Usability of the 4Ms Worksheet in the Emergency Department for Older Patients: A Qualitative Study.

Introduction: Older adults often have multiple comorbidities; therefore, they are at high risk for adverse events after discharge. The 4Ms framework-what matters, medications, mentation, mobility-has been used in acute and ambulatory care settings to identify risk factors for adverse events in older adults, although it has not been used in the emergency department (ED). We aimed to determine whether 1) use of the 4Ms worksheet would help emergency clinicians understand older adult patients' goals of care and 2) use of the worksheet was feasible in the ED. Methods: We conducted a qualitative, descriptive study among patients aged ≥60 years and emergency clinicians from January-June 2022. Patients were asked to fill out a 4Ms worksheet; following this, semi-structured interviews were conducted with patients and clinicians separately. We analysed data to create codes, which were divided into categories and sub-categories. Results: A total of 20 older patients and 19 emergency clinicians were interviewed. We identified two categories based on our aims: understanding patient goals of care (sub-categories: clinician/ patient concordance; understanding underlying goals of care; underlying goals of care discrepancy) and use of 4Ms Worksheet (sub-categories: worksheet to discussion discrepancy; challenges using worksheet; challenge completing worksheet before discharge). Rates of concordance between patient and clinician on main concern/goal of care and underlying goals of care were 82.4% and 15.4%, respectively. Conclusion: We found that most patients and emergency clinicians agreed on the main goal of care, although clinicians often failed to elicit patients' underlying goal(s) of care. Additionally, many patients preferred to have the interviewer fill out the worksheet for them. There was often discrepancy between what was written and what was discussed with the interviewer. More research is needed to determine the best way to integrate the 4Ms framework within emergency care.

Older adults' goals of care in the emergency department setting: A qualitative study guided by the 4Ms framework.

Background: We sought to identify what matters to older adults (60 years and older) presenting to the emergency department (ED) and the challenges or concerns they identify related to medication, mobility, and mentation to inform how the 4Ms framework could improve care of older adults in the ED setting. Methods: A qualitative study was conducted using the 4Ms to identify what matters to older adults (≥60 years old) presenting to the ED and what challenges or concerns they identify related to medication, mobility, and mentation. We conducted semi-structured interviews with a convenience sample of patients in a single ED. Interview guide responses and interviewer field notes were entered into REDCap. Interviews were reviewed by the research team (2 coders per interview) who inductively assigned codes. A codebook was created through an iterative process and was used to group codes into themes and sub-themes within the 4Ms framework. Results: A total of 20 ED patients participated in the interviews lasting 30-60 minutes. Codes identified for "what matters" included problem-oriented expectation, coordination and continuity, staying engaged, being with family, and getting back home. Codes related to the other 4Ms (medication, mobility, and mentation) described challenges. Medication challenges included: non-adherence, side effects, polypharmacy, and knowledge. Mobility challenges included physical activity and independence. Last, mentation challenges included memory concerns, depressed mood, and stress and worry. Conclusions: Our study used the 4Ms to identify "what matters" to older adults presenting to the ED and the challenges they face regarding medication, mobility, and mentation. Understanding what matters to patients and the specific challenges they face can help shape and individualize a patient-centered approach to care to facilitate the goals of care discussion and handoff to the next care team.

Comparative Implementation of a Brief App-Directed Protocol for Delirium Identification by Hospitalists, Nurses, and Nursing Assistants : A Cohort Study.

BACKGROUND: Systematic screening improves delirium identification among hospitalized older adults. Little data exist on how to implement such screening. OBJECTIVE: To test implementation of a brief app-directed protocol for delirium identification by physicians, nurses, and certified nursing assistants (CNAs) in real-world practice relative to a research reference standard delirium assessment (RSDA). DESIGN: Prospective cohort study. SETTING: Large urban academic medical center and small rural community hospital. PARTICIPANTS: 527 general medicine inpatients (mean age, 80 years; 35% with preexisting dementia) and 399 clinicians (53 hospitalists, 236 nurses, and 110 CNAs). MEASUREMENTS: On 2 study days, enrolled patients had an RSDA. Subsequently, CNAs performed an ultra-brief 2-item screen (UB-2) for delirium, whereas physicians and nurses performed a 2-step protocol consisting of the UB-2 followed in those with a positive screen result by the 3-Minute Diagnostic Assessment for the Confusion Assessment Method. RESULTS: Delirium was diagnosed in 154 of 924 RSDAs (17%) and in 114 of 527 patients (22%). The completion rate for clinician protocols exceeded 97%. The CNAs administered the UB-2 in a mean of 62 seconds (SD, 51). The 2-step protocols were administered in means of 104 seconds (SD, 99) by nurses and 106 seconds (SD, 105) by physicians. The UB-2 had sensitivities of 88% (95% CI, 72% to 96%), 87% (CI, 73% to 95%), and 82% (CI, 65% to 91%) when administered by CNAs, nurses, and physicians, respectively, with specificities of 64% to 70%. The 2-step protocol had overall accuracy of 89% (CI, 83% to 93%) and 87% (CI, 81% to 91%), with sensitivities of 65% (CI, 48% to 79%) and 63% (CI, 46% to 77%) and specificities of 93% (CI, 88% to 96%) and 91% (CI, 86% to 95%), for nurses and physicians, respectively. Two-step protocol sensitivity for moderate to severe delirium was 78% (CI, 54% to 91%). LIMITATION: Two sites; limited diversity. CONCLUSION: An app-directed protocol for delirium identification was feasible, brief, and accurate, and CNAs and nurses performed as well as hospitalists. PRIMARY FUNDING SOURCE: National Institute on Aging.

Implementing a Rapid, Two-Step Delirium Screening Protocol in Acute Care: Barriers and Facilitators.

BACKGROUND/OBJECTIVES: An effective and efficient protocol for delirium identification is needed to improve health outcomes for older adults and reduce healthcare costs. This study describes the barriers and facilitators related to the implementation of the ultra-brief confusion assessment method (UB-CAM), a rapid two-step delirium identification protocol (ultra-brief screen, followed by CAM in positives), field tested with hospitalized older adults (70+). DESIGN: A qualitative descriptive design using observational data collection and brief semi-structured interviews. SETTINGS: An urban academic medical center and a community teaching hospital. PARTICIPANTS: Participants included 50 physician hospitalists, 189 registered nurses, and 83 nursing assistants (NAs). MEASUREMENTS: Field researchers guided by a modified multi-level implementation framework, collected observational data as participants administered the UB-CAM (n = 767). Thematic analysis was conducted on five observational categories: structural, organizational, patient, clinician, and innovation. Field notes and brief semi-structured interviews (n = 231) with clinicians, explored the utility, acceptability, and feasibility of the protocol, and supplemented the observations. RESULTS: The UB-CAM was generally positively received by all three clinician types. Six themes describe barriers and/or facilitators to implementing the UB-CAM: (1) physical setting and milieu; (2) practice environment; (3) integrating into role; (4) adaptive techniques; (5) patient responses; and (6) systematic assessment. The composition and interaction of the six themes determined if the theme was expressed as a barrier or facilitator, affirming the importance of context when implementing system-level delirium screening. CONCLUSION: This is one of the first studies to test a two-step process for delirium identification, and to involve NAs in screening, and the findings demonstrate overall support from clinicians for delirium identification, and describe the need for a multifaceted, contextualized, and systemic approach to implementation and evaluation of delirium screening.

Nature as nurture: Rural older women's perspectives on the natural environment.

Rural older women are surrounded by nature, a dynamic context for human development. Informed by place attachment and attention restoration theory, and guided by a life course perspective, this qualitative study focused on the perceived influence of nature in the lives of 34 rural older women. Using grounded theory techniques to analyze in-depth interviews, two primary findings emerged: (a) nature was integral to the women's identity; and (b) interactions with nature were motivated by prior positive spiritual and psychological outcomes. Findings revealed the power of the natural environment as a resource for coping with the challenges associated with aging.

Older women with cardiovascular disease: perceptions of initial experiences and long-term influences on daily life.

In 2004, we conducted qualitative interviews with 29 White women diagnosed with cardiovascular disease (CVD) living in Southwest Virginia, aged 69 to 92 years (M age = 79.2 years; SD = 6.8); time since diagnosis ranged from 1 to 50 years (M = 14.3; SD = 11.2). We explored the women's initial illness episode and the influence of CVD on their current daily functioning, family activities and relationships, and social engagement. The women were slow to seek help for CVD symptoms. Postrecovery, 62% of women perceived their heart disease as influencing change in their daily lives. The influence of CVD varied depending on how congruent behavior changes were with their sense of self.

Older women's experiences with multiple health conditions: daily challenges and care practices.

Guided by life-course theory and a trajectory model of chronic illness, we examined the health care practices and management strategies used by 17 older women with multiple chronic conditions. Qualitative analyses revealed that the women played an active role in shaping the course of their illness within their everyday lives. Pain and a decline in energy frequently interfered with completion of daily activities. To compensate, many women reduced and slowed down the pace of activities they performed while emphasizing the importance of maintaining independence and autonomy. Appreciative of support from family members, at times the women received more help and advice than they preferred.