Rates of Delirium Diagnosis Do Not Improve with Emergency Risk Screening: Results of the Emergency Department Delirium Initiative Trial.

OBJECTIVES: To determine whether a bundled risk screening and warning or action card system improves formal delirium diagnosis and person-centered outcomes in hospitalized older adults. DESIGN: Prospective trial with sequential introduction of screening and interventional processes. SETTING: Two tertiary referral hospitals in Australia. PARTICIPANTS: Individuals aged 65 and older presenting to the emergency department (ED) and not requiring immediate resuscitation (N = 3,905). INTERVENTION: Formal ED delirium screening algorithm and use of a risk warning card with a recommended series of actions for the prevention and management of delirium during the subsequent admission MEASUREMENTS: Delirium diagnosis at hospital discharge, proportion discharged to new assisted living arrangements, in-hospital complications (use of sedation, falls, aspiration pneumonia, death), hospital length of stay. RESULTS: Participants with a positive risk screen were significantly more likely (relative risk = 6.0, 95% confidence interval = 4.9-7.3) to develop delirium, and the proportion of at-risk participants with a positive screen was constant across three study phases. Delirium detection rate in participants undergoing the final intervention (Phase 3) was 12.1% (a 2% absolute and 17% relative increase from the baseline rate) but this was not statistically significant (P = .29), and a similar relative increase was seen over time in participants not receiving the intervention CONCLUSION: A risk screening and warning or action card intervention in the ED did not significantly improve rates of delirium detection or other important outcomes.

Nurse screening for delirium in older patients attending the emergency department.

BACKGROUND: Delirium in older emergency department (ED) patients is common, associated with many adverse outcomes, and costly to manage. Delirium detection in the ED is almost universally poor. OBJECTIVES: The authors aimed to develop a simple clinical risk screening tool that could be used by ED nurses as part of their initial assessment to identify patients at risk of delirium. METHODS: A prospective cross-sectional study of patients 65 years and older attending a single ED. RESULTS: Of 320 enrolled patients, 23 (7.2%) had delirium. Logistic regression analysis revealed 3 risk factors strongly associated with delirium risk: cognitive impairment, depression, and an abnormal heart rate/rhythm. Weighting these variables based on the strength of their association with delirium yielded a risk score from 0-4 inclusive. A cutoff of 2 or more in that score would have given a sensitivity of 87%, specificity of 70%, and NPV of 99%, while avoiding further diagnostic workup for delirium in approximately two-thirds of all patients, when used as an initial screen. CONCLUSIONS: A simple risk screening tool using factors evident on initial nurse assessment can be used to identify patients at risk of delirium. Further trials are needed to test whether the tool improves patient outcomes.

A questionnaire to determine nurses' knowledge of delirium and its risk factors.

Delirium is a frequent complication of hospital admission, especially among the elderly. It can have serious consequences in terms of morbidity, mortality and decreased quality of life. Nevertheless, an extensive literature review found that it is poorly recognised and poorly managed by medical and nursing staff. Although some researchers have found that education programs for nurses can improve outcomes for patients with delirium, no research assessing nurses' knowledge was found. The objective of this research was to determine nurses' level of knowledge regarding delirium and its risk factors. A questionnaire survey sent to nurses at a teaching hospital found that nurse's knowledge of delirium was generally inadequate, although one ward which had had in-service education attained better results. It is recommended that cognitive assessment in general and delirium in particular be incorporated into nursing education. Improved education could potentially lead to improved health outcomes and considerable cost savings.

Assessing cognition in elderly patients presenting to the emergency department.

INTRODUCTION AND BACKGROUND: Delirium occurs frequently among elderly patients in the Emergency Department (ED), and accurate assessment is difficult without knowledge of the patient's usual cognitive functioning. This audit was designed to determine whether routine cognitive screening of elderly patients in ED could lead to early identification of delirium. METHODOLOGY: An audit using the abbreviate mental test (AMT) and Confusion Assessment Method (CAM) tools assessed 28 elderly ED patients for the presence of delirium. RESULTS: Fourteen (50%) of the 28 patients had no cognitive deficit on admission. Eleven (39.3%) displayed a cognitive deficit other than delirium and three (10.7%) had delirium, but only one had been diagnosed prior to the audit. DISCUSSION: The prevalence rate of delirium in elderly ED patients was similar to those reported in the literature. The audit demonstrated the importance of cognitive assessment, as cognitive changes can be an early and sensitive indicator of physiological dysfunction. However, the AMT had limitations which inhibited its use in ED. A four question version known as the AMT4 may be more suitable. RECOMMENDATIONS: ED nurses should routinely establish baseline cognitive functioning and assess for delirium. The AMT4 may be more suitable because of its brevity, but requires further research.