Eskenazi Health Foundation

Delirium is a neuropsychiatric syndrome characterized by fluctuating disturbances in attention and awareness, associated with worse clinical outcomes and higher mortality. Previous research studies have noted an association between geographic disadvantage and delirium, but it is unknown if this association extends to critically ill adults. This study aimed to explore the relationship between geographic disadvantage and ICU delirium characteristics. We performed a secondary analysis of data collected from an National Institutes of Health-funded clinical trial, the Pharmacologic Management of Delirium study. Adults 18 years old or older admitted to the ICU who experienced delirium based on the Confusion Assessment Method for the ICU (CAM-ICU) were included. None. The study population included 326 participants: 54.5% were female and 48% Black, with a mean age of 60.3 years, mean Acute Physiology and Chronic Health Evaluation II score of 20, and in-hospital mortality rate of 12.3%. The area deprivation index (ADI), a composite measure of geographic disadvantage derived from census data that yields a national percentile score ranging from 1 to 100 (with higher scores representing greater disadvantage), was obtained for each participant's address. Main outcome variables included delirium duration, which was assessed by the number of delirium- and coma-free days (DCFDs), and delirium severity, which was assessed by mean CAM-ICU-7 scores. Analysis of covariance models were used to examine differences in DCFDs and mean CAM-ICU-7 scores between ADI quintiles while controlling for demographic and clinical variables. Other clinical outcomes of interest included discharge home rates and in-hospital mortality. The sample was heavily skewed toward higher national ADI percentile scores (indicating greater disadvantage); only 11.7% of patients had an ADI score lower than 50. Our regression analyses did not reveal any associations between ADI quintile and DCFDs or mean CAM-ICU-7 scores, or between ADI quintile and discharge home rates or in-hospital mortality. However, the Black race was associated with longer delirium duration and greater delirium severity in the first week of ICU hospitalization. Our study did not find an association between geographic disadvantage and delirium duration or severity in the ICU. However, an association with race was observed, highlighting the need for further research into how socioeconomic determinants of health relate to delirium.

Detection of Alzheimer disease and related dementias (ADRD) is a challenge in primary care settings. The Quick Dementia Rating System (QDRS) and the Passive Digital Marker (PDM) were developed as 2 scalable tools for early detection of ADRD. The QDRS is a patient-reported outcome measure, while the PDM is a machine learning algorithm that uses electronic health record (EHR) data. Both can be embedded in the EHR for ease of use. To evaluate the effect of the combined approach of QDRS plus PDM in improving the annual rate of new documented ADRD diagnoses in primary care practices. This randomized clinical trial was performed between July 2, 2022, and July 1, 2024. Nine federally qualified primary health care clinics in Indianapolis, Indiana, were randomized to usual care (no routine screening for ADRD), PDM only, or QDRS plus PDM. Participants were treated as per the randomization arm. Participants included adults 65 years and older, without a diagnosis of mild cognitive impairment, dementia, or severe mental illness. Data analysis was based on intention to treat and was performed between November 1, 2024, and August 20, 2025. Randomization of clinic to usual care, PDM only, or QDRS plus PDM. The primary outcome was 12-month cumulative incidence of ADRD diagnoses; the secondary outcome was any ADRD diagnostic workup, such as laboratory tests, neuropsychological testing, or brain imaging. The study included 5325 patients (mean [SD] age, 71.1 [5.9] years), 3312 (62.2%) of whom were female. Compared with the usual care clinics (12-month incidence, 213 of 1724 [12.4%]), the odds of an incident ADRD diagnosis were higher in the clinics randomized to QDRS plus PDM (12-month incidence, 355 of 2301 [15.4%]; adjusted odds ratio [AOR], 1.31; 95% CI, 1.05-1.64) but not the clinics randomized to PDM only (12-month incidence, 134 of 1300 [10.3%]; AOR, 0.84; 95% CI, 0.63-1.11]). Compared with the usual care clinics (12-month incidence, 500 of 1724 [29.0%]), the odds of ADRD diagnostic assessments were higher in the QDRS plus PDM clinics (12-month incidence, 844 of 2301 [36.7%]; AOR, 1.41; 95% CI, 1.12-1.77) but not the PDM clinics (12-month incidence, 362 of 1300 [27.8%]; AOR, 0.94; 95% CI, 0.72-1.22). This randomized clinical trial found that the combined approach was effective at scale for the early detection of ADRD in primary care settings. This is an important feature in busy primary care settings that can benefit both the health care system and patients. ClinicalTrials.gov Identifier: NCT05231954.

Abstract Introduction Point of care for burn survivors has traditionally been the inpatient burn unit. Advances in burn care have resulted in significantly reduced length of stay or allowed survivors to avoid admission. However, an outpatient shift within burn care only emphasizes a growing need for rehabilitation resources. This study surveyed burn centers within the United States (US) to determine current outpatient burn clinic structure and evaluate utilization of burn therapy. Methods A 20-question survey was electronically distributed to burn clinicians at burn centers within the US. Questions included the location of their burn clinic, operational hours, dedicated staff, and utilization of burn therapy services. Chi-square test was used to analyze frequency differences between American Burn Association (ABA) verified and non-verified centers with significance set at < 0.05. Results The survey was completed by representatives of 54 burn centers treating Adults (n=17), Pediatric (n=7), or both (n=30). Burn centers were ABA verified (61%, n=33) and non-verified (39%, n=21) centers. Outpatient clinics included permanently dedicated burn therapists at 65% (n=35) of responding burn centers (OT= 32, PT =28) (Table 1). Respondents reported that therapy services in the outpatient clinics saw “Almost all patients,” 15% (n=8) of the time, while the majority stated therapist saw “Most” (30%, n=16) or “Some” patients (24%, n=13). Only 7 centers report standing therapy orders, while the majority report pre-screening by APPs/physicians (n=43). Only 39% (n=21) reported that reconstructive patients were “Often” referred for therapy. The greatest barriers to outpatient follow up were “distance from burn center”(n=43) and “transportation”(n=30), with 50% of respondents offering transportation support for patients. Verified burn centers were statistically more likely to have either PT or OT dedicated to the burn clinic (79%, p=0.007) than non-verified centers. However, there was no difference in verification status for therapy treating “Most” or “All” patients (50%, p=0.112), and having a dedicated burn therapy treatment space (59%, p=0.067) Conclusions Outpatient Burn Rehabilitation is currently being underutilized, with many centers setting standards below those established for inpatient burn care. Transitioning care to the outpatient setting does not eliminate, or reduce patients’ need for specialized burn therapy. Hospital, physician, and outpatient leaders must consider the rehabilitative needs of burn patients as care is shifted to outpatient and ensure adequate therapy involvement in care. Applicability of Research to Practice Burn centers must prepare to treat an increasing number of burn survivors throughout the entire burn continuum of care. Therapy resources must be optimized within the outpatient setting to match the shift in care toward the ambulatory environment to adequately support burn survivors. Funding for the Study N/A

Abstract Introduction New graduate nurses receive limited pediatric burn background information and/or direct practice with ointments, dressings, and other burn products prior to unit shifts as part of standard orientation. To enhance opportunities for clinical growth, a burn dressing class was developed and taught by a core group of pediatric burn nurse advisors to new graduate nurses. This experiential learning session entailed a pre- and post-questionnaire in addition to a class evaluation to assess knowledge and relevance. Methods A six-hour class created and led by two burn clinical advisors was taught to five new burn nurses. A six-question multiple choice test was administered to the participating nurses immediately pre- and post- instruction. A dressing skills validation was also completed after an instructor-led hand and head wrapping demonstration. Teach back was the method utilized to ensure learning had occurred. At the conclusion of the class, an evaluation assessing relevance and understanding was distributed. Results Results demonstrated the nurses increased their knowledge from the pre- to post-assessment by 40%. The nurses completed the head and hand wrapping skills validations with 100% accuracy. Four of the five participants completed the post-class evaluation. All felt the class was relevant to current practice, while 50% stated they could now be successful and had a solid understanding of the concepts taught. All participants shared they were either completely riveted or their attention rarely wandered during the presentation. Conclusions For this new pediatric burn nurse group, results illustrated learning occurred and practice relevance was appreciated immediately after the class concluded. This score improvement demonstrated a knowledge and application gap in burn care in the new graduate burn nurse orientation which was addressed by this course. Assessment from a competency lens or organizational perspective would be the next step for higher level evaluation. Applicability of Research to Practice Pediatric burn nursing is a specialty field with which many new graduate nurses have no background knowledge or experience. By creating a pediatric-specific burn course, new nurses can have the chance to learn, apply and demonstrate burn wrapping skills prior to completing orientation. This instruction may be impactful on future research of orientation best practices as well as learning needs of new pediatric burn nurses. Funding for the Study N/A

Abstract Introduction Palliative care is a commonly used consultation service in the trauma world, however, interestingly, only 2% of burn patients, a subset of trauma patients, have the luxury of a palliative care consult during hospitalization. The early introduction of palliative care during a burn survivor’s hospitalization may reduce miscommunication, the feeling of hopelessness, and incongruent care coordination. The purpose of this study is to evaluate the incidence of palliative care consultations on a verified adult burn center by comparing pre- and post- intervention data following the implementation of a palliative care assessment tool, the Palliative Care Problem Severity Score (PCPSS). Methods A retrospective chart review was conducted to analyze the pre- and post-intervention groups. Specifically, 57 patient charts were reviewed for the presence of palliative care in the three months leading up to project implementation. After the project was initiated and the PCPSS was implemented, post-intervention chart reviews were completed on a total of 33 patients. A Fisher’s Exact Test was used for data analysis. Demographic data was also collected for the pre- and post-intervention groups for further comparison. Results A Fisher’s Exact Test was conducted to appropriately measure pre- and post-intervention data. The test was able to sufficiently evaluate the effectiveness of the PCPSS, rendering statistically significant results (p = 0.029). Objectively, only one out of 57 patients (1.75%) received a palliative care consultation in the pre-intervention group while five out of 33 patients (15.15%) received a palliative care consultation in the post-intervention group, resulting in a 13.4% increase in palliative care consultations after the implementation. The PCPSS was able to reduce the time from patient admission to initial palliative care consultation from 44 to 2.8 days. Conclusions Advanced Practice Providers can be at the forefront of the palliative care movement within the burn specialty by streamlining the use of the PCPSS within their practice. The results of the chosen palliative care assessment tool surpassed the expectations of the initially proposed project, and its effects will linger in the lives of the burn patients whose outcomes were optimized by the introduction of palliative care early in the acute phase of their burn injury. Applicability of Research to Practice Ultimately, the implementation of the PCPSS is the first step towards formalizing a palliative care consultation process within adult verified burn centers. The project’s results can formalize a palliative care consultation standard within a verified adult burn center while bridging the identified literature gap between two specialty services that, if united, will provide limitless resources to burn survivors from the time of injury to rehabilitation. Funding for the Study N/A

Care management benefits community-dwelling patients with dementia, but studies include few patients with moderate to severe dementia or from racial and ethnic minority populations, lack palliative care, and seldom reduce health care utilization. To determine whether integrated dementia palliative care reduces dementia symptoms, caregiver depression and distress, and emergency department (ED) visits and hospitalizations compared with usual care in moderate to severe dementia. A randomized clinical trial of community-dwelling patients with moderate to severe dementia and their caregivers enrolled from March 2019 to December 2020 from 2 sites in central Indiana (2-year follow-up completed on January 7, 2023). Electronic health record screening identified patients with dementia; caregivers confirmed eligibility, including dementia stage. The intervention consisted of monthly calls from a trained nurse or social worker and evidence-based protocols to help caregivers manage patients' neuropsychiatric symptoms, caregiver distress, and palliative care issues (eg, advance care planning, symptoms, and hospice) (n = 99). Usual care caregivers received written dementia resource information and patients received care from usual clinicians (n = 102). The primary outcome was Neuropsychiatric Inventory Questionnaire (NPI-Q) severity score (scores range from 0-36, with higher scores indicating worse patient symptoms). Secondary outcomes included Symptom Management in End-of-Life Dementia scores, caregiver depression (Patient Health Questionnaire-8) scores, caregiver distress (NPI-Q distress) scores, and combined ED and hospitalization events. Outcomes were assessed quarterly for 24 months or until patient death. A total of 201 dyads were enrolled (patients were 67.7% female; 43.3% African American; mean [SD] age, 83.6 [7.9] years); 3 dyads withdrew and 83 patients died over the course of the study, with at least 90% of eligible dyads in both groups completing each of the quarterly assessments. For the dementia palliative care vs usual care groups, mean NPI-Q severity scores were 9.92 vs 9.41 at baseline and 9.15 vs 9.39 at 24 months, respectively (between-group difference at 24 months, -0.24 [95% CI, -2.33 to 1.84]). There was no significant difference in the rate of change in NPI-Q severity from baseline between groups over time (P = .87 for the group and time interaction). There were no significant differences in the secondary outcomes, except that there were fewer combined ED and hospitalization events in the dementia palliative care group (mean events/patient, 1.06 in dementia palliative care vs 2.37 in usual care; between-group difference, -1.31 [95% CI, -1.93 to -0.69]; relative risk, 0.45 [95% CI, 0.31 to 0.65]). Among community-dwelling patients with moderate to severe dementia and their caregivers, dementia palliative care, compared with usual care, did not significantly improve patients' neuropsychiatric symptoms through 24 months. ClinicalTrials.gov Identifier: NCT03773757.

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ObjectiveTo determine whether availability of behavioral health crisis care services is associated with changes in emergency department (ED) utilization.Data Sources and Study SettingWe used longitudinal panel data (2016–2021) on ED utilization from the Healthcare Cost and Utilization Project's State ED Databases and a novel dataset on crisis care services compiled using information from the Substance Abuse and Mental Health Services Administration's National Directories of Mental Health Treatment Facilities. A total of 1002 unique zip codes from Arizona, Florida, Kentucky, Maryland, and Wisconsin were included in our analyses.Study DesignTo estimate the effect of crisis care availability on ED utilization, we used a linear regression model with zip code and year fixed effects and standard errors accounting for clustering at the zip code‐level. ED utilization related to mental, behavioral, and neurodevelopmental (MBD) disorders served as our primary outcome. We also examined pregnancy‐related ED utilization as a nonequivalent dependent variable to assess residual bias in effect estimates.Data Collection/Extraction MethodsWe extracted data on crisis care services offered by mental health treatment facilities (n = 14,726 facility‐years) from the National Directories. MBD‐related ED utilization was assessed by applying the Clinical Classification Software Refined from the Healthcare Cost and Utilization Project to the primary ICD‐10‐CM diagnosis code on each ED encounter (n = 101,360,483). All data were aggregated to the zip code‐level (n = 6012 zip‐years).Principal FindingsThe overall rate of MBD‐related ED visits between 2016 and 2021 was 1610 annual visits per 100,000 population. Walk‐in crisis stabilization services were associated with reduced MBD‐related ED utilization (coefficient = −0.028, p = 0.009), but were not significantly associated with changes in pregnancy‐related ED utilization.ConclusionsWalk‐in crisis stabilization services were associated with reductions in MBD‐related ED utilization. Decision‐makers looking to reduce MBD‐related ED utilization should consider increasing access to this promising alternative model.