Development and validation of a delirium risk assessment tool in older patients admitted to the Emergency Department Observation Unit.
Ontology highlight
ABSTRACT: Background
Delirium is frequent though undetected in older patients admitted to the Emergency Department (ED).Aims
To develop and validate a delirium risk assessment tool for older persons admitted to the ED Observation Unit (OU).Methods
We used data from two samples of 65 + year-old patients, one admitted to the ED of Brescia Hospital (n = 257) and one to the ED of Desio Hospital (n = 107), Italy. Data from Brescia were used as training sample, those collected in Desio as testing one. Delirium was assessed using the 4AT and patients' characteristic were retrieved from medical charts. Variables found to be associated with delirium in the training sample were tested for the creation of a delirium risk assessment tool. The resulting tool's performances were assessed in the testing subsample.Results
Of all possible scores tested, the combination with the highest discriminative ability in the training sample included: age ≥ 75 years, dementia diagnosis, chronic use of neuroleptics, and hearing impairment. The delirium score exhibited an AUC of 0.874 and 0.893 in the training and testing samples, respectively. For a 1-point increase in the score, the odds of delirium increased more than twice in both samples.Discussion
We propose a delirium risk assessing tool that includes variables that can be easily collected at ED admission and that can be calculated rapidly.Conclusion
A risk assessment tool could help improving delirium detection in older persons referring to ED.
SUBMITTER: Zucchelli A
PROVIDER: S-EPMC8531045 | biostudies-literature |
REPOSITORIES: biostudies-literature
Similar Datasets
Project description:In the emergency department (ED), health care providers miss delirium approximately 75% of the time, because they do not routinely screen for this syndrome. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a brief (<1 minute) delirium assessment that may be feasible for use in the ED. The study objective was to determine its validity and reliability in older ED patients.In this prospective observational cohort study, patients aged 65 years or older were enrolled at an academic, tertiary care ED from July 2009 to February 2012. An emergency physician (EP) and research assistants (RAs) performed the CAM-ICU. The reference standard for delirium was a comprehensive (~30 minutes) psychiatrist assessment using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. All assessments were blinded to each other and were conducted within 3 hours. Sensitivities, specificities, and likelihood ratios were calculated for both the EP and the RAs using the psychiatrist's assessment as the reference standard. Kappa values between the EP and RAs were also calculated to measure reliability.Of 406 patients enrolled, 50 (12.3%) had delirium. The median age was 73.5 years old (interquartile range [IQR] = 69 to 80 years), 202 (49.8%) were female, and 57 (14.0%) were nonwhite. The CAM-ICU's sensitivities were 72.0% (95% confidence interval [CI] = 58.3% to 82.5%) and 68.0% (95% CI = 54.2% to 79.2%) in the EP and RAs, respectively. The CAM-ICU's specificity was 98.6% (95% CI = 96.8% to 99.4%) for both raters. The negative likelihood ratios (LR-) were 0.28 (95% CI = 0.18 to 0.44) and 0.32 (95% CI = 0.22 to 0.49) in the EP and RAs, respectively. The positive likelihood ratios (LR+) were 51.3 (95% CI = 21.1 to 124.5) and 48.4 (95% CI = 19.9 to 118.0), respectively. The kappa between the EP and RAs was 0.92 (95% CI = 0.85 to 0.98), indicating excellent interobserver reliability.In older ED patients, the CAM-ICU is highly specific, and a positive test is nearly diagnostic for delirium when used by both the EP and RAs. However, the CAM-ICU's sensitivity was modest, and a negative test decreased the likelihood of delirium by a small amount. The consequences of a false-negative CAM-ICU are unknown and deserve further study.
| S-EPMC4034173 | biostudies-literature
Project description:IntroductionThe emergency department (ED) observation unit has become a unique practice opportunity to liberate inpatient capacity in the United States. Substantial variations in clinical practice and level of comfort among ED providers existed in a large health care system. We aimed to study the effectiveness of an educational module targeted for emergency medicine providers.MethodsWe developed a 20-minute online module including pretest, learning module, and posttest. The format consisted of Likert-scale (1 = least comfortable, 5 = most comfortable), true-or-false, and multiple-choice questions. The learning module contained slides, script, and figures describing management strategy for commonly encountered conditions in the observation unit. The institutional review board granted exempted review. Pre- and posttest scores were evaluated with the Wilcoxon rank-sum test, and a p value of less than .05 was considered significant.ResultsTwenty-one participants completed the pretest, with a mean score of 63.8 (SD = 19.3), and 14 participants completed the posttest, with a mean score of 87.9 (SD = 9.7; p = .0001). Eight participants responded to a follow-up survey, a response rate of 57%. Responses demonstrated that levels of provider comfort in selection of observation (M = 4.3, SD = 1.5), choice of stress test for chest pain (M = 4.3, SD = 1.0), asthma management (M = 4.1, SD = 1.0), anaphylaxis care (M = 4.1, SD = 1.4), and documentation (M = 4.3, SD = 0.9) were high.DiscussionAn online learning module can be useful to enhance the knowledge of observation medicine among emergency medicine providers.
| S-EPMC6464449 | biostudies-literature
Project description:Background: Hospitals' use of observation status for patients with cancer presenting to the emergency department (ED) is not well understood. This model of care delivery may be a viable alternative to inpatient admission for patients with cancer presenting with certain conditions. Our objective was to assess the use of observation status among Medicare beneficiaries with and without cancer. Methods: Population-based SEER-Medicare data were used to assess differences in the use of observation status between Medicare beneficiaries aged ≥66 years with and without cancer using a matched analysis (n=151,183 per cohort). We assessed the ratio of observation unit use to inpatient admission, between cancer and noncancer cohorts, and for patients diagnosed with breast, colon, lung, and prostate cancers. Poisson regression models were used to calculate observation rate estimates and 95% CIs while adjusting for selected patient characteristics. Results: When considering the volume of hospitalizations, observation status is used less frequently among beneficiaries with cancer than those without (43 vs 69 observation status visits per 1,000 inpatient admissions, respectively). The estimated observation rate per 1,000 inpatient admissions was higher for beneficiaries aged <75 years versus those aged ≥75 years, those with a Charlson comorbidity index of 0 vs 1 or ≥2, and those without a prior hospitalization versus those with ≥1 prior hospitalizations. Patients with breast and prostate cancers had higher adjusted and unadjusted observation rates per 1,000 inpatient admissions compared with those with colon and lung cancers. Conclusions: Observation status is used proportionately less for beneficiaries with cancer than those without. There may be opportunities to develop standards for ED staff to manage certain conditions for patients with cancer in observation status, and to reserve hospital resources for those who need it most.
| S-EPMC7539684 | biostudies-literature
Project description:ObjectivesThe outcome of emergency medicine (EM) training is to produce physicians who can competently run an emergency department (ED) shift. However, there are few tools with supporting validity evidence specifically designed to assess multiple key competencies across an entire shift. The investigators developed and gathered validity evidence for a novel entrustment-based tool to assess a resident's ability to safely run an ED shift.MethodsThrough a nominal group technique, local and national stakeholders identified dimensions of performance that are reflective of a competent ED physician and are required to safely manage an ED shift. These were included as items in the Ottawa Emergency Department Shift Observation Tool (O-EDShOT), and each item was scored using an entrustment-based rating scale. The tool was implemented in 2018 at the University of Ottawa Department of Emergency Medicine, and quantitative data and qualitative feedback were collected over 6 months.ResultsA total of 1,141 forms were completed by 78 physicians for 45 residents. An analysis of variance demonstrated an effect of training level with statistically significant increases in mean O-EDShOT scores with each subsequent postgraduate year (p < 0.001). Scores did not vary by ED treatment area. Residents rated as able to safely run the shift had significantly higher mean ± SD scores (4.8 ± 0.3) than those rated as not able (3.8 ± 0.6; p < 0.001). Faculty and residents reported that the tool was feasible to use and facilitated actionable feedback aimed at progression toward independent practice.ConclusionsThe O-EDShOT successfully discriminated between trainees of different levels regardless of ED treatment area. Multiple sources of validity evidence support the O-EDShOT as a tool to assess a resident's ability to safely run an ED shift. It can serve as a stimulus for daily observation and feedback making it practical to use within an EM residency program.
| S-EPMC7592826 | biostudies-literature
Project description:Atrial fibrillation (AF) is a common, growing, and costly medical condition. We aimed to evaluate the impact of a management algorithm for symptomatic AF that used an emergency department observation unit on hospital admission rates and patient outcomes.This retrospective cohort study compared 563 patients who presented consecutively in the year after implementation of the algorithm, from July 2013 through June 2014 (intervention group), with 627 patients in a historical cohort (preintervention group) who presented consecutively from July 2011 through June 2012. All patients who consented to have their records used for chart review were included if they had a primary final emergency department diagnosis of AF. We observed no significant differences in age, sex, vital signs, body mass index, or CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke or transient ischemic attack) score between the preintervention and intervention groups. The rate of inpatient admission was significantly lower in the intervention group (from 45% to 36%; P<0.001). The groups were not significantly different with regard to rates of return emergency department visits (19% versus 17%; P=0.48), hospitalization (18% versus 16%; P=0.22), or adverse events (2% versus 2%; P=0.95) within 30 days. Emergency department observation unit admissions were 40% (P<0.001) less costly than inpatient hospital admissions of ≤1 day's duration.Implementation of an emergency department observation unit AF algorithm was associated with significantly decreased hospital admissions without increasing the rates of return emergency department visits, hospitalization, or adverse events within 30 days.
| S-EPMC4802469 | biostudies-other
Project description:BACKGROUND:Emergency Department (ED) Observation Units (Obs Units) are prevalent in the US, but little is known regarding older adults in observation. Our objective was to describe the Obs Units nationally and observation patients with specific attention to differences in care with increasing age. DESIGN:This is an analysis of 2010-2013 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national observational cohort study including ED patients. Weighted means are presented for continuous data and weighted percent for categorical data. Multivariable logistic regression was used to identify variables associated with placement in and admission from observation. RESULTS:The number of adult ED visits varied from 100 million to 107 million per year and 2.3% of patients were placed in observation. Adults ≥65 years old made up a disproportionate number of Obs Unit patients, 30.6%, compared to only 19.7% of total ED visits (odds ratio 1.5 (95% CI 1.5-1.6), adjusting for sex, race, month, day of week, payer source, and hospital region). The overall admission rate from observation was 35.6%, ranging from 31.3% for ages 18-64 years to 47.5% for adults ≥85 years old (p < 0.001). General symptoms (e.g., nausea, dizziness) and hypertensive disease were the most common diagnoses overall. Older adults varied from younger adults in that they were frequently observed for diseases of the urinary system (ICD-9 590-599) and metabolic disorders (ICD-9 270-279). CONCLUSIONS:Older adults are more likely to be cared for in Obs Units. Older adults are treated for different medical conditions than younger adults.
| S-EPMC6565511 | biostudies-literature
Project description:BACKGROUND:To test if the 5-item compassion measure (a tool previously validated in the outpatient setting to measure patient assessment of clinician compassion) is a valid and reliable tool to quantify a distinct construct (i.e. clinical compassion) among patients evaluated in the emergency department (ED). METHODS:Cross-sectional study conducted in three academic emergency departments in the U.S. between November 2018 and April 2019. We enrolled adult patients who were evaluated in the EDs of the participating institutions and administered the 5-item compassion measure after completion of care in the ED. Validity testing was performed using confirmatory factor analysis. Cronbach's alpha was used to test reliability. Convergent validity with patient assessment of overall satisfaction questions was tested using Spearman correlation coefficients and we tested if the 5-item compassion measure assessed a construct distinct from overall patient satisfaction using confirmatory factor analysis. RESULTS:We analyzed 866 patient responses. Confirmatory factor analysis found all five items loaded well on a single construct and our model was found to have good fit. Reliability was excellent (Cronbach's alpha?=?0.93) among the entire cohort. These results remained consistent on sub-analyses stratified by individual institutions. The 5-item compassion measure had moderate correlation with overall patient satisfaction (r?=?0.66) and patient recommendation of the ED to friends and family (r?=?0.57), but reflected a patient experience domain (i.e. compassionate care) distinctly different from patient satisfaction. CONCLUSIONS:The 5-item compassion measure is a valid and reliable tool to measure patient assessment of clinical compassion in the ED.
| S-EPMC6827199 | biostudies-literature
Project description:Objectives Diabetes is a debilitating disease that affects the way the body uses or produces insulin. Research evaluating the usefulness in screening patients admitted to a clinical decision unit (CDU) from the emergency department (ED) has been limited. Methods A retrospective chart review of patients admitted to a CDU from the ED was performed. Patients included were > 18-year-old who were observed in the CDU, had blood glucose drawn greater than eight hours after admission, and who had not been previously diagnosed with diabetes. Age, sex, and fasting glucose level were collected. The analysis was done to evaluate the percentage of patients undiagnosed and at risk for diabetes mellitus by assessing fasting blood glucose the morning after admission. Results Study revealed that 27.8% of the patients analyzed in this study had fasting blood glucose levels meeting or exceeding the diagnostic threshold of 126 mg/dL and could potentially have undiagnosed diabetes. Conclusion Screening patients admitted to a CDU from the emergency department identified that 27.8% had fasting plasma glucose levels ? 126 mg/dL. Consideration should be made to obtain a fasting blood glucose level in those without a previous diagnosis of diabetes who are observed overnight in a CDU.
| S-EPMC6279010 | biostudies-other
Project description:Backgroundthe ageing demographic means that increasing numbers of older people will be attending emergency departments (EDs). Little previous research has focused on the needs of older people in ED and there have been no evaluations of comprehensive geriatric assessment (CGA) embedded within the ED setting.Methodsa pre-post cohort study of the impact of embedding CGA within a large ED in the East Midlands, UK. The primary outcome was admission avoidance from the ED, with readmissions, length of stay and bed-day use as secondary outcomes.Resultsattendances to ED increased in older people over the study period, whereas the ED conversion rate fell from 69.6 to 61.2% in people aged 85+, and readmission rates in this group fell from 26.0% at 90 days to 19.9%. In-patient bed-day use increased slightly, as did the mean length of stay.Discussionit is possible to embed CGA within EDs, which is associated with improvements in operational outcomes.
| S-EPMC3861335 | biostudies-literature
Project description:BackgroundDelirium in emergency department (ED) patients occurs frequently and often remains unrecognized. Most instruments for delirium detection are complex and therefore unfeasible for the ED. The aims of this pilot study were first, to confirm our hypothesis that there is an unmet need for formal delirium assessment by comparing informal delirium ratings of ED staff with formal delirium assessments performed by trained research assistants. Second, to test the feasibility of an algorithm for delirium screening, detection and management, which includes the newly developed modified Confusion Assessment Method for the Emergency Department (mCAM-ED) at the ED bedside. Third, to test interrater reliability of the mCAM-ED.MethodsThis was a pilot study with a pre-post-test design with two data collection periods before and after the implementation of the algorithm. Consecutive ED patients aged 65 years and older were screened and assessed in the ED of a tertiary care center by trained research assistants. The delirium detection rate of informal ratings by nurses and physicians was compared with the standardized mCAM-ED assessment performed by the research assistants. To show the feasibility at the ED bedside, defined as adherence of ED staff to the algorithm, only post-test data were used. Additionally, the ED nurses' assessments were analyzed qualitatively. To investigate the agreement between research assistants and the reference standard, the two data sets were combined.ResultsIn total, 207 patients were included in this study. We found that informal delirium assessment was inappropriate, even after a teaching intervention: Sensitivity of nurses to detect delirium without formal assessment was 0.27 pretest and 0.40 post-test, whilst sensitivity of physicians' informal rating was 0.45 pre-test and 0.6 post-test. ED staff demonstrated high adherence to the algorithm (76.5%). Research assistants assessing delirium with the mCAM-ED demonstrated a high agreement compared to the reference standard (kappa = 0.729).ConclusionsInformal assessment of delirium is inadequate. The mCAM-ED proved to be useful at the ED bedside. Performance criteria need to be tested in further studies. The mCAM-ED may contribute to early identification of delirious ED patients.
| S-EPMC3975151 | biostudies-literature