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Shih RD, Alter SM, Wells M, Solano JJ, Engstrom G, Clayton LM, Hughes PG, Goldstein L, Lottenberg L, Ouslander JG. The Florida Geriatric Head Trauma CT Clinical Decision Rule. J Am Geriatr Soc 2024. [PMID: 38959158 DOI: 10.1111/jgs.19057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/24/2024] [Accepted: 06/05/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Several clinical decision rules have been devised to guide head computed tomography (CT) use in patients with minor head injuries, but none have been validated in patients 65 years or older. We aimed to derive and validate a head injury clinical decision rule for older adults. METHODS We conducted a secondary analysis of an existing dataset of consecutive emergency department (ED) patients >65 years old with blunt head trauma. The main predictive outcomes were significant intracranial injury and Need for Neurosurgical Intervention on CT. The secondary outcomes also considered in the model development and validation were All Injuries and All Intracranial Injuries. Predictor variables were identified using multiple variable logistic regression, and clinical decision rule models were developed in a split-sample derivation cohort and then tested in an independent validation cohort. RESULTS Of 5776 patients, 233 (4.0%) had significant intracranial injury and an additional 104 (1.8%) met CT criteria for Need for Neurosurgical Intervention. The best performing model, the Florida Geriatric Head Trauma CT Clinical Decision Rule, assigns points based on several clinical variables. If the points totaled 25 or more, a CT scan is indicated. The included predictors were arrival via Emergency Medical Services (+30 points), Glasgow Coma Scale (GCS) <15 (+20 points), GCS <14 (+50 points), antiplatelet medications (+17 points), loss of consciousness (+16 points), signs of basilar skull fracture (+50 points), and headache (+20 points). Utilizing this clinical decision rule in the validation cohort, a point total ≥25 had a sensitivity and specificity of 100.0% (95% CI: 96.0-100) and 12.3% (95% CI: 10.9-13.8), respectively, for significant intracranial injury and Need for Neurosurgical Intervention. CONCLUSIONS The Florida Geriatric Head Trauma CT Clinical Decision Rule has the potential to reduce unnecessary CT scans in older adults, without compromising safe emergency medicine practice.
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Affiliation(s)
- Richard D Shih
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
| | - Scott M Alter
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Mike Wells
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Joshua J Solano
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Gabriella Engstrom
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Lisa M Clayton
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Patrick G Hughes
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Depatment of Emergency Medicine, Delray Medical Center, Delray Beach, Florida, USA
- Depatment of Emergency Medicine, Bethesda Hospital East, Boynton Beach, Florida, USA
| | - Lara Goldstein
- Department of Emergency Medicine, Memorial Healthcare System, Hollywood, Florida, USA
| | - Lawrence Lottenberg
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, Florida, USA
| | - Joseph G Ouslander
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
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Wu M, Chen Z, Xu Y, Zhao L, Zhao L, Xia L. A qualitative study of geriatric specialist nurses' experiences to navigate delirium in the elderly. BMC Nurs 2024; 23:426. [PMID: 38918789 PMCID: PMC11197179 DOI: 10.1186/s12912-024-02100-x] [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: 04/23/2024] [Accepted: 06/17/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND The experiences and perceptions of geriatric specialist nurses are pivotal to understanding the complexities of managing delirium and to developing effective nursing interventions. This qualitative study aims to explore these experiences and perceptions to inform the enhancement of clinical geriatric nursing and care practices. METHODS Utilizing a qualitative exploratory design, this research engaged a convenience sample of geriatric specialist nurses at a tertiary hospital in Shanghai, China through focus groups and semi-structured interviews. Data were rigorously analyzed using Colaizzi's phenomenological method, which facilitated the identification of themes that emerged from the narratives of the geriatric specialist nurses. RESULTS The thematic analysis yielded three major themes that encapsulate the nurses' experiences and perceptions. Theme 1: Understanding of Delirium, highlighted the nurses' awareness of the condition's significance, yet it was often deprioritized due to the pressing demands of managing more acute and immediately life-threatening conditions. Theme 2: Barriers in Application, brought to light the multifaceted challenges faced by nurses, including language barriers, the frequency and consistency of delirium assessments, the social determinants of health, and the nurses' own competencies in assessment. Theme 3: Evolution of Nursing Approaches, detailed the adaptive strategies employed by nurses, such as managing nursing adverse events, improving communication with patients' families, and adopting a proactive stance towards long-term patient outcomes. CONCLUSIONS The findings suggest that while geriatric specialist nurses recognize the importance of delirium assessment, there are several barriers to effective application. The study underscores the imperative for the advancement of more refined delirium assessment and care protocols, tailored to address the unique requirements of geriatric nursing care.
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Affiliation(s)
- Mei Wu
- Department of nursing, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Day Surgery Unit, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Zhen Chen
- Surgical Intensive Care Unit, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Yamin Xu
- Day Care Chemotherapy, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Liting Zhao
- Department of nursing, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Lirong Zhao
- Department of Neurology, Huadong Hospital Affiliated to Fudan University, Shanghai, China.
| | - Lu Xia
- Day Surgery Unit, Huadong Hospital Affiliated to Fudan University, Shanghai, China.
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Lee S, Skains RM, Magidson PD, Qadoura N, Liu SW, Southerland LT. Enhancing healthcare access for an older population: The age-friendly emergency department. J Am Coll Emerg Physicians Open 2024; 5:e13182. [PMID: 38726466 PMCID: PMC11079440 DOI: 10.1002/emp2.13182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/29/2023] [Accepted: 01/24/2024] [Indexed: 05/12/2024] Open
Abstract
Healthcare systems face significant challenges in meeting the unique needs of older adults, particularly in the acute setting. Age-friendly healthcare is a comprehensive approach using the 4Ms framework-what matters, medications, mentation, and mobility-to ensure that healthcare settings are responsive to the needs of older patients. The Age-Friendly Emergency Department (AFED) is a crucial component of a holistic age-friendly health system. Our objective is to provide an overview of the AFED model, its core principles, and the benefits to older adults and healthcare clinicians. The AFED optimizes the delivery of emergency care by integrating age-specific considerations into various aspects of (1) ED physical infrastructure, (2) clinical care policies, and (3) care transitions. Physical infrastructure incorporates environmental modifications to enhance patient safety, including adequate lighting, nonslip flooring, and devices for sensory and ambulatory impairment. Clinical care policies address the physiological, cognitive, and psychosocial needs of older adults while preserving focus on emergency issues. Care transitions include communication and involving community partners and case management services. The AFED prioritizes collaboration between interdisciplinary team members (ED clinicians, geriatric specialists, nurses, physical/occupational therapists, and social workers). By adopting an age-friendly approach, EDs have the potential to improve patient-centered outcomes, reduce adverse events and hospitalizations, and enhance functional recovery. Moreover, healthcare clinicians benefit from the AFED model through increased satisfaction, multidisciplinary support, and enhanced training in geriatric care. Policymakers, healthcare administrators, and clinicians must collaborate to standardize guidelines, address barriers to AFEDs, and promote the adoption of age-friendly practices in the ED.
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Affiliation(s)
- Sangil Lee
- Department of Emergency MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Rachel M. Skains
- University of Alabama at BirminghamBirminghamAlabamaUSA
- Geriatric Research, Education, and Clinical CenterBirmingham VA Medical CenterBirminghamAlabamaUSA
| | | | - Nadine Qadoura
- Department of Emergency MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Shan W. Liu
- Massachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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Ehrlich A, Oh ES, Ahmed S. Managing Delirium in the Emergency Department: An Updated Narrative Review. CURRENT GERIATRICS REPORTS 2024; 13:52-60. [PMID: 38855352 PMCID: PMC11156174 DOI: 10.1007/s13670-024-00413-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 06/11/2024]
Abstract
Purpose of Review Emergency departments (EDs) are facing an epidemic of overcrowding and ED boarding, particularly of older adults who often present with, or develop, delirium in the ED. Delirium is associated with increased complications, longer hospital length of stay, mortality, and costs to the healthcare system. However, we only have limited knowledge of how to successfully prevent and treat delirium in the ED in a pragmatic, sustainable, and cost-effective way. We present a narrative review of recent literature of delirium prevention and treatment programs in the ED. We aim to describe the components of successful delirium management strategies to be used by EDs in building delirium management programs. Recent Findings We reviewed 10 studies (2005-2023) that report delirium interventions in the ED, and describe the different components of these interventions that have been studied. These interventions included: optimizing hemodynamics and oxygenation, treating pain, hydration and nutrition support, avoiding sedative hypnotics, antipsychotics and anticholinergics, promoting sleep, sensory stimulation, limiting the time spent in the ED, educating providers and staff, and developing multidisciplinary delirium protocols integrated into the electronic health record. Summary Through our narrative review of the recent literature on delirium prevention and treatment programs in the ED, we have identified nine components of successful delirium prevention strategies in the ED. We also discuss three high priority areas for further research including identification of most effective components of delirium prevention strategies, conduct of additional high-quality trials in non-hip.
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Affiliation(s)
- April Ehrlich
- Division of Geriatric Medicine and Gerontology, Department of Medicine, The Johns Hopkins University, 5200, Eastern Avenue, Suite , 2200 Baltimore, MD, 21224, USA
| | - Esther S. Oh
- Division of Geriatric Medicine and Gerontology, Department of Medicine, The Johns Hopkins University, 5200, Eastern Avenue, Suite , 2200 Baltimore, MD, 21224, USA
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University, Baltimore, MD, USA
- Division of Neuropathology, Department of Pathology, The Johns Hopkins University, Baltimore, MD, USA
- The Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - Shaista Ahmed
- Division of Geriatric Medicine and Gerontology, Department of Medicine, The Johns Hopkins University, 5200, Eastern Avenue, Suite , 2200 Baltimore, MD, 21224, USA
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Carpenter CR, Lee S, Kennedy M, Arendts G, Schnitker L, Eagles D, Mooijaart S, Fowler S, Doering M, LaMantia MA, Han JH, Liu SW. Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments. Acad Emerg Med 2024. [PMID: 38757369 DOI: 10.1111/acem.14935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening. METHODS We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds. RESULTS Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%. CONCLUSIONS The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.
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Affiliation(s)
| | - Sangil Lee
- University of Iowa, Iowa City, Iowa, USA
| | - Maura Kennedy
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Glenn Arendts
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Linda Schnitker
- Bolton Clarke Research Institute, Bolton Clarke School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | | | - Simon Mooijaart
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, The Netherlands
| | - Susan Fowler
- University of Connecticut Health Sciences, Farmington, Connecticut, USA
| | - Michelle Doering
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | | | - Jin H Han
- Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shan W Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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6
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Zhou C, Wang H, Wang L, Zhou Y, Wu Q. Diagnostic accuracy of the Family Confusion Assessment Method for delirium detection: A systematic review and meta-analysis. J Am Geriatr Soc 2024; 72:892-902. [PMID: 38018490 DOI: 10.1111/jgs.18692] [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: 06/16/2023] [Revised: 10/03/2023] [Accepted: 10/26/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Delirium is frequently disproportionately under-recognized despite its high prevalence, detrimental impact, and potential lethality. Informant-based delirium detection tools can offer structured assessment and increase the timeliness and frequency of detection. We aimed to examine the diagnostic accuracy of the Family Confusion Assessment Method (FAM-CAM) for delirium detection. METHODS We systematically searched the MEDLINE, EMBASE, PsycINFO, CINAHL, CNKI, WANFANG, and SinoMed databases from January 1988 to December 2022. Two reviewers independently screened studies and evaluated methodological quality using the revised quality assessment of diagnostic accuracy studies (QUADAS-2) tool. A bivariate random effects model was undertaken, and univariable meta-regression was carried out to explore heterogeneity. RESULTS Seven studies with 483 dyads of participants and family caregivers were identified. Pooled sensitivity and specificity were 0.74 (95% CI: 0.59, 0.86) and 0.91 (95% CI: 0.83, 0.95), respectively, with an area under curve (AUC) of 0.91. The positive likelihood ratio was 8.27 (95% CI: 3.97, 17.25), and the negative likelihood ratio was 0.28 (95% CI: 0.16, 0.50). Settings impacted specificity (p = 0.02). CONCLUSIONS Available evidence indicates that FAM-CAM exhibits moderate sensitivity and high specificity for delirium screening in adults. The FAM-CAM is concise and easy to use, making it appropriate for routine clinical practice, which might benefit early delirium detection and potentially foster delirium management. PROSPERO REGISTRATION NUMBER CRD42022378742.
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Affiliation(s)
- Chenxi Zhou
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Wang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lan Wang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanrong Zhou
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiansheng Wu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Filiatreault S, Kreindler SA, Grimshaw JM, Chochinov A, Doupe MB. Developing a set of emergency department performance measures to evaluate delirium care quality for older adults: a modified e-Delphi study. BMC Emerg Med 2024; 24:28. [PMID: 38360551 PMCID: PMC10868025 DOI: 10.1186/s12873-024-00947-6] [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: 10/25/2023] [Accepted: 02/05/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Older adults are at high risk of developing delirium in the emergency department (ED); however, it is under-recognized in routine clinical care. Lack of detection and treatment is associated with poor outcomes, such as mortality. Performance measures (PMs) are needed to identify variations in quality care to help guide improvement strategies. The purpose of this study is to gain consensus on a set of quality statements and PMs that can be used to evaluate delirium care quality for older ED patients. METHODS A 3-round modified e-Delphi study was conducted with ED clinical experts. In each round, participants rated quality statements according to the concepts of importance and actionability, then their associated PMs according to the concept of necessity (1-9 Likert scales), with the ability to comment on each. Consensus and stability were evaluated using a priori criteria using descriptive statistics. Qualitative data was examined to identify themes within and across quality statements and PMs, which went through a participant validation exercise in the final round. RESULTS Twenty-two experts participated, 95.5% were from west or central Canada. From 10 quality statements and 24 PMs, consensus was achieved for six quality statements and 22 PMs. Qualitative data supported justification for including three quality statements and one PM that achieved consensus slightly below a priori criteria. Three overarching themes emerged from the qualitative data related to quality statement actionability. Nine quality statements, nine structure PMs, and 14 process PMs are included in the final set, addressing four areas of delirium care: screening, diagnosis, risk reduction and management. CONCLUSION Results provide a set of quality statements and PMs that are important, actionable, and necessary to a diverse group of clinical experts. To our knowledge, this is the first known study to develop a de novo set of guideline-based quality statements and PMs to evaluate the quality of delirium care older adults receive in the ED setting.
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Affiliation(s)
- Sarah Filiatreault
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada.
| | - Sara A Kreindler
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, K1H8L6, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
| | - Alecs Chochinov
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
- Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Malcolm B Doupe
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
- Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, 750 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
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Morales-Puerto M, Ruiz-Díaz M, García-Mayor S, León-Campos Á, Morales-Asencio JM, Canca-Sánchez JC, Gavira-Guerra S, Toledo-Fernandez C, Aranda-Gallardo M. Spanish transcultural adaptation of the 4AT score for the evaluation of delirium in the emergency department: a prospective diagnostic test accuracy study. BMC Nurs 2024; 23:101. [PMID: 38321514 PMCID: PMC10845719 DOI: 10.1186/s12912-023-01638-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 12/05/2023] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Delirium is one of the most common adverse events in older people during hospitalization, especially in the emergency department. Reliable, easy-to-use instruments are necessary to properly manage delirium in this setting. This study aims to evaluate the diagnostic validity of the Spanish version of the 4 'A's Test (4AT) in the ED. METHODS A diagnostic accuracy study was conducted in patients over 65 years old admitted to the Emergency Department who did not have a formal diagnosis of dementia or a severe mental health disorder. Face and content validity were evaluated by an expert panel. Emergency nurses performed the evaluation with 4AT, whilst blinded and trained researchers assessed patients with the Revised Delirium Rating Scale as the gold standard. The content validity index, sensitivity, specificity, positive and negative predictive values, likelihood ratios, Youden's Index and ROC curves were calculated to evaluate the diagnostic accuracy of the instrument. RESULTS Of 393 eligible patients, 380 were finally analyzed. Content validity yielded a median content validity index of 4 (interquartile range: 0). The Spanish 4AT sensitivity (95.83%; 95% ECI: 78.9-99.9%), specificity (92.98%; 95% CI: 89.8-95.4%), positive predictive value (47.92%) and negative predictive value (99.7%) were satisfactory. Youden's index was 0.89. Positive likelihood ratio was 13.65, and negative likelihood ratio 0.045. The area under the curve was 0.97. CONCLUSIONS The Spanish version of the 4AT for use in the Emergency Departments is easy-to-use and applicable. The validation results indicate that it is a valid instrument with sufficient predictive validity to identify patients at risk of delirium in the Emergency Departments. Moreover, it is a tool that facilitates the management of an adverse event that is associated with increased mortality and morbidity.
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Affiliation(s)
- Marta Morales-Puerto
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
| | - María Ruiz-Díaz
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
| | - Silvia García-Mayor
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain
| | - Álvaro León-Campos
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain.
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain.
| | - José Miguel Morales-Asencio
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain
| | - José Carlos Canca-Sánchez
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain
| | - Sonia Gavira-Guerra
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
| | - Cecilia Toledo-Fernandez
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
| | - Marta Aranda-Gallardo
- Hospital Costa del Sol. Servicio Andaluz de Salud, Autovía A7, Km. 187. Marbella, Malaga, 29603, Spain
- Faculty of Health Sciences, Department of Nursing, Universidad de Málaga, C/ Arquitecto Francisco Peñalosa 3, Malaga, 29017, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA-Bionand), C/ Miguel Díaz Recio, Malaga, 29010, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), Instituto de Salud Carlos III, Bizkaia, Spain
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Nickel CH, Kellett J. Assessing Physiologic Reserve and Frailty in the Older Emergency Department Patient: Should the Paradigm Change? Clin Geriatr Med 2023; 39:475-489. [PMID: 37798060 DOI: 10.1016/j.cger.2023.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Older patients are more vulnerable to acute illness or injury because of reduced physiologic reserve associated with aging. Therefore, their assessment in the emergency department (ED) should include not only vital signs and their baseline values but also changes that reflect physiologic reserve, such as mobility, mental status, and frailty. Combining aggregated vitals sign scores and frailty might improve risk stratification in the ED. Implementing these changes in ED assessment may require the introduction of senior-friendly processes to ensure ED treatment is appropriate to the older patients' immediate discomfort, personal goals, and likely prognosis.
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Affiliation(s)
- Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, Basel CH-4031, Switzerland.
| | - John Kellett
- Department of Emergency Medicine, Odense University Hospital, University of Southern Denmark, Denmark
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Southerland LT, Gulker P, Van Fossen J, Rine-Haghiri L, Caterino JM, Mion LC, Carpenter CR, Cardone MS, Hill M, Hunold KM. Implementation of geriatric screening in the emergency department using the Consolidated Framework for Implementation Research. Acad Emerg Med 2023; 30:1117-1128. [PMID: 37449967 PMCID: PMC11195318 DOI: 10.1111/acem.14776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 07/03/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Implementation of evidence-based care processes (EBP) into the emergency department (ED) is challenging and there are only a few studies of real-world use of theory-based implementation frameworks. We report final implementation results and sustainability of an EBP geriatric screening program in the ED using the Consolidated Framework for Implementation Research (CFIR). METHODS The EBP involved nurses screening older patients for delirium (Delirium Triage Screen), fall risk (4-Stage Balance Test), and vulnerability (Identification of Seniors at Risk score) with subsequent appropriate referrals to physicians, therapy specialists, or social workers. The proportions of screened adults ≥65 years old were tracked monthly. Outcomes are reported January 2021-December 2022. Barriers encountered were classified according to CFIR. Implementation strategies were classified according to the CFIR-Expert Recommendations for Implementing Change (ERIC). RESULTS Implementation strategies increased geriatric screening from 5% to 68%. This did not meet our prespecified goal of 80%. Change was sustained through several COVID-19 waves. Inner setting barriers included culture and implementation climate. Initially, the ED was treated as a single inner setting, but we found different cultures and uptake between ED units, including night versus day shifts. Characteristics of individuals barriers included high levels of staff turnover in both clinical and administrative roles and very low self-efficacy from stress and staff turnover. Initial attempts with individualized audit and feedback were not successful in improving self-efficacy and may have caused moral injury. Adjusting feedback to a team/unit level approach with unitwide stretch goals worked better. Identifying early adopters and conducting on-shift education increased uptake. Lessons learned regarding ED culture, implementation in interconnected health systems, and rapid cycle process improvement are reported. CONCLUSIONS The pandemic exacerbated barriers to implementation in the ED. Cognizance of a large ED as a sum of smaller units and using the CFIR model resulted in improvements.
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Affiliation(s)
| | - Peg Gulker
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jenifer Van Fossen
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Lorri Rine-Haghiri
- The Ohio State University James Cancer Hospital & Solove Research Center, Columbus, Ohio, USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Lorraine C. Mion
- College of Nursing, The Ohio State University, Columbus, Ohio, USA
| | | | - Michael S. Cardone
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Michael Hill
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Katherine M. Hunold
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
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11
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Lee S, Howard MA, Han JH. Delirium and Delirium Prevention in the Emergency Department. Clin Geriatr Med 2023; 39:535-551. [PMID: 37798064 DOI: 10.1016/j.cger.2023.05.006] [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] [Indexed: 10/07/2023]
Abstract
This article covers the epidemiology of delirium and the overlapping condition of altered mental status and encephalopathy that is relevant to those who practice in the emergency department.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, 312 Oxford House, Nashville, TN 37232-4700, USA; Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, 1310 24th Avenue South, Nashville, TN 37212-2637, USA
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12
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Bonfichi A, Ceresa IF, Piccioni A, Zanza C, Longhitano Y, Boudi Z, Esposito C, Savioli G. A Lethal Combination of Delirium and Overcrowding in the Emergency Department. J Clin Med 2023; 12:6587. [PMID: 37892725 PMCID: PMC10607343 DOI: 10.3390/jcm12206587] [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: 08/28/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Delirium is a common public health concern that significantly impacts older patients admitted to the Emergency Department (ED). This condition is linked to adverse outcomes such as reduced long-term functionality, higher mortality rates, extended hospital stays, and increased medical costs. The identification of risk factors is crucial for the early recognition and management of delirium in ED patients. Aging, cognitive decline, polypharmacy, and sensory impairment are some of the most common general risk factors described in the literature. Although validated delirium assessment tools already exist, they are not practical for the fast-paced ED environment because of their extended evaluation period or specialized training request. Moreover, clear guidance is needed to select the most suitable tool for detecting delirium, balancing between the accuracy and the swiftness required in an overcrowded, high-stress, and understaffed healthcare setting. This narrative review aims to analyze the updated literature on delirium risk factors in older ED patients and focuses on the methods for better screening, managing, and treating this condition in the ED.
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Affiliation(s)
- Alessandra Bonfichi
- Department of Internal Medicine, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| | - Iride Francesca Ceresa
- Department of Emergency Medicine, Humanitas University-Research Hospital, 20089 Rozzano, Italy; (I.F.C.); (Y.L.)
| | - Andrea Piccioni
- Department of Emergency, Fondazione Policlinico Universitario A. Gemelli, IRCCS Fondazione Policlinico San Matteo, 00168 Roma, Italy;
| | - Christian Zanza
- Italian Society of Pre-Hospital Emergency Medicine (SIS-118), 74121 Taranto, Italy;
| | - Yaroslava Longhitano
- Department of Emergency Medicine, Humanitas University-Research Hospital, 20089 Rozzano, Italy; (I.F.C.); (Y.L.)
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15260, USA
| | - Zoubir Boudi
- Department of Emergency Medicine, Dr Sulaiman Alhabib Hospital, Dubai 2542, United Arab Emirates;
| | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy;
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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13
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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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14
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Filiatreault S, Grimshaw JM, Kreindler SA, Chochinov A, Linton J, Chatterjee R, Azeez R, Doupe MB. A critical appraisal and recommendation synthesis of delirium clinical practice guidelines relevant to the care of older adults in the emergency department: An umbrella review. J Eval Clin Pract 2023; 29:1039-1053. [PMID: 37316463 DOI: 10.1111/jep.13883] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/16/2023]
Abstract
RATIONALE Older adults are at high risk of developing delirium in the emergency department (ED); however, it is often missed or undertreated. Improving ED delirium care is challenging in part due to a lack of standards to guide best practice. Clinical practice guidelines (CPGs) translate evidence into recommendations to improve practice. AIM To critically appraise and synthesize CPG recommendations for delirium care relevant to older ED patients. METHODS We conducted an umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations were critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II; and Appraisal of Guidelines Research and Evaluation-Recommendations Excellence (AGREE-REX) instruments. A threshold of 70% or greater in the AGREE-II Rigour of Development domain was used to define high-quality CPGs. Delirium recommendations from CPGs meeting this threshold were included in the synthesis and narrative analysis. RESULTS AGREE-II Rigour of Development scores ranged from 37% to 83%, with 5 of 10 CPGs meeting the predefined threshold. AGREE-REX overall calculated scores ranged from 44% to 80%. Recommendations were grouped into screening, diagnosis, risk reduction, and management. Although none of the included CPGs were ED-specific, many recommendations incorporated evidence from this setting. There was agreement that screening for nonmodifiable risk factors is important to define high-risk populations, and those at risk should be screened for delirium. The '4A's Test' was the recommended tool to use in the ED specifically. Multicomponent strategies were recommended for delirium risk reduction, and for its management if it occurs. The only area of disagreement was for the short-term use of antipsychotic medication in urgent situations. CONCLUSION This is the first known review of delirium CPGs including a critical appraisal and synthesis of recommendations. Researchers and policymakers can use this synthesis to inform future improvement efforts and research in the ED. REGISTRATION This study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6OSF.IO/TG7S6.
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Affiliation(s)
- Sarah Filiatreault
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sara A Kreindler
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alecs Chochinov
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Janice Linton
- Neil John Maclean Health Sciences Library, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rashmita Chatterjee
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rilwan Azeez
- Department of Immunology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Malcolm B Doupe
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre for Care Research, Western University of Applied Sciences, Bergen, Norway
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15
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Arneson ML, Oliveira J E Silva L, Stanich JA, Jeffery MM, Lindroth HL, Ginsburg AD, Bower SM, Mullan AF, Bellolio F. Association of delirium with increased short-term mortality among older emergency department patients: A cohort study. Am J Emerg Med 2023; 66:105-110. [PMID: 36738568 PMCID: PMC10038894 DOI: 10.1016/j.ajem.2023.01.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023] Open
Abstract
STUDY OBJECTIVE To evaluate the association between delirium and subsequent short-term mortality in geriatric patients presenting to the emergency department (ED). METHODS This was an observational cohort study of adults age ≥75 years who presented to an academic ED and were screened for delirium during their ED visit. The Delirium Triage Screen followed by the Brief Confusion Assessment Method were used to ascertain the presence of delirium. In-hospital, 7-day, and 30-day mortality were compared between patients with and without ED delirium. Odds ratios with 95% confidence intervals (CIs) were calculated through logistic regression after adjusting for confounders including age, sex, history of dementia, ED disposition, and acuity. RESULTS A total of 967 ED visits were included for analysis among which delirium was detected in 107 (11.1%). The median age of the cohort was 83 years (IQR 79, 88), 526 (54.4%) were female, 285 (29.5%) had documented dementia, and 171 (17.7%) had a high acuity Emergency Severity Index triage level 1 or 2. During the hospitalization, 5/107 (4.7%) of those with delirium and 4/860 (0.5%) of those without delirium died. Within 7 days of ED departure, 6/107 (5.6%) of those with delirium and 6/860 (0.7%) of those without delirium died (unadjusted OR 8.46, 95% CI 2.68-26.71). Within 30 days, 18/107 (16.8%) of those with delirium and 37/860 (4.3%) of those without delirium died (unadjusted OR 4.50, 95% CI 2.46-8.23). ED delirium remained associated with higher 7-day (adjusted OR 5.23, 95% CI 1.44-19.05, p = 0.008) and 30-day mortality (adjusted OR 2.82, 95% CI 1.45-5.46, p = 0.002). CONCLUSION Delirium is an important prognostic factor that ED clinicians and nurses must be aware of to optimize delirium prevention, management, disposition, and communication with patients and families.
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Affiliation(s)
| | - Lucas Oliveira J E Silva
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Jessica A Stanich
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Section of Geriatric Medicine, Mayo Clinic, Rochester, MN, USA
| | - Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | | | - Alexander D Ginsburg
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Section of Palliative Care, Mayo Clinic, Rochester, MN, USA
| | - Susan M Bower
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Nursing, Mayo Clinic, Rochester, MN, USA
| | - Aidan F Mullan
- Department of Quantitative Health Sciences, Division of Biostatistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Section of Geriatric Medicine, Mayo Clinic, Rochester, MN, USA; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA.
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16
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Lo AX, Kennedy M. It's time to mobilize: Moving mobility interventions for delirium from inpatient units to the emergency department. J Am Coll Emerg Physicians Open 2023; 4:e12900. [PMID: 36776215 PMCID: PMC9902676 DOI: 10.1002/emp2.12900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 02/10/2023] Open
Affiliation(s)
- Alexander X. Lo
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA,Center for Health Services & Outcomes ResearchNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA,Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
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17
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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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18
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Challenges in the Detection of Clinically Useful Biomarkers for the Diagnosis of Delirium in Older People in the Emergency Department-A Case-Control Study. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081127. [PMID: 36013306 PMCID: PMC9409784 DOI: 10.3390/life12081127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/16/2022] [Accepted: 07/26/2022] [Indexed: 11/17/2022]
Abstract
Background: The identification of biomarkers associated with delirium in the emergency department could contribute to the understanding, prediction and diagnosis of this disorder. The present study was carried out to identify biomarkers included in easily and quickly obtained standard blood examinations in older patients with delirium in the emergency department. Methods: A case–control study was carried out in the emergency department of Francesc de Borja Hospital (Gandía, Valencia, Spain). Older adults (≥65 years of age) diagnosed with delirium (n = 128) were included. Cases due to alcohol or substance abuse were excluded. Controls were selected on a randomized basis from the remaining patients (n = 128). All laboratory test parameters included in the routine blood and urine tests of the emergency department were collected. Results: The mean age of the patients was 81.24 ± 7.51 years, and 56.2% were males, while the mean age of the controls was 78.97 ± 7.99 years, and 45.3% were males. Significant differences were found between the cases and controls in relation to the following parameters: urea 43 (32–58) mg/dL versus 50 (37–66) mg/dL, respectively; neutrophils 69.6 (62.05–78.75)% versus 75.5 (65.1–83.2)%; monocytes 8.7 (7–10.4)% versus 7.6 (5.5–9.2)%; platelets 213 (159–266) × 109/L versus 224 (182–289) × 109/L; neutrophil–lymphocyte ratio 3.88 (2.45–7.07) versus 5 (2.75–8.83); platelet–lymphocyte ratio 281.4 (210–360) versus 357.1 (257.8–457.1); and mean platelet volume 10.6 (10–11.5) fl versus 10.4 (9.67–10.9) fl. Although the mean values were above desirable levels in both groups, they were higher for most parameters in the control group. No significant differences were observed in C-reactive protein concentration (9.99 (1.69–51) mg/L versus 12.3 (3.09–65.97) mg/L). Conclusions: The identification of delirium biomarkers poses difficulties due to the urgent nature of the disorders found in older people admitted to the emergency department. Research in this field is needed, since it would allow early identification and treatment of delirium.
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