Screening, detection and management of delirium in the emergency department – a pilot study on the feasibility of a new algorithm for use in older emergency department patients: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED)

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Christian H Nickel¹  Reto W Kressig³  Roland Bingisser¹  Andreas Graber²  Wolfgang Hasemann²  Florian F Grossmann¹ 

[1] Emergency Department, University Hospital Basel, Basel, Switzerland;Department for Practice Development, University Hospital Basel, Basel, Switzerland;Felix Platter Hospital Basel, University Center for Medicine of Aging, Basel, Switzerland

关键词: Confusion assessment method;    Feasibility;    Geriatrics;    Delirium;    Emergency department;    Emergency nursing;    Emergency medicine;   

Others  :  804872
DOI  :  10.1186/1757-7241-22-19

 received in 2013-12-08, accepted in 2014-02-25,  发布年份 2014

【 摘 要 】

Background

Delirium 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.

Methods

This 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.

Results

In 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).

Conclusions

Informal 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.

【 授权许可】

   
2014 Grossmann et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]American Psychiatric Association. Task force on DSM-IV: Diagnostic and Statistial Manual of Mental Disorders: DSM-IV-TR. 4th edition. Wachington, DC: American Psychiatric Association; 2000.
• [2]Vida S, Galbaud du Fort G, Kakuma R, Arsenault L, Platt RW, Wolfson CM: An 18-month prospective cohort study of functional outcome of delirium in elderly patients: activities of daily living. Int Psychogeriatr 2006, 18:681-700.
• [3]Han JH, Eden S, Shintani A, Morandi A, Schnelle J, Dittus RS, Storrow AB, Ely EW: Delirium in older emergency department patients is an independent predictor of hospital length of stay. Acad Emerg Med 2011, 18:451-457.
• [4]Gross AL, Jones RN, Habtemariam DA, Fong TG, Tommet D, Quach L, Schmitt E, Yap L, Inouye SK: Delirium and long-term cognitive trajectory among persons with dementia. Arch Intern Med 2012, 172:1324-1331.
• [5]Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA: Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA 2010, 304:443-451.
• [6]Hustey FM, Meldon SW, Smith MD, Lex CK: The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med 2003, 41:678-684.
• [7]Han JH, Zimmerman EE, Cutler N, Schnelle J, Morandi A, Dittus RS, Storrow AB, Ely EW: Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med 2009, 16:193-200.
• [8]Samaras N, Chevalley T, Samaras D, Gold G: Older patients in the emergency department: a review. Ann Emerg Med 2010, 56:261-269.
• [9]Hustey FM, Meldon SW: The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med 2002, 39:248-253.
• [10]Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC: Unrecognized delirium in ED geriatric patients. Am J Emerg Med 1995, 13:142-145.
• [11]Elie M, Rousseau F, Cole M, Primeau F, McCusker J, Bellavance F: Prevalence and detection of delirium in elderly emergency department patients. CMAJ 2000, 163:977-981.
• [12]Inouye SK, Foreman MD, Mion LC, Katz KH, Cooney LM Jr: Nurses’ recognition of delirium and its symptoms: comparison of nurse and researcher ratings. Arch Intern Med 2001, 161:2467-2473.
• [13]Press Y, Margulin T, Grinshpun Y, Kagan E, Snir Y, Berzak A, Clarfield AM: The diagnosis of delirium among elderly patients presenting to the emergency department of an acute hospital. Arch Gerontol Geriatr 2009, 48:201-204.
• [14]Morandi A, Davis D, Taylor JK, Bellelli G, Olofsson B, Kreisel S, Teodorczuk A, Kamholz B, Hasemann W, Young J, Morandi A, Davis D, Taylor JK, Bellelli G, Olofsson B, Kreisel S, Teodorczuk A, Kamholz B, Hasemann W, Young J, Agar M, de Rooij SE, Meagher D, Trabucchi M, MacLullich AM: Consensus and variations in opinions on delirium care: a survey of European delirium specialists. Int Psychogeriatr 2013, 25:1-9.
• [15]Wong CL, Holroyd-Leduc J, Simel DL, Straus SE: Does this patient have delirium?: value of bedside instruments. JAMA 2010, 304:779-786.
• [16]Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI: Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990, 113:941-948.
• [17]Folstein MF, Folstein SE, McHugh PR: “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975, 12:189-198.
• [18]Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, Speroff T, Gautam S, Bernard GR, Inouye SK: Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001, 29:1370-1379.
• [19]Han JH, Morandi A, Ely EW, Callison C, Zhou C, Storrow AB, Dittus RS, Habermann R, Schnelle J: Delirium in the nursing home patients seen in the emergency department. J Am Geriatr Soc 2009, 57:889-894.
• [20]Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, Truman B, Speroff T, Gautam S, Margolin R, Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, Truman B, Speroff T, Gautam S, Margolin R, Hart RP, Dittus R: Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001, 286:2703-2710.
• [21]Neufeld KJ, Hayat MJ, Coughlin JM, Huberman AL, Leistikow NA, Krumm SK, Needham DM: Evaluation of two intensive care delirium screening tools for non-critically ill hospitalized patients. Psychosomatics 2011, 52:133-140.
• [22]Han JH, Wilson A, Vasilevskis EE, Shintani A, Schnelle JF, Dittus RS, Graves AJ, Storrow AB, Shuster J, Ely EW: Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med 2013, 62:457-465.
• [23]Definition of an older or elderly personhttp://www.who.int/healthinfo/survey/ageingdefnolder/en/ webcite
• [24]Stillman MJ, Rybicki LA: The bedside confusion scale: development of a portable bedside test for confusion and its application to the palliative medicine population. J Palliat Med 2000, 3:449-456.
• [25]Kahn RL, Goldfarb AI, Pollack M, Peck A: Brief objective measures for the determination of mental status in the aged. Am J Psychiatry 1960, 117:326-328.
• [26]MacKenzie DM, Copp P, Shaw RJ, Goodwin GM: Brief cognitive screening of the elderly: a comparison of the mini-mental state examination (MMSE), abbreviated mental test (AMT) and mental status questionnaire (MSQ). Psychol Med 1996, 26:427-430.
• [27]Fillenbaum GG: Comparison of two brief tests of organic brain impairment, the MSQ and the short portable MSQ. J Am Geriatr Soc 1980, 28:381-384.
• [28]Inouye SK: The Confusion Assessment Method (CAM). Training Manual and Coding Guide. New Haven: Yale-New Haven Hospital; 2003.
• [29]Hart RP, Levenson JL, Sessler CN, Best AM, Schwartz SM, Rutherford LE: Validation of a cognitive test for delirium in medical ICU patients. Psychosomatics 1996, 37:533-546.
• [30]Gilboy N, Tanabe P, Travers D, Rosenau A: A Triage Tool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition. Rockville: Agency for Healthcare Research and Quality; 2012:2011.
• [31]Nemec M, Koller MT, Nickel CH, Maile S, Winterhalder C, Karrer C, Laifer G, Bingisser R: Patients presenting to the emergency department with non-specific complaints: the Basel Non-specific Complaints (BANC) study. Acad Emerg Med 2010, 17:284-292.
• [32]Boustani M, Campbell N, Munger S, Maidment I, Fox G: Impact of anticholinergics on the aging brain: a review and practical application. Aging Health 2008, 4:311-320.
• [33]Charlson ME, Pompei P, Ales KL, MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987, 40:373-383.
• [34]Fabbri RM, Moreira MA, Garrido R, Almeida OP: Validity and reliability of the Portuguese version of the confusion assessment method (CAM) for the detection of delirium in the elderly. Arq Neuropsiquiatr 2001, 59:175-179.
• [35]Monette J, Galbaud du Fort G, Fung SH, Massoud F, Moride Y, Arsenault L, Afilalo M: Evaluation of the Confusion Assessment Method (CAM) as a screening tool for delirium in the emergency room. Gen Hosp Psychiatry 2001, 23:20-25.