group n°6 els devriendt (belgium) camilla gÖras (sweden) sara levati (italie) laura-maria murtola...
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Group N°6Els DEVRIENDT (Belgium)
Camilla GÖRAS (Sweden)
Sara LEVATI (Italie)
Laura-Maria MURTOLA (Finland)
Sebastien KEREVER (France)
Early detection of delirium in older people in the emergency department
Nijmegen 5th July 2013
Background• Delirium: disturbance of consciousness, attention, cognition, and
perception that appears after a short period of time (usually hours to days) and tends to fluctuate during the course of the day
• Prevalence of delirium: 8-10% of older patients (≥70 yo) admitted to the Emergency Departement, underdiagnosed in 57% to 83% of the cases
• Multifactorial problem associated with a increasing of:– Hospital mortality– Hospital length of stay– Healthcare costs– Long-term functional and cognitive decline
Missing delirium detection Missing diagnosis
safety and quality of care impairment
Barron EA & Al, 2013; NICE, 2010; Han & Al , 2010; Innoye & Al, 1990; Press & Al, 2009. 2
Question
What is the impact of an e-learning program on nurses to
improve the early detection of delirium in older patients
in an emergency department?
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Methods
MRC METHODS
1. Developement
Evidence base Systematic ReviewQualitative studies: Focus groups
Identifying Theory Competency framework
Modelling intervention Expert Pannel Meeting
2. Feasibility/piloting
Testing procedures Before/After Pilot study Qualitative feasibility study
Estimation of recruitment/retention Review of the litterature + a priori information
Number of subject needed for the pilot study
Sample size determinationInclusion rate estimation
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Ishikawa - fishbone flowchart(Cause & Effect Diagram)
Underdetection of delirium in older patients
in ED
5Ishikawa K , “Introduction to quality control”, 1990.
EnvironementEnvironement CompetencesCompetences
Screening toolScreening tool DocumentationDocumentation
Theoretical framework
• Focus Group:
– Qualitative part• Skills
• Knowledge
• Attitudes
• Behavior
– Quantitative part• Proportion
• Distribution
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%
%
%
Cheetham G & Al, “Towards a holistic model of professional competence”, J Eur Indus Training, 1996
Personal Competence (Behavior)
Cognitive Competence (Knowledge)
%
Intervention development
• Educational program – Philosophy: self constructive program– Methods: e-learning platform (modules and toolbox)– Content:
• Skills: using the CAM screening tool, how to deal with the target population• Knowledge: incidence, risk factors, consequences, screening methods• Attitudes: organisational culture, climate within the team, attitudes towards
the population, safety, motivation• Behavior: emotional control (aggresivity)
– Competence tests (part of the e learning)
• Modelling – Expert panel meeting: geriatric and emergency team.
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Methodology – Pilot study
• Model
– Monocentric prospective quasi experimental before and after pilot study
– Primary outcome: proportion of delirium documented during the first 72h at the ED (%)
– Secondary outcome: Increased competence (questionnaire, nurse competence scales, vignette study)
• Sample size
– Attended effect Δ + 20% (systematic review & previous study)
– α = 5%, power = 90%, two tailed
– n = 260
• Inclusion rate
– Rate of patient 2/days with delirium (≥ 70 yo)
– Length 8 months (3 before, 2 teaching, 3 after)
– n = 360 (+ 40%, refusal, withdraw, dementia, lost to follow up, missing)
– Cost 35 000 euros
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Future Perspectives
• Meta analysis– Risk factors (HR), Mortality
• Multicentric international cluster RCT– Long term mortality– Long term e-learning
• Cost Effectiveness Study– E learning vs. Cost of avoid delirium
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Why Us ?
• Conclusion: “Delirium is a significant concern in the ED, with many delirious patients not identified by physicians. To improve delirium outcomes and hospital management, measures must include mechanisms to improve detection” Barron & Al, 2013
• The team experience– Els DEVRIENDT (Geriatric and Emergency Room)– Camilla GÖRAS (Safety & Quality of care)– Sara LEVATI (Complex Intervention & net work tools)– Laura-Maria MURTOLA (ICU, management, care organisation)– Sebastien KEREVER (ICU, Methodology, Biostatistic)
• The results– Improving Patient outcome– Saving institutional money – Increase Nursing Competence
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