to service slowdowns. Addressing these concerns may improve the quality of care transitions and provide future pandemic mitigation strategies.

Engagement of Older Adults Receiving Home Care Services and Their Caregivers in Health Decisions in Partnership With Clinical Teams: Protocol for a Multimethod Study to Prioritize and Culturally Adapt Decision Aids for Home Care.

BACKGROUND: Older adults (people aged 65 years and older) face many difficult decisions. Patient decision aids (PtDAs) can help them and their families make informed value-congruent decisions. Some PtDAs have been developed for the home care context, but little is known about scaling them for use with older adults in a different culture. OBJECTIVE: This study aims to (1) assess the scalability of existing PtDAs for older adults in the home care context; (2) prioritize those that best match the decisional needs of older adults in home care; and (3) culturally adapt the prioritized PtDAs so they can be scaled successfully to the Quebec health care system. METHODS: This multimethod study includes 3 phases. All phases will be overseen by a steering committee of older adults, caregivers, health professionals, decision makers, community organization representatives, and researchers with the needed expertise. In phase 1, we will use the Innovation Scalability Self-administered Questionnaire, a validated scalability self-assessment tool, to assess the scalability of 33 PtDAs previously identified in a systematic review. Based on their scalability, their quality (based on the International Patient Decision Aids Standards), and the importance of the decision point, we will retain approximately a third of these. In phase 2, we will conduct a 2-round web-based Delphi to prioritize the PtDAs selected in phase 1. Using a snowball recruitment strategy, we aim to recruit 60 Delphi participants in the province of Quebec, including older adults, caregivers, health professionals, decision makers involved in home care services, and PtDA experts. In the first round, we will ask participants to rate the importance of several PtDA decision points according to various criteria such as prevalence and difficulty on a 5-point Likert scale (1=not important to 5=very important). Approximately 6 of the highest-rated PtDAs will be retained for presentation in the second round, and we will select up to 3 PtDAs judged as having the highest priority for cultural adaptation. In phase 3, using the Chenel framework and user-centered design methods, we will update and adapt the PtDAs to the Quebec health care system and integrate these PtDAs into an interprofessional shared decision-making training program for home care teams. The adapted PtDAs will respect the International Patient Decision Aids Standards criteria. RESULTS: This study was funded in March 2022 by the Canadian Institutes of Health Research. Data collection for the web-based Delphi began in October 2023. Results are expected to be published in May 2024. CONCLUSIONS: This project will provide relevant and culturally appropriate decision support tools for older adults making difficult decisions and their home care teams that will be ready for scaling across the province of Quebec. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/53150.

The OptimaMed intervention to reduce medication burden in nursing home residents with severe dementia: results from a pragmatic, controlled study.

BACKGROUND: Nursing home (NH) residents with severe dementia use many medications, sometimes inappropriately within a comfort care approach. Medications should be regularly reviewed and eventually deprescribed. This pragmatic, controlled trial assessed the effect of an interprofessional knowledge exchange (KE) intervention to decrease medication load and the use of medications of questionable benefit among these residents. METHODS: A 6-month intervention was performed in 4 NHs in the Quebec City area, while 3 NHs, with comparable admissions criteria, served as controls. Published lists of "mostly", "sometimes" or "exceptionally" appropriate medications, tailored for NH residents with severe dementia, were used. The intervention included 1) information for participants' families about medication use in severe dementia; 2) a 90-min KE session for NH nurses, pharmacists, and physicians; 3) medication reviews by NH pharmacists using the lists; 4) discussions on recommended changes with nurses and physicians. Participants' levels of agitation and pain were evaluated using validated scales at baseline and the end of follow-up. RESULTS: Seven (7) NHs and 123 participants were included for study. The mean number of regular medications per participant decreased from 7.1 to 6.6 in the intervention, and from 7.7 to 5.9 in the control NHs (p-value for the difference in differences test: < 0.05). Levels of agitation decreased by 8.3% in the intervention, and by 1.4% in the control NHs (p = 0.026); pain levels decreased by 12.6% in the intervention and increased by 7% in the control NHs (p = 0.049). Proportions of participants receiving regular medications deemed only exceptionally appropriate decreased from 19 to 17% (p = 0.43) in the intervention and from 28 to 21% (p = 0.007) in the control NHs (p = 0.22). The mean numbers of regular daily antipsychotics per participant fell from 0.64 to 0.58 in the intervention and from 0.39 to 0.30 in the control NHs (p = 0.27). CONCLUSIONS: This interprofessional intervention to reduce inappropriate medication use in NH residents with severe dementia decreased medication load in both intervention and control NHs, without important concomitant increase in agitation, but mixed effects on pain levels. Practice changes and heterogeneity within these 7 NHs, and a ceiling effect in medication optimization likely interfered with the intervention. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov: # NCT05155748 (first registration 03-10-2017).

Clinical Assessment of Judgment in Adults and the Elderly: Development and Validation of the Three Domains of Judgment Test-Clinical Version (3DJT-CV).

(1) Background: This article discusses the first two phases of development and validation of the Three Domains of Judgment Test (3DJT). This computer-based tool, co-constructed with users and capable of being administered remotely, aims to assess the three main domains of judgment (practical, moral, and social) and learn from the psychometric weaknesses of tests currently used in clinical practice. (2) Method: First, we presented the 3DJT to experts in cognition, who evaluated the tool as a whole as well as the content validity, relevance, and acceptability of 72 scenarios. Second, an improved version was administered to 70 subjects without cognitive impairment to select scenarios with the best psychometric properties in order to build a future clinically short version of the test. (3) Results: Fifty-six scenarios were retained following expert evaluation. Results support the idea that the improved version has good internal consistency, and the concurrent validity primer shows that 3DJT is a good measure of judgment. Furthermore, the improved version was found to have a significant number of scenarios with good psychometric properties to prepare a clinical version of the test. (4) Conclusion: The 3DJT is an interesting alternative tool for assessing judgment. However, more studies are needed for its implementation in a clinical context.

Identifying Quality Indicators for the Care of Hospitalized Injured Older Adults: A Scoping Review of the Literature.

OBJECTIVES: Older adults represent more than 50% of trauma admissions in many high-income countries. Furthermore, they are at increased risk for complications, resulting in worse health outcomes than younger adults and a significant health care utilization burden. Quality indicators (QIs) are used to assess the quality of care in trauma systems, but few QIs reflect responses to older patients' specific needs. We aimed to (1) identify QIs used to assess acute hospital care for injured older patients, (2) assess support for identified QIs and, (3) identify gaps in existing QIs. DESIGN: Scoping review of the scientific and gray literature. METHODS: Selection and data extraction were performed by 2 independent reviewers. The level of support was assessed by the number of sources reporting QIs and whether they were developed according to scientific evidence, expert consensus, and patients' perspectives. RESULTS: Of 10,855 identified studies, 167 were eligible. Among 257 different QIs identified, 52% were hip fracture specific. Gaps were identified for head injuries, rib, and pelvic ring fractures. Although 61% of QIs assessed care processes, 21% and 18% focused on structures and outcomes, respectively. Although most QIs were based on literature reviews and/or expert consensus, patients' perspective was rarely accounted for. The 15 QIs with the highest level of support included minimum time between emergency department arrival and ward admission, minimum time to surgery for fractures, assessment by a geriatrician, orthogeriatric review for hip fracture patients, delirium screening, prompt and appropriate analgesia, early mobilizations, and physiotherapy. CONCLUSION AND IMPLICATIONS: Multiple QIs were identified, but their level of support was limited, and important gaps were identified. Future work should focus on achieving consensus for a set of QIs to assess the quality of trauma care to older adults. Such QIs could be used for quality improvement and ultimately improve outcomes for injured older adults.

A Quality Assessment of Goals of Care Forms in a Sample of Older Patients in Various Care Settings in Quebec, Canada.

OBJECTIVE:  The objective of this study is to assess the completion and content of the Goals of Care (GOC) forms in three care settings in the province of Quebec, Canada. METHODS: This is a retrospective, cross-sectional, mixed methods analysis of data extracted from the charts and GOC forms of patients aged over 65 who received services during the year 2018 in one of the three following care settings: (i) long-term care facility, (ii) acute care hospital, and (iii) home support services of a regional healthcare and social services center. The completion of the GOC form includes six essential sections. If one or more of the sections were not fulfilled, we considered the form incomplete. We used descriptive analysis to look at the information in the six sections and a thematic analysis to assess the information in an open-ended section. RESULTS: We audited 589 charts, of which 67% contained a GOC form and only 96 (16%) a completed one. The most popular goal of care was ensuring comfort as a priority over prolonging life, selected on 40% of the forms. The majority of the included patients (89%) did not want cardiopulmonary resuscitation (CPR) to be attempted in the case of cardiac arrest. There was no indication of the use of advance medical directives, and scarce indication of the use of former GOC forms (18%) and living wills (2%) in completing the forms. Comments were included in 65% of the open-ended sections. The most frequent themes related to the use or non-use of interventions and to potential transfers to the hospital or to an intensive care unit. We found that the open-ended section was used on 24 forms to specify a different goal of care applicable in the event of further health deterioration. DISCUSSION AND CONCLUSIONS: A significant proportion of charts (84%) did not contain a completed GOC form; key aspects of advance care planning were rarely considered in establishing the patient's goal of care, and the form itself lacked utility given the frequency and nature of qualitative comments. As a final product of serious illness communication and decision-making, our findings suggest that there are significant quality issues, that patients are at risk of intensification of care at the end of life, and that more needs to be done to improve serious illness decision-making and documentation.

Reorganizing Pharmaceutical Care in Family Medicine Groups for Older Adults With or at Risk of Major Neurocognitive Disorders: Protocol for a Mixed Methods Study.

BACKGROUND: The latest global figures show that 55 million persons lived with major neurocognitive disorders (MNCDs) worldwide in 2021. In Quebec, Canada, most of these older adults are cared for by family physicians in interdisciplinary primary care clinics such as family medicine groups (FMG). When a person has a MNCD, taking potentially inappropriate medications or polypharmacy (5 different medications or more) increases their vulnerability to serious adverse events. With the recent arrival of pharmacists working in FMGs and their expanded scope of practice and autonomy, new possibilities for optimizing older adults' pharmacotherapy are opening. OBJECTIVE: This project aims to evaluate the impact of involving these pharmacists in the care trajectory of older adults living with MNCD, in an interdisciplinary collaboration with the FMG team, as well as home care nurses and physicians. Pharmacists will provide medication reviews, interventions, and recommendations to improve the pharmacotherapy and support offered to these patients and their caregivers. METHODS: This 2-step mixed methods study will include a quasi-experimental controlled trial (step 1) and semistructured interviews (step 2). Older adults undergoing cognitive assessment, recently diagnosed with MNCD, or receiving care for this at home will be identified and recruited in FMGs in 2 Quebec regions. FMGs implementing the intervention will involve pharmacists in these patients' care trajectory. Training and regular mentoring will be offered to these FMGs, especially to pharmacists. In control FMGs, no FMG pharmacist will be involved with these patients, and usual care will be provided. RESULTS: Medication use (including appropriateness) and burden, satisfaction of care received, and quality of life will be assessed at study beginning and after 6 months of follow-up and compared between groups. At the end of the intervention study, we will conduct semistructured interviews with FMG care team members (pharmacists, nurses, and physicians) who have experienced the intervention. We will ask about the feasibility of integrating the intervention into practice and their satisfaction with and their perception of the intervention's impacts for older adults and their families. We will assess the effect of improved pharmaceutical care for older adults with or at risk of MNCDs through the involvement of FMG pharmacists and a reorganization of pharmaceutical care. CONCLUSIONS: The inclusion of pharmacists in interdisciplinary care teams is recent and rising, strengthened by more substantial pharmacist practice roles. Results will inform the processes required to successfully involve pharmacists and implement developed tools and procedures transposable to other care settings to improve patient care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04889794; https://clinicaltrials.gov/ct2/show/NCT04889794. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42577.

Optimizing Practices, Use, Care, and Services-Antipsychotics (OPUS-AP) in Long-Term Care Centers in Quebec, Canada: A Successful Scale-Up.

OBJECTIVES: To evaluate the scale-up of the OPUS-AP program to improve the care of residents at long-term care (LTC) centers through the systematic implementation of resident-centered approaches to care, the application of nonpharmacologic interventions for the management of behavioral and psychological symptoms of dementia (BPSD), and the deprescribing of antipsychotics where these are not clinically indicated. DESIGN: Prospective, closed cohort. SETTING AND PARTICIPANTS: Residents with major neurocognitive disorder (MNCD) from 24 (phase 1) and 129 (phase 2) publicly funded LTC centers in Quebec, Canada. METHODS: The primary outcome was antipsychotic deprescribing (cessation or dose reduction). Secondary outcomes included changes in benzodiazepine and antidepressant prescriptions, BPSD, and falls. Comparisons were made between assessments at baseline and after 9 months. RESULTS: OPUS-AP phase 2 was conducted from March to December 2019 in 329 clinical wards at 129 LTC centers. At baseline, the 10,601 included residents had a mean age of 82.9: 64.6% were of female sex, 73.7% had a diagnosis of MNCD, and 47.0% had an antipsychotic prescription. These characteristics were similar to those of the 1054 residents at the 24 LTC centers in phase 1. In phase 2, successful antipsychotic deprescribing was achieved for 77.1% of residents in whom this approach was attempted, compared to 85.5% in phase 1. Phase 1 and 2 showed statistically significant improvements in the Cohen-Mansfield Agitation Inventory score and reduced use of benzodiazepines in residents with successful antipsychotic deprescribing. These improvements were of a smaller magnitude in phase 2. Statistically significant reductions in falls were observed in phase 2. CONCLUSIONS AND IMPLICATIONS: The scale-up of the OPUS-AP program from 24 to 129 LTC centers was successful and resulted in a significant reduction in antipsychotic use, as well as improvement in BPSD, and reductions in benzodiazepine use and falls in residents with successful antipsychotic deprescribing.

Implementation conditions leading to the scale-up of an innovation involving the optimal use of antipsychotics in long-term care centers: The Optimizing Practices, Use, Care and Services-Antipsychotics (OPUS-AP) program.

BACKGROUND: Antipsychotics are often used for the first-line management of behavioral and psychological symptoms of dementia despite their limited efficacy and the risk of serious adverse drug events, compounded with disregard for guidelines recommending prioritizing non-pharmacological interventions. Some innovative interventions promote the deprescription of antipsychotics in long term care (LTC) settings. OBJECTIVE: The objective of this article is to present the conditions leading to the scale-up of an innovative program on the appropriate use of antipsychotics in LTC centers. METHODS: The Optimizing Practices, Use, Care and Services-Antipsychotics (OPUS-AP) program is a mixed-method project that aims to improve LTC residents' care through increased knowledge and competency among staff, resident-centered approaches, nonpharmacologic interventions, and by deprescribing antipsychotics when appropriate. This article consists of a qualitative study focused on exploring the implementation conditions of the OPUS-AP program. This study was carried out in an integrated health area of Québec. It consisted of 46 semi-structured interviews with staff members and managers involved in the implementation of OPUS-AP. The qualitative data analysis was inspired by a realistic evaluation approach, which shed light on the causal chain between context, mechanisms, and perceived effects. RESULTS: This study identified certain conditions conducive to scaling up the OPUS-AP program: an integrated, collaborative and evidence-based approach; communications in support of the process; stakeholder engagement at the strategic, tactical and operational levels; an implementation climate conducive to change; and an integrated knowledge translation strategy. CONCLUSION: Despite evidence of clinical efficacy, deprescribing programs require great deal of scaling up efforts. Hence, this study underscores the need to further examine conditions for scaling up medication usage programs in real life contexts.

Predictors of delirium in older patients at the emergency department: a prospective multicentre derivation study.

OBJECTIVE: The objective of this study was to identify the predictors of incident delirium in this high-risk population. METHODS: This study was a planned sub-analysis of the INDEED multicentre cohort study. We recruited patients aged ≥ 65, independent/semi-independent, with an emergency department (ED) length of stay ≥ 8 h and admitted to any hospital ward. Patients were followed up during their ED stay up to 24 h after ward admission. Sociodemographic characteristics, comorbidities, functional status (OARS), illness severity, level of frailty, cognitive status (TICS-m) and ED/patient environment evaluation were collected during initial interview. Patients were screened for delirium twice a day using the Confusion Assessment Method. Multivariate logistic regression was performed to identify the predictors of delirium. RESULTS: Incident delirium was detected in 68 patients of the 612 patients included (11%). Initially, seven candidate predictors were included in a regression model, of which four were retained using a stepwise selection procedure. Presence of cognitive impairment at baseline (OR 3.6, p < 0.001), absence of mobilization during the whole ED length of stay (OR 3.3, p = 0.002), longer ED length of stay (OR 1.02, p = 0.006) were associated with a higher risk of incident delirium while higher functional status was associated with a lower risk (OR 0.8, p < 0.001). CONCLUSION: More work is needed to determine which tool(s) are most appropriate for the ED use to increase delirium screening compliance among health professionals working in this department. It is really the first step to be able to suggest interventions to decrease delirium incidence.

RéSUMé: OBJECTIF: L'objectif de cette étude était d'identifier les prédicteurs du délirium incident dans cette population à hautrisque. MéTHODES: Cette étude était une sous-analyse planifiée de l'étude de cohorte multicentrique INDEED. Nous avons recruté des patients âgés de ≥ 65 ans, indépendants/semi-indépendants, ayant une durée de séjour au département d'urgence (DU) ≥ 8 h et admis dans n'importe quel service. Les patients ont été suivis pendant leur séjour aux urgences jusqu'à 24 h après leur admission. Les caractéristiques sociodémographiques, les comorbidités, l'état fonctionnel (OARS), la gravité de la maladie, le niveau de fragilité, l'état cognitif (TICS-m) et l'évaluation de l'environnement des urgences/patients ont été recueillis lors de l'entretien initial. Les patients ont été soumis à un dépistage du délirium deux fois par jour à l'aide de la méthode d'évaluation de la confusion. Une régression logistique multivariée a été effectuée pour identifier les prédicteurs de délirium. RéSULTATS: Le délirium incident a été détecté chez 68 des 612 patients inclus (11%). Au départ, sept prédicteurs candidats ont été inclus dans un modèle de régression, dont quatre ont été retenus par une procédure de sélection par étapes. La présence d'un déficit cognitif initial (RC 3,6, p < 0,001), l'absence de mobilisation pendant toute la durée du séjour à l'urgence (RC 3,3, p = 0,002), une durée de séjour plus longue à l'urgence (RC 1,02, p = 0,006) étaient associées à un risque plus élevé de délirium incident, tandis qu'un état fonctionnel plus élevé était associé à un risque plus faible (RC 0,8, p < 0,001). CONCLUSIONS: Des travaux supplémentaires sont nécessaires pour déterminer quel(s) outil(s) sont les plus appropriés au DU afin d'accroître le dépistage du délirium par les professionnels de santé travaillant dans ce service. C'est vraiment la première étape pour pouvoir proposer des interventions visant à diminuer l'incidence du délirium.

Family Medicine Supervisors' Preferences for Improving Their Teaching Skills in Senior Care.

BACKGROUND AND OBJECTIVES: Many clinical supervisors in family medicine feel ill-equipped to teach senior care to their family medicine residents (trainees). We therefore sought to explore their preferred learning strategies for improving their clinical and teaching skills with regard to senior care. METHODS: In this qualitative study, we conducted focus groups and interviews with supervisors from four family medicine clinics, to explore their preferred educational strategies. We selected four clinics using a maximum-variation strategy, based on a survey assessing continuing professional development (CPD) needs. The qualitative thematic analysis followed an inductive/deductive approach based on McGuire's attributes of persuasive communication. RESULTS: The four focus groups and nine interviews with 53 supervisors (37 physicians, 9 nurses, 4 psychologists, 1 social worker, 1 nutritionist, 1 sexologist) revealed that supervisors preferred being trained by experienced trainers specialized in senior care, from various professional backgrounds, and knowledgeable about local community resources. They valued practical training the most, such as clinical case discussions based on real cases, clinical tools, and mentoring. The findings also suggest that training in senior care should be adapted to the supervisors' experience, profession, workload, and scope of intervention. Supervisors valued repeated CPD with longitudinal follow-up and easy access to trainers and to up-to-date training content. CONCLUSIONS: The findings of this project will allow those who design CPD activities to adapt such activities to the preferences of supervisors, so as to improve their clinical and teaching skills in senior care. This, in turn, may help supervisors to embody an appealing professional role model for learners.

User-centered and theory-based design of a professional training program on shared decision-making with older adults living with neurocognitive disorders: a mixed-methods study.

BACKGROUND: We know little about the best approaches to design training for healthcare professionals. We thus studied how user-centered and theory-based design contribute to the development of a distance learning program for professionals, to increase their shared decision-making (SDM) with older adults living with neurocognitive disorders and their caregivers. METHODS: In this mixed-methods study, healthcare professionals who worked in family medicine clinics and homecare services evaluated a training program in a user-centered approach with several iterative phases of quantitative and qualitative evaluation, each followed by modifications. The program comprised an e-learning activity and five evidence summaries. A subsample assessed the e-learning activity during semi-structured think-aloud sessions. A second subsample assessed the evidence summaries they received by email. All participants completed a theory-based questionnaire to assess their intention to adopt SDM. Descriptive statistical analyses and qualitative thematic analyses were integrated at each round to prioritize training improvements with regard to the determinants most likely to influence participants' intention. RESULTS: Of 106 participants, 98 completed their evaluations of either the e-learning activity or evidence summary (93%). The professions most represented were physicians (60%) and nurses (15%). Professionals valued the e-learning component to gain knowledge on the theory and practice of SDM, and the evidence summaries to apply the knowledge gained through the e-learning activity to diverse clinical contexts. The iterative design process allowed addressing most weaknesses reported. Participants' intentions to adopt SDM and to use the summaries were high at baseline and remained positive as the rounds progressed. Attitude and social influence significantly influenced participants' intention to use the evidence summaries (P < 0.0001). Despite strong intention and the tailoring of tools to users, certain factors external to the training program can still influence the effective use of these tools and the adoption of SDM in practice. CONCLUSIONS: A theory-based and user-centered design approach for continuing professional development interventions on SDM with older adults living with neurocognitive disorders and their caregivers appeared useful to identify the most important determinants of learners' intentions to use SDM in their practice, and validate our initial interpretations of learners' assessments during the subsequent evaluation round.

Functional and cognitive decline in older delirious adults after an emergency department visit.

BACKGROUND: the aim of this study was to evaluate the impact of emergency department (ED) stay-associated delirium on older patient's functional and cognitive status at 60 days post ED visit. METHODS: this study was part of the multi-centre prospective cohort INDEED study. This project took place between March 2015 and July 2016 in five participating EDs across the province of Quebec. Independent non-delirious patients aged ≥65, with an ED stay ≥8 hours, were monitored for delirium until 24 hours post ward admission. A 60-day follow-up phone assessment was conducted. Participants were screened for delirium using the Confusion Assessment Method. Functional and cognitive statuses were assessed at baseline and at the 60-day follow-up using OARS and TICS-m. RESULTS: a total of 608 patients were recruited, 393 of which completed the 60-day follow-up. The Confusion Assessment Method was positive in 69 patients (11.8%) during ED stay or within the first 24 hours following ward admission. At 60 days, delirium patients experienced an adjusted loss of -2.9/28 [95%CI: -3.9, -2.0] points on the OARS scale compared to non-delirious patients who lost -1.6 [95%CI: -1.9, -1.3] (P = 0.006). A significant adjusted difference in cognitive function was also noted at 60 days, as TICS-m scores in delirious patients decreased by -1.6 [95%CI: -3.5, 0.2] compared to non-delirious patients, who showed a minor improvement of 0.5 [95%CI: -0.1, 1.1] (P = 0.03). CONCLUSION: seniors who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients, and they will experience a more significant decline at 60 days post ED visit.

Learning Integrated Health System to Mobilize Context-Adapted Knowledge With a Wiki Platform to Improve the Transitions of Frail Seniors From Hospitals and Emergency Departments to the Community (LEARNING WISDOM): Protocol for a Mixed-Methods Implementation Study.

BACKGROUND: Elderly patients discharged from hospital experience fragmented care, repeated and lengthy emergency department (ED) visits, relapse into their earlier condition, and rapid cognitive and functional decline. The Acute Care for Elders (ACE) program at Mount Sinai Hospital in Toronto, Canada uses innovative strategies, such as transition coaches, to improve the care transition experiences of frail elderly patients. The ACE program reduced the lengths of hospital stay and readmission for elderly patients, increased patient satisfaction, and saved the health care system over Can $4.2 million (US $2.6 million) in 2014. In 2016, a context-adapted ACE program was implemented at one hospital in the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS-CA) with a focus on improving transitions between hospitals and the community. The quality improvement project used an intervention strategy based on iterative user-centered design prototyping and a "Wiki-suite" (free web-based database containing evidence-based knowledge tools) to engage multiple stakeholders. OBJECTIVE: The objectives of this study are to (1) implement a context-adapted CISSS-CA ACE program in four hospitals in the CISSS-CA and measure its impact on patient-, caregiver-, clinical-, and hospital-level outcomes; (2) identify underlying mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly; and (3) identify underlying mechanisms by which the Wiki-suite contributes to context-adaptation and local uptake of knowledge tools. METHODS: Objective 1 will involve staggered implementation of the context-adapted CISSS-CA ACE program across the four CISSS-CA sites and interrupted time series to measure the impact on hospital-, patient-, and caregiver-level outcomes. Objectives 2 and 3 will involve a parallel mixed-methods process evaluation study to understand the mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly and by which our Wiki-suite contributes to adaptation, implementation, and scaling up of geriatric knowledge tools. RESULTS: Data collection started in January 2019. As of January 2020, we enrolled 1635 patients and 529 caregivers from the four participating hospitals. Data collection is projected to be completed in January 2022. Data analysis has not yet begun. Results are expected to be published in 2022. Expected results will be presented to different key internal stakeholders to better support the effort and resources deployed in the transition of seniors. Through key interventions focused on seniors, we are expecting to increase patient satisfaction and quality of care and reduce readmission and ED revisit. CONCLUSIONS: This study will provide evidence on effective knowledge translation strategies to adapt best practices to the local context in the transition of care for elderly people. The knowledge generated through this project will support future scale-up of the ACE program and our wiki methodology in other settings in Canada. TRIAL REGISTRATION: ClinicalTrials.gov NCT04093245; https://clinicaltrials.gov/ct2/show/NCT04093245. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17363.

Professional training on shared decision making with older adults living with neurocognitive disorders: a mixed-methods implementation study.

BACKGROUND: Shared decision making with older adults living with neurocognitive disorders is challenging for primary healthcare professionals. We studied the implementation of a professional training program featuring an e-learning activity on shared decision making and five Decision Boxes on the care of people with neurocognitive disorders, and measured the program's effects. METHODS: In this mixed-methods study, we recruited healthcare professionals in family medicine clinics and homecare settings in the Quebec City area (Canada). The professionals signed up for training as a continuing professional development activity and answered an online survey before and after training to assess their knowledge, and intention to adopt shared decision making. We recorded healthcare professionals' access to each training component, and conducted telephone interviews with a purposeful sample of extreme cases: half had completed training and the other half had not. We performed bivariate analyses with the survey data and a thematic qualitative analysis of the interviews, as per the theory of planned behaviour. RESULTS: Of the 47 participating healthcare professionals, 31 (66%) completed at least one training component. Several factors restricted participation, including lack of time, training fragmentation into several components, poor adaptation of training to specific professions, and technical/logistical barriers. Ease of access, ease of use, the usefulness of training content and the availability of training credits fostered participation. Training allowed Healthcare professionals to improve their knowledge about risk communication (p = 0.02), and their awareness of the options (P = 0.011). Professionals' intention to adopt shared decision making was high before training (mean ± SD = 5.88 ± 0.99, scale from 1 to 7, with 7 high) and remained high thereafter (5.94 ± 0.9). CONCLUSIONS: The results of this study will allow modifying the training program to improve participation rates and, ultimately, uptake of meaningful shared decision making with patients living with neurocognitive disorders.

Unrecognized Incident Delirium in Older Emergency Department Patients.

BACKGROUND: It is documented that health professionals from various settings fail to detect > 50% of delirium cases. OBJECTIVE: This study aimed to describe the proportion of unrecognized incident delirium in five emergency departments (EDs). Secondary objectives were to compare the two groups (recognized/unrecognized) and assess the impact of unrecognized delirium at 60 days regarding 1) unplanned consultations and 2) functional and cognitive decline. METHOD: This is a sub-analysis of a multicenter prospective cohort study. Independent patients aged ≥ 65 years who tested negative for delirium on the initial interview with an ED stay ≥ 8 h were enrolled. Patients were assessed twice daily using the Confusion Assessment Method (CAM) and the Delirium Index up to 24 h into hospital admission. Medical records were reviewed to assess whether delirium was recognized or not. RESULTS: The main study reported a positive CAM in 68 patients. Three patients' medical files were incomplete, leaving a sample of 65 patients. Delirium was recognized in 15.4% of our participants. These patients were older (p = 0.03) and female (p = 0.01) but were otherwise similar to those with unrecognized delirium. Delirium Index scores were higher in patients with recognized delirium (p = 0.01) and they experienced a more important functional decline at 60 days (p = 0.02). No association was found between delirium recognition and health care services utilization or decline in cognitive function. CONCLUSIONS: This study confirms reports of high rates of missed or unrecognized delirium (84.6%) in ED patients compared to routine structured screening using the CAM performed by a research assistant. Patients with recognized delirium were older women with a greater severity of symptoms and experienced a more significant functional decline at 60 days.

The OptimaMed intervention to reduce inappropriate medications in nursing home residents with severe dementia: results from a quasi-experimental feasibility pilot study.

BACKGROUND: Medication regimens in nursing home (NH) residents with severe dementia should be frequently reviewed to avoid inappropriate medication, overtreatment and adverse drug events, within a comfort care approach. This study aimed at testing the feasibility of an interdisciplinary knowledge exchange (KE) intervention using a medication review guidance tool categorizing medications as either "generally", "sometimes" or "exceptionally" appropriate for NH residents with severe dementia. METHODS: A quasi-experimental feasibility pilot study with 44 participating residents aged 65 years or over with severe dementia was carried out in three NH in Quebec City, Canada. The intervention comprised an information leaflet for residents' families, a 90-min KE session for NH general practitioners (GP), pharmacists and nurses focusing on the medication review guidance tool, a medication review by the pharmacists for participating residents with ensuing team discussion on medication changes, and a post-intervention KE session to obtain feedback from team staff. Medication regimens and levels of pain and of agitation of the participants were evaluated at baseline and at 4 months post-intervention. A questionnaire for team staff explored perceived barriers and facilitators. Statistical differences in measures comparing pre and post-intervention were assessed using paired t-tests and Cochran's-Q tests. RESULTS: The KE sessions reached 34 NH team staff (5 GP, 4 pharmacists, 6 heads of care unit and 19 staff nurses). Forty-four residents participated in the study and were followed for a mean of 104 days. The total number of regular medications was 372 pre and 327 post-intervention. The mean number of regular medications per resident was 7.86 pre and 6.81 post-intervention. The odds ratios estimating the risks of using any regular medication or a "sometimes appropriate" medication post-intervention were 0.81 (95% CI: 0.71-0.92) and 0.83 (95% CI: 0.74-0.94), respectively. CONCLUSION: A simple KE intervention using a medication review guidance tool categorizing medications as being either "generally", "sometimes" or "exceptionally" appropriate in severe dementia was well received and accompanied by an overall reduction in medication use by NH residents with severe dementia. Levels of agitation were unaffected and there was no clinically significant changes in levels of pain. Staff feedback provided opportunities to improve the intervention.

A Hazardous Materials Educational Curriculum Improves Pediatric Emergency Department Staff Skills.

OBJECTIVE: Emergency department (ED) providers require competency in responding to hazardous materials (HAZMAT) events. The optimal strategies to teach HAZMAT response principles to ED providers and to ensure skill retention are not known. Our aim was to design, implement, and evaluate a multifaceted, interprofessional educational curriculum for pediatric ED staff to improve their skills, knowledge, and confidence in responding to a HAZMAT event. METHODS: In this longitudinal cohort study, we created and assessed a 3-hour educational curriculum comprised of didactics, skills stations, a tabletop exercise, and a simulated multivictim disaster. Learning objectives included critical aspects of pediatric HAZMAT incident response with an emphasis on donning personal protective equipment (PPE). The primary outcome was the number of HAZMAT PPE donning steps correctly completed within 10 minutes at pre- and postcurriculum assessments measured using a 32-item checklist. Secondary outcomes included skill retention at 3 months, change in knowledge assessed using multiple-choice questions, and change in participant confidence. RESULTS: Eighty-one of 84 participants (96%) completed the entire curriculum. Compared to the precurriculum assessment, participants completed more donning steps correctly after the intervention (mean increase = 58%, 95% confidence interval [CI] = 48%-70%). Relative to the baseline, more steps were also correctly completed at 3 months (mean increase = 49%, 95% CI = 38%-61%). Performance on multiple-choice knowledge questions and confidence in skills also significantly increased from the pre- to postcurriculum assessments. CONCLUSIONS: A newly developed HAZMAT educational curriculum improved skills-based performance, knowledge, and confidence in PPE and decontamination skills. Brief, multifaceted educational interventions for ED staff can effectively develop sustainable skills needed for uncommon emergency events.

Incidence of delirium in the Canadian emergency department and its consequences on hospital length of stay: a prospective observational multicentre cohort study.

OBJECTIVE: We aim to determine the incidence of delirium and describe its impacts on hospital length of stay (LOS) among non-delirious community-dwelling older adults with an 8-hour exposure to the emergency department (ED) environment. DESIGN: This is a prospective observational multicentre cohort study (March-July 2015). Patients were assessed two times per day during their entire ED stay and up to 24 hours on hospital ward. SETTING: The study took place in four Canadian EDs. PARTICIPANTS: 338 included patients: (1) aged ≥65 years; (2) who had an ED stay ≥8 hours; (3) were admitted to hospital ward and (4) were independent/semi-independent. MAIN OUTCOMES AND MEASURES: The primary outcomes of this study were incident delirium in the ED or within 24 hours of ward admission and ED and hospital LOS. Functional and cognitive status were assessed using validated Older Americans Resources and Services and the modified Telephone Interview for Cognitive Status tools. The Confusion Assessment Method was used to detect incident delirium. Univariate and multivariate analyses were conducted to evaluate outcomes. RESULTS: Mean age was 76.8 (±8.1), 17.7% were aged >85 years old and 48.8% were men. The mean incidence of delirium was 12.1% (n=41). Median IQR ED LOS was 32.4 (24.5-47.9) hours and hospital LOS was 146.6 (75.2-267.8) hours. Adjusted mean hospital LOS was increased by 105.4 hours (4.4 days) (95% CI 25.1 to 162.0, P<0.001) for patients who developed an episode of delirium compared with non-delirious patient. CONCLUSIONS: An incident delirium was observed in one of eight independent/semi-independent older adults after an 8-hour ED exposure. An episode of delirium increases hospital LOS by 4 days and therefore has important implications for patients and could contribute to ED overcrowding through a deleterious feedback loop.

What Do Clinical Supervisors Require to Teach Residents in Family Medicine How to Care for Seniors?

We assessed clinicians' continuing professional development (CPD) needs at family practice teaching clinics in the province of Quebec. Our mixed methodology design comprised an environmental scan of training programs at four family medicine departments, an expert panel to determine priority clinical situations for senior care, a supervisors survey to assess their perceived CPD needs, and interviews to help understand the rationale behind their needs. From the environmental scan, the expert panel selected 13 priority situations. Key needs expressed by the 352 survey respondents (36% response rate) included behavioral and psychological symptoms of dementia, polypharmacy, depression, and cognitive disorders. Supervisors explained that these situations were sometimes complex to diagnose and manage because of psychosocial aspects, challenges of communicating with patients and families, and coordination of interprofessional teams. Supervisors also reported more CPD needs in long-term and home care, given the presence of caregivers and complexity of senior care in these settings.