Process quality indicators targeting cognitive impairment to support quality of care for older people with cognitive impairment in emergency departments

Schnitker, Linda M., Martin-Khan, Melinda, Burkett, Ellen, Beattie, Elizabeth R.A., Jones, Richard N., Gray, Len C., & Carpenter, Christopher R. (2015) Process quality indicators targeting cognitive impairment to support quality of care for older people with cognitive impairment in emergency departments. Academic Emergency Medicine, 22(3), pp. 285-298.

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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.

Impact and interest:

5 citations in Scopus
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5 citations in Web of Science®

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ID Code: 84071
Item Type: Journal Article
Refereed: Yes
Additional Information: Special Issue: Special Content Focus: Neurologic Emergencies
Keywords: aged, Article, clinical indicator, cognitive defect, controlled study, delirium, elderly care, emergency care, emergency ward, evidence based practice, female, field study, follow up, health care quality, human, length of stay, major clinical study, male, mental health, needs assessment, pain assessment, priority journal, process quality indicator, risk assessment, very elderly
DOI: 10.1111/acem.12616
ISSN: 1069-6563
Subjects: Australian and New Zealand Standard Research Classification > MEDICAL AND HEALTH SCIENCES (110000) > NURSING (111000) > Nursing not elsewhere classified (111099)
Divisions: Current > QUT Faculties and Divisions > Faculty of Health
Current > Institutes > Institute of Health and Biomedical Innovation
Current > Schools > School of Nursing
Copyright Owner: Copyright 2015 Blackwell Publishing Inc.
Deposited On: 12 May 2015 23:57
Last Modified: 20 May 2015 05:08

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