Group N°6 Els DEVRIENDT (Belgium) Camilla GÖRAS (Sweden) Sara LEVATI (Italie) Laura-Maria MURTOLA (Finland) Sebastien KEREVER (France) Early detection.

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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