Process Quality Indicators Targeting Cognitive Impairment to Support Quality of Care for Older People with Cognitive Impairment in Emergency Departments

Abstract

Objectives: The objective of this study was to develop process quality indicators (PQIs) to support the improvement of care services for older people with cognitive impairment in emergency departments (ED).Methods: A structured research approach was taken for the development of PQIs for the care of older people with cognitive impairment in EDs, including combining available evidence with expert opinion (phase 1), a field study (phase 2), and formal voting (phase 3). A systematic review of the literature identified ED processes targeting the specific care needs of older people with cognitive impairment. Existing relevant PQIs were also included. By integrating the scientific evidence and clinical expertise, new PQIs were drafted and, along with the existing PQIs, extensively discussed by an advisory panel. These indicators were field tested in eight hospitals using a cohort of older persons aged 70 years and older. After analysis of the field study data (indicator prevalence, variability across sites), in a second meeting, the advisory panel further defined the PQIs. The advisory panel formally voted for selection of those PQIs that were most appropriate for care evaluation.Results: In addition to seven previously published PQIs relevant to the care of older persons, 15 new indicators were created. These 22 PQIs were then field tested. PQIs designed specifically for the older ED population with cognitive impairment were only scored for patients with identified cognitive impairment. Following formal voting, a total of 11 PQIs were included in the set. These PQIs targeted cognitive screening, delirium screening, delirium risk assessment, evaluation of acute change in mental status, delirium etiology, proxy notification, collateral history, involvement of a nominated support person, pain assessment, postdischarge follow-up, and ED length of stay.Conclusions: This article presents a set of PQIs for the evaluation of the care for older people with cognitive impairment in EDs. The variation in indicator triggering across different ED sites suggests that there are opportunities for quality improvement in care for this vulnerable group. Applied PQIs will identify an emergency services' implementation of care strategies for cognitively impaired older ED patients. Awareness of the PQI triggers at an ED level enables implementation of targeted interventions

A national survey of Canadian emergency medicine residents’ comfort with geriatric emergency medicine

“…Because numerous studies have demonstrated deficiencies in ED care for older adults 36,37 with falls, 38 dementia, 39,40 or delirium, 40 a concern exists that …”

Structural Quality Indicators to Support Quality of Care for Older People With Cognitive Impairment in Emergency Departments

“…This care concept as a SQI triggered in none of the participating EDs and, yet, some EDs did use a screening tool (though minimal). Therefore, in recognition of the importance of screening, the companion process quality indicator set 31 includes screening as a measure of care. SQI = structural quality indicator.…”

“…If quality indicators are effective in stimulating change in practice, then they have a limited life span; after a period of implementation, existing indicators should be reevaluated to ensure that the point of difference in quality across hospitals is still being targeted. Figure 1 gives an overview of process 28,31,32 and outcome quality indicators for the care of older ED patients with cognitive impairment. This study (a subset of the primary study) focused on the development of SQIs targeting the special needs of the older ED population with cognitive impairment.…”

“…31 The method developing PQIs for the care of older ED patients with cognitive impairment included a similar approach, including a literature review, a consultative process engaging experts, and field testing. Field testing involved the implementation and evaluation of drafted PQIs using a cohort consisting of 580 older ED patients, of whom 191 had cognitive impairment.…”

Is Your Department's Quality Good Enough for Your Grandmother? Quality Indicators for Patients With Dementia and Delirium

“…In this issue of Academic Emergency Medicine, Schnitker et al 10,11 succeed in pushing the evidence base further and addressing our understanding of older people's issues. Their two articles empirically and quantitatively evaluate quality care for older patients who present to the ED with cognitive impairment.…”