Prevalence, management and outcomes of unrecognized delirium in a National Sample of 1,493 older emergency department patients: how many were sent home and what happened to them?

BACKGROUND: Retrospective studies estimate Emergency Department (ED) delirium recognition at <20%; few prospective studies have assessed delirium recognition and outcomes for patients with unrecognized delirium. OBJECTIVES: To prospectively measure delirium recognition by ED nurses and physicians, document their confidence in diagnosis and disposition, actual dispositions, and patient outcomes. METHODS: Prospective observational study of people ≥65 years. We assessed delirium using the Confusion Assessment Method, then asked ED staff if the patient had delirium, confidence in their assessment, if the patient could be discharged, and contacted patients 1 week postdischarge. We report proportions and 95% confidence intervals (Cls). RESULTS: We enrolled 1,493 participants; mean age was 77.9 years; 49.2% were female, 79 (5.3%, 95% CI 4.2-6.5%) had delirium. ED nurses missed delirium in 43/78 cases (55.1%, 95% CI 43.4-66.4%). Nurses considered 12/43 (27.9%) patients with unrecognized delirium safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 7.0/10. Physicians missed delirium in 10/20 (50.0%, 95% CI 27.2-72.8) cases and considered 2/10 (20.0%) safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 8.0/10. Fifteen patients with unrecognized delirium were sent home: 6.7% died at 1 week follow-up vs. none in those with recognized delirium and 1.1% in the rest of the cohort. CONCLUSION: Delirium recognition by nurses and physicians was sub-optimal at ~50% and may be associated with increased mortality. Research should explore root causes of unrecognized delirium, and novel strategies to systematically improve delirium recognition and patient outcomes.

The use of a self-check-in kiosk for early patient identification and queuing in the emergency department.

OBJECTIVE: Delays in triage processes in the emergency department (ED) can compromise patient safety. The aim of this study was to provide proof-of-concept that a self-check-in kiosk could decrease the time needed to identify ambulatory patients arriving in the ED. We compared the use of a novel automated self-check-in kiosk to identify patients on ED arrival to routine nurse-initiated patient identification. METHODS: We performed a prospective trail with random weekly allocation to intervention or control processes during a 10-week study period. During intervention weeks, patients used a self-check-in kiosk to self-identify on arrival. This electronically alerted triage nurses to patient arrival times and primary complaint before triage. During control weeks, kiosks were unavailable and patients were identified using routine nurse-initiated triage. The primary outcome was time-to-first-identification, defined as the interval between ED arrival and identification in the hospital system. RESULTS: Median (interquartile range) time-to-first-identification was 1.4 minutes (1.0-2.08) for intervention patients and 9 minutes (5-18) for control patients. Regression analysis revealed that the adjusted time-to-first-identification was 13.6 minutes (95% confidence interval 12.8-14.5) faster for the intervention group. CONCLUSION: A self-check-in kiosk significantly reduced the time-to-first-identification for ambulatory patients arriving in the ED.

OBJECTIF: Les délais d'attente inhérents au processus de triage des malades au service des urgences (SU) peuvent mettre en péril leur sécurité. L'étude visait donc à valider le principe selon lequel l'utilisation d'un guichet d'auto-inscription diminuerait le temps nécessaire pour signaler l'arrivée des malades ambulatoires au SU. A été comparé le processus d'utilisation d'un guichet d'auto-inscription d'un nouveau type pour signaler l'arrivée des malades au SU avec le processus habituel d'inscription des malades par le personnel infirmier. MÉTHODE: L'étude consistait en un essai prospectif, à répartition aléatoire et hebdomadaire, d'inscription, réalisé selon le processus expérimental ou le processus témoin, sur une période de 10 semaines. Durant les semaines d'expérimentation, les malades se dirigeaient vers le guichet d'auto-inscription à leur arrivée; un signal électronique informait le personnel infirmier affecté au triage de l'heure d'arrivée des malades et des motifs de consultation avant le triage lui-même. Durant les semaines témoins, les guichets étaient fermés et les malades étaient inscrits selon le processus habituel de triage effectué par le personnel infirmier. Le principal critère d'évaluation était le temps écoulé avant le signal d'arrivée, défini comme l'intervalle entre l'arrivée des malades au SU et leur inscription dans le système de l'hôpital. RÉSULTATS: Le temps médian (écart interquartile) écoulé avant le signal d'arrivée était de 1,4 minute (1,0­2,08) durant les semaines d'expérimentation contre 9 minutes (5 ­18) durant les semaines témoins. D'après les résultats de l'analyse de régression, le temps rajusté écoulé avant le signal d'arrivée était de 13,6 minutes (IC à 95% : 12,8­14,5) plus court dans le groupe d'expérimentation que dans le groupe témoin. CONCLUSION: L'utilisation d'un guichet d'auto-inscription a permis de réduire considérablement le temps écoulé avant le signal d'arrivée des malades ambulatoires au SU.

Push-Alert Notification of Troponin Results to Physician Smartphones Reduces the Time to Discharge Emergency Department Patients: A Randomized Controlled Trial.

STUDY OBJECTIVE: For emergency department (ED) patients with chest pain, discharge decisions often hinge on troponin results. Push-alert notifications deliver results immediately to physician smartphones. Our objective is to determine whether troponin push alerts improve the time to discharge decisions for ED patients with chest pain. METHODS: In an academic ED, we assessed the effect of a quality improvement initiative using troponin push alerts to physician smartphones, with a cluster-randomized evaluation. Participating physicians were randomized to receive troponin push alerts (intervention) or not receive them (control). We retrospectively identified patients treated by participating physicians during the study period who were discharged from the ED with chest pain. The primary outcome was the time from final troponin result to discharge decision. Secondary outcomes included length of stay. A linear mixed model was used to adjust for physician clustering. RESULTS: During the study, 1,554 patients were discharged from the ED with chest pain. There were 551 patients in the control group and 554 in the intervention group who met inclusion criteria. The overall median interval from final troponin result to discharge decision was 79.7 minutes (interquartile range [IQR] 33.6 to 167.8 minutes); it was 94.3 minutes (IQR 36.2 to 177.8 minutes) in the control group and 68.5 minutes (IQR 30.5 to 157.2 minutes) in the intervention group. This 25.8-minute difference in medians (95% confidence interval 24.6 to 28.0 minutes) was statistically significant. Total ED length of stay was 345 minutes (IQR 261 to 419 minutes) in the control group and 328 minutes (IQR 250 to 408 minutes) in the intervention group. CONCLUSION: Physicians who received troponin push alerts discharged their patients with chest pain 26 minutes faster than those without troponin notifications. Total ED length of stay did not significantly improve for these patients.