scholarly journals Use of a digital delirium pathway and quality improvement to improve delirium detection in the emergency department and outcomes in an acute hospital

2020 ◽  
Vol 49 (4) ◽  
pp. 672-678 ◽  
Author(s):  
Emma Vardy ◽  
Niamh Collins ◽  
Umang Grover ◽  
Rebecca Thompson ◽  
Alexandra Bagnall ◽  
...  
Keyword(s):  
Emergency Department ◽  
Quality Improvement ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Treatment Quality ◽  
Training And Education ◽  
Automated Coding ◽  
Delirium Management ◽  
Detection And Diagnosis

Abstract Background delirium is a common condition associated with hospital admission. Detection and diagnosis is important to identify the underlying precipitating cause and implement effective management and treatment. Quality improvement (QI) methodology has been applied in limited publications. There are even fewer publications of the role of development of the electronic health record (EHR) to enhance implementation. Methods we used QI methodology to improve delirium detection in the emergency department (ED). Plan Do Study Act (PDSA) cycles could be broadly categorised into technology, training and education and leadership. As part of the technology PDSA an electronic delirium pathway was developed as part of an NHS England digital systems improvement initiative (NHS England Global Digital Exemplar). The electronic pathway incorporated the 4AT screening tool, the Confusion Assessment Method, the TIME delirium management bundle, investigation order sets and automated coding of delirium as a health issue. Results development of the EHR combined with education initiatives had benefit in terms of the number of people assessed for delirium on admission to the ED and the total number of people diagnosed with delirium across the organisation. The implementation of a delirium pathway as part of the EHR improved the use of 4AT in those 65 years and over from baseline of 3% completion in October 2017 to 43% in January 2018. Conclusion we showed that enhancement of the digital record can improve delirium assessment and diagnosis. Furthermore, the implementation of a delirium pathway is enhanced by staff education.

scholarly journals Validation of the Confusion Assessment Method for the Intensive Care Unit in Older Emergency Department Patients

2014 ◽  
Vol 21 (2) ◽  
pp. 180-187 ◽  
Author(s):  
Jin H. Han ◽  
Amanda Wilson ◽  
Amy J. Graves ◽  
Ayumi Shintani ◽  
John F. Schnelle ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Emergency Department ◽  
Intensive Care ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Confusion Assessment ◽  
Emergency Department Patients

Early detection of delirium – using the CAM score

2019 ◽  
Vol 2 (3) ◽  
pp. 50
Author(s):  
Lise Rekvad
Keyword(s):  
Emergency Department ◽  
Health Care Providers ◽  
Research Team ◽  
Clinical Importance ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
University Hospital ◽  
Care Providers ◽  
Old Patients ◽  
Hospital Acquired

Background: Delirium is common in elderly patients and has been identified as an independent marker for increased mortality and hospital-acquired complications, yet it is poorly recognized by health care providers. The aim of this study was to investigate whether systematic use of the validated screening tool Confusion Assessment Method (CAM) would result in a higher recognizing of delirium in patients ≥ 65 years old admitted at Odense Emergency Department (FAM). Methods: All caregivers in the Emergency department (ED) at Odense University Hospital received 2 hours of education in delirium and how to use the CAM score. They were asked to systematically perform CAM score in all patients ≥ 65 years at arrival to the ED and at least every 8 hours.  During 2 periods of 5 days - one before the caregivers was educated (pre-CAM) and one 4 weeks after CAM scoring was started (during-CAM). A research team interviewed all ≥ 65 year old patients and their caregivers at the first and second day of admission. In relation to the interviews all patients underwent a cognitive assessment using the CAM by a trained investigator. These results were blinded to the clinical personal. After discharge patient files were screened with the aim to identify any delirium registered by the clinical personal. Results: Out of 276 screened patients 192 where included in the project. 100 patients and were included in the pre-CAM group and 92 patients in the during-CAM group. According to the registrations by the research team 24 of 100 (24% 95%CI 16%-34%) patients experience delirium in the pre-CAM group and 18 of 92 (20% 95%CI 12%-29%) in the during-CAM group. Increasing age and comorbidity was related to delirium.  Prevalence of the diagnoses delirium registered in the patient file increased from 1 of 24 (4% 95%CI  0%-21%) to 9 of 18 (50% 95%CI 26%-74%). Conclusion: One out of four elderly acute patients has deliria symptoms during the first 2 days at hospital. Systematic CAM scoring does not change the prevalence but increase the awareness significantly. The high prevalence underlines the clinical importance of the problem.

scholarly journals Serial Ottawa 3DY assessments to detect delirium in older emergency department community dwellers

2019 ◽  
Vol 49 (1) ◽  
pp. 130-134
Author(s):  
Krishan Yadav ◽  
Valérie Boucher ◽  
Pierre-Hugues Carmichael ◽  
Philippe Voyer ◽  
Debra Eagles ◽  
...  
Keyword(s):  
Emergency Department ◽  
Sensitivity And Specificity ◽  
Primary Outcome ◽  
Screening Tool ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Multicenter Cohort Study ◽  
Delirium Assessment ◽  
Lengths Of Stay ◽  
History Of

Abstract Background delirium is associated with increased morbidity and mortality among older emergency department (ED) patients. When using physician gestalt, delirium is missed in the majority of patients. The Ottawa 3DY (O3DY) has been validated to detect cognitive dysfunction among older ED patients. Objectives to determine the sensitivity and specificity of serial O3DY assessments to detect delirium in older ED patients. Design a prospective observational multicenter cohort study. Setting four Quebec EDs. Participants independent or semi-independent older patients (age ≥ 65 years) with an ED stay of at least 8 hours that required hospitalisation. Measurements eligible patients were evaluated using serial O3DY assessments at least 6 hours apart. The primary outcome was delirium after at least 8 hours in the ED. The reference standard for delirium assessment was the confusion assessment method (CAM). The sensitivity and specificity of the serial O3DY to detect delirium were calculated. Results we enrolled 301 patients (mean age 77 years, 49.5% male, 3.0% with a history of mild dementia). Thirty patients (10.0%) were CAM positive for delirium. Patients had a median of three O3DY assessments. Serial O3DY evaluations to detect delirium among patients with at least one abnormal O3DY had a sensitivity of 86.7% (95% confidence interval—CI 69.3–96.2%) and a specificity of 44.3% (95%; CI 38.3–50.4%). Conclusion serial O3DY testing demonstrates good sensitivity as a screening tool to detect delirium among older adult patients with prolonged ED lengths of stay. Emergency physicians should consider the use of the serial O3DY over clinician gestalt to improve delirium detection.

76 Validation of the Brief Confusion Assessment Method in Older Emergency Department Patients

2012 ◽  
Vol 60 (4) ◽  
pp. S28-S29 ◽  
Author(s):  
J.H. Han ◽  
A. Wilson ◽  
A. Shintani ◽  
A.J. Graves ◽  
J.F. Schnelle ◽  
...  
Keyword(s):  
Emergency Department ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Confusion Assessment ◽  
Emergency Department Patients

scholarly journals MP30: Validation of the 4AT questionnaire in the emergency department

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S75
Author(s):  
A. Gagné ◽  
P. Voyer ◽  
V. Boucher ◽  
M. Pelletier ◽  
E. Gouin ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cognitive Impairment ◽  
Telephone Interview ◽  
Rapid Assessment ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Cognitive Status ◽  
French Version ◽  
Elderly Inpatients ◽  
Patients At Risk

Introduction: Delirium is a very prevalent cognitive impairment in elderly inpatients, but it often goes undetected, especially in the emergency department (ED). The tools currently available to screen or diagnose patients at risk of delirium are very time-consuming and are impossible to systematically perform in the ED environment. For this reason, short tests are necessary to screen for delirium in this fast-paced setting. The objective of this study was to evaluate the performance of the French version of the Rapid Assessment Test for Delirium (4AT) for the detection of delirium and cognitive impairment in older patients. The 4AT takes less than 2 minutes to administer, which is a great advantage on the others tests. Methods: The study was conducted in four emergency departments across the province of Québec. Participants were independent or semi-independent patients aged 65 and older, admitted to hospital and who had an 8-hour exposure to the ED. The Telephone Interview for Cognitive Status (TICS) was administered at the initial interview and the Confusion Assessment Method (CAM) as well as the 4AT were administered to patients twice a day during their ED or hospital stay. The 4AT’s sensitivity and specificity were compared to that of the CAM (for delirium), and to that of the TICS (for cognitive impairment). Results: 324 patients were included in the study, with a mean age of 76 years old. Among the recruited participants, 21 (6.5%) had a prevalent delirium according to the CAM, and 30 (10.2%) had an incident delirium. According to the 4AT, 48 patients (14.9%) had cognitive impairment and 81 (25.2%) had a prevalent delirium. According to the TICS, 87 patients (29.2%) have cognitive impairment. The 4AT has a sensitivity of 68,4% (IC 95% : 47,5-89,3) and a specificity of 73.2% (IC 95% : 67,8-78,7) for delirium, and a sensitivity of 50% (IC 95% : 35,9-64,1) and a specificity of 87,0% (IC 95% : 81,2-92) for cognitive impairment. Conclusion: The French Version of the 4AT could be a fast and reliable screening tool for delirium and cognitive impairment in ED. Further research is necessary for its validation in the ED.

scholarly journals Quality improvement project: delirium awareness and training in coventry memory services

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S229-S229
Author(s):  
Nurul Yahya ◽  
Karim Saad
Keyword(s):  
Quality Improvement ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Basic Knowledge ◽  
List Type ◽  
Nice Guidelines ◽  
Memory Assessment ◽  
Confusion Assessment ◽  
Brief Training ◽  
Strongly Agree

AimsBy way of Quality Improvement, this project aims to identify awareness levels, deliver a brief training and thus increasing the confidence of Memory Assessment Clinicians in detecting delirium.BackgroundPeople with dementia are at greater risk of delirium, and the acute confusion associated with delirium may be mistaken as part of their dementia. Despite having an estimated prevalence in care homes of 14.2% in the UK, delirium is under-recognised. Memory Assessment Clinicians may have low confidence in identifying and have low awareness of delirium despite being tasked with a triage and diagnostic role in dementia assessment. NICE has recently updated the guidelines on Delirium in March 2019 with recommendations on prevention and treatment of Delirium.MethodWe delivered a survey pertaining: (a)Awareness of Delirium NICE Guidelines(b)Confidence in spotting DeliriumWe used convenience sample of Memory Assessment Clinicians in Coventry. Overall, this survey was uptake by 17 clinicians. The pre training survey was done in early October 2019 and the post training survey was done shortly after the training, at the end of October 2019.A brief training comprising NICE Guidelines and using Confusion Assessment Method (CAM) was delivered. The survey is repeated post training and differences in result of level of confidence is done to measure changes. The survey assessed knowledge, beliefs, practices and confidence level regarding delirium detection.ResultPre training:17 clinicians took part in the survey. 59% was aware that there is a delirium NICE guidelines. 12% felt strongly agree, 41% agree and 47% felt neutral in their confidence of detecting delirium.Post training:10 clinicians took part in the survey. 50% felt strongly agree and 50% agree that they are confident in detecting delirium.Overall, the mean difference is 2 and the p value is 0.92034. we used Mann- Whitney Test to measure the difference in pre and post training which showed not significant at p < 0.05.Participants felt that the training was useful and relevant to practice.ConclusionThis study showed our clinicians have a good basic knowledge in detecting delirium. As a result of this study, we have created ‘Delirium checklist’ and Confusion Assessment Method (CAM) to be used during duty work. We also feel that the majority of delirium cases referred to us comes from the community base, thus our next step of the project will be to involve educational work with the community care home.

Assessment and Management of Delirium in Critically Ill Veterans

2020 ◽  
Vol 40 (4) ◽  
pp. 42-52
Author(s):  
Denise M. Kresevic ◽  
Donna Miller ◽  
Carole W. Fuseck ◽  
Mia Wade ◽  
Laura Whitney ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Quality Improvement ◽  
Education Program ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Surgical Intensive Care ◽  
Delirium Assessment ◽  
Confusion Assessment ◽  
Interactive Education

Background Delirium is a complex syndrome prevalent in the intensive care unit. It has been associated with significant morbidity including distress, longer hospital stays, prolonged cognitive impairment, and increased mortality. Objective To describe a nurse-led interdisciplinary quality improvement initiative to increase nurses’ knowledge of delirium, documentation of delirium assessment, and patient mobility. Methods Sixty-seven nurses in medical and surgical intensive care units were required to attend an interactive education program on delirium assessment and management. Scores on tests taken before and after the education program were used to evaluate knowledge. Medical records and bedside rounds were used to validate Confusion Assessment Method for the Intensive Care Unit documentation and interventions. Descriptive statistics were used to describe changes over time. A delirium resource team composed of nurses, physicians, and therapists provided didactic education paired with simulation training and bedside coaching. Mobility screening tests and computer templates guided assessments and interventions. Results Documentation of the Confusion Assessment Method improved from less than 50% to consistently 99%. Mobilization in the surgical intensive care unit increased from 90% to 98% after intervention. Days of delirium significantly decreased from 51% before intervention to 31% after intervention (χ12=7.01, P = .008). Conclusions The success of this quality improvement project to enhance recognition of delirium and increase mobility (critical components of the pain assessment, breathing, sedation choice, delirium, early mobility, and family education bundle) was contingent on nursing leaders hip, interdisciplinary team collaboration, and interactive education.

Using Telehealth to Improve the Accuracy of Delirium Screening by Bedside Critical Care Nurses

2022 ◽  
Vol 31 (1) ◽  
pp. 73-76
Author(s):  
Liron Sinvani ◽  
Craig Hertz ◽  
Saurabh Chandra ◽  
Anum Ilyas ◽  
Suzanne Ardito ◽  
...  
Keyword(s):  
Management Training ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Patient Centered ◽  
Inappropriate Use ◽  
Spot Check ◽  
Delirium Management ◽  
The Mean ◽  
Icu Delirium ◽  
Knowledge Deficits

Background Delirium affects up to 80% of patients in the intensive care unit (ICU) but is missed in up to 75% of cases. Telehealth in the ICU (tele-ICU) has become the standard for providing timely, expert care to remotely located ICUs. Objectives This pilot study assessed the feasibility and acceptability of using tele-ICU to increase the accuracy of delirium screening and recognition by ICU nurses. Methods The pilot sites included 4 ICUs across 3 hospitals. A geriatrician with delirium expertise remotely observed 13 bedside ICU nurses administering the Confusion Assessment Method for the ICU (CAM-ICU) to patients in real time via the tele-ICU platform and subsequently provided training on CAM-ICU performance and delirium management. Training evaluation consisted of a validated spot check form, a 2-item satisfaction/change-of-practice survey, and a qualitative question on acceptability. Results Thirteen ICU nurses were observed performing 26 bedside delirium assessments. The top observed barriers to accurate delirium screening were CAM-ICU knowledge deficits, establishment of baseline cognition, and inappropriate use of the “unable to assess” designation. The mean percentage of correct observations improved from 40% (first observation) to 90% (second observation) (P &lt; .001). All 13 nurses strongly agreed that the training was beneficial and practice changing. Conclusions The use of tele-ICU to improve the accuracy of delirium screening by ICU nurses appears to be feasible and efficient for leveraging delirium expertise across multiple ICUs. Future studies should evaluate the effects of tele-ICU delirium training on patient-centered outcomes.

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