Improving Delirium Screening and Detection for Older Adults Presenting to the Emergency Department (ED): A Novel ED Delirium Screening and Detection Program

改善急诊科 (ED) 老年人的谵妄筛查和检测：一种新颖的 ED 谵妄筛查和检测计划

• 批准号: 10701799
• 负责人: Liron Danay Sinvani
• 金额: $ 20.94万
• 依托单位: FEINSTEIN INSTITUTE FOR MEDICAL RESEARCH
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-09-15 至 2025-05-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10701799
• 关键词: Accident and Emergency department; Address; Adherence; Adoption; Affect; Chemicals; Clinical; Clinical Management; Cluster randomized trial; Complex; Data; Delirium; Dementia; Detection; Discipline of Nursing; Documentation; Educational workshop; Elderly; Electronic Health Record; Eligibility Determination; Emergency Medicine; Enrollment; Ensure; Environment; Failure; Goals; Health system; Hospitals; Impaired cognition; Intensive Care Units; Intervention; Interview; Knowledge; Leadership; Maintenance; Methods; Modeling; Nurses; Outcome; Outcome Assessment; Patients; Physical Restraint; Prevention; Psychological reinforcement; Randomized; Reach, Effectiveness, Adoption, Implementation, and Maintenance; Research; Screening procedure; Site; Standardization; Structure; Testing; Time; Trainers Training; Training; Training Programs; United States; Validation; clinical practice; confusion assessment method; demographics; emergency settings; experience; implementation evaluation; implementation outcomes; implementation science; improved; improved outcome; innovation; mortality; multimodality; novel; prevent; primary outcome; programs; recruit; response; restraint; retention rate; screening; secondary outcome; standard of care; success; telehealth

Over 23 million older adults present to the Emergency Department (ED) each year in the United States, and up to 20% will experience delirium while in the ED. Yet, it is estimated that over 75% of ED delirium cases are missed. Failure to systematically screen and detect ED delirium affects clinical management (e.g., use of chemical and physical restraints) and outcomes (e.g., increased mortality and dementia). Barriers to ED delirium detection consist of a lack in screening tool use, competing priorities, and wide-ranging knowledge deficits. Even when validated screening tools (e.g., brief confusion assessment method, bCAM) are prioritized and integrated into nursing workflow, they are rarely used consistently or accurately in clinical practice, leading to lack of delirium detection. Our long-term goal is to implement and disseminate a comprehensive ED Delirium Detection Program (ED-DDP) that will improve screening, detection, and management of ED delirium in older adults. Our group has previously developed and tested the innovative DDP in the intensive care unit (ICU- DDP). The ICU-DDP utilizes a “train-the-trainer” model, and consists of: 1) a multicomponent one-day delirium champion workshop; 2) real-time direct observation, training, and reinforcement via telehealth (tele-delirium training); and 3) training of nurses by champions. The ICU-DDP improved delirium detection from 9.1% to 30.1% (p = 0.005). Subsequently, we refined the ICU-DDP for the ED (ED-DDP) through semi-structured interviews with ED stakeholders and a pilot of ED tele-delirium training. ED stakeholder interviews revealed that participation in the ED-DDP was of high priority, acceptable, and feasible. The overarching aim of this proposal is to determine the preliminary efficacy of the ED-DDP for improving ED delirium screening, detection, and management in older adults, while also evaluating implementation outcomes of the ED-DDP for champions and nurses. We propose to: 1) conduct a pilot stepped wedge cluster randomized trial (SW-CRT) of the ED-DDP across 3 diverse EDs to determine preliminary efficacy of the ED-DDP; and 2) use a mixed- methods approach to assess RE-AIM implementation outcomes (Reach, Efficacy, Adoption, Implementation, and Maintenance) of the ED-DDP. Our team with expertise in delirium, emergency medicine, hospital-based interventions, and implementation science, is well-poised to complete the following 2 Specific Aims: 1) Conduct a pilot SW-CRT across 3 ED sites to determine the preliminary efficacy of the ED-DDP for improving delirium screening, detection, and management in older adults presenting to the ED; and 2) Grounded in the RE-AIM framework, we will use mixed methods to conduct implementation outcome assessments of the ED-DDP for champions and nurses. The proposal addresses a critical need for improving ED delirium screening, detection, and management, which will improve outcomes for the millions of older adults presenting to the ED each year. Our findings will: inform approaches to ensure program fidelity; enable validation and refinement of the ED- DDP; and estimate effect sizes for a subsequent full-scale SW-CRT of the ED-DDP.

在美国，每年有超过 2300 万老年人到急诊室 (ED) 就诊，甚至更多 20% 的人在急诊科期间会出现谵妄，但据估计，超过 75% 的急诊科病例会出现谵妄。 未能系统地筛查和检测 ED 谵妄会影响临床管理（例如，使用 化学和物理限制）和结果（例如，死亡率增加和痴呆症）。 谵妄检测包括缺乏筛查工具的使用、相互竞争的优先事项和广泛的知识 即使优先考虑经过验证的筛查工具（例如，简短的混淆评估方法，bCAM）。 并集成到护理工作流程中，但在临床实践中很少一致或准确地使用它们，导致 缺乏谵妄检测 我们的长期目标是实施和传播全面的 ED Delirium。 检测计划 (ED-DDP) 将改善老年人 ED 谵妄的筛查、检测和管理 我们的团队之前已在重症监护病房（ICU-）中开发并测试了创新的 DDP。 ICU-DDP 采用“培训师培训”模型，包括：1) 多成分一日谵妄。 冠军研讨会；2) 通过远程医疗（远程谵妄）进行实时直接观察、培训和强化 3) ICU-DDP 将谵妄检出率从 9.1% 提高到了冠军对护士的培训。 随后，我们通过半结构化改进了 ED 的 ICU-DDP（ED-DDP）。 对 ED 利益相关者的采访以及 ED 远程谵妄培训试点显示。 参与 ED-DDP 具有高度优先性、可接受且可行。 该提案旨在确定 ED-DDP 在改善 ED 谵妄筛查、检测、 和老年人的管理，同时还评估 ED-DDP 的实施结果 我们建议： 1) 进行一项试点阶梯楔形聚类随机试验 (SW-CRT) 跨 3 个不同 ED 的 ED-DDP 以确定 ED-DDP 的初步功效；以及 2) 使用混合- 评估 RE-AIM 实施成果的方法（范围、功效、采用、实施、 ED-DDP 的团队拥有谵妄、急诊医学、医院专业知识。 干预措施和实施科学已准备好完成以下 2 个具体目标： 1) 行为 在 3 个 ED 站点进行试点 SW-CRT，以确定 ED-DDP 对改善谵妄的初步功效 对到急诊科就诊的老年人进行筛查、检测和管理；2) 以 RE-AIM 为基础； 框架下，我们将采用混合方法对 ED-DDP 的实施成果进行评估 该提案解决了改善 ED 谵妄筛查、检测、 和管理，这将改善每年数百万到急诊科就诊的老年人的治疗结果。 我们的研究结果将： 提供确保程序保真度的方法； 实现 ED 的验证和完善； DDP；并估计 ED-DDP 后续全面 SW-CRT 的效果大小。