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A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients.

ABSTRACT: Introduction:Agitation, mental illness, and delirium are common reasons for older adults to seek care in the emergency department (ED). There are significant knowledge gaps in understanding how to best screen older adults for these conditions and how to manage them. In addition, in areas where research has been performed, implementation has been slow. A working group convened to develop a set of high-priority research questions that would advance the understanding of optimal management of older adults with acute behavioral changes in the ED. This manuscript is the product of a breakout session on "Special Populations: Agitation in the Elderly" from the 2016 Coalition on Psychiatric Emergencies' first Research Consensus Conference on Acute Mental Illness. Methods:Participants were identified with expertise in emergency medicine (EM), geriatric EM, and psychiatry. Background literature reviews were performed prior to the in-person meeting in four key areas: delirium; dementia; substance abuse or withdrawal; and mental illness in older adults. Input was solicited from all participants during the meeting, and questions were iteratively focused and revised, voted on, and ranked by importance. Results:Fourteen questions were identified by the group with high consensus for their importance related to the care of older adults with agitation in the ED. The questions were grouped into three topic areas: screening and identification; management strategies; and the approach to delirium. Conclusion:It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes, have the tools to screen older adults for those causes, and employ methods to treat the underlying causes and ameliorate their symptoms. Answers to the identified research questions have great potential to improve the care of older adults presenting with behavioral changes.

SUBMITTER: Shenvi C

PROVIDER: S-EPMC6404700 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

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A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients.

Shenvi Christina C Wilson Michael P MP Aldai Alessandra A Pepper David D Gerardi Michael M

The western journal of emergency medicine 20190219 2

<h4>Introduction</h4>Agitation, mental illness, and delirium are common reasons for older adults to seek care in the emergency department (ED). There are significant knowledge gaps in understanding how to best screen older adults for these conditions and how to manage them. In addition, in areas where research has been performed, implementation has been slow. A working group convened to develop a set of high-priority research questions that would advance the understanding of optimal management o ...[more]

PMID: 30881563

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Project description:Introduction:Emergency departments (ED) manage a wide variety of critical medical presentations. Traumatic, neurologic, and cardiac crises are among the most prevalent types of emergencies treated in an ED setting. The high volume of presentations has led to collaborative partnerships in research and process development between experts in emergency medicine (EM) and other disciplines. While psychosis is a medical emergency frequently treated in the ED, there remains a paucity of evidence-based literature highlighting best practices for management of psychotic presentations in the ED. In the absence of collaborative research, development of best practice guidelines cannot begin. A working group convened to develop a set of high-priority research questions to address the knowledge gaps in the care of psychotic patients in the ED. This article is the product of a subgroup considering "Special Populations: Psychotic Spectrum Disorders," from the 2016 Coalition on Psychiatric Emergencies first Research Consensus Conference on Acute Mental Illness. Methods:Participants were identified with expertise in psychosis from EM, emergency psychiatry, emergency psychology, clinical research, governmental agencies, and patient advocacy groups. Background literature reviews were performed prior to the in-person meeting. A nominal group technique was employed to develop group consensus on the highest priority research gaps. Following the nominal group technique, input was solicited from all participants during the meeting, questions were iteratively focused and revised, voted on, and then ranked by importance. Results:The group developed 28 separate questions. After clarification and voting, the group identified six high-priority research areas. These questions signify the perceived gaps in psychosis research in emergency settings. Questions were further grouped into two topic areas: screening and identification; and intervention and management strategies. Conclusion:While psychosis has become a more common presentation in the ED, standardized screening, intervention, and outcome measurement for psychosis has not moved beyond attention to agitation management. As improved outpatient-intervention protocols are developed for treatment of psychosis, it is imperative that parallel protocols are developed for delivery in the ED setting.

Project description:ObjectivesTo describe clinical characteristics and management of acute lymphadenitis and to identify risk factors for complications.MethodsHealth record review of children ≤17 years with acute lymphadenitis (≤2 weeks) in a tertiary paediatric emergency department (2009-2014); 10% of charts were reviewed by a blinded second reviewer. Multivariate logistic regression identified factors associated with intravenous antibiotic treatment, unplanned return visits warranting intervention, and surgical drainage.ResultsOf 1,023 health records, 567 participants with acute lymphadenitis were analyzed. The median age = 4 years (interquartile range [IQR]: 2 to 8 years), and median duration of symptoms = 1.0 day (IQR: 0.5 to 3.0 days). Cervical lymphadenitis was most common. Antibiotics were prescribed in 73.5% of initial visits; 86.9% of participants were discharged home. 29.0% received intravenous antibiotics, 19.3% had unplanned emergency department return visits, and 7.4% underwent surgical drainage. On multivariate analysis, factors associated with intravenous antibiotic use included history of fever (odds ratio [OR]=2.07, 95% confidence interval [CI]: 1.11 to 3.92), size (OR=1.74 per cm, 95% CI: 1.44 to 2.14), age (OR=0.84 per year, 95% CI: 0.76 to 0.92), and prior antibiotic use (OR=4.45, 95% CI: 2.03 to 9.88). The factors associated with unplanned return visit warranting intervention was size (OR=1.30 per cm, 95% CI: 1.06 to 1.59) and age (OR=0.89, 95% CI: 0.80 to 0.97). Factors associated with surgical drainage were age (OR=0.68 per year, 95% CI: 0.53 to 0.83) and size (OR=1.80 per cm, 95% CI: 1.41 to 2.36).ConclusionsThe vast majority of children with acute lymphadenitis were managed with outpatient oral antibiotics and did not require return emergency department visits or surgical drainage. Larger lymph node size and younger age were associated with increased intravenous antibiotic initiation, unplanned return visits warranting intervention and surgical drainage.

Project description:Background and importanceDiagnosing acute heart failure (AHF) is difficult in elderly patients presenting with acute dyspnea to the emergency department.ObjectivesTo assess the diagnostic accuracy of NT-proBNP, high-sensitivity cardiac troponin-I (Hs-cTnI), soluble ST2 (ST2), galectin-3 and CD146 alone and in combination for diagnosing AHF in elderly patients presenting with acute dyspnea to the emergency department.Design, settings and participantsThis was a prospective, multicenter study performed between September 2016 and January 2020, including elderly patients presenting with acute dyspnea to the emergency department of 6 French hospitals.InterventionMeasurement of NT-proBNP, hs-cTnI, ST2, galectin-3 and CD146.Outcome measure and analysisThe reference standard, AHF, was adjudicated by two independent physicians based on ED and hospitalization clinical, biological (excluding biomarkers), radiological and echocardiography data (performed by a cardiologist in the cardiology department specifically for this study). Three exploratory methods (two using a cross-sectional approach with logistic regression and counting all biomarker combinations, and one using a sequential approach with gray zone optimizations) were applied to create comprehensive combinations of the 5 biomarkers for measuring diagnostic accuracy.Main resultsTwo hundred thirty-eight patients (median age of 85 years, IQR = 8) were analyzed, and 110 (46%) were diagnosed with AHF. The accuracies of NT-proBNP, CD146, hs-cTnI, galectin-3, and ST2 were 0.72 [95% confidence interval (CI) 0.66-0.77], 0.63 (95% CI 0.57-0.69), 0.59 (95% CI 0.53-0.65), 0.55 (95% CI 0.49-0.61) and 0.51 (95% CI 0.45-0.57), respectively. Regardless of the approach used or how the 5 biomarkers were combined, the best accuracy for diagnosing AHF (0.73, 95% CI 0.67-0.78) did not differ from that of NT-proBNP alone.ConclusionIn this study, NT-proBNP alone exhibited the best diagnostic accuracy for diagnosing AHF in elderly patients presenting with acute dyspnea to the emergency departments. None of the other biomarkers alone or combined improved the accuracy compared to NT-proBNP, which is the only biomarker to use in this setting.

Project description:Anecdotal evidence suggested that the management of patients with eye complaints in the Emergency Department (ED) at King's College Hospital, London was suboptimal. Acute ophthalmology is often poorly covered at undergraduate level in the United Kingdom which can affect patient safety. Furthermore, it was notoriously difficult to obtain specialist advice within working hours. Contact lens (CL) wearers are prone to Pseudomonas conjunctivitis which requires certain antibiotics and mismanagement of this has led to sight-threatening consequences locally. Junior doctor surveys suggested under-confidence in managing eye problems and initial audit showed that eye assessments are frequently incomplete during ED clerkings. For example, CL status and visual acuity were documented in 63% and 77% of cases respectively; however, these were increased when a dedicated pro forma was used. To address these multiple issues, a new 'eye examination pro forma' was created, along with integrated clinical guidelines based on local expert practice. This would prompt staff to elicit key information to help guide management. A new referral pathway was also introduced to facilitate access to ophthalmology services. On re-auditing seven months later, the new pro forma was completed for only 28% of patients, though this was associated with a higher rate of documentation of all parameters. The referral pathways worked efficiently and patients with red flag features were identified and managed more appropriately than before. We learnt that it is important that someone personally drives the innovations from the outset, otherwise prolonged change is difficult. Secondly, junior doctors may not be proficient with slit lamp use, for instance, so targeted teaching is required, not simply new pathways. Full engagement with the pro forma and effective patient management should then improve simultaneously. Specific teaching is now being implemented and permanent staff have been recruited to oversee the project. We plan to re-audit in November 2014.

Project description:IntroductionThere are numerous challenges in delivering appropriate treatment for multidrug-resistant tuberculosis (MDR-TB) and the evidence base to guide those practices remains limited. We present the third updated Research Agenda for the programmatic management of drug-resistant TB (PMDT), assembled through a literature review and survey.MethodsPublications citing the 2008 research agenda and normative documents were reviewed for evidence gaps. Gaps were formulated into questions and grouped as in the 2008 research agenda: Laboratory Support, Treatment Strategy, Programmatically Relevant Research, Epidemiology, and Management of Contacts. A survey was distributed through snowball sampling to identify research priorities. Respondent priority rankings were scored and summarized by mean. Sensitivity analyses explored weighting and handling of missing rankings.ResultsThirty normative documents and publications were reviewed for stated research needs; these were collapsed into 56 research questions across 5 categories. Of more than 500 survey recipients, 133 ranked priorities within at least one category. Priorities within categories included new diagnostics and their effect on improving treatment outcomes, improved diagnosis of paucibacillary and extra pulmonary TB, and development of shorter, effective regimens. Interruption of nosocomial transmission and treatment for latent TB infection in contacts of known MDR-TB patients were also top priorities in their respective categories. Results were internally consistent and robust.DiscussionPriorities retained from the 2008 research agenda include shorter MDR-TB regimens and averting transmission. Limitations of recent advances were implied in the continued quest for: shorter regimens containing new drugs, rapid diagnostics that improve treatment outcomes, and improved methods of estimating burden without representative data.ConclusionThere is continuity around the priorities for research in PMDT. Coordinated efforts to address questions regarding shorter treatment regimens, knowledge of disease burden without representative data, and treatment for LTBI in contacts of known DR-TB patients are essential to stem the epidemic of TB, including DR-TB.

Project description:ObjectivesEdication management is a process in which medications are selected, procured, delivered, prescribed, reviewed, administered and monitored to assure high-quality patient care and safety. This paper explores clinicians' attitudes towards medication management which is both open to influence and strongly linked to successful changes in mediation behaviour. We aimed to investigate effects of engaging in participatory action research to improve emergency medicine clinicians' attitudes to safety in medication management.SettingEmergency department of one university affiliated hospital.ParticipantsA total of 85 clinicians including nurses and physicians partook as participants. Eight managers and clinicians participated as representatives.DesignData are drawn from two-cycle participatory action research. Initially, a situation analysis on the current medication management and clinician views regarding medication management was conducted using three focus groups. Evaluation and reflection data were obtained through qualitative interviews. All qualitative data were analysed using content analysis.ResultsClinicians initially expressed negative attitudes towards existing and new plans for medication management, in that they were critical of current medication-related policy and procedures, as well as wary of the potential relevance and utility of potential changes to medication management. Through the action research, improvement actions were implemented including interprofessional courses, pharmacist-led interventions and the development of new guidelines regarding medication management. Participants and their representatives were engaged in all participatory action research stages with different levels of involvement. Extracted results from evaluation and reflection stages revealed that by engaging in the action research and practice new interventions, clinicians' attitude towards medication management was improved.ConclusionsThe results support the impact of participatory action research on enhancing clinicians' positive attitudes through their involvement in planning and implementing safety enhancing aspects of medication management.

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A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients.

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A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients.

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