Schnitker Linda M, Martin-Khan Melinda, Burkett Ellen, Beattie Elizabeth R A, Jones Richard N, Gray Len C
The Centre for Research in Geriatric Medicine, University of Queensland, Brisbane, Australia.
Acad Emerg Med. 2015 Mar;22(3):285-98. doi: 10.1111/acem.12616.
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).
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.
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.
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 to improve any suboptimal processes of care. Further validation and utility of the indicators in a wider population is now indicated.
本研究的目的是制定过程质量指标（PQIs），以支持改善急诊科（ED）中认知障碍老年人的护理服务。
采用结构化研究方法来制定急诊科中认知障碍老年人护理的PQIs，包括将现有证据与专家意见相结合（第一阶段）、实地研究（第二阶段）和正式投票（第三阶段）。对文献进行系统综述，确定针对认知障碍老年人特定护理需求的急诊科流程。还纳入了现有的相关PQIs。通过整合科学证据和临床专业知识，起草了新的PQIs，并与现有的PQIs一起由一个咨询小组进行广泛讨论。这些指标在八家医院对70岁及以上的老年人群体进行了实地测试。在分析实地研究数据（指标患病率、各地点的变异性）后，咨询小组在第二次会议上进一步确定了PQIs。咨询小组正式投票选出最适合护理评估的那些PQIs。
除了七个先前发表的与老年人护理相关的PQIs外，还创建了15个新指标。然后对这22个PQIs进行了实地测试。专门为急诊科中有认知障碍的老年人群体设计的PQIs仅对已确定有认知障碍的患者进行评分。经过正式投票，该组中总共纳入了11个PQIs。这些PQIs针对认知筛查、谵妄筛查、谵妄风险评估、精神状态急性变化评估、谵妄病因、代理人通知、旁证病史、指定支持人员的参与、疼痛评估、出院后随访以及急诊科住院时间。
本文提出了一组用于评估急诊科中认知障碍老年人护理的PQIs。不同急诊科地点指标触发情况的差异表明，对这一弱势群体的护理质量有改进的机会。应用PQIs将确定急诊服务部门对认知障碍老年急诊科患者护理策略的实施情况。在急诊科层面了解PQI触发因素能够实施有针对性的干预措施，以改善任何不理想的护理流程。现在表明需要在更广泛的人群中对这些指标进行进一步验证和实用性评估。
