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Factors that impact residents' transition and psychological adjustment to long-term aged care: A systematic literature review

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Exploring Antipsychotic Use for Delirium Management in Adults in Hospital, Sub-Acute Rehabilitation and Aged Care Settings: A Systematic Literature Review

Emily j. tomlinson.

1 Deakin University, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Geelong, Victoria Australia

2 Deakin University, School of Nursing and Midwifery, Geelong, Victoria Australia

Linda M. Schnitker

3 School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, QLD Australia

4 Bolton Clarke Research Institute, Kelvin Grove, Brisbane, QLD Australia

Penelope A. Casey

5 Deakin University, Centre for Quality and Patient Safety Research-Eastern Health Partnership, Geelong, Victoria Australia

Associated Data

International guidelines discourage antipsychotic use for delirium; however, concerns persist about their continued use in clinical practice.

We aimed to describe the prevalence and patterns of antipsychotic use in delirium management with regard to best-practice recommendations. Primary outcomes investigated were prevalence of use, antipsychotic type, dosage and clinical indication.

Eligibility criteria: studies of any design that examined antipsychotic use to manage delirium in adults in critical care, acute care, palliative care, rehabilitation, and aged care were included. Studies of patients in acute psychiatric care, with psychiatric illness or pre-existing antipsychotic use were excluded. Information sources: we searched five health databases on 16 August, 2023 (PubMed, CINAHL, Embase, APA PsycInfo, ProQuest Health and Medical Collection) using MeSH terms and relevant keywords, including ‘delirium’ and ‘antipsychotic’. Risk of bias: as no included studies were randomised controlled trials, all studies were assessed for methodological quality using the Mixed Methods Appraisal Tool. Synthesis of results: descriptive data were extracted in Covidence and synthesised in Microsoft Excel.

Included studies: 39 studies published between March 2004 and August 2023 from 13 countries ( n = 1,359,519 patients). Most study designs were retrospective medical record audits ( n = 16). Synthesis of results: in 18 studies, participants’ mean age was ≥65 years (77.79, ±5.20). Palliative care had the highest average proportion of patients with delirium managed with antipsychotics (70.87%, ±33.81%); it was lower and varied little between intensive care unit (53.53%, ±19.73%) and non-intensive care unit settings [medical, surgical and any acute care wards] (56.93%, ±26.44%) and was lowest in in-patient rehabilitation (17.8%). Seventeen different antipsychotics were reported on. In patients aged ≥65 years, haloperidol was the most frequently used and at higher than recommended mean daily doses (2.75 mg, ±2.21 mg). Other antipsychotics commonly administered were olanzapine (mean 11 mg, ±8.54 mg), quetiapine (mean 64.23 mg, ±43.20 mg) and risperidone (mean 0.97 mg, ±0.64 mg).

Conclusions

The use of antipsychotics to manage delirium is strongly discouraged in international guidelines. Antipsychotic use in delirium care is a risk for adverse health outcomes and a longer duration of delirium, especially in older people. However, this study has provided evidence that clinicians continue to use antipsychotics for delirium management, the dose, frequency and duration of which are often outside evidence-based guideline recommendations. Clinicians continue to choose antipsychotics to manage delirium symptoms to settle agitation and maintain patient and staff safety, particularly in situations where workload pressures are high. Sustained efforts are needed at the individual, team and organisational levels to educate, train and support clinicians to prioritise non-pharmacological interventions early before deciding to use antipsychotics. This could prevent delirium and avert escalation in behavioural symptoms that often lead to antipsychotic use.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-024-01122-z.

Introduction

Delirium is a serious neurocognitive disorder that is common in patients with acute medical illnesses, chronic medical conditions and cognitive impairment. Incidence rates vary across clinical settings, and have been reported as between 33% [ 1 ] and 80% [ 2 ] in intensive care units (ICUs), between 26% and 62% during hospitalisation in inpatient palliative care units [ 3 ], 26% in acute stroke settings [ 4 ] and 3–29% in medical in-patients [ 5 ]. Additionally, an Australian study identified approximately 15% [ 6 ] of residents living in aged care homes presented to hospital with symptoms of delirium. Moreover, a study in Canada in 12 nursing homes found the incidence was as high as 40% during a nursing home stay (on average 32 months) [ 7 ].

Delirium is a sudden change in cognition characterised by inattention, disorganised thinking and an altered level of consciousness, the course of which fluctuates [ 8 ]. Three subtypes are commonly described: hyperactive, hypoactive and mixed delirium in which those affected move between the hyperactive and hypoactive states. Psychomotor agitation, aggression and perceptual disturbances, such as paranoia and hallucinations [ 9 , 10 ], are often associated with hyperactive and mixed delirium.

These behavioural manifestations [ 9 ] can interfere with provision of care to people with delirium in hospitals and residential aged care [ 11 ], especially if staff lack the requisite knowledge, skills and resources to prevent and de-escalate behaviours [ 12 ]. A recent qualitative descriptive study that examined doctors’ and nurses’ experiences ( n = 42) of antipsychotic use for people with delirium in Australia [ 13 ] identified that concerns for safety of nurses and the patient with delirium were the most common reasons antipsychotics were administered. Nurses also reported being unable to complete clinical work unless the person with disruptive delirium symptoms was sedated [ 13 ]. Both doctors and nurses reported they chose to use antipsychotics in anticipation that behavioural symptoms could escalate [ 13 ]. In a similar study, interviews with 21 physicians, nurses and pharmacists in an ICU in Canada also found that reasons given for antipsychotic use were to ensure patient and staff safety, promote sleep and settle patients when staffing was inadequate, and workloads were high [ 14 ]. International guidelines allow for antipsychotic use when safety is a concern and non-pharmacological strategies have not been effective. However, in these two studies [ 13 , 14 ] it was not clear whether non-pharmacological strategies were implemented prior to antipsychotic use. It is a grave concern that systems issues around staffing and workload are a driver for antipsychotic use. Antipsychotics can be considered a ‘chemical restraint’ when used to make patients more manageable and to serve the perceived best interests of healthcare providers rather than patients [ 15 ]. Further research is needed to fully understand the prescribing and use of antipsychotics for people with delirium.

The rapid sedating effects of antipsychotics contributes to their frequent use in the management of disruptive behaviours [ 13 , 15 ]. In a study that examined the occurrence of delirium in a cohort of over 2 million hospital patients in the USA, 29% ( n = 24,787) of patients with delirium were treated with antipsychotics [ 16 ]. Similarly, a retrospective chart review study of 212 acutely ill patients aged ≥65 years in a geriatric ward identified the prevalence of antipsychotic use to manage delirium was 58% ( n = 123) with an additional 23.1% ( n = 49) receiving a combination of an antipsychotic and lorazepam [ 17 ]. In a retrospective cross-sectional study of patients aged ≥65 years ( n = 133) admitted to an acute geriatric care unit, antipsychotic use was prescribed to 74% ( n = 73) of patients in the management of delirium symptoms [ 18 ].

There is limited evidence that antipsychotic use in any clinical setting is either effective for managing delirium or enhancing clinical outcomes. In a multi-centre, blinded, placebo-controlled trial of adults admitted to an ICU ( n = 987), treatment with haloperidol did not increase the number of ‘days alive’ [ 19 ]. Additionally, a randomised double-blinded trial of patients ( n = 1183) with acute respiratory failure or shock and hypoactive or hyperactive delirium in an ICU found that antipsychotics did not significantly alter the duration of delirium [ 20 ]. The REDUCE Randomized Clinical Trial, which investigated the prophylactic haloperidol use in critically ill adults ( n = 1789) at high risk of delirium in 21 ICUs in the Netherlands, found no improvement in survival at 28 days ( p = 0.93) [ 21 ]. A randomised clinical trial (RCT) in 11 Australian inpatient hospice and palliative care services ( n = 247, mean age 74.9, standard deviation [SD] 9.8 years) investigated the efficacy of risperidone or haloperidol on delirium severity, extrapyramidal effects, sedation and survival [ 22 ]. Those in both the risperidone (0.73; 95% confidence interval [CI] 0.09–1.37; p  = 0.03) and haloperidol (0.79; 95% CI 0.17–1.41; p  = 0.01) groups experienced more extrapyramidal effects than those in the placebo group [ 22 ]. Moreover, those receiving haloperidol also had worse overall survival (hazard ratio, 1.73; 95% CI 1.20–2.50; p  = 0.003). The authors concluded that individualised management of delirium precipitants with non-pharmacological strategies in the placebo group resulted in less severe symptoms and a shorter duration of symptoms than when antipsychotics were given [ 22 ]. A systematic review of delirium in surgical (mean age range 61–87 years) and mixed medical/surgical/ICU (mean age range 39–84 years) settings, which included 16 RCTs (2288 participants), two prospective cohort trials (458 participants) and one historical controlled trial (476 participants), showed that antipsychotic use did not decrease the duration of delirium, length of stay or mortality [ 23 ]. Similarly, a systematic review of the efficacy of antipsychotics in hospitalised non-ICU patients, which included nine randomised and quasi‐randomised trials (727 participants), found no reduction in delirium severity, symptom duration or rate of mortality [ 24 ]. Moreover, a systematic review of the benefits and harms of antipsychotic use to manage delirium in hospitalised adults, which examined 16 RCTs (1768 participants) and ten observational studies (3839 participants), concluded there was little evidence to support the routine use of antipsychotics for delirium and there was an increased risk for cardiac side effects [ 25 ].

Older people (aged ≥65 years) are at a heightened risk of delirium, and the use of antipsychotics in this population is linked to significant harm. The anticholinergic, extrapyramidal and sedative effects associated with antipsychotics increase the risk of falls [ 26 ]. Polypharmacy in older people also increases the likelihood of drug interactions, and side effects such as QT prolongation (leading to rapid heartbeats) and extrapyramidal symptoms (parkinsonism, akathisia and tardive dyskinesia), as well as being associated with an increased risk of stroke, pneumonia [ 26 – 28 ] and death [ 26 , 29 ].

Internationally, current evidence-based guidelines do not recommend routine antipsychotic use for the prevention or first-line management of delirium. The American Geriatrics Society’s ‘Beers Criteria for Potentially Inappropriate Medication Use in Older Adults’ [ 28 , 30 ] strongly recommends, based on moderate-quality evidence, to avoid antipsychotic use for behavioural management unless non-pharmacologic interventions have failed and/or there is a high risk of the person harming themself or others. If used, they recommend only the lowest effective dose [ 28 , 30 ]. Similarly, the ‘Screening Tool of Older Persons’ Prescriptions (STOPP)—Screening Tool to Alert to Right Treatment (START)’ criteria [ 31 ] recommends to cease antipsychotic use in older people unless other care avenues have failed. In Australia, the Delirium Clinical Care Standard states that non-pharmacological strategies are first-line treatment, and antipsychotics are not recommended [ 32 ]. In situations where non-drug strategies are not working and there is imminent risk of harm because of behavioural symptoms, only using the lowest appropriate dose for the shortest possible duration is recommended (ACSQHC, 2021:28). Despite an international consensus that antipsychotics are to be avoided in the treatment and management of delirium (see summary of guidelines in Table ​ Table1), 1 ), there are concerns that their use persists in clinical practice.

International guideline recommendations regarding the use of antipsychotics in delirium

ICU intensive care unit

A preliminary search found no existing systematic review reported on the prescribing and use of antipsychotics in delirium. Hence, there is a lack of synthesised evidence on the rates of use and prescribing patterns of antipsychotics for delirium management across healthcare settings. Therefore, this review aimed to describe the prevalence and patterns of antipsychotic use in adult delirium management, with a specific focus on the proportions of people with delirium given antipsychotics, the types of antipsychotics used, the dosages, including the amount, frequency and duration, and the indications for use.

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 33 ].

Literature Search Strategy

An initial search of MEDLINE and CINAHL was undertaken and was followed by an analysis of text in titles and abstracts, and of the index terms used to describe relevant articles. This then informed development of the search strategy, which was tailored for each information source. Database-specific search strategies were developed (as shown in the Electronic Supplementary Material) with assistance from a university health librarian. Using MeSH terms and relevant keywords, an example of the keyword combinations used were: ((deliri* OR confus*OR “cognitive dysfunction”) AND (antipsychotic OR “'chemical restraint” OR “pharmacological management”) AND (prescription OR “prescribing practice OR “medication administration”)). The reference lists of all studies selected for critical appraisal were also screened for additional studies using backward and forward reference searching. The searches were rerun immediately prior to analysis in August 2023 to ensure that the most current information was retrieved.

Criteria for Inclusion in the Review

This review considered studies of adults (aged ≥18 years) diagnosed with delirium. For the purposes of this review, delirium was defined as “a disturbance of attention or awareness that is accompanied by a change in baseline cognition that cannot be better explained by a pre-existing or evolving neurocognitive disorder” [ 8 ]. We considered delirium to have been present if diagnosed using validated and reliable delirium diagnostic tools, such as the Confusion Assessment Method [ 34 ], and a clinician diagnosis using criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM) in accordance with versions DSM-III, DSM-III-R, DSM-IV or DSM-5. This review included studies set in acute care (e.g. ICUs, medical, surgical settings), aged care (residential care), palliative care, sub-acute in-patient rehabilitation and community settings. Studies of patients in acute psychiatric care, with psychiatric illness or pre-existing antipsychotic use were excluded.

Outcome measures of interest were the description of prescribing and administration patterns (rates of use) of antipsychotics. Studies were included if they provided data regarding prevalence of use, or patterns of prescribing, such as the type of antipsychotic, the dosage including the amount, frequency and duration, and clinical indications for use.

Types of Studies

We included cross-sectional, case-control, correlational, prospective, or retrospective cohort, retrospective audits or observational research study designs. Surveys of practice were also included.

Study Screening and Selection

Retrieved studies were downloaded into Covidence (Version 2) where initial title and abstract screening were undertaken independently by two authors (ET and LS). Studies that met inclusion criteria were retrieved and their full text independently assessed for eligibility by two authors (ET and LS). Any disagreements over the eligibility of studies were resolved through discussion with a third author (PC).

Assessment of Methodological Quality

All included studies were critically appraised using the Mixed Methods Appraisal Tool (MMAT) for quantitative non-randomised studies or quantitative descriptive studies [ 35 ]. The MMAT tool allows appraisal of methodological quality against five categories for a range of study designs [ 35 ]. In MMAT Part 1, studies are screened using two questions to determine if they are empirical studies; non-empirical studies were excluded [ 35 ]. In Part 2, five methodological quality criteria were assessed [ 35 ]. Each criterion is rated as ‘Yes’ or ‘No’ or ‘Can’t Tell’. The ‘Can’t Tell’ response signifies that the appropriate information is not reported. Studies were rated on a scale of 5 (all five criteria met) to 1 (only one criterion met). Each study was appraised independently by two authors (ET, LS or PC) with the third person as the arbiter when required.

Data Extraction

Descriptive and quantitative data were extracted using a tool specific to the outcomes of this study, developed within Covidence Review Software. Data were abstracted by one author (ET) and checked by a second (LS or PC). Descriptive data included demographic information on study participants (age in years, sex, setting) and method of delirium diagnosis. Data on prescribing patterns included (i) the rates of use of antipsychotics, (ii) generic name/s of medication, (iii) prescription frequency, (iv) dose, (v) number of antipsychotics given, (vi) days of treatment, (vii) reasons for administration and (viii) continuation of antipsychotics on discharge.

Analysis and Synthesis Method

The results of the studies included in the analysis were systematically summarised. Data gathered in Covidence were exported to Microsoft Excel (Version 2312) for the final synthesis. Only studies containing pertinent data related to each specific objective were included in the synthesis for that particular outcome. The summarised results are presented in tables, and any data suitable for graphical representation were compiled in Excel. Descriptive data analyses, including mean, median and standard deviation calculations, were performed in Excel. The presentation of findings is organised according to the research objectives. In order to address the risk of bias arising from any potential missing results in our synthesis, we contacted authors of one study [ 36 ] for additional information regarding their findings.

Search Findings

A total of 2359 references were imported for screening from the initial search strategy and 428 duplicates were removed. The authors screened 1931 against title and abstract. Of these, 178 studies underwent a full text review for eligibility. One study was identified by citation searching of the relevant literature that was not identified in the search strategy. Thirty-nine studies ( n = 1,359,519 patients) met the inclusion criteria and were included in this review (Fig. ​ (Fig.1 1 ).

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 flow diagram for new systematic reviews, which included searches of databases [ 33 ] (diagram created using Haddaway et al. [ 89 ]). APA American Psychiatric Association, CINAHL Cumulated Index to Nursing and Allied Health Literature

Study Characteristics

Surveys of practice.

Nine studies reported data from self-report questionnaires/surveys (Table ​ (Table2). 2 ). Survey cohorts were psychiatrists ( n = 2), pharmacists ( n = 1), palliative medicine physicians ( n = 1), hospital doctors ( n = 1), geriatric specialists ( n = 1), ICU physicians ( n = 1), health professionals who cared for patients with delirium ( n = 1) and delirium experts ( n = 1). Response rates were reported from five studies and rates varied between 21.1% and 92%. Study samples ranged in size from 48 to 2122 participants.

Characteristics of studies that used survey methodology

EDA  European Delirium Association, ICU intensive care unit, MMAT Mixed Methods Appraisal Tool

Prospective Studies

Three studies used prospective designs including: prospective cohort, point prevalence survey and prospective observational clinical audit (Table ​ (Table3). 3 ). Two were conducted in palliative care settings and one in a medical/surgical setting. No RCTs were included. The total number of patients in the prospective studies was 4480.

Characteristics of studies that used prospective designs

MMAT Mixed Methods Appraisal Tool

Retrospective Studies

Retrospective medical record audits were the most common study design ( n = 16). This included retrospective cohort studies ( n = 8), a retrospective case/control study ( n = 1), a repeated cross-sectional study ( n = 1) and a retrospective cross-sectional study ( n = 1). The total number of patients in the retrospective studies was 1,355,039. Summarised characteristics of these studies are reported in Table ​ Table4 4 .

Characteristics of studies that used retrospective designs

HSCT hematopoietic stem cell transplantation, ICU intensive care unit, MMAT Mixed Methods Appraisal Tool

Methodological Quality Assessment

The MMAT [ 35 ] was used to appraise the methodological quality of studies. Methodological quality of studies was generally high; six studies met all five MMAT criteria and 28 met four criteria. Quality assessment ratings of each study are provided in Tables ​ Tables2, 2 , ​ ,3 3 and ​ and4 4 .

Patient Characteristics

Retrospective and prospective studies reported on antipsychotic prescribing for individuals with delirium across several settings. This included general acute care wards ( n = 12), palliative care ( n = 5), ICU ( n = 5), medical and surgical wards ( n = 4), geriatric care ( n = 1), stroke centre ( n = 1) and skilled nursing facility [sub-acute rehabilitation] ( n = 1). No studies were identified from aged care/residential care settings. Methods of diagnosing delirium varied, however, clinical diagnosis was the most common ( n = 16). The average age (years) of patients by setting was 65.31 (SD 8.17) in palliative care, 62.03 (SD 5.00) in the ICU and 75.07 (SD 8.59) in general acute surgical/medical (non-ICU). Eight studies included only older hospitalised patients (aged ≥65 years). In 18 studies, there were patient populations whose mean age exceeded 65 years; across these studies the average age (years) was 77.79 (SD 5.20). Demographics of populations in the included studies are summarised in Table ​ Table5 5 .

Patient demographics in included studies

AD Alzheimer’s disease, ADRD Alzheimer’s disease or related dementia, CAM Confusion Assessment Method, CAM ICU Confusion Assessment Method Intensive Care Unit, DRS Delirium Rating Scale, F05 ICD Code ‘delirium due to a known physical condition’, ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification, ICD-10 International Classification of Diseases, Tenth Revision, 4AT 4 As Test, # age reported as mean ± standard deviation or mean (interquartile range) unless indicated by * as median and (interquartile range)

Administration of Antipsychotics

Twenty studies reported on the proportions of people with delirium prescribed antipsychotics for its management (Fig. ​ (Fig.2). 2 ). The average proportion of people receiving antipsychotics in all settings was 54.89% (median 58.00%, range 17.80–95.00%). Palliative care settings had the greatest proportion of people with delirium who were prescribed antipsychotics for its management (mean 70.87%, SD 33.81%, median 83.50%, range 21.50–95.00%). The average proportions varied little between ICU (mean 53.53%, SD 19.73%, median 45.60%, range 39.00–76.00%) and non-ICU settings [medical, surgical and any acute care wards] (mean 56.93%, SD 26.44%, median 64.34%, range 18.30–93.20%).

Proportion of people prescribed antipsychotics for the management of delirium

In patients aged ≥65 years in non-ICU settings (surgical/medical/acute care), the average proportion administered antipsychotics was 53% (mean 53.06%, SD 27.34%, median 61.17%) (see Table ​ Table6). 6 ). For all studies across settings with patients aged ≥65 years (including nine acute hospital/medical, one skilled nursing facility and two palliative care), the average proportion of antipsychotic administration was 50.78% (SD 27.27%, median 58.00%).

Patients aged over 65 years with delirium administered antipsychotics in non-ICU settings

ICU intensive care unit, SD standard deviation

Reppas-Rindlisbacher et al. [ 37 ] reported increased monthly rates of new prescriptions for antipsychotics (per 1000 discharges) from 6.9 before the COVID-19 pandemic (1 January, 2017, to 31 March, 2020) to 8.8 during the first 2 years of the COVID pandemic (1 March, 2020 to 31 March, 2022). The online survey by Hosie et al. [ 38 ] reported that 55% of respondents had used antipsychotics to manage delirium in the past 12 months. Of those, 60% reported using antipsychotics in one third of patients experiencing delirium, whereas 21% reported using antipsychotics in more than two thirds. The highest proportion of antipsychotic use to treat delirium (in the last 12 months) was reported by respondents from palliative care (79%, n = 112/142).

Types of Antipsychotics

Nineteen studies reported on the types of antipsychotics used (Table ​ (Table7). 7 ). Thirteen different antipsychotics were reported. The typical antipsychotic haloperidol was the most frequently prescribed ( n = 16), followed by atypical antipsychotics such as quetiapine ( n = 13), risperidone ( n = 9) and olanzapine ( n = 10). Flurie et al. [ 39 ] reported that 98% of patients with delirium in the medical ICU were prescribed haloperidol. On average, 57.74% of patients received a typical antipsychotic and 37.05% received an atypical antipsychotic.

Percentage (%) of patients administered antipsychotics by type (typical/atypical) and name (generic/brand)

HA hyperactive delirium, HO hypoactive delirium, ICU intensive care unit, MICU medical intensive care unit, M mixed delirium, *indicates studies with greater than the sum of 100% indicating use of multiple antipsychotics for some patients

Note: any missing data indicate that this information was not included in the original paper

In studies that surveyed clinical practice ( n = 4), between 35% and 98% of clinicians self-reported haloperidol as the medication of choice when managing delirium (Table ​ (Table8 8 ).

Survey participants’ choices regarding antipsychotics for delirium management (%)

HA hyperactive delirium, HO hypoactive delirium

Note: any missing data indicates that this information was not included in the original paper

Doses of Antipsychotics

Thirteen studies reported daily average or daily median doses of antipsychotics administered to manage delirium. For all antipsychotics, the daily doses varied widely (Table ​ (Table9). 9 ). Haloperidol was the most frequently reported antipsychotic for which doses were reported. Across studies and settings, the mean daily dose of haloperidol ranged from 1.5 mg to 9.4 mg and averaged 4.01 mg/day (SD 2.63, median 3.42 mg/day). Intensive care units had the highest average daily dose of haloperidol (8.45 mg/day, SD 1.34, median 8.45 mg/day). Patients in palliative care settings received an average of 3.05 mg/day of haloperidol (SD 1.34, median 3.05 mg/day). In general medical and surgical settings, older people received an average of 3.23 mg/day of haloperidol (SD 2.01, median 2.71 mg/day). The average daily dose of olanzapine across studies was 8.91 mg/day (SD 5.52, median 8.4 mg/day). Refer to Table ​ Table9 9 for doses of other reported medications (including risperidone and quetiapine).

Average daily doses (mg) of antipsychotic given for delirium management

IM intramuscular, IV intravenous, NPC no psychiatric consult, O oral, PC psychiatric consult, # age (years) reported as either mean or median, * median

Given the high risk for delirium in older people, a sub-group analysis was performed on studies where the average participant age was over 65 years (Table ​ (Table10). 10 ). In this sub-analysis, most studies were conducted in medical/acute (non-ICU) areas. The average daily dose of haloperidol to manage delirium in patients aged over 65 years in these settings was 2.75 mg (SD 2.21, median 2.25mg) and 11 mg for olanzapine (SD 8.54) (Table ​ (Table10). 10 ). In survey methodology studies, respondents recommended daily dose of haloperidol varied from 0.5 mg to 30 mg across the settings (Table ​ (Table11 11 ).

Average mg/day of antipsychotic used for delirium management in patients aged ≥65 years

IQR interquartile range, IM intramuscular, IV intravenous, NPC no psychiatric consult, O oral, PC psychiatric consult, SD standard deviation, # age (years) reported as either mean or median, * median

Survey respondents’ recommended dosage (mg) of antipsychotic for delirium management

Number of Doses of Antipsychotics Administered

Only three studies reported the number of antipsychotic doses that people with delirium received (Table ​ (Table12). 12 ). In the study by Flurie [ 39 ], mean number of doses of haloperidol were 7.7 (SD 9.1) in the medical ICU and 2.8 (SD 1.7) in the medical ward ( p = 0.01) whereas mean number of doses of olanzapine were 9.8 (SD 13.7) in the medical ICU and 19 (SD 19.8) in the medical ward ( p = 0.53). Nguyen et al. [ 18 ] reported both the scheduled and pro re nata (PRN) number of prescriptions. Different quantities were noted between scheduled and PRN dosing for haloperidol, with eight scheduled prescriptions and 112 PRN prescriptions. Notably, only 2% of the PRN doses for haloperidol were administered [ 18 ].

Number of doses patients received for the management of delirium

MICU medical intensive care unit, PRN pro re nata (as required)

Number of Types of Antipsychotics Administered

Four studies reported on the number of different types of antipsychotics administered for each person with delirium (Table ​ (Table13). 13 ). All four studies examined patient cohorts aged over 60 years. A single type of antipsychotic was used for between 29.5% ( n = 26/156) and 76.3% ( n = 119/156) of people with delirium. Two types of medications were used for between 9% ( n = 14/156) and 43% ( n = 34/79) of people with delirium (Table ​ (Table13). 13 ). The medications reported were haloperidol, risperidone, quetiapine and olanzapine. Data that specify the combination of these types of antipsychotics for those patients receiving two or more was not provided.

Number of different antipsychotic used to manage delirium

ICU intensive care unit, # age (years) reported as mean ± standard deviation, * median, ** medications reported (including haloperidol, risperidone, quetiapine, olanzapine) but the actual combinations were not specified

Halavonich et al. [ 40 ] reported the median number of antipsychotics used differed between patients with delirium seen by a psychiatric consult group (median =2) compared with those in the non-consult group (median =1). Flurie et al. [ 39 ] also reported that the median number of antipsychotics administered per patient in the medical ICU was 1, whereas it was 1.5 in the medical ward.

Days of Antipsychotic Treatment

Seven studies reported on the number of days (median or mean) that antipsychotics were used to manage delirium (Table ​ (Table14). 14 ). Most studies reported all antipsychotics together and did not specify the medication type. The median number of days of treatment with any antipsychotic ranged from 4 to 7 days (mean 3.6–16.8 days). In three survey studies, respondent recommendations on the duration of antipsychotics were reported. One quarter (27%, n = 32) of survey respondents in the study by Morandi et al. [ 41 ] stated that antipsychotics should be continued until delirium resolution. Survey respondents in the study by Alexopoulos et al. [ 42 ] stated that if there is an inadequate response to an antipsychotic, the medication should be changed, or dose altered after 1 day. Respondents also recommended antipsychotics be continued for 1 week after a response to medication was observed before considering discontinuing treatment [ 42 ]. Similarly, in the study by Franco et al. [ 43 ], survey respondents indicated pharmacological treatment could be continued for 1 week (18.8%, n = 19/101), 1–2 weeks (10.9%, n = 11/101), until the patient improves (9.9%, n = 10/101) or 2 weeks (8.9%, n = 9/101).

Average number of days antipsychotics were used in delirium management

ICU intensive care unit, IQR interquartile range, MICU medical intensive care unit, NPC no psychiatric consult, O oral, PC psychiatric consult, * median

Clinical Indications for Administration

Eight studies reported on the reasons that antipsychotics were administered to people with delirium. The most common response cited was acute agitation (Table ​ (Table15). 15 ). Moreover, Hosie et al. [ 38 ] reported the most common goals of care when using antipsychotics for patients with delirium were to decrease the intensity of patient distress (79%, n = 153) and/or to restrain unsafe behaviours (67%, n = 130, e.g. physical aggression).

Reasons for the administration of antipsychotics

Continuation of Antipsychotic Therapy on Discharge

Three studies reported on the continuation of antipsychotics at discharge, where ‘discharge’ included transfer from the ICU to an acute care ward, or from acute care to home/place of residence. Halavonich et al. [ 40 ] reported that 34.2% ( n = 52) of patients with delirium (from areas including critical care units and general medicine floors) remained on antipsychotics at discharge from hospital, the majority of which were prescribed as regular scheduled doses. In the study by Boncyk et al. [ 44 ], 20.6% ( n = 804) of patients newly initiated on antipsychotics in the ICU were discharged from the hospital still on the medication. Additionally, Flurie et al. [ 39 ] reported that 26% ( n = 23) of patients with delirium were continued on antipsychotic therapy after transfer from a medical ICU to the medical ward, and 39% ( n = 9) of those patients remained on antipsychotics when discharged from hospital [ 39 ]. Likewise, in the study by Nguyen et al. [ 18 ], one third of patients who started antipsychotics continued after discharge ( n = 24).

Antipsychotic Use According to Delirium Subtype

Two studies described the use of antipsychotics according to delirium subtype. Nguyen et al. [ 18 ] reported that 22% of patients ( n = 11) with hypoactive delirium, 25% ( n = 11) with hyperactive delirium and 51% ( n = 2) with mixed delirium were administered antipsychotics. Furthermore, Fang et al. [ 45 ] reported that in palliative care, antipsychotics were administered to 8.2% ( n = 73) of patients with hypoactive delirium (all were haloperidol), 65.2% ( n = 23) of patients with hyperactive delirium (of which most were haloperidol) and 18.2% ( n = 2) of patients classified as having mixed delirium.

In the survey conducted by Morandi et al. [ 41 ], a majority of respondents would adopt a combined pharmacological/non-pharmacological approach (60%, n = 103) in the management of hyperactive delirium, whereas 30% ( n = 51) would use a non-pharmacological approach and 9.4% ( n = 16) would use only a pharmacological approach. Haloperidol (62%, n = 92) and risperidone (12%, n = 18) were the antipsychotics most commonly suggested to manage hyperactive delirium. Respondents took a different approach for the management of hypoactive delirium, with most applying non-pharmacological approaches only (67.5%, n = 108) and only 3% ( n = 5) reporting they would only use pharmacological measures. Haloperidol was again the antipsychotic of choice for managing hypoactive delirium (46%, n = 31) followed by risperidone (16%, n = 11).

Outcome of Antipsychotic Use

In the study by Boncyk et al. [ 44 ], a significantly increased hazard of mortality was associated with the use of haloperidol (hazard ratio 1.46, 95% CI 1.10–1.93, p = 0.01) and olanzapine (hazard ratio 1.67, 95% CI 1.14–2.45, p = 0.01). Furthermore, people with delirium who received antipsychotics experienced a longer median length of stay (median 10.0, interquartile range 7.0–14.0) compared with those who did not receive antipsychotics (median 8.0, interquartile range 5.3–10.8). Furthermore, Egberts et al. [ 17 ] found that the incidence of post-discharge institutionalisation was notably higher in persons who received antipsychotics compared with those who did not (59.3% vs 45.0%).

This review aimed to describe antipsychotic use for delirium management in clinical practice. We examined how often people diagnosed with delirium were given antipsychotics, the types of antipsychotics they received, the doses of those medications and if the initiated antipsychotic was continued at discharge. Currently, no drug is approved to treat delirium by either the Australian Therapeutic Guidelines (Psychotropic) [hereafter referred to as the Australian Guideline] [ 46 ] or the US Food and Drug Administration. The Australian Guideline recommendations on antipsychotic use in delirium were identified by the authors of this review as the most comprehensive available and served as the benchmark in this discussion. Delirium guidelines specific to clinical settings are also discussed regarding the findings where appropriate. The key findings of this review were that contrary to recommendations in international guidelines, in everyday clinical practice, antipsychotics were used to manage delirium: (1) in a high proportion of patients; (2) off-label and in doses that exceeded recommendations for safe use; and (3) for longer than recommended. Each of these are discussed in turn in the following sections.

High prescribing rates of antipsychotics to manage delirium found in this review indicated that the gap between best practice and clinical practice remains. Given the recommendation by numerous international guidelines to avoid antipsychotic use, especially in older people [ 32 , 47 – 53 ], this finding is particularly concerning. All guidelines suggest antipsychotics only be used after first addressing contributory predisposing and precipitating factors, or when symptoms are unsafe or causing significant distress to the individual [ 54 ], and, that they only be used in low doses for short periods [ 46 , 51 , 55 ]. We speculate the reasons for prescribing antipsychotics are related in part to the clinical context in which delirium occurs.

Delirium is a complex fluctuating condition that often occurs in medically unwell patients in settings where staff and resources can be suboptimal, and this can influence clinicians’ decisions to prescribe and use antipsychotics [ 13 , 14 ]. Eight studies in this review reported indications for prescribing antipsychotics for delirium, such as behavioural concerns, acute agitation, to decrease patient distress, or restrain unsafe behaviours, e.g. physical or verbal aggression [ 16 , 38 , 56 – 61 ]. This suggests safety concerns were commonly a factor in clinicians’ decisions to use antipsychotics, although there was little evidence provided to explain how the clinical context influenced the decision. In addition to safety concerns, Tomlinson et al. [ 13 ] identified that nurses were concerned by the considerable amounts of time and attention needed to provide care for people with hyperactive or mixed delirium especially when they had high workloads and were time poor. Nurses wanted people with delirium to be calm and settled otherwise they “can’t do my job” properly [ 13 ]. Nurses’ also experienced stress when they struggled to manage aggressive behaviours and would pressure doctors into prescribing antipsychotics [ 13 ]. A lack of people and staff trained to deploy non-pharmacological interventions for delirium, which are recommended first-line management [ 9 ], may contribute to the use of antipsychotics [ 13 , 15 ].

Evidence has shown that the addition of trained personnel (e.g. volunteers) in the care of patients with delirium can reduce antipsychotic use. A pilot study in Poland investigated the effectiveness of a volunteer-led multi-component non-pharmacological intervention on the reduction in outcomes including antipsychotic prescriptions in internal medicine patients ( n = 130) [ 62 ]. The intervention, which included regular patient visits to support orientation, physical activity, nutrition, hydration and sleep quality [ 62 ], significantly reduced the initiation of antipsychotics (16.9% intervention [ n = 65] versus 32.3% control [ n = 65], p = 0.04) [ 62 ]. The benefit of non-pharmacological interventions has also been corroborated in a study from the USA that examined the effect of the Hospital Elder Life Program (HELP), which involved a personalised care plan delivered by trained volunteers [ 63 ], on a range of outcomes including the prevalence of newly prescribed antipsychotics to hospitalised patients aged ≥65 years ( N = 12,281) [ 64 ]. Antipsychotics were ordered significantly less often in the HELP group ( n = 1411) than in the standard care group ( n = 10,807) [8.9% n = 125 vs 31.5% n = 3400, p < 0.001] [ 64 ]. Of the 31.5% ( n = 3400) of patients in the standard care group who received an antipsychotic, 85.3% ( n = 2899) received a first-generation antipsychotic (including chlorpromazine, haloperidol, perphenazine, prochlorperazine, fluphenazine) [ 64 ]. For patients who were diagnosed with delirium in the HELP group (2.7%,  n  = 38), approximately 50% ( n = 19) were given an antipsychotic compared with 62.4% of patients ( n = 918) with delirium in the standard care group. However, more research is needed, not only to explore the effects of non-pharmacological strategies on antipsychotic use, but also how evidence-based approaches to implementation could support clinicians to adhere to best practices.

In this review, consistent with previous research, we identified that amongst the wide range of antipsychotics used, haloperidol was the most frequent across settings. Findings from two systematic reviews indicate that available evidence does not support the use of haloperidol or other second-generation antipsychotics to treat the symptoms of delirium in older adults [ 23 , 25 ]. Furthermore, there is mixed evidence regarding the efficacy of haloperidol, it has potential for serious side effects [ 55 ] and has been linked to adverse outcomes [ 65 ]. Additionally, in a recent review of the use of haloperidol in older people with delirium, the Medicines and Healthcare products Regulatory Agency [ 55 ] advised special caution is needed. Evidence is lacking as to why, despite emerging evidence, haloperidol continues to be so widely used in delirium management.

The dosages of antipsychotics reported in studies in this review varied across settings but consistently exceeded that recommended in guidelines. Guidelines across all clinical settings recommend antipsychotics be only used at the lowest appropriate dose for the shortest possible duration [ 32 , 51 , 55 , 66 ]. The Australian Guideline recommends haloperidol only be used if clinically indicated and then be given as a single oral dose of 0.5 mg, or up to 1 mg for younger patients [ 46 ]. However, we found reported haloperidol doses across all settings far exceed guideline recommendations.

In addition to haloperidol, use of olanzapine also exceeded recommended doses. Although numerous studies did not report every individual dose, the high daily average dose reported suggests multiple doses were given in a single day. The Australian Guideline suggests that, if used, a single oral dose of olanzapine between 1.25 and 2.5 mg be given, and up to 5 mg for younger patients [ 46 ]. We found daily doses of olanzapine generally exceeded guideline recommendations. Notably, use of risperidone adhered more closely to the recommended guideline of a single oral 0.5-mg dose with up to 1 mg for younger patients [ 46 ]. Studies in this review reported doses that ranged from 0.5 mg to 1.7 mg. However, in the subgroup analysis of people aged ≥65 years, the average dose of 0.97 mg was higher than recommended. In addition to excessive dosages, these findings highlight a significant variation in the amounts of antipsychotics used for delirium management.

International guidelines for antipsychotic use in delirium management are consistent and vary little between settings or clinical contexts and as such should be followed as closely as possible in all patients with delirium. Clinical Practice Guidelines for Adults in the Intensive Care Unit [ 53 ] recommend not routinely using haloperidol or an atypical antipsychotic to treat delirium. The recommendation is based on evidence that typical antipsychotics (e.g. haloperidol) and atypical antipsychotics (e.g. quetiapine, ziprasidone) are not associated with a shorter duration of delirium or decreased mortality. They further state that patients who experience significant distress or are at risk of harm may benefit from short-term haloperidol or an atypical antipsychotic until symptoms resolve [ 53 ]. A multicentre blinded placebo-controlled trial of 987 patients admitted to the ICU [ 19 ] identified that treatment of delirium using haloperidol did not lead to a greater number of days alive. Furthermore, a randomised, double-blind, placebo-controlled trial of 566 ICU patients [ 20 ] found that neither haloperidol nor ziprasidone significantly altered the duration of delirium (odds ratio, 0.88 [95% CI 0.64–1.21]. Doses of haloperidol used in ICUs in studies included in this review were extremely high and well above the recommendations for use of haloperidol in the ICU Clinical Practice Guidelines [ 53 ].

Guidelines for delirium management at the end of life [ 52 ] recommend avoiding antipsychotics in terminal patients. If pharmacological treatment is needed, a short-term low-dose antipsychotic is recommended for symptoms of perceptual disturbance, to control severe agitation, or if there are safety concerns [ 52 ]. Our review identified that ~70% of patients in palliative care settings had delirium managed with antipsychotics, and the average daily haloperidol dose of 3.05 mg exceeds recommendations. Even though patients may be terminal, potential risks associated with antipsychotic use should still be considered. A recent Cochrane systematic review [ 67 ] that investigated four RCTs of drug therapies in terminally ill adults ( n = 399) concluded that haloperidol may slightly worsen delirium symptoms (median 0.49, 95% CI 0.10–0.88; n = 123) and increase extrapyramidal adverse events (median 0.79, 95% CI 0.17–1.41; n = 123). Furthermore, antipsychotics can appear to reduce some delirium symptoms through their sedating action but do not treat the underlying pathology of delirium [ 52 ]. Adding an antipsychotic can change delirium from hyperactive to hypoactive, which is equally distressing for the patient [ 52 ]. Shared decision making between clinicians, patients and family caregivers prior to antipsychotic use could reduce the risk of inappropriate prescribing and dosing, and facilitate active decision making to consider discontinuation when clinically appropriate [ 52 ].

There were very few studies that reported the use of antipsychotics according to the subtype of delirium. It is not surprising that for patients with hyperactive delirium, who may experience increased agitation and combative or uncooperative behaviour [ 9 ], there was a trend towards higher rates of antipsychotic use. As antipsychotics can reduce agitation and psychotic symptoms, and have a sedating effect, they are recommended if the patient is severely distressed and at risk of harming themselves or others [ 46 ]. However, studies in this review highlighted that some patients with hypoactive delirium also received antipsychotics [ 18 , 45 ]. Patients with hypoactive delirium have reduced motor activity, increased lethargy and are quiet and withdrawn, symptoms that do not align with recommendations to consider antipsychotic use for reasons of agitation, distress or safety concerns. Indeed, antipsychotics are not recommended for the management of patients with hypoactive delirium [ 68 ]. The use of antipsychotics in patients with hypoactive delirium should be further investigated and future research should look specifically at delirium subtypes.

Antipsychotics were given repeatedly and over several days to many patients in studies in this review. This is well beyond the Australian Guideline’s recommendation of “a single dose of an antipsychotic is usually adequate” [ 46 ]. Irrespective of whether the number of doses or days of treatment were described, all studies in this review reported treatment that exceeded recommendations for the use of antipsychotics in people with delirium in all reported settings. The study by Tomlinson et al. [ 13 ] offers a possible explanation. In this qualitative study, clinicians (doctors and nurses) described that they would continue antipsychotics in anticipation of worsening behaviours. This means that antipsychotics were prescribed pre-emptively, in the absence of behavioural symptoms, to reduce the likelihood of disruptive agitated behaviours [ 13 ]. Regular evaluation of continued treatment with antipsychotics is essential [ 15 ]. More research needs to be done to understand clinicians’ rationale for giving repeat doses and prolonged treatment: if the intention is chemical restraint or “delirium treatment”, then an important focus of future research will be to investigate what will support clinicians to adopt best practice and support the use of non-pharmacological strategies early and throughout care.

Continuation of newly initiated antipsychotics at discharge was reported in only four studies [ 18 , 39 , 40 , 44 ]. The rationale for post-discharge continuation of antipsychotics was not disclosed in the studies. The findings of this review indicated that a large proportion of newly prescribed antipsychotics were continued at discharge. According to the Australian Guideline [ 46 ], antipsychotics should be ceased as soon as possible; however, a short course of regular low-dose antipsychotics may be appropriate if the patient experiences severe distress that persists beyond a day [ 46 ]. Persistent use of antipsychotics beyond transitions of care may lead to avoidable adverse effects. Our study highlights that opportunities exist to examine the transition of care practices, regarding antipsychotic continuation or discontinuation at discharge. Further research is needed to understand the reluctance clinicians may have in discontinuing antipsychotics for people with delirium in readiness for discharge.

Strengths and Limitations of the Systematic Review

To the best of the authors’ knowledge, this review is the first to synthesise available evidence on the prevalence of antipsychotic use in the routine clinical management of delirium. It provides evidence of the continual overuse and inappropriate prescribing of antipsychotics for delirium management. This review offers valuable insights for clinicians to think critically about antipsychotic use within their healthcare organisation, and consider how changes in approach to patient care and support for clinicians could reduce current usage.

This research has some limitations that should be considered. Most included studies in this review were retrospective medical record audits, which can present issues with the quality of data available, especially as data may be missing, inaccurate or not accurately represent clinical practices. Additionally, not all research studies provided the same level of detail regarding how medications were used. Some studies reported on only one aspect of the outcomes sought in this review. Furthermore, some studies that may have been eligible were excluded as there was insufficient detail regarding how delirium was diagnosed, or results were not stratified by clinical indication for antipsychotic use. We also acknowledge the risk of publication bias. As this systematic review included published studies in English, there may be missing relevant data on the wider state of antipsychotic use in clinical settings associated with unpublished works and those reported only in other languages. Consequently, the findings of this systematic review may not comprehensively reflect the full spectrum of evidence. Moreover, this review did not include any RCTs as it aimed to provide a descriptive overview of clinical practice, thus correlations and relationships between delirium severity, antipsychotic use and outcomes cannot be provided.

Implications for Research

There is currently a paucity of prospective observational research that examines how antipsychotics are used for people with delirium. This is particularly the case in aged care, where no published studies were found, and sub-acute care (in-patient rehabilitation) where only one study met inclusion criteria and data were limited to the percentage of people administered antipsychotics. Observational research is needed, as it can elucidate patterns of use (e.g. indications for use, individual doses and route of administration) and the effects on patients and the course of delirium. Additionally, the extent to which first-line non-pharmacological interventions are applied in relation to the initiation of antipsychotics warrants further investigation. The economic implications of reducing antipsychotic use in delirium care are yet to be explored.

Implications for Clinical Practice, Staff Education and Guidelines

There is a pressing need for healthcare organisations to prioritise the implementation of established clinical practice guidelines for delirium. Practical support for clinicians, such as additional trained personnel or volunteers, should urgently be provided to reduce reliance on antipsychotics without compromising safety. Monitoring antipsychotic use, especially in older individuals, should be undertaken as a routine measure of care quality. Clinician education and training are needed on how to implement non-pharmacological strategies and de-escalate disruptive behaviours early to avoid behavioural control through antipsychotic use. To support clinicians in reaching balanced decisions in using antipsychotics, we recommend delirium guidelines clearly articulate that antipsychotic use is a restrictive practice because of its sedating effects and requires caution equivalent to that used when considering the use of physical restraint. Family and other carers should also be involved in decision making when considering the use of antipsychotics for delirium management.

This systematic review presented evidence that antipsychotics are overused in the management of delirium. Studies included in this review demonstrated that antipsychotics remain a common choice to manage symptoms of delirium. Notably, haloperidol was the most frequently administered antipsychotic, often in doses that exceeded the recommended therapeutic amount in all clinical settings. The discrepancy between clinical practice and established guidelines is evident and potentially impacts on the quality of care. Further research is needed to determine the impact of antipsychotics on people with delirium and how to support the clinical workforce to implement evidence-based recommendations for antipsychotic use.

Below is the link to the electronic supplementary material.

Acknowledgements

We thank Leslie Brautigam for her work in the initial screening of studies for inclusion in the review.

Declarations

Open Access funding enabled and organized by CAUL and its Member Institutions.

Emily J. Tomlinson, Linda M. Schnitker and Penelope A. Casey have no conflicts of interest that are directly relevant to the content of this article.

Not applicable.

Excel files of extracted data and methodological quality checking are available upon request to the corresponding author.

ET designed the study, implemented the search strategy, screened papers, reviewed the data, conducted quality assessments, extracted the data and wrote the manuscript. LS assisted with developing the search strategy, screened papers, assisted with data extraction, conducted the quality assessment and reviewed the manuscript. PC assisted with data extraction, conducted the quality assessment, and assisted with writing the paper and reviewed the manuscript. All authors have read and approve the final version of the manuscript, and agree to be accountable for the work.

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• Published: 03 September 2024

A systematic review and quality appraisal of guidelines and recommendations for home enteral tube feeding in adults

• Andriana Korai   ORCID: orcid.org/0000-0001-5537-1931 1 , 2   na1 ,
• Isabella Thomson 1 , 2   na1 ,
• Sharon Carey   ORCID: orcid.org/0000-0003-4155-5240 1 , 3 &
• Margaret Allman-Farinelli 1 , 2  

European Journal of Clinical Nutrition ( 2024 ) Cite this article

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• Health policy

Home Enteral Tube Feeding (HETF) is a viable option for people within primary care settings when oral intake is insufficient to meet nutritional needs. As HETF is not a risk-free therapy, guidelines exist to enable its safe provision. This review aims to summarise existing guidelines and their recommendations pertaining to the provision of HETF and appraise their methodological quality. A systematic review was conducted according to the Cochrane Handbook for Systematic Reviews, PRISMA-checklist and a 2019 methodological guide specific to the review of clinical practice guidelines (PROSPERO registration: CRD42023456223). Records were sourced from five bibliographical databases (Medline, Embase, PsychINFO, Scopus, Cinahl) and the grey literature (64 websites, seven guideline repositories). The AGREE-II tool was applied to eligible guidelines. The recommendations of guidelines meeting a predetermined threshold score (domain 3 ‘rigour of development’ score >70%) were extracted, grouped, and assessed using the AGREE-REX tool. A total of 2707 records were screened with 15 guidelines meeting eligibility criteria. The median (IQR) overall AGREE-II score (/7) of all guidelines was 3 (3–5) and only 3/15 guidelines achieved a domain 3 score >70%. The median (IQR) overall AGREE-REX score was 33% (26–37%). No recommendation group achieved a domain score above 70%. No guideline or recommendation group was suggested for use without modification. Key limitations included suboptimal stakeholder involvement and implementability, and lack of methodological transparency. Current HETF guidelines inadequately align with methodological standards. This review highlights key areas HETF guideline developers should consider to create more relevant and implementable guidelines.

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Introduction.

Enteral nutrition (EN) enables optimisation or preservation of nutritional status in individuals with malnutrition or risk thereof and with compromised oral intake. Indications for the initiation of EN may include increased nutritional requirements, gastrointestinal tract malignancies, reduced nutrient absorption due to inflammatory conditions or swallowing difficulties arising from neurological disorders [ 1 ]. EN is mostly administered through nasoenteric or the stomal route, where percutaneous feeding devices can be inserted endoscopically, radiographically, or surgically [ 2 , 3 ]. While EN can be provided across the continuum of care, home enteral tube feeding (HETF) specifically involves delivering liquid nutrition via one of these routes within a domiciliary care setting [ 4 ]. While the cost-effectiveness of HETF compared to treatment in hospital has not been thoroughly evaluated, cost savings analyses have shown savings in HETF sub-groups, and across the care continuum in England of up to £65,484,550 for all forms of nutrition support inclusive of HETF [ 5 , 6 ].

Attempts have been made to estimate the global point prevalence of people receiving HETF through large-scale surveys and retrospective studies as national registries are limited [ 7 ]. In the last five years, national prevalence has only been reported in Australia and New Zealand (234 HETF patients per million) and Poland has reported total HETF cases, although both used clinician-administered surveys which are prone to underestimation [ 7 , 8 ]. Challenges with provision of HETF have been reported internationally in terms of clinical complications, funding and organisation of services, supply of consumables and research and development [ 9 , 10 ]. This is reflected in the significant variability noted in the provision of care to HETF patients on a national and global level [ 7 , 11 ]. The need for comprehensive clinical guidelines which additionally address barriers and facilitators to providing optimal care to this population group have been advocated [ 11 ]. Guidelines from well-known professional societies and government agencies have widespread use by clinicians caring for people receiving HETF [ 12 , 13 ], however, all available guidelines have not previously been collated or assessed for their quality.

Multiple standards and guidance for development of high-quality clinical practice guidelines exist [ 14 ]. The development of evidence-based recommendations alone is insufficient to produce a high-quality guideline as guidelines should be outcome focused, capable of adaptation to various global audiences, frequently updated and involve collaboration between all relevant stakeholders including consumer-led expert opinion [ 14 ]. Groups such as the Scottish Intercollegiate Guidelines Network and the Guidelines International Network have endorsed use of the tools produced by the Appraisal of Guidelines REsearch and Evaluation (AGREE) collaboration to evaluate the quality of clinical practice guidelines [ 15 , 16 ]. This review aimed to systematically identify and summarise existing guidelines pertaining to the provision of HETF in adults and assess the quality of guidelines and their recommendations using internationally recognised quality assessment tools.

A protocol for this systematic review of guidelines was developed a priori and registered with PROSPERO (identification CRD42023456223) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [ 17 ]. A protocol amendment was submitted (12 th December 2024) with changes to the grey literature sources searched and eligibility criteria after piloting the study selection process. Further detail for the data extraction plan was also provided. This review was also informed by the Cochrane Handbook for Systematic Reviews of Interventions and Johnston et al. methodological guide for systematic reviews of clinical practice guidelines [ 18 , 19 ].

Literature search

Five bibliographical databases (MEDLINE, EMBASE and PsycInfo (OVID interface), CINAHL, and Scopus) were searched for published eligible guidelines on HETF on September 26, 2023. A search strategy was developed for Medline and translated across the remaining four databases (Table S1 ).

Additionally a grey literature search including seven guideline repositories and 64 key government health agency and nutrition association websites was conducted on September 29, 2023. The choice of guideline repository was based on Cochrane recommendations and the websites included were informed by a preliminary Google search and content experts on the research team. A summary of the sources and search methods used is provided in Table S2 . The reference lists of included guidelines were also hand-searched to identify additional potentially eligible guidelines.

Eligibility criteria

Included guidelines contained a dedicated set of recommendations specific to the provision of HETF to people aged over 18 years old. Guidelines covering any aspect or stage of the patient journey associated with HETF, from initiation to management and discontinuation were included. These had to be explicitly identified as a guide, guideline, standard or recommendations. Guidelines had to be evidence-based and/or developed through consensus, although could be presented in any format and with any intended end-user. Records providing inadequate methodological detail to ascertain whether evidence-based and/or consensus methods were used were excluded. Guidelines pertaining exclusively to short term enteral feeding or where the duration of feeding could not be determined were excluded, as where guidelines for specific diseases or conditions unless they specifically addressed HETF. Narrative reviews and opinion pieces were excluded. Guidelines were included if they were available in English and were produced from 2000 onwards to ensure currency.

Study selection

All bibliographical records were imported into the reference management software EndNote (Version 20, Clarivate Philadelphia) where duplicates were removed as previously described [ 20 ]. The remaining records were imported into Covidence Systematic Review Software (Veritas Health Innovation, Australia 2023) for two-step screening conducted independently by two reviewers (AK, IT). Titles and abstracts were screened against eligibility criteria. Full-texts of records deemed eligible from this step were then obtained and screened. When consensus could not be reached between the two reviewers, conflicts were resolved through discussion with a third reviewer (SC). Where multiple editions existed, the most recent guideline was selected.

Data extraction and quality assessment of guidelines

A data extraction form was created in Excel (Microsoft Corporation Version 16.77.1, 2023) to collate pertinent information from eligible guidelines. Information extracted included: guideline title, authorship, publication and update year, applicable geographical region, any affiliated agencies or associations, the aspect(s) of HETF considered, the applicable population group, whether a systematic search was conducted, methods used to evaluate the body of evidence and what consensus method was used.

Quality appraisal was completed with the AGREE-II tool. This tool evaluates the methodological rigour of guideline development through 23 items organised into six domains, where each item is rated against specific criteria and considerations using a 7-point grading system (1 – strongly disagree to 7 – strongly agree). Guidelines are then assigned an overall assessment (1 – lowest possible quality to 7 – highest possible quality) accompanied by a statement on recommended use which considers the overall quality of the guideline and its appropriateness for use in practice [ 21 ].

Supporting documents including previous and abridged versions, quick reference guides, technical reports, methodological manuals, guideline development policy statements, standard operating procedures and supplementary materials were retrieved prior to quality appraisal. Where applicable, corresponding authors were contacted twice to request access to supporting documents cited in the guideline but not publicly available. If no response was received quality appraisal was conducted without the additional documents.

Data extraction and quality appraisal using AGREE-II was conducted concurrently by two independent reviewers (AK, IT). All appraisers were trained to apply the AGREE-II tool by studying the manual and relevant publications [ 21 , 22 ]. Application of the tool was also discussed prior to its use by the research team to promote consistency in how the tool was applied (MAF, AK, IT). For AGREE-II items which were not applicable to a guideline a rating of 1 (absence of information) was provided and this score was contexualised as recommended in the AGREE-II manual [ 21 ]. ‘Recommendations for use’ were informed by both the quality assessment and the availability of alternative guidelines. Differences in scores were resolved through discussion and final item scores and overall assessments reached through consensus. An experienced user of the tool (SC) then reviewed consensus scores from items where the two appraisers’ scores differed by >1. Consensus is an appropriate approach when less than four appraisers are available and has been previously employed [ 23 , 24 ]

Scaled domain scores were calculated using consensus scores and the formula: (obtained consensus score – minimum possible score)/(maximum possible score – minimum possible score) [ 21 ]. As the AGREE-II user manual does not define quality cut-off scores, high quality guidelines were considered those with domain 3 ‘rigour of development’ scaled scores ≥70% as a high score in this domain is indicative of high methodological quality and transparency in reporting [ 25 ]. The quality of recommendations from high quality guidelines were then assessed using the AGREE-Recommendation EXcellence (AGREE-REX) tool [ 26 ].

Data extraction and quality assessment of recommendations

The AGREE-REX tool assesses the quality of recommendations made by guidelines as determined by their clinical credibility, trustworthiness and implementability. The tool consists of nine items categorised into three domains. Each item consists of two evaluations, the first is informed by whether the recommendation(s) considered the criteria relevant to each item in their development, and the second optional evaluation rates the suitability of the recommendation(s) to a particular setting. Both evaluations use a 7-point grading system (1 – strongly disagree to 7 – strongly agree). For this quality appraisal only the first evaluation was completed as the results were not intended to guide adoption in a particular setting.

A second data extraction form was created in Excel (Microsoft Corporation Version 16.77.1, 2023) to collate all recommendations related to care of people receiving HETF from the included guidelines and their assigned grading. Relevant recommendations were extracted by one researcher (AK) and reviewed by a second (SC). The AGREE-REX tool was then applied to clusters of recommendations addressing a similar HETF topic within each included guideline. This approach was taken as it was believed that quality may vary between recommendations given the widely reported scarcity of high-quality research in this area and resource constraints made it unfeasible to assess each recommendation separately [ 26 ]. Six clusters were used, adapted from the categorisations used in the ESPEN Home Enteral Nutrition guideline [ 4 ], which was the sole high-quality guideline dedicated explicitly to HETF, and the nutrition care process [ 27 ]. Clusters included: commencement of HETF; care of feeding site and enteral access devices; recommendations for feeding; monitoring HETF; termination of HETF and requirements of HETF services. Additional detail for the clusters used is provided in Table S 3 . AGREE-REX assessment was independently completed by two reviewers (AK, IT) and final scores were agreed through consensus. Both assessors studied the AGREE-REX manual, and the tool was piloted on one cluster for a single guideline and results discussed prior to completing the remaining assessments. Scaled domain and overall scores were calculated using consensus scores and the formula: (obtained consensus score – minimum possible score)/(maximum possible score – minimum possible score) [ 26 ]. All data extraction forms and extracted data will be made available upon reasonable request.

Data synthesis

Guideline characteristics were summarised descriptively. Domain scores were presented as percentages (scaled scores) and overall assessments as a score of seven for AGREE-II and as a scaled percentage for AGREE-REX. Overall assessments were accompanied by a statement on the assessors’ recommendations for use. Item, domain and overall scores were summarised using descriptive statistics (median with interquartile range (IQR)) for both tools across all eligible guidelines. Median and range was used only when comparing AGREE-REX scaled domain scores across recommendation clusters as only two to three scores were being summarised. Domain results from both tools were also presented as colour-coded quartiles and recommendation gradings were presented as proportions. All analyses were carried out using Excel (Microsoft Corporation Version 16.77.1, 2023).

The database search identified 3650 records. A total of 970 duplicates were removed and 2680 records were screened based on their title and abstract. Following exclusion of 2635 records, 42 records were successfully retrieved for full-text screening and six guidelines were included. The grey literature search identified an additional 20 records from websites and guideline repositories, of which seven met the eligibility criteria. Seven additional records identified from citation chaining of included guidelines were screened of which two met eligibility criteria. A total of 15 guidelines were included in this review. The PRISMA flow diagram outlining the selection process is shown in Fig. 1 .

A total of 2707 unique records were identified from all sources, of which 15 were included.

Guideline characteristics

All guidelines were produced by professional associations or government agencies. The guidelines originated from the USA ( n  = 4), Europe ( n  = 3), the UK ( n  = 3), Australia ( n  = 2), France ( n  = 1), Italy ( n  = 1) and Korea ( n  = 1). The primary focus of most guidelines ( n  = 10) was clinical management of one or more methods of nutrition support. Of these, three were exclusive to HETF [ 4 , 28 , 29 ], two covered enteral nutrition more broadly [ 30 , 31 ], one addressed enteral and parenteral nutrition [ 32 ] and four encompassed all forms of nutrition support [ 12 , 33 , 34 , 35 ]. Four guidelines were dedicated to care of feeding sites and enteral access devices [ 36 , 37 , 38 , 39 , 40 ] and two studies focused on organisation of services providing care to people receiving HETF [ 29 , 41 ]. Seven of the guidelines included children in the target population, while exclusion of children was unclear in two guidelines. Eight of the guidelines employed a systematic literature search as part of their methodology and nine used standardised evidence grading systems. Four guidelines consistently used and clearly described a structured approach to reach consensus of recommendations. All guideline characteristics are outlined in Table 1 .

Assessment of guidelines using the AGREE-II tool

AGREE-II quality scores of the 15 guidelines included are presented in Table 2 . The median overall quality score out of 7 for all guidelines was 3 [3–5]. The NICE guideline on nutrition support for adults was the highest scoring guideline (6/7) both in terms of overall quality and across all six domains. The highest scoring domain across all guidelines was ‘clarity of presentation’ (83% [64–86%]) and the lowest scoring domain was ‘applicability’ (8% [2–15%]). Of all domain scores, 23% (21/90) had scaled domain scores ≥75% and 29% (26/90) had scaled domain scores <25%. The highest rated item across all guidelines was item 16 ‘the different options for management of the condition or health issue are clearly presented’ (domain 4) (7 [6–7]), while the lowest rated was item 20 ‘the potential resource implications of applying the recommendations have been considered’ (domain 5) (1 [1–1]). Raw consensus item scores are available in Table S 4 . Only three guidelines scored ≥70% for domain 3 ‘rigour of development’, proceeding to AGREE-REX appraisal.

Guideline recommendations and their assessment using the AGREE-REX tool

Of all recommendations 66% (72/109) were graded as Good Practice Points while 6% (6/109) were of grade A, 18% (20/109) of grade B and 10% (11/109) of grade O. All recommendations were grouped into six clusters which were each assessed using the AGREE-REX tool. A summary of recommendation grades stratified by cluster and guideline is presented in Table S 5 .

Clusters for all guidelines scored below 70% for all three domains of the AGREE-REX tool, with no overall score for any cluster >50% (Table 3 ). Across all guidelines, ‘Clinical Applicability’ (56% [39–61%]) was the highest scoring domain, with ‘care of feeding sites and enteral access devices’ (61% [33–61%]) and ‘recommendations for HETF feeds’ (61% [56–67%]) the highest scoring clusters in this domain. These clusters also consisted of the highest proportion of A-O graded recommendations with 45% (17/38) and 45% (9/20) respectively (Table S 5 ). ‘Values and Preferences’ (21% [17–25%]) was the lowest scoring domain with the corresponding item 6 ‘values and preferences of policy/decision-makers’ (1[1–2]) and item 7 ‘values and preferences of guideline developers’ (1 [1–2]) the lowest scoring items. Raw consensus item scores are available in Table S 6 . All recommendation clusters were recommended for use with modifications (Table S 6 ).

This review is the first to systematically identify, synthesise and evaluate the methodological quality of available guidelines and their recommendations for HETF. We identified and assessed 15 guidelines of which many were of poor methodological quality, either failing to employ systematic searches of the literature, utilising informal consensus methods, or simply lacking transparency and detail as to the methods employed. Only three of the identified guidelines were of high methodological quality however none of the recommendation clusters relevant to HETF from these guidelines achieved an overall AGREE-REX quality score > 50%. Numerous low-scoring items and domains from both the AGREE-II and AGREE-REX evaluations were attributed to the same methodological shortcomings of the appraised guidelines.

‘Rigour of development’ has been acknowledged as a critical domain in the appraisal of guideline quality [ 42 ]. While scores in this domain were low there was an improvement in the use of systematic search methods and structured consensus over time. A noticeable limitation of most guidelines was the absence of criteria for regular update with only four guidelines ever having been renewed. In the past six years, no updates had been made. ‘Evidence’ scores were generally low with a majority of recommendations being good practice points, based on low-level evidence or extrapolated from moderate-level evidence. Inconsistent alignment between the definitiveness of some of these good practice point recommendations and the rationale provided, or lack thereof, was the main reason for lower scoring on ‘applicability to target users’. Discordant recommendations, that is, when the strength of a recommendation is not reflective of the certainty of evidence, are warranted when there is low quality evidence suggesting benefit in life-threatening situations [ 43 , 44 , 45 , 46 ]. The absence of clinical equipoise in providing EN would constitute the conduct of certain randomised controlled trials in this population unethical [ 47 ]. When evidence is limited, guideline developers should be transparent as to the considerations made when formulating recommendations. This would include the perspective taken, the value assigned to relevant outcomes, acceptability of the recommendation to relevant stakeholders, resource requirements and the feasibility of implementation [ 48 , 49 ]. Scarcity of high-quality evidence should not deter guideline developers from creating or updating clinical guidance, rather the well documented limitations of the evidence base could support a redistribution of some resources to rigorous conduct in other aspects of guideline development such as stakeholder engagement and ensuring implementability. Benchmarking studies of local guideline uptake have demonstrated inconsistent adherence [ 7 ] and thus further engagement with HETF stakeholders including people receiving HETF, their carers, clinicians involved in service provision, service managers and guideline and policy-makers, would be warranted.

The practical utility of a guideline is only possible when developed with a plan of implementation. Most guidelines disregarded facilitators, barriers, and resource considerations to applying their recommendations. Qualitative studies with HETF service users and providers have highlighted the benefit of having access to providers with expertise in HETF including management of complications [ 50 ]. There are often financial barriers however in accessing services and challenges with co-ordinating care by a multidisciplinary team [ 10 ]. Oftentimes what may be clinically most suitable for a patient (e.g. feeding mode, formula choice or frequency of review) may not be feasible within the client and health service resources. Guidelines acknowledged implementation barriers and facilitators although tools and resources to address these were infrequently provided as were monitoring and auditing criteria. This may in part be secondary to the minimal involvement of key stakeholders in the development process and external review of these guidelines. Quality appraisals of guidelines for critical care nutrition and medical nutrition therapy in liver cirrhosis have also highlighted similar limitations in stakeholder consultation, applicability and consideration of values and preferences in formulating recommendations [ 51 , 52 , 53 , 54 ]. Economic analyses are also crucial in assuring the implementability of recommendations [ 55 ] although were noticeably absent in the guidelines assessed. Cost savings have been reported with the implementation of HETF-dedicated outpatient clinics [ 56 ] and advanced practice dietitian roles in gastrostomy management [ 57 ] – both practices which would have allowed for closer adherence to HETF guidelines. With ethical restrictions in the conduct of RCTs, economic modelling may serve as a more suitable approach to showcase the benefit of recommendations made for this population group.

All three high quality guidelines were recommended for use with modifications secondary to the prospect of improving quality with subsequent updates. NICE guidance was originally developed over two decades ago with an overall high methodological quality although with some informal consensus methods. New evidence has been considered in the need to update this guideline [ 58 ] and some supporting tools to facilitate implementation have been provided [ 59 , 60 ] although the healthcare space has changed drastically since its original inception. For instance, community-based replacement of gastrostomy tubes following traumatic displacement has become more commonplace following the COVID-19 pandemic [ 61 ] with the NHS also issuing a recovery plan for urgent and emergency services which involved expanded community services [ 62 ]. The guideline would now likely benefit from more current and meaningful consultation with stakeholders to ensure its relevance and usability [ 63 ]. Similarly, ESPEN guidelines’ quality could also be improved through wider or more clearly explicated consultation with consumers and policymakers. This has proven difficult secondary to unclear guidance [ 64 ] although some direction has been provided and the Cochrane Multi-Stakeholder Engagement (MuSE) Consortium seeks to provide guidance on the matter [ 65 ].

All guidelines were developed by professional associations and/or government agencies with suboptimal reporting of editorial independence. Funding body influence was not always applicable as many professional bodies are interested in generating guidelines to improve patient management, thus assigned scores of ‘1 (absence of information)’ reduced the overall domain 6 score. Conflict of interest was however poorly reported with most guidelines not describing the type of competing interests considered nor the methods employed in attaining them. While it is likely editorial independence existed for most guidelines, many did not indicate this correctly, similarly to other aspects of guideline development.

Strengths and limitations

Strengths of this review include using a systematic search of five databases and an extensive grey literature search where authors were contacted to source supporting materials. This study also used the AGREE-II and AGREE-REX tools which are reliable and valid tools dedicated to assessing the quality of guidelines and their recommendations. While the minimum number of appraisers assessed each guideline, a consensus method was used in both assessments to address this. Finally, predominantly publicly available guidelines were included, and it is possible that documents produced by associations only accessible via subscription were missed.

Conclusions

This review identified and analysed 15 guidelines regarding home enteral tube feeding from seven geographical regions, three of which were considered high quality. Despite their higher quality, even the NICE and ESPEN guidelines had methodological weaknesses which limit their usability and for this reason no guideline or recommendation cluster was recommended for use without modification. These findings highlight the importance of transparent and detailed reporting practices and the need to consider meaningful involvement of people receiving HETF and their carers, clinicians and service managers in guideline development to ensure recommendation applicability and implementability. Guideline developers should invest in economic analyses to accompany recommendations relating to service structure and provide targeted tools and resources such as competency criteria to support education and training of both clinicians and people receiving HETF.

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Acknowledgements

The authors thank academic librarians Ms Bernadette Carr and Ms Tess Aitken for their assistance in developing the search strategy.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. AK is supported by a Research Training Program Stipend Scholarship from the Australian Government and the King and Amy O’Malley Trust Foundation Postgraduate Research Scholarship. MAF declares funding for other projects from National Health and Medical Research Council, Australian Research Council and NSW Health. SC declares funding for other projects from Sydney Local health District, Medical Research Future Fund and unrestricted research grants from Baxter Pharmaceuticals and Nutricia Australia. These funding sources had no involvement in, or restrictions on publication. Open Access funding enabled and organized by CAUL and its Member Institutions.

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Nutrition and Dietetics Group, Sydney Nursing School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia

Andriana Korai, Isabella Thomson, Sharon Carey & Margaret Allman-Farinelli

Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia

Andriana Korai, Isabella Thomson & Margaret Allman-Farinelli

Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, NSW, Australia

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AK, SC, MAF contributed to conceptualisation, developed methodology and provided supervision. AK, IT conducted investigations (search strategy, screening, data extraction, quality appraisal), formal analysis and visualisation. SC also conducted quality appraisal. AK, IT drafted the original manuscript and SC, MAF were involved in review and editing. All authors read and approved the final manuscript.

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Korai, A., Thomson, I., Carey, S. et al. A systematic review and quality appraisal of guidelines and recommendations for home enteral tube feeding in adults. Eur J Clin Nutr (2024). https://doi.org/10.1038/s41430-024-01500-1

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Algorithmic decision-making (ADM) utilises algorithms to collect and process data and develop models to make or support decisions. Advances in artificial intelligence (AI) have led to the development of support systems that can be superior to medical professionals without AI support in certain tasks. However, whether patients can benefit from this remains unclear. The aim of this systematic review is to assess the current evidence on patient-relevant benefits and harms, such as improved survival rates and reduced treatment-related complications, when healthcare professionals use ADM systems (developed using or working with AI) compared to healthcare professionals without AI-related ADM (standard care)—regardless of the clinical issues.

Following the PRISMA statement, MEDLINE and PubMed (via PubMed), Embase (via Elsevier) and IEEE Xplore will be searched using English free text terms in title/abstract, Medical Subject Headings (MeSH) terms and Embase Subject Headings (Emtree fields). Additional studies will be identified by contacting authors of included studies and through reference lists of included studies. Grey literature searches will be conducted in Google Scholar. Risk of bias will be assessed by using Cochrane’s RoB 2 for randomised trials and ROBINS-I for non-randomised trials. Transparent reporting of the included studies will be assessed using the CONSORT-AI extension statement. Two researchers will screen, assess and extract from the studies independently, with a third in case of conflicts that cannot be resolved by discussion.

It is expected that there will be a substantial shortage of suitable studies that compare healthcare professionals with and without ADM systems concerning patient-relevant endpoints. This can be attributed to the prioritisation of technical quality criteria and, in some cases, clinical parameters over patient-relevant endpoints in the development of study designs. Furthermore, it is anticipated that a significant portion of the identified studies will exhibit relatively poor methodological quality and provide only limited generalisable results.

Systematic review registration

This study is registered within PROSPERO (CRD42023412156).

Peer Review reports

Artificial intelligence (AI) is a broad term referring to the field of computer science that develops algorithms mimicking human cognitive functions such as learning, perception, problem-solving and decision-making. AI encompasses various approaches, including machine learning (ML) and deep learning. It comprises a range of technologies and techniques, including algorithmic decision-making (ADM) ([ 9 ]: 1). ADM refers to the process of using these algorithms to gather, process, model and use input data to make or support decisions. Feedback from these decisions can then be used for improving the system ([ 2 ]: 612). An ADM can take various forms depending on how it is framed and presented to the user or decision subject. It can be a simple algorithm that has been known and used for decades, such as classification trees [ 37 ], or a more complex system like a recommender or AI that can provide recommendations to human decision-makers, nudge its users in a certain direction or perform fully automated decision-making processes without human involvement ([ 2 ]: 613). We specify AI-related algorithmic decision-making systems (AI-related ADM) as decision support systems that either apply AI (relying on ML models) or have been developed with the help of AI.

Recent advances in AI have resulted in the development of more complex and sophisticated systems that can outperform humans in certain tasks. For example, in the field of computer vision, systems like DeepMind’s AlphaFold have revolutionised protein structure prediction, solving a decades-old challenge in biology by accurately predicting 3D protein structures [ 18 ]. Additionally, AI innovations have transformed financial services, with machine learning models now being used to predict market trends, optimise trading strategies and enhance fraud detection [ 12 ]. Furthermore, generative AI has demonstrated remarkable capabilities in generating human-like text and performing a wide range of language-related tasks with unprecedented accuracy [ 13 ]. Recently, ChatGPT was evaluated for its clinical reasoning ability by testing its performance on questions from the United States Medical Licensing Examination, where it scored at or near the passing threshold on all three exams without any special training or reinforcement [ 21 ].

These advances in AI seem to have enormous potential to transform many different fields and industries, which begs the question: will AI do so in healthcare?

In clinical trials, AI systems have already shown potential to help clinicians make better diagnoses [ 3 , 22 ], help personalise medicine and monitor patient care [ 6 , 16 ] and contribute to drug development [ 7 ]. However, successful application in practice is limited ([ 30 ]: 77) and potential issues that may be responsible for this gap between research and practice should be revealed by our work.

By searching PubMed for the term ‘artificial intelligence’, we found over 2000 systematic reviews and meta-analyses published in the last 10 years, with a yearly increasing trend. These include several reviews conducted in the area of AI in healthcare that provide an overview of the current state of AI technologies in specific clinical areas, including AI systems for breast cancer diagnosis in screening programmes [ 8 ], ovarian cancer [ 38 ], early detection of skin cancer [ 17 ], COVID-19 and other pneumonia [ 15 ], prediction of preterm birth [ 1 ] or diabetes management [ 19 ]. Other reviews have focused on comparing clinicians and AI systems in terms of their performance to show their capabilities in a clinical setting [ 24 , 27 , 34 ].

Although these reviews are crucial to the further development of AI systems, they offer little insight into whether patients actually benefit from their use by medical professionals. Indeed, these studies focus on the analytical performance of these systems, rather than on healthcare-related metrics. In most of the studies mentioned here, the underlying algorithms have been evaluated using a variety of parameters, such as the F1 score for error classification, balanced accuracy, false positive rate and area under the receiver operating characteristic curve (AUROC). However, measures of a system’s accuracy often provide non-replicable results ([ 25 ]: 4), do not necessarily indicate clinical efficiency ([ 20 ]: 1), AUROC does not necessarily indicate clinical applicability ([ 10 ]: 935) and in fact, none of these measures reflects beneficial change in patient care ([ 4 ]: 1727, [ 33 ]: 1).

To summarise, as with any other new technology introduced into healthcare, the clinical effectiveness and safety of AI compared to the standard of care must be evaluated through properly designed studies to ensure patient safety and maximise benefits while minimising any unintended harm ([ 31 ]: 328). Therefore, a critical analysis of patient-relevant outcomes is needed, especially the benefits and harms of decisions informed by or made by AI systems.

To this end, this review goes beyond previous studies in several ways. First, we study clinical AI systems that enable algorithmic decision-making (AI-related ADM) in general and therefore do not limit ourselves to selected clinical problems. In particular, we focus on machine learning systems that infer rules from observations. Although we omit rule-based systems, we apply the term AI throughout our work because it is often incorrectly and redundantly used for ML and deep learning in the literature we study. Second, we focus on studies that report patient-relevant outcomes that, according to German Institute for Quality and Efficiency in Healthcare ([ 14 ]: 44), describe how patients feel, how they can perform their functions and activities or if they survive. These may include, for example, mortality, morbidity (with regard to complaints and complications), length of hospital stay, readmission, time to intervention and health-related quality of life. Third, we focus only on studies that compare medical professionals supported by AI-related ADM systems with medical professionals without AI-related ADM systems (standard care). By doing so, this review provides an overview of the current literature on clinical AI-related ADM systems, summarises the empirical evidence on their benefits and harms for patients and highlights research gaps that need to be addressed in future studies.

The aim of this review is to systematically assess the current evidence on patient-relevant benefits and harms of ADM systems which are developed or used with AI (AI-related ADM) to support medical professionals compared to medical professionals without this support (standard care).

Are there studies that compare patient-relevant effectiveness of AI-related ADM for medical professionals compared to medical professionals without AI-related ADM?

Do these studies show adequate methodological quality and are their findings generalisable?

Can AI-related ADM systems help medical professionals to make better decisions in terms of benefits and harms for patients?

Methods/design

In accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) statement [ 26 ], the study protocol for this systematic is registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42023412156). If necessary, post-registration changes to the protocol will be detailed under the PROSPERO record with an accompanying rationale.

We will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [ 29 ] and the Methodological Expectations of Cochrane Intervention Reviews (MECIR) standards [ 11 ].

We will search systematically using English free text terms in title/abstract, Medical Subject Headings (MeSH) terms and Embase Subject Headings (Emtree) fields for various forms of keywords related to ‘artificial intelligence’ and relevant subcategories of computer generated and processed decision-making algorithms, ‘medical professionals’ and keywords describing effectiveness parameters and outcomes as well as preferred study types. Based on the block building approach, keywords and terms are combined using the Boolean operators AND and OR and progressively checked for relevant hits.

Databases to be used for searches

MEDLINE and PubMed (via PubMed), Embase (via Elsevier) and Institute of Electrical and Electronics Engineers (IEEE) Xplore will be searched for peer-reviewed articles as well as ClinicalTrials.gov and ICTRP (via CENTRAL) for ongoing trials and protocols.

To reduce potential publication bias, additional studies will be identified by contacting authors of included studies, contacting experts in the field and through reference lists of relevant studies. Grey literature searches will be conducted in Google Scholar. For this purpose, the keywords used in the systematic search will be used in different combinations, as well as their German equivalents. Google Scholar will be searched up to the 10th hit page. The detailed search strategy for each database will be reported under the PROSPERO record once the searches have been conducted.

Search strategy

We developed our search strategy using the PICOS scheme (Table  1 ).

While doing preliminary searches for basic literature in MEDLINE and PubMed (via PubMed), we noticed that study conductors from different scientific fields (e.g. computer scientists) used different terms for the intervention outcomes we were looking for. In addition, some studies were not indexed appropriately in PubMed, which complicated our initial search strategy. To carry out the search strategy, we have created and tested the blocks consecutively to gather the best results from each block, expanding and narrowing the search strategy. To assess the right direction of the search strategy, we have used fundamental literature, such as Choudhury and Asan [ 5 ], Park et al. [ 31 ] and Nagendran et al. [ 27 ] as test sets, making sure the results of our search had common ground with these studies.

The resulting search string for MEDLINE and PubMed in the individual blocks can be found in Table  2 and describes the basis for other databases.

Types of studies to be included

For the systematic search, peer-reviewed interventional and observational studies published in German or English 10 years retrospectively from the date of the search will be considered. For the search of grey literature, scientific reports published in German or English 10 years retrospectively from the date of the search will be considered. To extract potentially relevant studies from (systematic) reviews and meta-analyses, secondary studies will be gathered and screened. However, secondary studies will not be included in the synthesis.

In contrast to studies of effectiveness and safety, pure efficacy studies (e.g. focusing on algorithms accuracy) will be excluded as these outcomes are not directly relevant for patients. Patient-relevant outcomes will be defined according to the IQEHC method paper [ 14 ]. In addition, studies that used AI systems beyond our scope, such as robotics (systems that support the implementation of decisions), will be excluded. Editorials, commentaries, letters and other informal publication types will be excluded as well.

We will provide a list of all references screened in full text including exclusion reasons in the appendix of the final study.

Participants

Our study is focusing on human patients without restriction of age or sex. Therefore, the input data for the algorithms must include real human data gathered either during routine care and saved for use in research or generated specifically for the individual study.

Intervention

Out study is focusing on medical professionals utilising an AI-related ADM system to address a clinical problem.

In our working definition, a medical professional is a qualified individual who has the authority to perform necessary medical procedures within their professional scope of practice. Their goal is to improve, maintain or restore the health of individuals by examining, diagnosing, prognosticating and/or treating clinical problems. This may include medical doctors, registered nurses and other medical professionals. Clinical problems can encompass illnesses, injuries and physical or mental disorders, among other conditions.

In our working definition, an AI-related ADM system is a clinical decision support system that either applies AI in the sense of machine learning (ML, excluding rule-based systems) or has been developed with the help of ML. Clinical decision support models without any involvement of AI will be excluded.

Medical professionals, as described in the working definition, are addressing a clinical problem without the support of an AI-related ADM system (standard care).

Patient-relevant benefits and harms, according to the IQEHC method paper [ 14 ], are gathered. These may include, for example, mortality, morbidity (with regard to complaints and complications), length of hospital stay, readmission, time to intervention and health-related quality of life.

Study types

We will collect both interventional and observational studies, which may encompass randomised controlled trials, cohort studies, case–control studies, randomised surveys, retrospective and prospective studies and phase studies, as well as non-inferiority or diagnostic studies.

Data extraction

Records arising from the literature search will be stored in the citation manager Citavi 6 (c) by Swiss Academic Software. After removing duplicates, two reviewers will independently review all titles and abstracts via the browser application Rayyan [ 28 ]. Studies potentially meeting the inclusion criteria will then be screened in full text independently by two reviewers using Citavi 6 (c). Disagreements over eligibility of studies will be discussed and, if necessary, resolved by a third reviewer. Authors of the included studies will be contacted if clarification of their data or study methods is required. The PRISMA 2020 flow diagram [ 29 ] will be used to keep the study selection process transparent.

Using a standardised data collection form, two reviewers will extract data independently from the included studies and will compare them for discrepancies. Missing data will be requested from study authors. Extracted data will include country of conduction, setting, study design, observational period, patient-relevant outcomes, intervention, comparator, characteristics of patient and medical professional populations and characteristics of the used algorithm. Additionally, studies will be classified by type of system, medical specialty or clinical area, prediction or classification goal of the AI-related ADM, supported decision, investigated benefits and harms, private or public study funding, applicable regulation (e.g. FDA, MDR), medical device classification (based on the risk and nature of the product) and whether the product is commercially available in its respective class (Table  3 ).

Risk of bias and quality assessment

Risk of bias will be assessed by using the revised Cochrane risk-of-bias tool for randomised trials (RoB 2) [ 36 ] and the risk-of-bias in non-randomised studies for interventions (ROBINS-I) tool [ 35 ]. Disagreements between the authors over the risk of bias in the included studies will be resolved by discussion or with involvement of a third author if necessary. Transparent reporting of the included studies will be assessed trough the Consolidated Standards of Reporting Trials interventions involving Artificial Intelligence (CONSORT-AI) extension by Liu et al. [ 23 ]. The CONSORT-AI extension includes 14 new items that were considered sufficiently important for AI interventions to be routinely reported in addition to the core CONSORT items by Schulz et al. [ 32 ]. CONSORT-AI aims to improve the transparency and completeness in reporting clinical trials for AI interventions. It will assist to understand, interpret and critically appraise the quality of clinical trial design and risk of bias in the reported outcomes. We will assess studies conducted prior to the introduction of the CONSORT-AI guidelines in 2020 against these standards where possible. Although these studies may not fully meet the new criteria, application of the guidelines may still identify potential reporting gaps and ensure a consistent assessment framework across studies. We will discuss limitations related to this retrospective requirement to ensure a balanced and comprehensive analysis.

Data synthesis

Given the expected likelihood of heterogeneity between studies in the different medical specialties in terms of outcome measures, study designs and interventions, we do not know if performing a meta-analysis will be possible. However, a systematic narrative synthesis will be provided of the results with an overview of the relevant effects for the outcomes, with information presented in the text and tables to summarise and explain the characteristics and findings of the included studies. We will analyse the geographic distribution, study settings and medical specialties of the included studies. Additionally, we will examine funding sources and conduct a detailed risk of bias assessment. Compliance with reporting standards, such as CONSORT-AI and TRIPOD-AI, will be evaluated. We also plan to analyse patient demographics, including age, sex and race/ethnicity, as well as the involvement and training of medical professionals. ADM systems will be categorised into applicable regulation (e.g. FDA, MDR), medical device classification (based on the risk and nature of the product) and whether the product is commercially available in its respective class. Outcome analyses will focus on assessing both benefits and harms. Furthermore, we will analyse the validation of algorithms, considering both internal and external validation, and review the data availability statements to evaluate the accessibility of data used for algorithm development. Studies with an unclear or high risk of bias are not excluded to avoid potential selection bias and to ensure that valuable findings, particularly in emerging areas, are not lost. By including them, but clearly acknowledging and discussing their limitations, we aim to provide a more comprehensive overview of the available evidence. For this reason, our narrative synthesis emphasises the qualitative aspects of the data and focuses on identifying and describing trends, patterns and inconsistencies in the studies, rather than attempting to quantify effect sizes. This is consistent with the approach of recent reviews examining the methodological quality of machine learning systems in clinical settings (e.g. [ 27 ]).

It is to be expected that there is a significant lack of suitable studies comparing healthcare professionals with and without AI-related ADM systems regarding patient-relevant outcomes. It is assumed that this is due to, first, the lack of approval regulations for AI systems, second, the prioritisation of technical and clinical parameters over patient-relevant outcomes in the development of study designs and, third, the prioritisation of AI for supporting clinical processes (e.g. administration). In addition, it is to be expected that a large proportion of the studies to be identified are of rather poor methodological quality and provide results that are rather difficult to generalise. Although reporting guidelines such as the Consolidated Standards of Reporting Trials (CONSORT) statement [ 32 ] are well-known and widely used in medical and public health research, they do not necessarily correspond to the novel protocol and study designs that are relevant for the assessment of the research questions relevant here. The extension of the Reporting Guidelines for Clinical Study Reports of Interventions Using Artificial Intelligence (CONSORT-AI) [ 23 ] may fill the gap but this guideline is relatively new and not necessarily always applied.

Availability of data and materials

Not applicable.

Abbreviations

• Algorithmic decision-making
• Artificial intelligence

Area under the receiver operating characteristic curve

Cochrane Central Register of Controlled Trials

Convolutional neural network

Consolidated Standards of Reporting Trials

Consolidated Standards of Reporting Trials for Artificial Intelligence

Centre for Reviews and Dissemination

Embase Subject Headings

Intensive care unit

Institute of Electrical and Electronics Engineers

German Institute for Quality and Efficiency in Healthcare

Methodological Expectations of Cochrane Intervention Reviews

Medical Subject Headings

Machine learning

Non-randomised controlled trial

Participants, Intervention, Control, Outcome

Preferred Reporting Items for Systematic Review and Meta-Analysis

Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols

International Prospective Register of Systematic Reviews

Randomised controlled trial

A convolutional neural network that is 18 layers deep

Revised Cochrane risk-of-bias tool for randomised trials

Risk-of-bias in non-randomised studies for interventions

Respiratory rate

Standard deviation

Oxygen saturation

Standards for Reporting Qualitative Research

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Christoph Wilhelm conceptualised, developed the methodology and wrote this protocol. He is the guarantor of the manuscript. Prof. Dr Anke Steckelberg validated the methodology of this protocol. Dr Felix G. Rebitschek conceptualised, reviewed, edited and supervised this protocol.

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Wilhelm, C., Steckelberg, A. & Rebitschek, F.G. Is artificial intelligence for medical professionals serving the patients? . Syst Rev 13 , 228 (2024). https://doi.org/10.1186/s13643-024-02646-6

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Binocular treatment for amblyopia: a systematic review

• Published: 02 September 2024
• Volume 44 , article number  362 , ( 2024 )

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• Zoi Tsani   ORCID: orcid.org/0000-0002-4048-8683 1 ,
• Dimitrios Ioannopoulos   ORCID: orcid.org/0009-0000-9016-1569 2 ,
• Sofia Androudi   ORCID: orcid.org/0000-0002-5303-7793 1 ,
• Efthimios Dardiotis   ORCID: orcid.org/0000-0003-2957-641X 3 &
• Eleni Papageorgiou   ORCID: orcid.org/0000-0003-1931-4168 1  

The treatment of unilateral amblyopia involves refractive adaptation, occlusion therapy or penalization with atropine drops. However, in recent years, the use of binocular digital therapy has shown promising results. Aim of this systematic review was to evaluate the effectiveness of binocular treatment of amblyopia compared with standard treatments or placebo therapy.

This systematic review was conducted in accordance to PRISMA statement. Electronic literature was thoroughly searched for articles published between 2013 and May 2024, in the following electronic database; Pubmed, CENTRAL, MedlinePlus, Medline Europe, PLOS, Scopus, Clinicaltrials.gov. The review comprised randomized control trials (RCTs) including patients with unilateral amblyopia, who received binocular therapy or standard amblyopia or placebo treatment for more than two weeks and who had visual acuity assessment pre- and post-treatment. Only articles written in English were included. Risk of bias was assessed with the Rob2 tool, while study quality was evaluated with the modified Jadad scale.

Twenty RCTs, including 1769 patients, were incorporated into this systematic review. Twelve different types of binocular amblyopia treatments were identified and categorized into two main types. The first type involves the presentation of low-contrast images in the fellow eye, including stimuli presented only in the amblyopic eye. The second type combines this approach with complementary dichoptic deficits in the images presented to both eyes to encourage their simultaneous use.

Binocular amblyopia treatment has shown promising results in addressing unilateral anisometropic, strabismic or mixed type of amblyopia. Nevertheless, further randomized controlled trials are essential to establish the exact dosage, type and duration of binocular therapy as a standard component of amblyopia care.

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The 100 most cited papers on amblyopia: a bibliographic perspective, data availability.

No datasets were generated or analysed during the current study.

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All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Tsani Zoi and Papageorgiou Eleni. The first draft of the manuscript was written by Tsani Zoi and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Tsani, Z., Ioannopoulos, D., Androudi, S. et al. Binocular treatment for amblyopia: a systematic review. Int Ophthalmol 44 , 362 (2024). https://doi.org/10.1007/s10792-024-03259-7

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Smooth muscle tumor of uncertain malignant potential (stump): a systematic review of the literature in the last 20 years.

1. Introduction

2. materials and methods, 3. results and discussion, 3.1. diagnosis and presentation, 3.2. comparison with leiomyomas and its variants, 3.3. tumor characteristics, 3.4. treatment, 3.5. recurrence, 3.6. improving patient outcomes.

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Bucuri, C.E.; Ciortea, R.; Malutan, A.M.; Oprea, V.; Toma, M.; Roman, M.P.; Ormindean, C.M.; Nati, I.; Suciu, V.; Mihu, D. Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP): A Systematic Review of the Literature in the Last 20 Years. Curr. Oncol. 2024 , 31 , 5242-5254. https://doi.org/10.3390/curroncol31090388

Bucuri CE, Ciortea R, Malutan AM, Oprea V, Toma M, Roman MP, Ormindean CM, Nati I, Suciu V, Mihu D. Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP): A Systematic Review of the Literature in the Last 20 Years. Current Oncology . 2024; 31(9):5242-5254. https://doi.org/10.3390/curroncol31090388

Bucuri, Carmen Elena, Razvan Ciortea, Andrei Mihai Malutan, Valentin Oprea, Mihai Toma, Maria Patricia Roman, Cristina Mihaela Ormindean, Ionel Nati, Viorela Suciu, and Dan Mihu. 2024. "Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP): A Systematic Review of the Literature in the Last 20 Years" Current Oncology 31, no. 9: 5242-5254. https://doi.org/10.3390/curroncol31090388

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• Open access
• Published: 06 September 2024

Association between pregnancy intention and completion of newborn and infant continuum of care in Sub-Saharan Africa: systematic review and meta-analysis

• Birye Dessalegn Mekonnen   ORCID: orcid.org/0000-0003-3879-1330 1 , 2 ,
• Vidanka Vasilevski   ORCID: orcid.org/0000-0002-2772-811X 1 , 3 ,
• Ayele Geleto Bali   ORCID: orcid.org/0000-0001-5139-6568 1 , 3 &
• Linda Sweet   ORCID: orcid.org/0000-0003-0605-1186 1 , 3  

BMC Pediatrics volume  24 , Article number:  567 ( 2024 ) Cite this article

Metrics details

The newborn and infant continuum of care such as essential newborn care, early initiation and exclusive breastfeeding, and immunisation are highly recommended for improving the quality of life and survival of infants. However, newborn and infant mortality remains high across Sub-Saharan African countries. While unintended pregnancies are associated with adverse newborn and infant health outcomes, there is inconclusive evidence on whether pregnancy intention influences newborn and infant continuum of care completion. Therefore, this review aimed to pool findings reported in the literature on the association between pregnancy intention and newborn and infant health care across the continuum of care in Sub-Saharan Africa.

We searched MEDLINE Complete, EMBASE, CINAHL Complete, and Global Health databases for studies potentially eligible for this systematic review and meta-analysis. Two researchers independently screened the identified articles by abstract and title, and then full-text using Covidence. We used the Newcastle–Ottawa Scale to assess the quality of the included studies. The Cochran’s Q test and I 2 were executed to detect and quantify the presence of statistical heterogeneity in the studies. Meta-analysis was done for each outcome when more than one original study reported relevant data, using Stata statistical software version 18.

Eleven studies were included from a total of 235 articles identified by the search. The odds of completing essential newborn care (pooled odds ratio: 3.04, 95% CI: 1.56, 5.90), early initiation of breastfeeding (pooled odds ratio: 1.30, 95% CI: 1.13, 1.52), exclusive breastfeeding (pooled odds ratio: 2.21, 95% CI: 1.68, 2.89), and being fully immunised (pooled odds ratio: 2.73, 95% CI: 1.16, 6.40) were higher among infants born to women with intended pregnancies as compared to women with unintended pregnancies.

Intended pregnancy was positively associated with essential newborn care completion, early initiation and exclusive breastfeeding, and full immunisation of infants in SSA countries. Thus, policy-makers and stakeholders should strengthen the provision of quality family planning services to prevent unintended pregnancy. Furthermore, follow-up of women with unintended pregnancies is needed to increase women’s opportunity to access essential newborn health care services that further reduce the risk of newborn and infant morbidity and mortality.

Systematic review registration

PROSPERO registration number CRD42023409148.

Peer Review reports

Introduction

Improving the quality of life and survival chances of newborns, and children remains an urgent global challenge [ 1 ]. Worldwide, considerable progress has been made to reduce neonatal mortality from 5 million in 1990 to 2.4 million in 2019 [ 2 ], and under-five mortality from 12.5 million in 1990 to 5.3 million in 2018 [ 2 ]. However, substantial differences in child mortality continue to exist across regions where Sub-Saharan Africa (SSA) holds the highest perinatal mortality rates of 34.7 deaths per 1,000 live births [ 3 ], infant mortality rate of 53 deaths per 1,000 live births [ 4 ], and under-five mortality rate of 78 deaths per 1,000 live births [ 2 ]. In addition, about 41% of children in SSA are highly affected by stunting, which possibly contributes to increasing child morbidity and mortality [ 5 ]. Many of these deaths are preventable or curable using interventions that are simple and cost-effective such as adequate nutrition, vaccination, and appropriate newborn and infant care [ 6 , 7 ] as well as by improving access to maternal health care services [ 8 ].

Parental adherence to children’s preventive and curative health care sets children up for better long-term health and considerably reduces the risk for child morbidity and mortality [ 9 , 10 , 11 ]. Similarly, maternal pregnancy intention has a significant effect on parent–child attachment and bonding, with a potential impact on children’s long-term physical, developmental, and psychological health outcomes [ 12 , 13 , 14 ]. Women with unintended pregnancies face more difficulty in establishing a strong attachment with their babies, poor childcare practices, and breastfeeding difficulties [ 12 , 15 , 16 ]. Literature has shown that children born to mothers with unintended pregnancies had less secure mother-to-child attachment during infancy, poor preventive and curative care, and poor behavioural and educational outcomes than women with intended pregnancies [ 12 , 16 , 17 ]. In addition, unintended pregnancy was associated with childhood illness, stunting and underweight, and higher risks of infant and child mortality [ 16 , 18 ]. Furthermore, adverse birth outcomes, such as congenital anomalies, preterm birth, and low birthweight were observed among children born from unintended pregnancies [ 18 , 19 ]. Conversely, intended pregnancy was associated with a reduced risk of stillbirth compared to unintended pregnancies [ 14 ].

Mounting evidence has shown that women who experienced unintended pregnancy had lower likelihoods of timely initiation of breastfeeding, continuing to breastfeed, and exclusive breastfeeding than women with intended pregnancy [ 20 , 21 ], resulting in poorer physical health of their children [ 13 ]. Furthermore, children born from unintended pregnancy were less likely to receive childhood immunisation [ 20 , 22 , 23 ]. These effects could be caused by maternal behaviours during pregnancy, and late initiation, or low use of antenatal care [ 24 , 25 , 26 , 27 ]. Hence, the prevention of unintended pregnancy and effective implementation of the maternity continuum of care are highly recommended to enhance the survival of newborns and infants through promoting preventive health care practices for children [ 28 , 29 ]. A recent study has shown that completing the maternity continuum of care, which includes the use of antenatal care, birthing at health facility, and use of postnatal care can considerably improve the use of essential newborn care practices [ 30 ].

The World Health Organization and United Nations Children’s Fund [ 2 , 31 ] strongly recommended strategies for the newborn and infant continuum of care, such as exclusive and timely initiation of breastfeeding, improving child nutrition, and child vaccination. This is anticipated to achieve the Sustainable Development Goal aimed to decrease the high rates of neonatal deaths to 12 per 1000 live births and under-five deaths to 25 per 1000 live births by 2030 [ 32 , 33 ]. Though strong emphasis has been given to the newborn and infant continuum of care, in SSA, only 56.5% of children were fully vaccinated [ 34 ], 47% of infants were breastfed within one hour of birth and 35% of children received exclusive breastfeeding in the first six months of life [ 35 ]. However, none of these studies have analysed the association between maternal pregnancy intention and completion of the newborn and infant continuum of care including essential newborn care practices, exclusive and timely initiation of breastfeeding, and infant immunisation. Moreover, while unintended pregnancies are associated with adverse newborn and infant health outcomes, there is inconsistent and inconclusive evidence on whether pregnancy intention influences newborn and infant health care across the newborn and infant continuum of care.

Up-to-date evidence with pooled estimates is required to understand whether developing interventions targeting preventing unintended pregnancies with the aim of child survival is required. Therefore, this study aimed to pool findings reported in literature on the association between pregnancy intention and essential newborn and infant health care across the newborn and infant continuum of care in SSA to contribute reliable evidence that would inform newborn and infant health policy and practice.

Registration and reporting

We used the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist [ 36 ] to prepare and report this review (Supplementary File 1). After checking for a lack of other similar existing reviews and protocols, this systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) with registration number CRD42023409148.

Information sources and search strategy

The search terms were prepared based on the following concepts: pregnancy intention, essential newborn care practice, early initiation of breastfeeding, exclusive breastfeeding, full immunisation status, and Sub-Saharan Africa. The search keywords included free text keywords and Medical Subject Headings (MeSH) using Boolean operators, truncation, wildcards, and phrases in various databases. A comprehensive literature search was done in major databases such as MEDLINE Complete (EBSCOhost platform), EMBASE, CINAHL Complete (EBSCOhost platform), and Global Health (EBSCOhost platform) on August 13, 2023. These databases were selected as they index health and medical-related research. Furthermore, bibliographies of reviews and the identified studies were reviewed in Google Scholar for potentially relevant studies. The EBSCOhost MEDLINE was used to develop the initial search strategy, which was then adapted for other databases. Details of search strategies for each database are provided in Supplementary File 2. A scholarly expert librarian reviewed the search plans and provided advice to improve the search.

Eligibility criteria

Inclusion criteria.

We included observational studies that reported essential newborn care practice, or early initiation of breastfeeding, or exclusive breastfeeding, or child immunisation status as an outcome variable and pregnancy intention as an exposure variable. Furthermore, we included peer-reviewed studies published in the English language and conducted in SSA countries. Moreover, studies that reported the odds ratios (OR) with a 95% confidence interval (CI) or have raw data that allowed us to calculate the odds ratios with a 95% confidence interval were included.

Exclusion criteria

We excluded studies that did not report the associations of pregnancy intention with essential newborn care practice, or early initiation of breastfeeding, or exclusive breastfeeding, and full immunisation status. Review articles, qualitative studies, case reports, commentaries, case studies, conference abstracts, case series, and opinion pieces were excluded.

Study selection

We used Covidence systematic review software to screen studies. Two researchers (BDM, VV) independently conducted title and abstract screening after removing duplicates. Similarly, potentially eligible studies for full-text review were retrieved and then systematically screened against the eligibility criteria. The third reviewer (AGB) resolved any conflicts during the screening process. The results of the search in each database, screening, and selection process are summarised in a PRISMA 2020 flow diagram (see Fig.  1 ).

PRISMA flow diagram of the studies screening process

Quality assessment

Two researchers (BDM, AGB) assessed the quality of each primary study using the Newcastle–Ottawa Scale (NOS) for assessing the quality of non-randomised studies [ 37 ], with no discrepancies observed. The NOS tool has selection, comparability, and outcome domains and rate articles with a maximum of ten stars. The selection domain focuses on sample size, representativeness of the target population, response rate, and ascertainment of risk factors with a maximum of five stars. The comparability domain focuses on controlling the confounding factors that potentially influence the outcome of the variable with a maximum of two stars. The outcome domain assesses the outcomes of interest and appropriateness of the statistical tests with a maximum of three stars. The quality of the studies was ranked based on the overall number of stars. Accordingly, studies with a star number of 9 or 10, 7 or 8, and 5 or 6 were deemed to be very-good quality, good quality, and satisfactory quality respectively (Suplementary file 3). Studies with four or less stars were deemed unsatisfactory quality and were to be excluded from the review due to poor quality. The NOS tool has been used in previous similar studies [ 38 , 39 , 40 ].

Data extraction

Two researchers (BDM, VV) independently extracted data in a Microsoft Excel spreadsheet. No discrepancies occurred during data extraction. All relevant data items such as author(s), study setting and design, sample size, study population, data collection methods, response rate, publication year, odds ratio with a 95% CI for the association of pregnancy intention with each of the four outcome variables (essential newborn care, early initiation of breastfeeding, exclusive breastfeeding, and full immunisation status), and the definition of all four outcome variables were extracted from each included study. The pregnancy intention of participants was also extracted for each outcome variable.

Outcome measurement

The association between pregnancy intention and newborn and infant health care across the continuum of care was the outcome of interest in this review. For this research, the newborn and infant health continuum of care includes essential newborn care, early initiation of breastfeeding, exclusive breastfeeding, and full immunisation status. Essential newborn care is defined in this research as the newborn has received all the recommended elements of the services, including safe cord care, initiating skin-to-skin contact, eye care, and delayed baby bathing for at least 24 h after birth [ 41 ]. Early initiation of breastfeeding is defined as the provision of mother’s breast milk to the baby within the first hour of birth [ 42 ]. Exclusive breastfeeding is defined as an infant receiving only breast milk from birth until six months of age without adding water or any other food except for mineral supplements, vitamins, or prescribed medicines [ 42 ]. Full immunisation is defined as a child who has received a single dose of Bacillus Calmette–Guérin (BCG) vaccine, four poliomyelitis vaccines, three doses of pentavalent vaccines (diphtheria, pertussis, tetanus, hepatitis B and Haemophilus influenza type B), three doses of pneumococcal conjugate vaccine (PCV), two doses of Rota vaccine, and one dose of measles vaccine before their first birthday [ 43 ].

Pregnancy intention has been classified into intended and unintended [ 44 ]. For this study, intended pregnancy was when the woman reported that she planned or wanted her last pregnancy at the time of conception; otherwise, a pregnancy is considered an unintended pregnancy. Both unwanted pregnancies (no children are desired at all) and mistimed pregnancies (wanted at some time but occurred sooner than desired) were considered as unintended pregnancies [ 45 ].

Data analysis

The adjusted odds ratios (AOR) of the association between pregnancy intention and each outcome variable were extracted from each primary study as the measure of effect. For the outcome of early initiation of breastfeeding, the crude odds ratios (COR) and confidence intervals were calculated from the raw data. The COR was used for the outcome of early initiation of breastfeeding due to the lack of AOR data in the included studies. Since COR was calculated from all included studies for this outcome, this approach ensured that we did not mix AOR with COR in the same analysis. Logit transformations were made for the individual measure of effect before computing the pooled summary. When two or more studies reported relevant data, a quantitative meta-analysis was done for each outcome. Forest plots and tables are used to graphically display the summary of effect sizes with 95% CI and other results. The random-effects model was employed for the outcomes of essential newborn care, early initiation breastfeeding and child immunisation status. The random-effect model was employed to assume the variations or heterogeneity in the effect estimates across the studies [ 46 , 47 ]. For the outcome of exclusive breastfeeding, the fixed effects model was used as the number of included studies was only two, which makes it inappropriate to perform the random-effects model because the precision in estimating variability in studies is limited [ 46 , 48 ]. The weight of each study in the pooled estimates was calculated using the inverse of the variance. The potential variation between the primary studies was statistically estimated using Cochran’s Q test and quantified by I 2 with significant heterogeneity to be deemed at p -value < 0.1 or I 2  > 50% [ 49 , 50 ]. Since very few studies were included in the meta-analysis of each outcome, publication bias, subgroup analysis, and sensitivity analysis were not conducted [ 48 , 51 ]. In this analysis, early initiation of breastfeeding, while a component of essential newborn care, was analysed separately to better understand how pregnancy intention specifically influences this practice. The studies used for the early initiation of breastfeeding analysis differed from those included in the broader essential newborn care analysis, ensuring that our findings on early initiation are based on a unique set of data. Furthermore, unwanted and mistimed pregnancies were used interchangeably if the original studies had reported one of the two instead of unintended pregnancy. Likewise, wanted and planned pregnancy were used interchangeably if the original studies had reported one of the two instead of intended pregnancy. All statistical analyses were executed using Stata statistical software version 18.

The database searches produced a total of 231 records, with a further 4 articles identified from manual searches of bibliographies of relevant studies. After a comprehensive screening, eleven studies met the inclusion criteria and retained for the review [ 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 ]. The steps and outcomes of the study selection process are shown in the PRISMA flow diagram (see Fig.  1 ).

Studies characteristics

All the studies included in the review used cross-sectional study designs and were published between 2016 and 2022. A total of 18,781 study participants were involved in the original studies. Many studies ( n  = 9) were set in Ethiopia [ 52 , 53 , 54 , 56 , 57 , 59 , 60 , 61 , 62 ]. Eight studies collected the data via face-to-face surveys developed from literature reviews [ 52 , 53 , 54 , 57 , 58 , 59 , 60 , 62 ], two studies used the demographic and health survey [ 56 , 61 ], and the remaining one study used data from multiple indicator cluster survey [ 55 ]. Of the included studies in the review, eight studies employed multistage random sampling [ 52 , 53 , 54 , 55 , 56 , 58 , 59 , 61 ], two studies used systematic random sampling [ 60 , 62 ], and one study used simple random sampling to collect data [ 57 ]. Almost all ( n  = 10) of the studies were of good quality methodological rigour (7 or 8 stars) on the NOS assessment. The summary of the 11 papers is shown in Table  1 .

Association between pregnancy intention and newborn and infant continuum of care

Three studies examined the association between pregnancy intention and essential newborn care practice [ 52 , 53 , 54 ]. The results of the meta-analysis showed that women whose pregnancy was intended were about three times (AOR: 3.04, 95% CI: 1.56, 5.90) more likely to practice essential newborn care as compared to women with unintended pregnancy (Fig.  2 ).

Pooled odds ratio of the association between essential newborn care and pregnancy intention

Three studies were included to estimate the association between pregnancy intention and early initiation of breastfeeding [ 55 , 56 , 57 ]. Meta-analysis of the three studies showed that women with intended pregnancy had 1.31 times (COR: 1.30, 95% CI: 1.13, 1.52) higher odds of early initiation of breastfeeding than women who had an unintended pregnancy (Fig.  3 ).

Pooled odds ratio of the association between early initiation of breastfeeding and pregnancy intention

Two studies reported the association between pregnancy intention and exclusive breastfeeding [ 58 , 59 ]. Meta-analysis of the two studies showed that women with an intended pregnancy had 2.21 times (AOR: 2.21, 95% CI: 1.68, 2.89) higher odds of exclusive breastfeeding than women who had an unintended pregnancy (Fig.  4 ).

Pooled odds ratio of the association between exclusive breastfeeding and pregnancy intention

Three studies reported the association between pregnancy intention and child immunisation status [ 60 , 61 , 62 ]. Accordingly, the pooled odds of being fully immunised was 2.73 times (AOR: 2.73, 95% CI: 1.16, 6.40) higher in children born from mothers with an intended pregnancy than children born from mothers with an unintended pregnancy (Fig.  5 ).

Pooled odds ratio of the association between child immunisation status and pregnancy intention

Adjusted effect estimates were used to determine the association between pregnancy intention and newborn and infant continuum of care, including essential newborn care, early initiation and exclusive breastfeeding, and full immunisation. However, the studies did not control for the same mix of confounders. Furthermore, the association between pregnancy intention and early initiation of breastfeeding is likely to be affected by several other factors, as the analysis was executed based on an unadjusted effect measure. The results of the present meta-analyses did however suggest that intended pregnancy was associated with greater completion of essential newborn care practices, early initiation and exclusive of breastfeeding, and being fully immunised.

Women with intended pregnancy had higher odds of essential newborn care practice, early initiation and exclusive breastfeeding and fully immunised infants than women with unintended pregnancy. This could be explained by the fact that mothers with intended pregnancy may have greater psychological preparedness for providing care to their newborn infants [ 63 ]. Conversely, women experiencing an unintended pregnancy may not feel equipped to take on a maternal role, leading to poor mother-to-child attachment and low engagement with essential newborn practices [ 13 , 64 ]. Previous studies have indicated that negligence, carelessness, aggression, and maltreatment of children were observed more often in mothers with unintended pregnancies [ 65 , 66 ]. Furthermore, these women may have low health-seeking behaviour for themselves and their infants due to stress associated with unintended pregnancy, and less support from their partners or families [ 24 , 67 , 68 ]. Women who experience an unintended pregnancy may also receive little information and counselling regarding the benefit of appropriate newborn and infant feeding practices and care because of absent or delayed engagement with the continuum of perinatal health services [ 27 , 69 , 70 , 71 , 72 ].

This review implies that preventing unplanned pregnancy may have an important role in improving essential newborn care, early initiation and exclusive breastfeeding, and completion of immunisation of infants in SSA and possibly other low-resource settings. The prevention of unintended pregnancy could be achieved through improving access to quality family planning services [ 73 , 74 ]. Strengthening preconception services and information about the consequences of unintended pregnancy on newborn and infant health outcomes could improve newborn and infant health and survival [ 75 ]. Furthermore, counselling about maternal-child attachment in women with an unplanned pregnancy could contribute to better newborn and infant health outcomes [ 71 ].

Post-conception responses from partners, family and community members, and psychological consequences such as depression and anxiety following an unintended pregnancy possibly influence newborn and infant health care practices among women with unintended pregnancies [ 68 , 76 , 77 ]. Furthermore, women with unintended pregnancies may have several socioeconomic and cultural challenges to visiting health facilities [ 78 , 79 ]. Previous studies in low- and middle-income countries reported that multiple visits to healthcare facilities, which require travel, money, and assistance from others, substantially deter women from using antenatal care, skilled birth attendance, and postnatal care following the occurrence of an unintended pregnancy [ 80 , 81 , 82 ]. Hence, encouraging perinatal service use and preventive and curative care of infants resulting from unintended pregnancies may require policies and practices that support identification of women with unintended pregnancies. Behavioural change approaches regarding unintended pregnancy also need to be considered at individual, family, and community levels [ 83 , 84 , 85 ]. This may reduce the humiliation of women from unsolicited post-conception responses from partner, family and community members following unintended pregnancies [ 86 , 87 ].

This systematic review has the following limitations. In all the included studies, pregnancy intention was examined with other multiple determinants of newborn and infant continuum of care in cross-sectional studies for each outcome; it is thus not possible to establish causal effect relationships with certainty. Although there was significant heterogeneity among the included studies, addressing the sources of heterogeneity was not undertaken due to the limited number of studies included for each outcome. In addition, sensitivity analysis, publication bias and subgroup analyses were not conducted because of the limited number of studies included in each sub-topic. Furthermore, some studies were excluded due inconsistent categorisation of the exposure variable. Moreover, studies published in a language other than English and non-peer-reviewed articles may have been missed as only peer-reviewed articles published in English were included. While grey literature may exist on this topic, we included only peer-reviewed studies to ensure a robust approach and consistency across studies. Finally, the generalizability of this review may be limited because the included studies were not representative of all regions of SSA, with the majority of studies coming from Ethiopia. Nevertheless, this review used adjusted effect measures to quantitatively estimate the association between pregnancy intention on newborn and infant health across the continuum of care in SSA.

Conclusions

This review pinpointed that there were statistically significant positive associations between intended pregnancy and increased completion of essential newborn care practices, early initiation and exclusive breastfeeding and full immunisation of infants in SSA. There is a need for collaboration among stakeholders, policy-makers and health care providers to strengthen the provision of quality family planning services and enhancing preconception care services to prevent unintended pregnancy. Furthermore, strategies that help identify women with unintended pregnancies are needed to increase women’s access to essential maternal and neonatal/infant healthcare services that further reduce the risk of newborn and infant deaths. Moreover, further research with better design is needed to clearly understand the relationship between pregnancy intention and completion of newborn and infant health practices across the continuum of care.

Availability of data and materials

All relevant data is included either in the manuscript or as supplementary files.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Cumulative Index to Nursing and Allied Health Literature

Newcastle-Ottawa scale

International Prospective Register of Systematic Reviews

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

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Acknowledgements

The authors would like to thank Olivia Larobina (Scholarly Services Librarian at Deakin University) for her assistance in developing the systematic search strategy. We also would like to acknowledge Deakin University for providing PhD scholarship for the principal investigator of this research.

The first author is supported by Deakin University with a PhD research scholarship.

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Birye Dessalegn Mekonnen, Vidanka Vasilevski, Ayele Geleto Bali & Linda Sweet

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Birye Dessalegn Mekonnen

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All authors developed the conception of the review and study design. BDM conducted the literature review, study screening, data extraction, quality assessment, data analysis, interpretation of results, and drafting of the manuscript. VV, AGB and LS contributed to study screening, quality assessment, data extraction, assist data analysis, and critically reviewed the manuscript. All authors read and approved the final manuscript.

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Mekonnen, B.D., Vasilevski, V., Bali, A.G. et al. Association between pregnancy intention and completion of newborn and infant continuum of care in Sub-Saharan Africa: systematic review and meta-analysis. BMC Pediatr 24 , 567 (2024). https://doi.org/10.1186/s12887-024-05036-y

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Older residents' perspectives on aged sexuality in institutionalized elderly care: a systematic literature review

Affiliations.

• 1 Centre for Biomedical Ethics and Law, KU Leuven, Belgium. Electronic address: [email protected].
• 2 Centre for Biomedical Ethics and Law, KU Leuven, Belgium. Electronic address: [email protected].
• PMID: 26296654
• DOI: 10.1016/j.ijnurstu.2015.07.007

Objectives: The aim of this systematic literature review is to investigate older residents' thoughts on, experiences of and engagement in sexual behavior and aged sexuality within institutionalized elderly care.

Design: Systematic literature review.

Data sources: We conducted an extensive search of the electronic databases Cinahl, Medline, Pubmed, Embase, Web of Science and Invert for papers published between January 1980 and October 2014 when the searches were closed. Additional papers were identified through forward and backward citation chasing.

Review methods: Data from relevant studies were extracted by means of a data extraction form. Relevant data were isolated, summarized, compared, related and categorized according to theme. Quality assessment of the included studies focused on their adequacy of reporting the study's research aim, sampling, collection, and analysis procedures, ethical considerations and results.

Results: Twenty-five appropriate studies were identified. These studies varied in research design (using surveys, vignettes, focus groups, interviews, or observation), objectives, quality of reporting, and sample characteristics (i.e. male and/or female long-term care residents with and/or without dementia). Yet, they all point to the relevance of sex and sexuality in old age and emphasize the highly individual character of both sexual interest and expression. Older residents who wish to sexually express themselves, might do this in a wide variety of ways, including, but not limited to, daydreaming, dressing-up, looking for emotional and intellectual intimacy, stroking, caressing, kissing, and engaging in sexual intercourse. Overall, residents appear to have a rather positive attitude toward aged sexuality as such. When it comes to specific sexual behaviors or homosexuality, however, attitudes tend to be more negative. The perceived appropriateness of the displayed behavior is a predominant factor in determining older people's reactions to the sexual behavior of co-residents, rather than the potential emotional discomfort brought on by witnessing this behavior.

Conclusions: Relatively little work has been published on older residents' perspectives regarding aged sexuality in institutionalized elderly care. If, however, we wish to devote ourselves to individualized or person-centered nursing care, we will have to gain more insight into the patient's perspective and take notice of the needs, expectations, attitudes, experiences and behaviors of residents with regard to (aged) sexuality. Hence more research is needed that depicts the issue of aged sexuality in institutionalized elderly care from a patient's and thus resident oriented perspective.

Keywords: Aged; Attitude; Dementia; Residential facilities; Review; Sexual behavior; Sexuality.

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Emergency pediatric patients and use of the pediatric assessment triangle tool (PAT): a scoping review

• Tore A. G. Tørisen 1 ,
• Julie M. Glanville 2 ,
• Andres F. Loaiza 3 , 4 &
• Julia Bidonde 5  

BMC Emergency Medicine volume  24 , Article number:  158 ( 2024 ) Cite this article

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We conducted a scoping review of the evidence for the use of the Pediatric Assessment Triangle (PAT) tool in emergency pediatric patients, in hospital and prehospital settings. We focused on the psychometric properties of the PAT, the reported impact, the setting and circumstances for tool implementation in clinical practice, and the evidence on teaching the PAT.

We followed the Joanna Briggs Institute methodology for scoping reviews and registered the review protocol. We searched MEDLINE, PubMed Central, the Cochrane Library, Epistemonikos, Scopus, CINAHL, Grey literature report, Lens.org, and the web pages of selected emergency pediatrics organizations in August 2022. Two reviewers independently screened and extracted data from eligible articles.

Fifty-five publications were included. The evidence suggests that the PAT is a valid tool for prioritizing emergency pediatric patients, guiding the selection of interventions to be undertaken, and determining the level of care needed for the patient in both hospital and prehospital settings. The PAT is reported to be fast, practical, and useful potentially impacting overcrowded and understaff emergency services. Results highlighted the importance of instruction prior using the tool. The PAT is included in several curricula and textbooks about emergency pediatric care.

Conclusions

This scoping review suggests there is a growing volume of evidence on the use of the PAT to assess pediatric emergency patients, some of which might be amenable to a systematic review. Our review identified research gaps that may guide the planning of future research projects. Further research is warranted on the psychometric properties of the PAT to provide evidence on the tool’s quality and usefulness. The simplicity and accuracy of the tool should be considered in addressing the current healthcare shortages and overcrowding in emergency services.

Review registration: Open Science Framework; 2022. https://osf.io/vkd5h/

Peer Review reports

Emergency medical services (EMS) are crucial to emergency care systems providing effective emergency medical care to people in need [ 1 ]. The World Health Organization (WHO) Emergency Care System Framework [ 2 ] (see Additional file 1) notes that effective emergency care involves a coordinated and integrated system of care, including the provision of prehospital care, transportation, and emergency department (ED) services. The WHO framework emphasizes the importance of early recognition of health issues and the timely provision of appropriate interventions to reduce morbidity and decrease the incidence of death and illness. Pediatric emergencies, particularly acute injuries and illnesses, generate considerable numbers of ambulance calls and ED visits in developed countries [ 3 , 4 ].

There is a general understanding that lack of pediatric emergency flow (or crowding) may lead to adverse outcomes for the child. However, the prevalence of pediatric emergencies poses significant challenges to emergency healthcare providers [ 5 , 6 ]. In the UK, pediatric emergencies represent 5–10% of all emergencies [ 7 ] and in the USA, children represent 20% of ED patients [ 8 ]. Injuries are the leading cause of morbidity and mortality among children and adolescents [ 9 , 10 ].

Caring for critically ill or injured pediatric patients can be challenging for emergency healthcare workers (EHWs) [ 11 ]. Patients’ histories may be difficult to obtain if the patient cannot provide verbal information or has been found alone without a caregiver [ 12 ]. Taking vital signs can be difficult and may not provide accurate information due to normal age-based variations [ 12 ]. Furthermore, some EHWs may have not received training in pediatric emergencies, which can be stressful [ 13 ].

Despite these challenges, EHWs need to conduct a rapid and accurate assessment of the pediatric patient to deliver timely effective emergency treatment. EHWs also need to reassure patients and caregivers and bring order to potentially chaotic situations. EHWs who lack specialized training in pediatric emergencies may unintentionally exacerbate stressful situations [ 13 ]. Emergency pediatric training for healthcare professionals inside and outside of the hospital is essential to ensure the best outcomes for critically ill or injured pediatric patients [ 14 , 15 ].

Emergency triage involves quickly identifying patients who require medical attention to prioritize treatment efficiently for those in greatest need [ 14 ]. Triage tools such as the Manchester Triage System and the Emergency Severity Index are helpful [ 16 ]. The Paediatric Canadian Triage and Acuity Scale (PaedCTAS) was developed specifically for pediatric patients [ 17 ], using the Pediatric Assessment Triage (PAT) tool as the first step in assessing emergency patients. It includes the “general impression” stage using the PAT, primary assessment with the airway, breathing, circulation, disability, and exposure (ABCDE) approach [ 18 ], secondary assessment, diagnostic assessment, and reassessment.

The Pediatric Assessment Triangle (PAT)

The PAT is used to quickly identify critically ill or injured children needing immediate medical attention. It focuses on three presenting components (“arms”): appearance, work of breathing, and circulation (Fig. 1 ). It can be used in prehospital or hospital settings for efficient rapid assessment of the patient's level of consciousness, breathing, and circulation, without requiring hands-on assessment or equipment [ 5 , 19 ]. It can help identify key pathophysiological problems and whether urgent transport or resources are needed. The PAT assessment takes 30–60 s [ 5 , 19 ] and it can be performed remotely (a “through the room” assessment).

The Pediatric Assessment Triangle components (arms). Figure adapted from Fuchs S and McEvoy M [ 20 ]]

Scoping review aim and design

Give the current shortage of healthcare personnel worldwide, and overcrowding of emergency departments, gathering of the PAT’s evidence is essential. This review aimed to identify the available scientific evidence about the PAT and its use by EMS. Our objective was to complete a scoping review within the pre-and-hospital care to synthesize:

What are the psychometric properties of the PAT (e.g., validity, reliability, applicability)?

What are the reported impact(s) of the PAT? (e.g., improved triage, cost, better clinical outcomes)

What are the requirements or circumstances for PAT implementation in clinical practice?

What is the evidence on the value of teaching EMS workers about PAT?

We followed the Joanna Briggs Institute framework for scoping reviews [ 21 ]. The review protocol was registered [ 22 ]. The review is reported according to the PRISMA extension for scoping reviews [ 23 ] (Additional file 2).

Eligibility criteria

Eligible publications (Table  1 ) reported the use of the PAT with pediatric populations in prehospital, hospital or training settings. Eligible outcomes matched our specific aims as follows: 1) psychometric performance, 2) impact(s), 3) implementation of PAT utilization, and 4) evidence on teaching the PAT.

We searched MEDLINE (PubMed), PubMed Central (via LitSense), the Cochrane Library, Epistemonikos, Scopus and CINAHL, from 1995 to July 2022, to include publications before the introduction of the PAT in the curricula of Pediatric Education for Prehospital Professionals (PEPP) and Advanced Pediatric Life Support (APLS) in 2000 [ 24 ]. The database searches were conducted from 24 to 28 July 2022. Fourteen websites of organizations involved in policy making in emergency pediatrics were searched between 6 and 10 August 2022. We searched for unpublished (grey) literature using Grey Literature Report ( http://www.greylit.org/ ) and Lens.org ( https://www.lens.org/ ). Full searches are presented in additional file 3.

Study selection process

We deduplicated records in EndNote and conducted double independent screening (TT, AFL-B) in Covidence (Veritas) against the eligibility criteria (Table  1 ). Conflicts were resolved by consensus or arbitrated by a third reviewer (JB). Additional file 4 lists records excluded at full text with reasons. Records reporting the same study were grouped and we cite the earliest publication while presenting relevant data from any of the related publications.

Data collection process

Data were extracted from eligible studies into a Microsoft 365 Excel form which was piloted on a random sample of five included studies, and modified as required based on feedback from the team [ 22 ]. One reviewer (TT) completed data extraction and a second reviewer (AFL-B) verified the extracted data. Disagreements were resolved by consensus or arbitrated by a third reviewer (JB). Risk of bias was not assessed [ 21 ].

Knowledge user (KU)/patient engagement and methodological appraisal

We defined KU/ patient engagement as individuals who may be affected by the research findings. Since this review was time sensitive, we did not recruit knowledge users or patients.

We did not appraise methodological quality or risk of bias of the included articles, which is consistent with guidance on scoping review conduct.

The synthesis included quantitative (e.g. psychometric properties) and qualitative analyses (e.g. content analysis) of the components of the impact, implementation and teaching. A word cloud was drawn for the impact of the PAT using the online program WordClouds. The team members identified, coded, and charted relevant units of text from the articles using a framework established a priori as a guide. The framework was developed through team discussions upon reviewing the preliminary results. Data were grouped by question and overviews are provided using charts and tables generated using Microsoft 365 Excel.

Search results and publication characteristics

The searches identified 548 records (Fig. 2 ). Fifty-five publications were included (full citations listed in Additional file 5) of which three were books. Sixteen publications were in non-English languages, but with English abstracts, and of these we retrieved 14 full text publications (Spanish ( n  = 9), German ( n  = 2), French ( n  = 1), Turkish ( n  = 1), and assumed Taiwanese Mandarin ( n  = 1)). Of these, there were seven papers that described the psychometric properties of the PAT, 18 were about the PAT’s impact, 38 described implementation pros and cons, and 30 provided references to the PAT used in educational/training environments. The publication dates ranged from 1999 to 2022, representing 18 countries with the majority classified as "high income" (World Bank classification) [ 25 ] (see Additional file 6). Study designs were diverse: primary research ( n  = 27, 49.1%), secondary research ( n  = 4, 7.3%), and "other" ( n  = 24, 43.6%). We identified no randomized controlled trials, systematic reviews, or scoping reviews.

PRISMA flow chart

Psychometric properties

The seven papers reporting psychometric properties were as follows. Four studies (Table 2 ) reported sensitivity and specificity, measuring test accuracy [ 26 , 27 , 28 , 29 ], of which one study reported an area under the receiver operating characteristic curve (AUROCC) [ 29 ] and four studies reported likelihood ratios (LR) [ 26 , 27 , 28 , 30 ].

PAT sensitivity (Fig. 3 ) ranged from 77.4% to 97.3% (four studies) suggesting it can accurately identify a large proportion of patients with the targeted condition [ 26 , 27 , 28 , 29 ]. Specificity, measuring a test's ability to correctly identify patients without the condition, ranged from 22.9% to 99.15% (four studies) [ 26 , 27 , 28 , 29 ].

PAT sensitivity and specificity

One study evaluated the PAT’s validity and reliability [ 31 ] by collecting data for 157 patients triaged by a single trained observer and an “enfermera clasificadora” (classifying nurse). This single pair showed high inter-observer agreement in applying the PAT and no errors associated with polypnea, pre-existing pallor, or irritability.

Likelihood ratios (LR) measure a test’s diagnostic accuracy which are less likely to change with the prevalence of a disorder. A positive LR (LR +) indicates a positive test result is more likely in people with the condition and a negative LR (LR-) indicates that a negative test result is more likely in people without the condition of interest. One study reported LR + of 5.2 (95% CI 5–7.8) [ 26 ] with a statistically significant high odds ratio (OR 111, 95% CI 73–168.6; p  < 0.001), indicating the PAT has a high ability to correctly identify and classify initial severity of disease during triage. A second study reported a LR + of 7.7 (95% CI 5.9–9.1) [ 27 ]. A third study triaged 1002 children using the PAT, reporting a LR + of 0.12 (95% CI 0.06–0.25) for children deemed stable by the PAT ( n  = 200) [ 28 ]. This study’s results for categories of pathophysiology (respiratory distress, respiratory failure, shock, central nervous system/metabolic disorder, and cardiopulmonary failure) highlighted the need to consider the clinical scenario when interpreting the PAT in EMS. However, the moderate LR- value (0.22, 95% CI 0.18–0.26) indicated that the test is less able to correctly identify children who do not need urgent care. The study reported a LR- of 0.12 (95% CI 0.06–0.25) for children found to be stable by the PAT ( n  = 802) [ 28 ]. The LR- values for children with the five specified categories of pathophysiology suggest the PAT has relatively low LR for identifying respiratory distress and shock, indicating it is better at ruling out those conditions. However, the relatively high LR- for respiratory failure and cardiopulmonary failure suggests the PAT is less effective at ruling out those conditions.

One study (2017) found that abnormal PAT results were associated with an increased risk of admission to the hospital (OR 5.14, 95% CI 4.98–5.32; p  < 0.01) [ 30 ]. Abnormal appearance (OR 3.99, 95% CI 3.63–4.38) or having one or more components of the PAT (OR 14.99, 95% CI 11.99–18.74) were significantly associated with hospital admission [ 30 ]. The study identified adjusted age (OR 4.44, 95% CI 3.77–5.24; p  < 0.001) and triage (OR 1.78, 95% CI 1.72–1.84; p  < 0.001) as independent risk factors for intensive care unit admission and longer stays in the pediatric ED [ 30 ]. One study reported the PAT performed similarly to the Pediatric Early Warning Score (PEWS) (AUROCC 0.963 (PAT) and 0.966 (PEWS); x 2  = 0.10; p  = 0.74) [ 29 ].

Four studies reported high levels of reliability in PAT results [ 27 , 28 , 29 , 32 ]. One study reported 93.6% reliability (Kappa index 0.7, 95% CI 0.5–0.8) [ 29 ]. A second study found paramedics used the PAT highly consistently across its three arms (Kappa 0.93, 95% CI 0.91–0.95) [ 32 ] and the paramedics’ impression, completed using PAT on first contact with the patient, showed substantial agreement with the investigators’ retrospective chart review on diagnosis and disposition (Kappa 0.62, 95% CI 0.57–0.66) and categorization of stable versus unstable (Kappa 0.66, 95% CI 0.62–0.71). A third study reported substantial inter-rater reliability agreement on PAT scores ( n  = 1002, two pediatric emergency physicians and a pediatric nurse practitioner) (Fleiss' κ 0.7, p  < 0.001) [ 28 ]. A fourth study reported an agreement rate of 93.24% between the PAT and the condition of sick children [ 29 ].

Reported impacts of the PAT

Eighteen publications reported on impacts after PAT implementation; the word cloud of impact names is display in Fig.  4 . Terms most used were “triage –communication -vocabulary and care”.

The PAT reported impact

Impact reported were on mortality, safety, effectiveness of care, timeliness of care, triage, and communication [ 27 , 28 , 29 , 30 , 31 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 ]. Three studies showed the ability of the PAT to correctly assess critical cases (e.g. higher risk of mortality in patients with sepsis with an altered or unstable PAT) [ 33 , 34 , 36 ]. Two studies found that PAT helped to avoid unnecessary interventions or potential harm to patients [ 27 , 35 ]. One study reported that a normal PAT result did not exclude severe infections, and a proper examination was still necessary to diagnose emergency pediatric patients [ 33 ]. One study reported that the PAT was timely and rapid to apply (mean 32.4 s) [ 31 ] and two studies reported that the PAT was equally effective, but faster and easier to use, than the PEWS in predicting critical illness in pediatric patients [ 29 , 38 ].

Communication and documentation were another way the PAT’s impact were reported. The PAT’s “general impression” aided in care communication and helped prioritize management options. The specific vocabulary to describe a patient’s vital signs and physical findings allowed for easy documentation and transfer/flow of information between EHWs [ 27 , 28 , 37 ]. Two studies highlighted the power of a common vocabulary in EMS replacing subjective comments with specific assessments [ 27 , 28 ].

Studies offered insights into achieving optimal triage outcomes using the PAT. One study demonstrated the PAT’s usefulness when classifying non-urgent patients [ 40 ] and a second noted the importance of setting severity and prioritization criteria (1 to 5 depending on severity) and using the PAT to ensure proper attention [ 45 ].

Abnormal PAT findings helped to identify patients with a higher risk of hospitalization [ 30 ] and enabled earlier interventions for high-risk patients [ 42 ]. One study used the PAT for children experiencing secondary complications to hematopoietic cell transplantation [ 44 ] and reported that an unstable PAT, along with other factors, accurately predicted the need for admission (relative risk 3.4, 95% CI 2.6–4.6; p  < 0.001). A study investigated features of 17,243 cases referred from in-hospital areas to the pediatric ED (median age 42 months (range: 0–120)); 65% of transferred patients were PAT-assessed as stable [ 41 ]. One study assessed the PAT as a discriminator in the triage classification system and assessed the correlation between pathophysiological diagnosis and triage classification [ 31 ]. Four studies suggested the PAT was considered practical and helpful in identifying emergency pediatric patients in need of intervention and identifying the probable underlying cause of illness [ 26 , 28 , 38 , 46 ]. Treatment priorities were met in children with fever, and to a lesser extent for pain, respiratory distress, and oxygen needs.

One study concluded that an abnormal PAT and a more severe triage level (I-III) were independent factors in identifying asthmatic children requiring hospitalization and longer stays [ 43 ]. One study suggested that the PAT did not perform well for patients with anaphylaxis and as a result patients did not receive timely interventions [ 39 ].

We found no data for impacts on pediatric readmission, patient/caregiver experience, or provider burnout.

Setting and circumstances for PAT implementation

Ten studies evaluated pre-hospital triage using the PAT [ 6 , 20 , 27 , 30 , 38 , 47 , 48 , 49 , 50 ] and 28 evaluated hospital triage [ 24 , 26 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 ]. No studies reported PAT use in emergency call centers or telemedicine services. One study noted that the PAT may be implemented by midwives working in hospitals or prehospital settings [ 37 ]. A study of 391 admissions reported PAT was considered a useful triage tool in resource-poor hospitals [ 52 ].

Four studies recommended formal training on using the PAT as necessary for effective use [ 27 , 28 , 45 , 47 ]. One study ( n  = not reported) found that a low utilization rate for the PAT (patient report forms collected over a three-month period) following its introduction increased significantly following training in PAT use (12% vs 63.3%) [ 47 ]. After implementation, one study reported that the 30 emergency nurses involved preferred using the PAT over the PEWS when assessing emergency pediatric patients [ 29 ]. In a study of the Advanced Pediatric Life Support (APLS) course, attendees considered the systematic assessment approach incorporating the PAT crucial to their clinical practice, highlighting the importance of training prior implementation [ 54 ]. Studies acknowledged that applying the PAT with young infants (7–89 days old) was challenging [ 33 ], implementing the PAT requires skills, on-site senior emergency pediatric care providers, and a pediatric-friendly environment [ 59 ] and that the feasibility of the PAT is promising, but further research for “clinical validation” (not further defined) was needed [ 30 ].

We found no information about the implementation of PAT in clinical guidelines, requirements for recertification after PAT implementation, cost of implementation, or sustainability.

Teaching the PAT

Thirty studies presented data on teaching PAT to EHWs as follows: an early report suggested that the PAT was ideal for pediatric life support courses in all settings, based on its simplicity and reproducibility for both teachers and clinicians [ 60 ]. The PAT is included in one textbook of general emergency pediatrics [ 61 ] and two textbooks for emergency pediatric care in the prehospital environment [ 20 , 62 ]. Courses for EHWs on pediatric life support have incorporated the PAT for the “first impression” assessment, as well as training on the use of the PAT tool itself [ 29 , 30 , 63 ].

Methods for teaching the PAT tool included classroom-based, use of simulation, use of virtual reality and video for case training [ 54 , 64 , 65 ]. The PAT has been recommended as a teaching tool for the goal-directed management of shock in children [ 66 ].

The number of people who have received PAT training is unknown, but more than 170,000 EHWs had received formal training up to 2010 (worldwide) [ 63 ]. The numbers of EHWs trained in the studies ranged from 30 to 1520 [ 29 , 54 ].

Eighteen studies reported the care of emergency pediatric patients and provide insights into best practices for care which can, in turn, inform educational programs or be used to develop evidence-based protocols [ 30 , 37 , 48 , 49 , 50 , 56 , 57 , 59 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 ]. Four publications describe how emergency care providers use the PAT to assess emergency pediatric patients generally or with specific medical problems [ 30 , 49 , 59 , 67 ].

We identified 55 documents reporting the use of the PAT in hospital and pre-hospital emergency pediatric care. Research indicates that the PAT is a valid and reliable tool for evaluating emergency pediatric patients, prioritizing interventions, and determining the appropriate level of care. EHWs found the PAT is fast and practical, akin to the intuitive ‘gut feeling’ of experienced clinicians., but they should complete formal training before implementing the PAT. Several emergency pediatric care course curricula and key textbooks include the PAT.

We found only seven publications on the PAT’s psychometric properties, which suggest that the PAT has good sensitivity and some variability in specificity. The low research volume may reflect ethical challenges around research involving children, the unique and unpredictable nature of emergency situations, the impossibility of controlling all variables and difficulties in obtaining funding [ 77 ]. Research on psychometric properties can be expensive and funding for pediatric-focused psychometric research may not be a priority for research funders. The PAT’s ease of use may have contributed to its rapid adoption in practice before adequate psychometric testing was conducted and published. Implementing the PAT may still be challenging in terms of training or resistance to change [ 47 ]. Despite the challenges of research in the emergency setting, a third of the included studies reported positive impacts when using the PAT, suggesting its potential for triaging and improving patient outcomes in clinical settings which merits further investigation in an era of emergency department overcrowding and shortages of healthcare personnel.

Other tools are also used for emergency pediatric assessment (e.g., the Pediatric Glasgow Coma Scale, the PEWS, and the Pediatric Vital Sign Score) and each has its strengths and limitations. Choosing a tool depends on the specific circumstances and the healthcare provider's expertise. Based on the included comparative studies, the PAT is often favored for its simplicity, rapidity, and ease of use in remote or face-to-face emergency settings, since it does not require hands-on assessment or the use of specialized equipment. The available research and comparative studies merit further investigation.

Evidence was identified on training EHWs to use the PAT to assess accurately a child's appearance, work of breathing, and circulation. Proficiency is needed in using the tool and there is a need to use it regularly, to maintain their knowledge. While the PAT can provide a quick snapshot of a child's overall condition, it is only one part of a comprehensive assessment, and EHWs should use additional tools and techniques to assess a child's condition. Online courses, in-person workshops, and continuing education courses offered by professional organizations as well as guides or manuals with step-by-step instructions on how to use the PAT are all available. Healthcare providers who are considering preparing or updating their PAT training, perhaps using simulation-based approaches, should review these sources of evidence-based training [ 78 ].

The main challenges to PAT instruction noted to date are the limited provision of hands-on experience (i.e. real-life emergency situations), limited feedback on site to the EHW on their performance (to enable them to identify and correct areas of weakness in their assessment skills) and lack of standardization in the training programs. Skill decay is problematic as EHWs may forget the PAT steps without regular use. Re-certification requirements depend on the EHW’s professional organization and any employer’s certification requirements.

Although research evidence seems to show that the PAT is considered a valuable tool for rapid assessment of the status of a distressed patient, and its simplicity makes it easy to implement across a range of settings, we identified limited evidence on using the PAT in low-income settings [ 52 , 79 ]. Resource-limited settings may lack coordinated emergency systems including at the scene aid, a system of triage, emergency medical care and critical care [ 80 ]. In these situations, different approaches to pediatric assessments may be adopted, limited data may be recorded on the frequency and quality of PAT assessments [ 81 ] and access to PAT training may be limited. Workforce shortages can impact the availability of trained EHWs to provide PAT instruction. Despite the limited evidence, we anticipate that the PAT is still a feasible tool for EHWs with limited resources [ 52 ]. The PAT’s simplicity can be helpful in rural areas, remote communities, and resource-limited clinics. Based on evidence from this review, the PAT provides a practical and effective way for EHWs to assess children in emergency situations and make informed decisions about their care.

Limitations

This scoping review has limitations. Firstly, we focused on English language articles and there may be additional full text publications in non-English languages that might have provided information on low- and middle-income countries’ experiences of the PAT, its impact, or its psychometric properties. This scoping review was pragmatic, but a follow up review may identify additional studies in languages other than English. Secondly, the search for grey literature was conducted on 14 websites, was hampered by the varying quality (and sometimes absence) of website search engines and the list of websites was prepared by one author (TT). A full systematic review would ideally search a larger number of websites and other sources of grey literature to potentially identify further research, particularly for LMICs. and might have been enhanced by suggestions from experts in the field.

Options for a future systematic review and other areas of research

A full systematic review would likely focus on those research questions for which there are most data following the scoping review and would also include detailed data extraction as well as the grouping of studies by outcomes of interest to provide summaries of the evidence for each outcome. Scoping reviews typically do not conduct risk of bias assessments or evaluate publication bias. A future systematic review could include these steps to assess the strength and quality of the evidence for the use of the PAT.

Other areas for research identified are how the PAT affects pediatric readmissions, patient/caregiver experience, and provider burnout. This scoping review did not find evidence of implementation, that is requirements of recertification and costs or data on utilization for example use of the PAT by emergency call centers, assessments by videoconference or other telemedicine services. Evidence on the utilization of the PAT specific to different emergency transport services such as air medical services, disaster response, etc. was not found.

In summary, this scoping review shows that the PAT has been used in clinical settings for over 20 years. There is some evidence of its validity and reliability, impacts and that the tool is broadly accepted by EHWs. Although the PAT condenses years of experience into a practical and useful assessment suitable for use by less experienced personnel, the need for prior training and certification was highlighted. Although there are gaps in the literature, the evidence has increase in recent years. Scoping reviews are used to inform research agendas and identify implications for policy or practice. As such, psychometric tool data are imperative. Further research on impact and implementation is warranted, and in particular, there is a need to standardize the teaching of PAT teaching and its certification. The simplicity, friendliness and low resources requirement of the tool should be considered in addressing the current healthcare shortages and overcrowding in emergency services.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its additional information files].

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Acknowledgements

This work was submitted as a thesis requirement for the Master in Pre-Hospital Critical Care, University of Stavanger, Norway in December 2022. We thank the Norwegian Institute of Public Health for supporting this publication open access fees.

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Project conceptualization was done by TT, JB, JG, and AFL. TT and JB were primarily responsible for the methodology and resources, while TT, JB, and AFL carried out the data extraction and validation process, and TT led the analysis and synthesis. TT and JB wrote the original draft, with input and feedback from JG and AFL during the review and editing process. The visualization was primarily handled by TT and AFL. TT and JB supervised the project, and TT managed project administration. JB was responsible for software acquisition.

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Tore A. G. Tørisen is an instructor and medical supervisor for courses in “Pediatric Education for Prehospital Professionals” (PEPP) and he is registered with the American Academy of Pediatrics (AAP). The remaining authors declare no conflict of interest.

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Additional file 1: appendix b. prisma-scr, additional file 2. appendix c. search strategy, additional file 3. appendix d. excluded studies with reasons for exclusion, additional file 4. appendix e. included studies, additional file 5. tables, additional file 6. appendix a – who emergency care system framework, rights and permissions.

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Tørisen, T.A.G., Glanville, J.M., Loaiza, A.F. et al. Emergency pediatric patients and use of the pediatric assessment triangle tool (PAT): a scoping review. BMC Emerg Med 24 , 158 (2024). https://doi.org/10.1186/s12873-024-01068-w

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Received : 19 July 2023

Accepted : 08 August 2024

Published : 04 September 2024

DOI : https://doi.org/10.1186/s12873-024-01068-w

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