Piloting of a Toolkit for Delirium Detection and Management at Four Emergency Departments

ABSTRACT

Study Objectives: Approximately 10-30% of older patients in the emergency department (ED) exhibit delirium, which goes unrecognized by up to 75% of providers. Delirium is linked to increased lengths of stay, in-hospital falls, cognitive decline, and mortality, yet in a recent national survey of ACEP members, only 14% reported having a protocol addressing delirium in the ED. We conducted a feasibility pilot of a delirium toolkit developed to improve screening and management of delirium in the ED. Methods: Supported by a monthly workgroup, four EDs used the toolkit to develop and implement distinct quality improvement (QI) initiatives contextually appropriate to their ED (sites represented a range of ED environments). QI initiatives included delirium screening (using the CAM, bCAM, and/or DTS instruments) as well as delirium management strategies. Toolkit feasibility testing included assessment of implementation speed, protocol adherence, and qualitative feedback. Sites implemented and reported on process metrics for their QI initiatives from July – November 2020. Results: Findings reflect data from three sites (the fourth site did not contribute quantitative data). Over 73% of ED staff received delirium protocol training across sites in the first month of implementation, and staff participation in additional monthly trainings continued at a lower intensity over time. A total of 7,107 delirium screenings were conducted (representing 43% of older adults visiting the three EDs during the study period) and 4.5% of delirium screenings were positive. Over time, the monthly number and proportion of older adults screened for delirium trended slightly downwards, while the proportion of positive delirium screenings trended upwards. The sites provided 1,460 instances of delirium management activities (some patients received more than one). These activities were grouped into over a dozen different categories, with documenting an updated diagnosis or disposition being most common (300 instances), followed by orientation (239 instances) and hydration/nutrition interventions (196 instances). Conclusion: All pilot sites leveraged the ED-Delirium Toolkit to develop QI initiatives, with three of the four sites contributing data demonstrating successful implementation. These delirium QI initiatives were seen as complementary activities to the concurrent pandemic priorities given the recognition of delirium as both a presenting symptom as well as a common complication of COVID-19. ED nurses may have been able to improve targeted screening of patients over time based on the increasing positivity rate and declining proportion and number of screenings conducted. Given the number of staff trained and scale of delirium management activities, use of the toolkit increased awareness of and interventions for addressing delirium in the ED.