Edward R Marcantonio1, Donna M Fick2, Yoojin Jung3, Sharon K Inouye4, Marie Boltz5, Douglas L Leslie6, Erica K Husser5, Priyanka Shrestha5, Amber Moore7, Kimberlyann Sulmonte8, Jonathan Siuta9, Malaz Boustani10, Long H Ngo11. 1. Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts (E.R.M.). 2. Ross and Carol Nese College of Nursing, The Pennsylvania State University, University Park, Pennsylvania, and College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania (D.M.F.). 3. Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Y.J.). 4. Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, and Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts (S.K.I.). 5. Ross and Carol Nese College of Nursing, The Pennsylvania State University, University Park, Pennsylvania (M.B., E.K.H., P.S.). 6. College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania (D.L.L.). 7. Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, and Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts (A.M.). 8. Department of Nursing, Beth Israel Deaconess Medical Center, Boston, Massachusetts (K.S.). 9. Department of Medicine, Mount Nittany Medical Center, State College, Pennsylvania (J.S.). 10. Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, Indiana (M.B.). 11. Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts (L.H.N.).
Abstract
BACKGROUND: Systematic screening improves delirium identification among hospitalized older adults. Little data exist on how to implement such screening. OBJECTIVE: To test implementation of a brief app-directed protocol for delirium identification by physicians, nurses, and certified nursing assistants (CNAs) in real-world practice relative to a research reference standard delirium assessment (RSDA). DESIGN: Prospective cohort study. SETTING: Large urban academic medical center and small rural community hospital. PARTICIPANTS: 527 general medicine inpatients (mean age, 80 years; 35% with preexisting dementia) and 399 clinicians (53 hospitalists, 236 nurses, and 110 CNAs). MEASUREMENTS: On 2 study days, enrolled patients had an RSDA. Subsequently, CNAs performed an ultra-brief 2-item screen (UB-2) for delirium, whereas physicians and nurses performed a 2-step protocol consisting of the UB-2 followed in those with a positive screen result by the 3-Minute Diagnostic Assessment for the Confusion Assessment Method. RESULTS: Delirium was diagnosed in 154 of 924 RSDAs (17%) and in 114 of 527 patients (22%). The completion rate for clinician protocols exceeded 97%. The CNAs administered the UB-2 in a mean of 62 seconds (SD, 51). The 2-step protocols were administered in means of 104 seconds (SD, 99) by nurses and 106 seconds (SD, 105) by physicians. The UB-2 had sensitivities of 88% (95% CI, 72% to 96%), 87% (CI, 73% to 95%), and 82% (CI, 65% to 91%) when administered by CNAs, nurses, and physicians, respectively, with specificities of 64% to 70%. The 2-step protocol had overall accuracy of 89% (CI, 83% to 93%) and 87% (CI, 81% to 91%), with sensitivities of 65% (CI, 48% to 79%) and 63% (CI, 46% to 77%) and specificities of 93% (CI, 88% to 96%) and 91% (CI, 86% to 95%), for nurses and physicians, respectively. Two-step protocol sensitivity for moderate to severe delirium was 78% (CI, 54% to 91%). LIMITATION: Two sites; limited diversity. CONCLUSION: An app-directed protocol for delirium identification was feasible, brief, and accurate, and CNAs and nurses performed as well as hospitalists. PRIMARY FUNDING SOURCE: National Institute on Aging.
BACKGROUND: Systematic screening improves delirium identification among hospitalized older adults. Little data exist on how to implement such screening. OBJECTIVE: To test implementation of a brief app-directed protocol for delirium identification by physicians, nurses, and certified nursing assistants (CNAs) in real-world practice relative to a research reference standard delirium assessment (RSDA). DESIGN: Prospective cohort study. SETTING: Large urban academic medical center and small rural community hospital. PARTICIPANTS: 527 general medicine inpatients (mean age, 80 years; 35% with preexisting dementia) and 399 clinicians (53 hospitalists, 236 nurses, and 110 CNAs). MEASUREMENTS: On 2 study days, enrolled patients had an RSDA. Subsequently, CNAs performed an ultra-brief 2-item screen (UB-2) for delirium, whereas physicians and nurses performed a 2-step protocol consisting of the UB-2 followed in those with a positive screen result by the 3-Minute Diagnostic Assessment for the Confusion Assessment Method. RESULTS: Delirium was diagnosed in 154 of 924 RSDAs (17%) and in 114 of 527 patients (22%). The completion rate for clinician protocols exceeded 97%. The CNAs administered the UB-2 in a mean of 62 seconds (SD, 51). The 2-step protocols were administered in means of 104 seconds (SD, 99) by nurses and 106 seconds (SD, 105) by physicians. The UB-2 had sensitivities of 88% (95% CI, 72% to 96%), 87% (CI, 73% to 95%), and 82% (CI, 65% to 91%) when administered by CNAs, nurses, and physicians, respectively, with specificities of 64% to 70%. The 2-step protocol had overall accuracy of 89% (CI, 83% to 93%) and 87% (CI, 81% to 91%), with sensitivities of 65% (CI, 48% to 79%) and 63% (CI, 46% to 77%) and specificities of 93% (CI, 88% to 96%) and 91% (CI, 86% to 95%), for nurses and physicians, respectively. Two-step protocol sensitivity for moderate to severe delirium was 78% (CI, 54% to 91%). LIMITATION: Two sites; limited diversity. CONCLUSION: An app-directed protocol for delirium identification was feasible, brief, and accurate, and CNAs and nurses performed as well as hospitalists. PRIMARY FUNDING SOURCE: National Institute on Aging.
Authors: M S Albert; S E Levkoff; C Reilly; B Liptzin; D Pilgrim; P D Cleary; D Evans; J W Rowe Journal: J Geriatr Psychiatry Neurol Date: 1992 Jan-Mar Impact factor: 2.680
Authors: Erika Steensma; Wenxiao Zhou; Long Ngo; Jacqueline Gallagher; Sharon Inouye; Douglas Leslie; Marie Boltz; Ann Kolanowski; Lorraine Mion; Edward R Marcantonio; Donna Fick Journal: J Am Med Dir Assoc Date: 2019-07-03 Impact factor: 4.669
Authors: Jin H Han; Amanda Wilson; Eduard E Vasilevskis; Ayumi Shintani; John F Schnelle; Robert S Dittus; Amy J Graves; Alan B Storrow; John Shuster; E Wesley Ely Journal: Ann Emerg Med Date: 2013-07-31 Impact factor: 5.721
Authors: Erica K Husser; Donna M Fick; Marie Boltz; Priyanka Shrestha; Jonathan Siuta; Shannon Malloy; Abigail Overstreet; Douglas L Leslie; Long Ngo; Yoojin Jung; Sharon K Inouye; Edward R Marcantonio Journal: J Am Geriatr Soc Date: 2021-01-20 Impact factor: 5.562
Authors: Douglas L Leslie; Donna M Fick; Amber Moore; Sharon K Inouye; Yoojin Jung; Long H Ngo; Marie Boltz; Erica Husser; Priyanka Shrestha; Malaz Boustani; Edward R Marcantonio Journal: J Am Geriatr Soc Date: 2022-04-20 Impact factor: 7.538