Abstract
Delirium is a common and deadly problem in the emergency department affecting up to 30% of older adult patients. The 2013 Geriatric Emergency Department guidelines were developed to address the unique needs of the growing older population and identified delirium as a high priority area. The emergency department (ED) environment presents unique challenges for the identification and management of delirium, including patient crowding, time pressures, competing priorities, variable patient acuity, and limitations in available patient information. Accordingly, protocols developed for inpatient units may not be appropriate for use in the ED setting. We created a Delirium Change Package and Toolkit in the Emergency Department (ED-DEL) to provide protocols and guidance for implementing a delirium program in the ED setting. This article describes the multistep process by which the ED-DEL program was created and the key components of the program. Our ultimate goal is to create a resource that can be disseminated widely and used to improve delirium identification, prevention, and management in older adults in the ED.
Introduction
Delirium, a state of acute brain failure, is a serious, costly, and deadly syndrome estimated to affect 10%–30% of older adults presenting to the emergency department.1 Specifically, 8%–17% of older adults from the community and 40% from long-term care who go to the emergency department (ED) have delirium.2 Moreover, given that delirium is not measured in most EDs, these rates are likely to be underestimates considering the higher rates of delirium in older adults admitted to the hospital from the ED, ranging from 18% to 35%.2-4 Despite this high prevalence, delirium is diagnosed accurately by physicians in only 24%–35% of patients.1 Delirium leads to adverse outcomes, including greater functional and cognitive decline at 6 months after discharge compared to those without delirium.5 Unidentified delirium is associated with a substantially increased risk of death,6 and among patients discharged from the ED, diagnosed delirium is associated with a nearly 5-fold increase in 30-day mortality.7 Delirium is costly, with over $8 billion in annual Medicare expenditures for hospital costs and over $150 billion post-hospital costs attributable to delirium.8
The ED plays a critical role in delirium detection and management, serving as the entry point of care for the majority of persons with delirium. Although approximately one third of cases are preventable,9, 10 proven inpatient programs are not logistically feasible in the ED, and thus, new approaches are needed urgently. The 2013 Geriatric Emergency Department guidelines, endorsed by the American College of Emergency Physicians, Society for Academic Emergency Medicine, Emergency Nurses Association, and the American Geriatrics Society, outline the geriatric ED model of care and identified delirium as a priority area.11, 12 Given its frequency, underrecognition, adverse outcomes, and costs, delirium is a highly relevant target for quality improvement in EDs. There are many assessments and protocols that have been developed in the inpatient setting, intensive care units, and postoperative settings,13-16 but these have not been adapted for or evaluated in the ED setting. The ED setting poses unique challenges, including patient crowding, time pressures, competing priorities, and variable patient acuity.17 For example, the duration of the average triage assessment is typically 2 minutes or less.18 Protocols developed for inpatient units, where healthcare professionals care for patients over a period of days, may not be appropriate for use in the ED setting. Accordingly, ED-specific protocols addressing delirium identification, prevention, and management are essential. The Change Package and Toolkit for Delirium in the Emergency Department (ED-DEL) was created in direct response to the unique needs of implementing a delirium program in the ED. The goal of the present project was to provide EDs a roadmap or plan for how to implement more systematic delirium screening and management systems in their EDs without having to perform their own separate literature reviews to justify the program and without having to design their own change management approach. The ED-DEL Change Package and Toolkit were developed using a previously established and effective approach from the Institute for Healthcare Improvement (IHI) for implementing change in clinical settings.19 Following the IHI framework, we gathered the evidence based on a literature review and semistructured interviews with interprofessional staff members and experts, then used the IHI approach to create the ED-DEL Change Package and Toolkit to help EDs assess and manage delirium in the ED. It is important to note that the ED-DEL is not a screening tool, guideline, or clinical decision rule; however, it does provide information on a variety of screening tools, prediction rules, and guidelines related to delirium.