Emergency Nurses Recognize a Need for Education of Delirium Prevention and Management in the Emergency Department

Implementation of delirium screening in the emergency department: A qualitative study with early adopters

INTRODUCTION

Delirium affects 15% of older adults presenting to emergency departments (EDs) but is detected in only one-third of cases. Evidence-based guidelines for ED delirium screening exist, but are underutilized. Frontline staff perceptions about delirium and time and resource constraints are known barriers to ED delirium screening uptake. Early adopters of ED delirium screening can offer valuable lessons about successful implementation.

METHODS

We conducted semi-structured interviews with clinician-administrators leading ED delirium screening initiatives from 20 EDs in the United States and Canada. Interviews focused on experiences of planning and implementing ED delirium screening. Interviews lasted 15 to 50 minutes and were digitally recorded and transcribed. To identify factors that commonly impacted implementation of ED delirium screening, we used constructs from the Consolidated Framework for Implementation Research (CFIR), an Implementation Science framework widely used to evaluate healthcare improvement initiatives.

RESULTS

Overall, notable facilitators of successful implementation were having institutional and ED leadership support and designated clinical champions to longitudinally engage and educate frontline staff. We found specific examples of factors affecting implementation drawn from the following seven CFIR constructs: (1) intervention complexity, (2) intervention adaptability, (3) external policies and incentives, (4) peer pressure from other institutions, (5) the implementation climate of the ED, (6) staff knowledge and beliefs, and (7) engaging deliverers of intervention, that is, frontline ED staff.

CONCLUSION

Implementing ED delirium screening is complex and requires institutional resources as well as clinical champions to engage frontline staff in a sustained fashion.

Leveraging the Electronic Health Record to Implement Emergency Department Delirium Screening

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.

A Qualitative Study of Emergency Department Delirium Prevention Initiatives

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.