Delirium is a commonly missed diagnosis in emergency departments throughout the world, and this is associated with poor patient outcomes, and increased health care costs. Studies around the world have consistently demonstrated that a large number (roughly 70-80%) of delirium cases are missed in the ED, and that over 90% of these missed cases are subsequently missed on inpatient units (Han et al, 2009). Hypoactive delirium is more common, and more frequently missed in the ED. Older people are at increased risk of presenting with delirium, as well as developing delirium throughout their ED and inpatient stay. Fortunately, delirium screening and assessment tools exist which are rapid to perform and, when combined, are very sensitive and specific for detecting delirium.
With this in mind, we developed an ED Delirium Pathway to help enhance recognition and care of adults with delirium in emergency departments across the province of Saskatchewan, Canada. Saskatchewan is one of thirteen provinces and territories in Canada, with a populous of 1.2 million people spread over 650,000 km2 (larger than the entirety of France). There are two large urban centres (~250 000), three medium urban centres (30-40,000) and seven small urban centres (10 – 30,000), with the remainder of the population living in mixed rural and remote communities.
This ED delirium pathway is anticipated to be the first of a series of delirium works spanning the ED, inpatient care and possibly beyond (e.g. long term care). The team aims to create a unified and cohesive pathway surrounding prevention, diagnosis and care for patients with delirium. The focus is on delirium prevention, as well as improving non-pharmacologic care of patients with delirium, as well as improved decision making surrounding pharmacologic intervention when required. It is also anticipated that future care pathways and innovations will be developed regarding core geriatric concerns and presentations to the emergency department.
The ED Delirium Pathway utilizes evidence-based screening and assessment tools including the Delirium Triage Screen (DTS) (Sensitivity 98%, Specificity 55%) and the Brief Confusion Assessment Model (bCAM) (sensitivity 84%, specificity 95.8%) (Han et al, 2013); and incorporates the Canadian Triage and Assessment Score (CTAS) Frailty Modifier introduced in 2016 (Bullard et al, 2017).
The Pathway development was led by an emergency physician with a fellowship in geriatric emergency medicine, and an interprofessional working group consisting of a patient/family advisor; nurses; physicians including emergency, geriatrics and psychiatry; allied health (PT); pharmacy; and administrative leaders. The working group represented a variety of ED care settings across the province which was particularly relevant given the substantial spread of urban, rural, and remote communities, and the different demographics they serve. The interprofessional group has been a key element to the success of the work so far, as they bring a vast amount of experience and knowledge. They have contributed throughout the development process, and are also key to the educational activities associated with the pathway, as well as its implementation and evaluation.
To date, the working group is reviewing feedback from the second and final consultation, and the pathway, which has been overwhelmingly well received, will undergo pilot launches later in 2021, with province wide implementation predicted for late 2021/early 2022. For more information about this work, contact Dr Brittany Ellis at [email protected]
Bullard, M., Musgrave, E., Warren, D., Unger, B., Skeldon, T., Grierson, R., . . . Swain, J. (2017). Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) Guidelines 2016. CJEM, 19(S2), S18-S27. doi:10.1017/cem.2017.365
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 Nov;62(5):457-465. doi: 10.1016/j.annemergmed.2013.05.003.
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 Mar;16(3):193-200. doi: 10.1111/j.1553-2712.2008.00339.x.