The topic I have chosen for evidence-based practice is decreasing agitation and injuries that occur with dementia patients in the ED setting. Dementia is a type of neurocognitive disorder that manifests as memory, reasoning problems understanding speech patterns, and other cognitive impairments affecting a person’s daily activities (Dresden et al., 2022). With time, patients generally become more agitated and confused besides presenting responsive behavior in especially foreign environments like the ED.
Statistics on the Significance of Agitation in Dementia Patients in ED
In the literature, research shows that more than 40 to 60 percent of dementia patients visit ED every year(Leppla et al.,2013). Demented patients have more than twice the risk for adverse outcomes in the ED compared to unimpaired old persons (Abbott, et al., 2022). Agitation is perhaps the most prevalent example of a responsive behavior with up to 90% of ED patients suffering from dementia (Dresden, et al., 2022). Agitation causes more injuries to falls, prolonged ED length of stay and high rate restraints use, delirium unnecessary medication prescriptions leading to hospitalization (Leppla et al., 2019). Dementia patients were 2.4 times at increased odds of getting injuries from accidents or falls in the ED according to a study by Abbott et al., (20, 1n). With the increasing incidence of dementia, evidence-based intervention is urgently required to improve ED results.
PICOT Question
My PICOT question is: In emergency department patients with dementia (P), how does having a trained clinical liaison or companion (I) compared to no liaison or standard care (C) affect the incidence of agitation, injuries, and adverse events (O) over 6 months (T)?
Article 1 Summary
Kumar (2021) in his article discusses ethical and legal issues for wandering in dementia patients. The author talks about walkabout as a habitual response behavior and a major predisposing factor for injury. Environmental alterations, such as disguised exits and winding paths have shown a decline in falls by up to 50% The article highlights how 1:1 One effective approach in preventing incidences of elopement is 1 companionship by a trained health care worker. Although not a real case study, the advice of professionals gives vision for clinically significant consequences such as those injuries that my PICOT question is about. This article serves as a source of background evidence regarding how clinical Liaisons can mitigate harms caused by wandering behaviors in the ED.
Article 2 Summary
Hamm et al. (2022) proposed a team-based approach for enhancing the management of agitation in healthcare facilities based on the TeamSTEPPS model. The authors recommend designating staff members as 1:1. behavioral co-pilots are employed to reassure, distract, and defer agitation in patients with dementia. They refer to observational studies that attest such roles can reduce restraint prevalence and the requirement of psychiatric medications. While not an empirical study itself, the article synthesizes evidence that the 1:The use of 1 support modeled by clinical liaisons has been shown to decrease agitation-related adverse events. The organizational background of the implementation of dedicated dementia support roles in an ED is offered by the TeamSTEPPS framework.
Article 3 Summary
Cations et al. (2023) reported a systematic review of various psychiatric care models for dementia patients in hospitals and nursing homes. They discovered that in-reach services where Psychiatric Specialists such as liaison nurses worked directly with Dementia patients improved the detection of symptoms, decreased prescribing of risky medications, and even reduced restrictive practices compared to standard ward nurses. The review emphasizes that specialist nursing roles focused on behavioral management can increase the quality of care and lead to a reduction in adverse events for dementia patients. This strengthens the likelihood of clinical liaisons specifically designed to meet dementia patients’ unique needs in an ED setting.
Search Strategy
I started by exploring CINAHL with the terms “dementia OR Alzheimer’s” and “hospital” AND “injuries OR falls OR agitation.” The limitation to academic journals in the past 5 years provided me with results of 187. From this search, I chose the Kumar (2021) article. Secondly, I conducted a PubMed search on “dementia” AND“emergency department” AND patient care management.” The search within the last three years resulted in 42 hits. I selected the Hamm et al. (2022) article which presented TeamSTEPPS model Last, I searched Google Scholar using the keywords “psychiatric liaison nurse dementia systematic review.” The article by Cations et al. (2023) from page one of about 530 results was chosen.)
Conclusion
Therefore, my literature search determined that dementia patients are more prone to adverse events such as injuries or agitation in the ED which is an unfamiliar environment. Clinical liaisons show promise as an intervention to provide tailored 1:One support and counterbalance these threats. In turn, future studies are required to directly compare the outcomes of patients with and without clinical liaison support in EDs. This gap is the subject of my PICOT question.
References
Abbott, R. A., Rogers, M., Lourida, I., Green, C., Ball, S., Hemsley, A., Cheeseman, D., Clare, L., Moore, D., Hussey, C., Coxon, G., Llewellyn, D. J., Naldrett, T., & Thompson Coon, J. (2022). New horizons for caring for people with dementia in hospital: The dementia care pointers for service change. Age and Ageing, 51(9). https://doi.org/10.1093/ageing/afac190
Cations, M. (2023). Psychiatric service delivery for older people in hospital and residential aged care: An updated systematic review – Monica Cations, Bethany Wilton-Harding, Kate E Laver, Henry Brodaty, Lee-Fay Low, Noel Collins, David Lie, Duncan McKellar, Steve Macfarlane, Brian Draper, 2023. Australian & New Zealand Journal of Psychiatry. https://journals.sagepub.com/doi/abs/10.1177/00048674221134510
Dresden, S. M., Taylor, Z., Serina, P., Kennedy, M., Wescott, A. B., Hogan, T., Shah, M. N., Hwang, U., Aggarwal, N. T., Allore, H., Aloysi, A., Belleville, M., Bellolio, F. M., Betz, M. (Emmy), Biese, K., Brandt, C., Bruursema, S., Carnahan, R., Carpenter, C., … Weintraub, S. (2022). Optimal Emergency Department Care Practices for persons living with dementia: A scoping review. Journal of the American Medical Directors Association, 23(8). https://doi.org/10.1016/j.jamda.2022.05.024
Hamm, B., Pozuelo, L., & Brendel, R. W. (2022). General Hospital Agitation Management: Leadership Theory and Health Care Team Best Practices Using TeamSTEPPS. Journal of the Academy of Consultation-Liaison Psychiatry, 63(3), 213–224. https://doi.org/10.1016/j.jaclp.2021.10.007
Kumar, A. (2021). Approach to Management of Wandering in Dementia: Ethical and Legal Issue – Adesh Kumar Agrawal, Mahesh Gowda, Umesh Achary, Guru S. Gowda, Vijaykumar Harbishettar, 2021. Indian Journal of Psychological Medicine. https://journals.sagepub.com/doi/full/10.1177/02537176211030979
Leppla, I., Tobolowsky, W., Patel, S., Artin Mahdanian, Lobner, K., Caufield-Noll, C., Ponor, I. L., & Roy, D. (2023). Scoping Review on Educational Programs for Medical Professionals on the Management of Acute Agitation. Journal of the Academy of Consultation-Liaison Psychiatry, 64(5), 457–467. https://doi.org/10.1016/j.jaclp.2023.05.003
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