Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations

Unlocking therapeutic symphonies:Innovations in clinical decision support for drug-disease interactions in kidney transplantation

Introduction: Drug-disease interactions (DDSIs) are associated with increasing morbidity, mortality, and healthcare costs. These interactions are preventable if recognized and managed properly. Medication safety is critical in kidney transplant patients due to polypharmacy, co-morbidities, and susceptibility to adverse events. Clinical decision support systems (CDSSs) can play a key role therein. Therefore, this study aims to report on the process of developing an innovative, patient-centered, context-aware CDSS for managing DDSIs in kidney recipients. Material and Methods: Clinically important DDSIs were identified in the medications of patients at a kidney transplant outpatient clinic. Subsequently, rules for their detection and management were extracted based on pharmacology references and clinical expertise. A CDSS was developed and piloted following recommendations on medication CDSS design principles. Results: The knowledge base for this CDSS was developed with clinical context sensitivity. We defined priority levels for alerts, established associated display rules, and determined necessary actions based on the transplantation clinical workflow. The DDSI-CDSS correctly detected 37 DDSIs and displayed nine warnings and 28 cautionary alerts for the medications of 113 study patients (32.7% DDSI rate). The system fired three warnings for diltiazem in bradyarrhythmia, and two for each of the following medications and underlying diseases: aspirin in asthma, erythropoietin alfa in hypertension, and gemfibrozil in gall bladder disease. The potential consequences of the identified DDSIs were GI complications (17%), deterioration of the existing disease/condition (6.1%), and an increased risk of arrhythmias (2.6%), thrombosis (2.6%), and hypertension (1.7%). Complying with system alerts and recommendations would potentially prevent all these DDSIs. Conclusion: This study delineates the process of developing an evidence-based DDSI-CDSS for kidney transplantation, laying the groundwork for future advancements. Our results underscore the clinical significance of these interactions and emphasize the imperative for their accurate and timely detection, particularly in these vulnerable patients.</p

Subsyndromal Delirium And Postoperative Pain In Older Adults

Study Purpose and Design: The purpose of this study was to determine the relationship between subsyndromal delirium and pain in older adults following major elective orthopedic surgery. The design of this correlational study was based on Inouye and Charpentier\u27s (1996) multifactorial model of delirium. Methods: Delirium assessments of 62 older adults were completed at 24, 48, and 72 hours following major elective orthopedic surgery. Study measures included: a) the Iowa Pain Thermometer (0-10) pain intensity scale; and b) the Confusion Assessment Method (short form). Data were analyzed for relationships among delirium symptoms and pain, and secondarily, 24-hour opioid intake controlling for preoperative risk factors. Findings: Subsyndromal delirium occurred in 67.9 percent of participants in this study. Increased pain from 0 to 24 hours after surgery had a significant (p\u3c.05) relationship with subsyndromal delirium on the second postoperative day. Similarly, increased pain from 24 to 48 hours had a significant (p\u3c.05) relationship with delirium symptoms on the second postoperative day. Opioid intake was not significantly related to subsyndromal delirium. Conclusions and Implications for Clinical Practice: Findings from this study suggest older adults with higher levels of pain are at higher risk for developing delirium symptoms and subsyndromal delirium on the second day following major elective orthopedic surgery. Improved pain management may help reduce subsyndromal delirium when attention is given to pain on the second postoperative day

Utilizing artificial intelligence in perioperative patient flow:systematic literature review

Abstract. The purpose of this thesis was to map the existing landscape of artificial intelligence (AI) applications used in secondary healthcare, with a focus on perioperative care. The goal was to find out what systems have been developed, and how capable they are at controlling perioperative patient flow. The review was guided by the following research question: How is AI currently utilized in patient flow management in the context of perioperative care? This systematic literature review examined the current evidence regarding the use of AI in perioperative patient flow. A comprehensive search was conducted in four databases, resulting in 33 articles meeting the inclusion criteria. Findings demonstrated that AI technologies, such as machine learning (ML) algorithms and predictive analytics tools, have shown somewhat promising outcomes in optimizing perioperative patient flow. Specifically, AI systems have proven effective in predicting surgical case durations, assessing risks, planning treatments, supporting diagnosis, improving bed utilization, reducing cancellations and delays, and enhancing communication and collaboration among healthcare providers. However, several challenges were identified, including the need for accurate and reliable data sources, ethical considerations, and the potential for biased algorithms. Further research is needed to validate and optimize the application of AI in perioperative patient flow. The contribution of this thesis is summarizing the current state of the characteristics of AI application in perioperative patient flow. This systematic literature review provides information about the features of perioperative patient flow and the clinical tasks of AI applications previously identified

Measurement in Health: Advancing Assessment of Delirium

Rationale: Delirium is a serious, morbid condition affecting 2.6 million older Americans annually. A major problem plaguing delirium research is difficulty in identification, given a plethora of existing tools. The lack of consensus on key features and approaches has stymied progress in delirium research. The goal of this project was to use advanced measurement methods to improve delirium’s identification. Aims and Findings: (1) Determine the 4 most commonly used and well-validated instruments for delirium identification. Through a rigorous systematic review, I identified the Confusion Assessment Method (CAM), Delirium Observation Screening Scale (DOSS), Delirium Rating Scale-Revised-98 (DRS-R-98), and Memorial Delirium Assessment Scale (MDAS). (2) Harmonize the 4 instruments to generate a delirium item bank (DEL-IB), a dataset containing items and estimates of their population level parameters. In a secondary analysis of 3 datasets, I equated instruments on a common metric and created crosswalks. (3) Explore applications of the harmonized item bank through several approaches. First, identifying different cut-points that will optimize: (a) balanced high accuracy (Youden’s J-Statistic), (b) screening (sensitivity), and (c) confirmation of diagnosis (specificity) in identification of delirium. Second, comparing performance characteristics of example forms developed from the DEL-IB. Impact: The knowledge gained includes harmonization of 4 instruments for identification of delirium, with crosswalks on a common metric. This will pave the way for combining studies, such as meta-analyses of new treatments, essential for developing guidelines and advancing clinical care. Additionally, the DEL-IB will facilitate creating big datasets, such as for omics studies to advance pathophysiologic understanding of delirium

Cognitive impairment after ischemic and hemorrhagic stroke: a scientific statement from the American Heart Association/American Stroke Association

Purpose: Cognitive impairment is a common consequence of stroke and has direct implications for poststroke functioning and quality of life, including the ability to maintain a job, live independently, sustain interpersonal relationships, and drive a vehicle. In this scientific statement, we critically appraise the literature on the prevalence, diagnosis, and management of poststroke cognitive impairment (PSCI) and provide a framework for clinical care while highlighting gaps that merit further study. Methods: We performed a scoping literature review of randomized controlled clinical trials, prospective and retrospective cohort studies, case-control studies, clinical guidelines, review articles, and editorials on the incidence and prevalence, natural history, diagnosis, and management of PSCI. Scoping reviews determine the scope of a body of literature on a given topic to indicate the volume of literature and the studies currently available and provide an overview of its focus. Results: PSCI is common after stroke, especially in the first year, and ranges from mild to severe. Although cognitive impairment is reversible in some cases early after stroke, up to one-third of individuals with stroke develop dementia within 5 years. The pathophysiology is not yet fully elucidated but is likely attributable to an acute stroke precipitating a series of pathological events, often in the setting of preexisting microvascular and neurodegenerative changes. Screening for associated comorbidities and interdisciplinary management are integral components of the care of individuals with PSCI. There is a need for prospective studies evaluating the individual trajectory of PSCI and the role of the acute vascular event in the predisposition for Alzheimer disease and related dementias, as well as high-quality, randomized clinical trials focused on PSCI management

Distributed Computing and Monitoring Technologies for Older Patients

This book summarizes various approaches for the automatic detection of health threats to older patients at home living alone. The text begins by briefly describing those who would most benefit from healthcare supervision. The book then summarizes possible scenarios for monitoring an older patient at home, deriving the common functional requirements for monitoring technology. Next, the work identifies the state of the art of technological monitoring approaches that are practically applicable to geriatric patients. A survey is presented on a range of such interdisciplinary fields as smart homes, telemonitoring, ambient intelligence, ambient assisted living, gerontechnology, and aging-in-place technology. The book discusses relevant experimental studies, highlighting the application of sensor fusion, signal processing and machine learning techniques. Finally, the text discusses future challenges, offering a number of suggestions for further research directions

Neuropsychological Studies in older adults: A comprehensive MMSE-MoCA conversion table – Prevention of postoperative delirium – Cognitive sequelae of atrial fibrillation

As life expectancy increases, so does the proportion of elderly individuals in most industrialized countries. As people age, they undergo both physical and cognitive changes. Thus, cognitive difficulties and other agerelated pathologies such as cardiovascular and neurological diseases increase with age. In this context, atrial fibrillation (AF) and delirium are of great clinical relevance not only because of their epidemiological data but also, in particular, because of their major role in the development of cognitive dysfunction. Hence, sufficient knowledge and identification of potential risk factors of AF and delirium as well as early recognition are essential to take preventive measures. The present doctoral thesis aims to define corresponding scores for two widely used cognitive screening tools and provide insights into cognitive changes in elderly adults with atrial fibrillation and the validity of a preexisting preoperative delirium prediction model after cardiac surgery. In study I, a comprehensive conversion table of two commonly used cognitive screening tests was created. We could define corresponding scores for the Mini-Mental Status Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) in 803 German-speaking Memory Clinic outpatients. Further, a systematic review of existing MMSE-MoCA conversions was conducted to create a comprehensive conversion table. This enables a direct comparison of cognitive test scores at screening examinations and over the course of disease in patients with predominantly neurocognitive disorders. Study II investigated the associations between AF and cognition in aging. A small, constant increase in cognitive functioning over a median duration of 3.97 years in AF patients was found, presumably explained by learning effects that were less pronounced in non-paroxysmal AF patients, specifically in processing speed and executive functions. Some evidence suggests diabetes, history of stroke/transient ischemic attack (TIA) and depression being associated with faster cognitive decline in AF patients. In study III, an independent external validation of an existing preoperative risk prediction model for delirium was provided in 348 patients who had undergone cardiac surgery. The evaluated predictive model showed poor discriminative capacity but fair calibration. As an outlook, reflections on future directions concerning the role of cognitive performance in AF and delirium are given as well as discussed

Documentation: Delirium in the Hospitalized Older Adult

Background: Delirium is a common, life threatening and preventable geriatric syndrome. Because this condition is frequently addressed by administering dangerous antipsychotic drugs, it is imperative that accurate systematic assessments are charted to determine the actual need for these medications. The purpose of the study was to describe medical record documentation of a systematic assessment of delirium in older adults who had been administered an antipsychotic medication. Methods: A descriptive correlational retrospective design was used for this medical record data based study. The setting was a 107 bed acute care community hospital located in southern California. Inclusion criteria were medical records of patients who were 65 years or older, admitted to a medical/surgical/telemetry unit and had received lorazepam or haloperidol. Descriptive and inferential statistics were conducted using SPSS version 18. Results: For the total participant cases (N=70), age 65 to 97 years, and 60% female, there was no documentation of a systematic delirium assessment. Therefore, associations between a documented systematic assessment and other select variables could not be determined. However, antipsychotic medications were prescribed more often to females than males (p=.003). Conclusions: This study examined the documentation of a systematic assessment for delirium in hospitalized older adult patients who had been medicated with select antipsychotic medications. Documentation of a systematic assessment of delirium is important so causative factors can be remedied and appropriate interventions put into place to not only keep the patient safe, but hopefully improve the outcomes of hospitalized older adults