RationaleOlder adults are at high risk of developing delirium in the emergency department (ED); however, it is often missed or undertreated. Improving ED delirium care is challenging in part due to a lack of standards to guide best practice. Clinical practice guidelines (CPGs) translate evidence into recommendations to improve practice.AimTo critically appraise and synthesize CPG recommendations for delirium care relevant to older ED patients.MethodsWe conducted an umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations were critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)‐II; and Appraisal of Guidelines Research and Evaluation—Recommendations Excellence (AGREE‐REX) instruments. A threshold of 70% or greater in the AGREE‐II Rigour of Development domain was used to define high‐quality CPGs. Delirium recommendations from CPGs meeting this threshold were included in the synthesis and narrative analysis.ResultsAGREE‐II Rigour of Development scores ranged from 37% to 83%, with 5 of 10 CPGs meeting the predefined threshold. AGREE‐REX overall calculated scores ranged from 44% to 80%. Recommendations were grouped into screening, diagnosis, risk reduction, and management. Although none of the included CPGs were ED‐specific, many recommendations incorporated evidence from this setting. There was agreement that screening for nonmodifiable risk factors is important to define high‐risk populations, and those at risk should be screened for delirium. The ‘4A's Test’ was the recommended tool to use in the ED specifically. Multicomponent strategies were recommended for delirium risk reduction, and for its management if it occurs. The only area of disagreement was for the short‐term use of antipsychotic medication in urgent situations.ConclusionThis is the first known review of delirium CPGs including a critical appraisal and synthesis of recommendations. Researchers and policymakers can use this synthesis to inform future improvement efforts and research in the ED.RegistrationThis study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6OSF.IO/TG7S6.
Results of this review illustrate that not all practice guidelines are of equal quality. Given the costs associated with the development and maintenance of high-quality practice guidelines, such work may be more efficiently completed through international collaborations and then adapted for national and regional healthcare contexts.
A pilot study was conducted to determine the feasibility of a longitudinal investigation of patients' coping during the early postdischarge period. Recruitment was conducted on a general medical unit and a surgical orthopedic unit. Forty‐four participants were recruited with 95% retention. Demographic characteristics plus measures of discharge risk and perceived readiness (expected coping) were collected before discharge. Measures of coping (experienced) and the use of supports and services were collected on the first day postdischarge, the end of the first week, and during weeks 3 and 5. Considerable variability was evident in coping scores, and not all participants exhibited improvement over time. Four patterns of coping were identified: ongoing recovery, initial shock, bumpy road, and progressive decline. Further investigation is required to validate the observed coping patterns. A better understanding of conditions affecting patient coping during the transition from hospital to home will support efforts to reduce unplanned use of acute care services.
Background Up to 35% of older adults present to the emergency department (ED) with delirium or develop the condition during their ED stay. Delirium associated with an ED visit is independently linked to poorer outcomes such as loss of independence, increased length of hospital stay, and mortality. Improving the quality of delirium care for older ED patients is hindered by a lack of knowledge and standards to guide best practice. High-quality clinical practice guidelines (CPGs) have the power to translate the complexity of scientific evidence into recommendations to improve and standardize practice. This study will identify and synthesize recommendations from high-quality delirium CPGs relevant to the care of older ED patients. Methods We will conduct a multi-phase umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations will be critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II; and Appraisal of Guidelines Research and Evaluation – Recommendations Excellence (AGREE-REX) instruments, respectively. We will also synthesize and conduct a narrative analysis of high-quality CPG recommendations. Discussion This review will be the first known evidence synthesis of delirium CPGs including a critical appraisal and synthesis of recommendations. Recommendations will be categorized according to target population and setting as a means to define the bredth of knowledge in this area. Future research will use consensus building methods to identify which are most relevant to older ED patients. Trial registration This study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6.
Research on acute care reentry by recently discharged inpatients has generally focused on hospital readmissions, with less attention given to presentations to the emergency department (ED). This omission results in underestimation of the extent of reentry and its impact on ED patient volumes and flow. This project involved an analysis of administrative data to examine the rate of ED presentations by recently discharged inpatients using 3 time metrics—within 0–3 days, 0–7 days, and 0–30 days of discharge. Descriptive-correlational analyses were conducted to examine the rates of reentry and ability to predict ED presentations using patient demographic (age and sex) and clinical profile (length of hospital stay and day of presentation). Approximately 12% of hospital discharges to home involved patients who presented to the ED within 30 days, and almost half occurred within the first week. Results of multivariable analyses suggest that the influences of ED presentations differ depending on the time metric examined. Emergency department presentations within 3 and 7 days of discharge compared with 30 days were not predicted by patient age or sex but were more likely to involve those with shorter hospital stays. A weekend presentation was also more likely among case patients presenting within 3 days of discharge. Only about one third of ED presentations resulted in readmission. Emergency department presentations are an important component of acute care reentry. Establishment of a common reentry metric for ED presentations would facilitate efforts to determine the impact of these events. Emergency nurses working in advanced practice roles are ideally positioned to assume a leadership role in addressing the needs of recently discharged inpatients who present to the ED. By reviewing these cases and collaborating with the inpatient unit staff, it may be possible to identify strategies for augmenting discharge planning and the provision of transitional care.
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