Developing quality indicators for the care of older people with cognitive impairment presenting to emergency departments

Abstract

Older people with cognitive impairment (CI) in emergency departments (ED) are at higher risk of negative health outcomes and adverse events, compared to their counterparts without cognitive issues. There is evidence that up to 40% of olderpersons presenting to ED have a cognitive problem. The ED can be a confusing place for older people with CI. Bright lights, loud noises, crowding, interactions with multiple care givers, and separation from family or wellknown caregivers are examples of the challenges an older person with CI may experience when presenting to EDs. There are concerns that ED staff have insufficient knowledge to support older people, especially those with CI (e.g. dementia). Screening for cognitive issues is not common practice in EDs resulting in under recognition of CI. CI affects patient communication and may complicate the collection of anamnesis (e.g. does the patient experience pain) or comprehension of discharge instructions. Older people with CI are more likely to develop delirium especially when they are acutely unwell (e.g. people with hip fracture). However, delirium may be preventable and treatable. Behavioural and psychological symptoms in older people with CI may negatively affect collaboration in diagnostic procedures and treatments in EDs. Therefore EDs are faced to provide quality of care in a timely manner to this vulnerable ED population in order to achieve optimal health outcomes and prevent adverse events. The aim of this dissertation was to contribute to the improvement of the quality of care of the older ED population with CI by developing a suite of quality indicators (QI) for care evaluation. A secondary aim was to explore the relationship of existing process QIs to those indicators developed in this dissertation. In consideration of QI application in clinical practice, preliminary work included the evaluation of the current level of documentation on, and recognition of, cognitive issues and associated care, by using previously published process indicators in existing medical records. The results informed the larger body of work focused on developing a suite of QIs for older ED patients with CI. The scientific literature was evaluated systematically to address the following core concept areas: 1) negative health outcomes and adverse events in older persons presenting to EDs; 2) descriptors of best practice in assessment and management of geriatric ED patients with CI; and 3) existing quality measures for older people in ED and, where relevant, non-ED settings. Using the identified literature, a preliminary list of potential QIs was formulated and distributed to an advisory panel for review to initiate discussion at a first meeting (March 2012). An assessment of emergency care, including ED processes, structures and patients’ outcomes, was performed by comparing current emergency care against available scientific evidence. Draft QIs were tested in eight Australian emergency services to investigate whether data was feasible to collect and truly reflective of quality of care. The study followed the ED episode of a cohort of persons aged 70 years and over. The draft indicators, along with data from the field study were evaluated by an advisory panel at a second meeting (November 2013). A final indicator suite was established following a two round voting process using the RAND/ULCA appropriateness method. An indicator suite, including five structural and eleven process indicators, was established. The set of structural indicators is concerned with the availability of organisational ED policies, procedures, or protocols targeting the management of older people with CI and their carers, assessment and management of pain and behavioural issues, and delirium prevention in EDs. Process indicators include measures concerned with cognitive screening, delirium screening, delirium risk assessment, evaluation of acute change in mental status, potential delirium cause, attendance of nominated support person, collateral history, proxy notification, pain assessment, post-discharge follow-up, and ED length of stay. These sets of indicators enable the measurement of quality of care concerned with structure and process. Their use will enable the identification of the emergency services’ level of care for older people with CI. This will support a targeted response improving quality of care for older people with CI presenting to EDs.