How can we identify patients with delirium in the emergency department?

Tamune, Hidetaka; Yasugi, Daisuke

doi:10.1016/j.ajem.2017.05.026

Cited by 15 publications

(12 citation statements)

References 23 publications

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“…These two tests are useful to evaluate ischemia, which is an unusual cause of a visit to the ED. 21,22 Head traumas, acute delirium and strokes are common causes for visiting an ED, [23][24][25] as indicated in our results, where the head CT scan was the most frequent test requested. This proportion may also be the result of the guidelines implemented at our hospital, which are aimed at excluding brain injuries even in minor head traumas, therefore avoiding subsequent morbidity, especially in elderly taking antiplatelet agents and anticoagulants.…”

Section: Discussionmentioning

confidence: 61%

Appropriateness of Radiology Test Requests by an Emergency Department: A Retrospective Study

et al. 2020

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Introduction: Imaging tests are essential for diagnosis in the emergency context and convey clinical information that is essential to assess the appropriateness of the tests and improve their interpretation. Therefore, we aimed to analyze the imaging tests requested by the Emergency Department in a district hospital.Material and Methods: We retrospectively analyzed computed tomography and ultrasound scans requested by the Emergency Department at the Centro Hospitalar Universitário do Algarve and considered the following variables: requested test, clinical information provided (complete/incomplete), appropriateness of the test (appropriate/inappropriate), outcome (presence/absence of relevant findings) and findings related to the clinical information (yes/no). Pearson’s chi-squared and odds ratio association tests were used to evaluate the statistical association between the variables.Results: Out of 1427 requests, only 219 (15.3%) were considered to have complete clinical information. Nonetheless, 1075 (75.3%) requests were considered appropriate. Relevant findings were present in about one-third (n = 453; 31.7%) and most of these findings were related to the clinical context (n = 410; 90.5%). There was a significant association between test appropriateness and the presence of relevant findings in the test (p < 0.001). The odds ratio of having a relevant finding was 5.0 times higher in the tests considered appropriate when compared with those classified as inappropriate (CI = 3.4 - 7.3; p < 0.001).Discussion: The fact that appropriate tests potentiate the probability of having a relevant finding emphasizes the importance of defining guidelines so that only the adequate tests are performed.Conclusion: Creating guidelines should improve the appropriateness of imaging tests requested in the Emergency Department, yielding their result, with the consequent rationalization of the available resources.

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Section: Discussionmentioning

confidence: 61%

Appropriateness of Radiology Test Requests by an Emergency Department: A Retrospective Study

et al. 2020

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“…There are multiple instruments for delirium screening, diagnosis, severity assessment and monitoring. [48][49][50][51] Therefore, before deciding to design a new screening tool, we examined each of the available tools against the above criteria, focusing on screening tools such as the CAM. We also searched the literature systematically, including conference proceedings, books and book chapters, for any newly published tools, as well as to examine the study data for each tool.…”

Section: The Need For a New Assessment Toolmentioning

confidence: 99%

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

MacLullich

Shenkin

Goodacre

et al. 2019

Health Technol Assess

106

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Background Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 ‘A’s test (Arousal, Attention, Abbreviated Mental Test – 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. Methods Phase 1 – the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 – the 4AT’s diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. Results Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0–14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0–6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. Limitations Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. Conclusions These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. Future work Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. Trial registration Current Controlled Trials ISRCTN53388093. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.

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“…Although there are recent systematic [48,56] and literature reviews [72,73] on delirium in Emergency Departments, they indicate that further research in this area should be encouraged. The delirium assessment scales used (CAM, CAM-ICU, DTS, bCAM, and others due to language validation) are diverse—the most widely studied being the CAM-ICU.…”

Section: Assessment Of Delirium In the Emergency Departmentmentioning

confidence: 99%

Delirium Assessment in Older People in Emergency Departments. A Literature Review

Pérez‐Ros

Martínez-Arnau

2019

Diseases

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Delirium is a neuropsychiatric syndrome often manifesting in acute disease conditions, and with a greater prevalence in the older generation. Delirium in the Emergency Department (ED) is a highly prevalent problem that typically goes unnoticed by healthcare providers. The onset of a delirium episode in the ED is associated with an increase in morbidity and mortality. Because delirium is a preventable syndrome, these statistics are unacceptable. Emergency Department staff therefore should strive to perform systematic screening in order to detect delirium. Different tools have been developed for the assessment of delirium by healthcare professionals other than psychiatrists or geriatricians. Emergency Departments require delirium assessment scales of high sensitivity and specificity, suited to the characteristics of the Department, since the time available is scarce. In addition, the presence of dementia in the assessment of delirium may induce sensitivity bias. Despite the existence of numerous delirium rating scales, scales taking less than three minutes to complete are recommended. The choice of the tool depends on the characteristics of the ED. The only scale affording high sensitivity and specificity in older people with and without dementia is the Four “A”s Test (4AT); it requires no training on the part of the rater, and can be performed in under two minutes.

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How can we identify patients with delirium in the emergency department?

Cited by 15 publications

References 23 publications

Appropriateness of Radiology Test Requests by an Emergency Department: A Retrospective Study

Appropriateness of Radiology Test Requests by an Emergency Department: A Retrospective Study

The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study

Delirium Assessment in Older People in Emergency Departments. A Literature Review

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