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Fabrizi D, Rebora P, Spedale V, Locatelli G, Bellelli G, Di Mauro S, Ausili D, Luciani M. Diagnostic Accuracy of the Recognizing Acute Delirium as Part of Your Routine (RADAR) Scale for Delirium Assessment in Hospitalized Older Adults: A Cross-Sectional Study. Healthcare (Basel) 2024; 12:1294. [PMID: 38998829 PMCID: PMC11241281 DOI: 10.3390/healthcare12131294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/23/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
Delirium is highly prevalent among hospitalized older adults and is associated with unfavorable outcomes. However, delirium often remains undiagnosed in the hospital context. Having a valid, simple, and fast screening tool could help in limiting the additional workload for healthcare professionals, without leaving delirium undetected. The aim of this study was to estimate the sensitivity and specificity of the Recognizing Acute Delirium As part of your Routine (RADAR) scale in an Italian hospital. An observational cross-sectional study was conducted. A total of 150 patients aged ≥70 years were enrolled. Receiver operating characteristic (ROC) curves using the Confusion Assessment Method (CAM) criterion-defined delirium as the gold standard were plotted to evaluate the performance of the RADAR scale. The cut-off suggested by previous research was used to estimate the sensitivity, specificity, and positive and negative predictive values of the RADAR scale. The involved patients were mostly females (60%; n = 90), with a median age of 84 years (I-III quartiles: 80-88). According to the CAM and the RADAR scale, 37 (25%) and 58 (39%) patients were classified as experiencing delirium, respectively. The area under the ROC curve of the RADAR scale was 0.916. Furthermore, the RADAR scale showed robust sensitivity (95%), specificity (80%), and positive (60%) and negative predictive values (98%). The RADAR scale is thus suggested to be a valid tool for screening assessment of delirium in hospitalized older adults.
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Affiliation(s)
- Diletta Fabrizi
- Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
| | - Paola Rebora
- Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging (B4) Centre, School of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
- Biostatistics and Clinical Epidemiology, IRCCS San Gerardo dei Tintori Foundation, 20900 Monza, Italy
| | - Valentina Spedale
- Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
- Bachelor's Degree in Nursing Program, IRCCS San Gerardo dei Tintori Foundation, 20900 Monza, Italy
| | - Giulia Locatelli
- Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
| | - Giuseppe Bellelli
- Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
- Acute Geriatric Unit, IRCCS San Gerardo dei Tintori Foundation, 20900 Monza, Italy
| | - Stefania Di Mauro
- Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
| | - Davide Ausili
- Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
| | - Michela Luciani
- Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
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Soler-Sanchis A, Martínez-Arnau FM, Sánchez-Frutos J, Pérez-Ros P. The 4AT scale for rapid detection of delirium in emergency department triage. Front Med (Lausanne) 2024; 11:1345983. [PMID: 38808143 PMCID: PMC11130506 DOI: 10.3389/fmed.2024.1345983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 05/02/2024] [Indexed: 05/30/2024] Open
Abstract
Aims To assess the diagnostic accuracy and time impact of the 4AT scale in emergency department triage. Methods A Prospective diagnostic accuracy study was carried out. People aged ≥65 years presenting to the emergency department from 1 November 2021 to 30 June 2022 were included. Nurses opportunistically screened eligible patients using the 4AT scale during triage according to the Manchester Triage System Francesc de Borja Hospital emergency department, Gandía (Spain). Accuracy was compared with medical diagnosis of delirium. Time (seconds) spent in triage with and without screening was assessed. Results The study included 370 patients (55.1% men, mean age 81.8 years), of whom 58.4% (n = 216) were screened. A final diagnosis of delirium was made in 41.4% of those screened. The most frequently used presentational flow charts and discriminators were 'behaving strangely' (15%) and 'rapid onset' (33.3%). The highest accuracy was obtained for a score of 3 points or more (sensitivity 85.1%; specificity 66.9%; positive predictive value 52.8%; negative predictive value 71.7%). No significant differences were found in the time spent in triage according to the performance of screening. Conclusion A score of 3 points or more on the 4AT scale enables rapid detection of delirium in emergency department triage, without consuming more time than conventional triage.
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Affiliation(s)
- Angela Soler-Sanchis
- Department of Nursing, Universitat de València, Valencia, Spain
- Hospital Francesc de Borja, Generalitat Valenciana, Gandia, Valencia, Spain
| | - Francisco Miguel Martínez-Arnau
- Department of Nursing, Universitat de València, Valencia, Spain
- Department of Physiotherapy, Universitat de València, Valencia, Spain
| | | | - Pilar Pérez-Ros
- Department of Nursing, Universitat de València, Valencia, Spain
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Saviano A, Zanza C, Longhitano Y, Ojetti V, Franceschi F, Bellou A, Voza A, Ceresa IF, Savioli G. Current Trends for Delirium Screening within the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1634. [PMID: 37763753 PMCID: PMC10537118 DOI: 10.3390/medicina59091634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/14/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023]
Abstract
Delirium is an acute neurological disorder that involves attention and cognition. It is associated with a high risk of morbidity and mortality among older people (>65 years old). In the context of the Emergency Department (ED), it is frequently experienced by patients but often not recognized. Literature studies have identified some screening instruments for an initial evaluation of delirium. Most of these tools have not been validated yet in the context of emergencies, but, in other settings, they were very useful for assessing and maximizing the recognition of this condition among older patients. We conducted a review of the literature, including randomized control trials, clinical and observational studies, and research studies published in recent years, confirming that most of the screening tools for delirium used in the intensive care unit (ICU) or the geriatric department have not been tested in the ED, and the ideal timing and form of the delirium assessment process for older adults have not been defined yet. The aim of our review is to summarize the updated evidence about the screening tools for delirium in the context of the ED, due to the fact that overcrowding of the ED and the stressful condition of emergency situations (that contribute to the onset of delirium) could expose older patients to a high risk of complications and mortality if delirium is not promptly recognized. In conclusion, we support the evidence that delirium is a current and real condition that emergency physicians have to face daily, and we are aware that more research is needed to explore this field in order to improve the overall outcomes of older patients admitted to the ED.
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Affiliation(s)
- Angela Saviano
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy;
| | - Christian Zanza
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
- Italian Society of Prehospital Emergency Medicine (SIS 118), 74121 Taranto, Italy
| | - Yaroslava Longhitano
- Italian Society of Prehospital Emergency Medicine (SIS 118), 74121 Taranto, Italy
| | - Veronica Ojetti
- School of Medicine, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Francesco Franceschi
- Institute of Sciences in Emergency Medicine, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Abdelouahab Bellou
- Institute of Sciences in Emergency Medicine, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Department of Emergency Medicine, School of Medicine, Wayne State University, Detroit, MI 48201, USA
| | - Antonio Voza
- Emergency Department, Humanitas University, Via Rita Levi Montalcini 4, 20089 Milan, Italy
| | - Iride Francesca Ceresa
- Emergency Room and Internal Medicine, Istituti Clinici di Pavia e Vigevano, Gruppo San Donato, 27029 Milan, Italy
| | - Gabriele Savioli
- Department of Emergency Medicine, Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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Chary AN, Brickhouse E, Torres B, Santangelo I, Carpenter CR, Liu SW, Godwin KM, Naik AD, Singh H, Kennedy M. Leveraging the Electronic Health Record to Implement Emergency Department Delirium Screening. Appl Clin Inform 2023; 14:478-486. [PMID: 37054983 PMCID: PMC10284630 DOI: 10.1055/a-2073-3736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 04/06/2023] [Indexed: 04/15/2023] Open
Abstract
OBJECTIVE The aim of this study is to understand how emergency departments (EDs) use health information technology (HIT), and specifically the electronic health record (EHR), to support implementation of delirium screening. METHODS We conducted semi-structured interviews with 23 ED clinician-administrators, representing 20 EDs, about how they used HIT resources to implement delirium screening. Interviews focused on challenges participants experienced when implementing ED delirium screening and EHR-based strategies they used to overcome them. We coded interview transcripts using dimensions from the Singh and Sittig sociotechnical model, which addresses use of HIT in complex adaptive health care systems. Subsequently, we analyzed data for common themes across dimensions of the sociotechnical model. RESULTS Three themes emerged about how the EHR could be used to address challenges in implementation of delirium screening: (1) staff adherence to screening, (2) communication among ED team members about a positive screen, and (3) linking positive screening to delirium management. Participants described several HIT-based strategies including visual nudges, icons, hard stop alerts, order sets, and automated communications that facilitated implementation of delirium screening. An additional theme emerged about challenges related to the availability of HIT resources. CONCLUSION Our findings provide practical HIT-based strategies for health care institutions planning to adopt geriatric screenings. Building delirium screening tools and reminders to perform screening into the EHR may prompt adherence to screening. Automating related workflows, team communication, and management of patients who screen positive for delirium may help save staff members' time. Staff education, engagement, and access to HIT resources may support successful screening implementation.
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Affiliation(s)
- Anita N. Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, United States
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States
| | - Elise Brickhouse
- School of Medicine, Baylor College of Medicine, Houston, Texas, United States
| | - Beatrice Torres
- University of Texas School of Public Health, UT Health Science Center, Houston, Texas, United States
| | - Ilianna Santangelo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Christopher R. Carpenter
- Department of Emergency Medicine, Barnes Jewish Hospital, Washington University School of Medicine, Emergency Care Research Core, St. Louis, Missouri, United States
| | - Shan W. Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Kyler M. Godwin
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States
- University of Texas School of Public Health, UT Health Science Center, Houston, Texas, United States
- University of Texas Health Consortium on Aging, Houston, Texas, United States
| | - Hardeep Singh
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
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Chary A, Liu SW, Santangelo I, Godwin KM, Carpenter CR, Naik AD, Kennedy M. A Qualitative Study of Emergency Department Delirium Prevention Initiatives. DELIRIUM COMMUNICATIONS 2022; 2022:10.56392/001c.55690. [PMID: 39036726 PMCID: PMC11259403 DOI: 10.56392/001c.55690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
Background Delirium is a serious but preventable syndrome of acute brain failure. It affects 15% of patients presenting to emergency care and up to half of hospitalized patients. The emergency department (ED) often represents the entry point for hospital care for older adults and as such is an important site for delirium prevention. Objective We sought to characterize delirium prevention initiatives in EDs in the United States and Canada. Methods We conducted qualitative interviews with 16 ED administrators representing 14 EDs with delirium prevention initiatives. We used a combined deductive-inductive approach to code responses about involved staff, target patient population, and delirium prevention activities. Results ED delirium prevention initiatives were largely driven by bedside nurses and occurred on an ad hoc basis, rather than systematically. Due to resource limitations, three EDs targeted older adults with high-risk conditions for delirium, rather than all patients age 65 and over. The most common delirium prevention interventions were offering assistive sensory devices (hearing amplifiers, reading glasses), having a toileting protocol, and offering patients food and drink. Conclusions As minimal evidence exists about effective ED delirium prevention practices, low-cost and low-risk activities outlined by study participants are reasonable to use to improve patient experience and staff satisfaction.
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Affiliation(s)
- Anita Chary
- Department of Medicine, Baylor College of Medicine
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center
- Department of Emergency Medicine, Baylor College of Medicine
| | - Shan W Liu
- Harvard Medical School
- Department of Emergency Medicine, Massachusetts General Hospital
| | | | - Kyler M. Godwin
- Department of Medicine, Baylor College of Medicine
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center
| | - Christopher R. Carpenter
- Department of Emergency Medicine, Barnes Jewish Hospital, Washington University School of Medicine, Emergency Care Research Core
| | - Aanand D Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center
- University of Texas School of Public Health, UT Health Science Center
- University of Texas Health Consortium on Aging
| | - Maura Kennedy
- Harvard Medical School
- Department of Emergency Medicine, Massachusetts General Hospital
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Response to Chary letter. J Emerg Nurs 2022; 48:127-128. [DOI: 10.1016/j.jen.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 11/17/2022]
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Emergency Nurses Recognize a Need for Education of Delirium Prevention and Management in the Emergency Department. J Emerg Nurs 2022; 48:126-127. [DOI: 10.1016/j.jen.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 10/20/2021] [Accepted: 10/23/2021] [Indexed: 12/16/2022]
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Chary AN, Lesser A, Inouye SK, Carpenter CR, Stuck AR, Kennedy M. A SURVEY OF DELIRIUM SELF-REPORTED KNOWLEDGE AND PRACTICES AMONG EMERGENCY PHYSICIANS IN THE UNITED STATES. JOURNAL OF GERIATRIC EMERGENCY MEDICINE 2021; 2:5. [PMID: 35990043 PMCID: PMC9387655 DOI: 10.17294/2694-4715.1010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Anita N Chary
- Department of Emergency Medicine, Department of Internal Medicine, Center for Innovations in Quality, Effectiveness and Safety; Baylor College of Medicine
| | | | - Sharon K Inouye
- Department of Medicine, Harvard Medical School; Aging Brain Center, Marcus Institute of Aging Research, Hebrew Senior Life
| | | | | | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital
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