Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method.
Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method.
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DOI：
10.1016/j.annemergmed.2013.05.003
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发表时间：
2013-11
影响因子：
6.2
通讯作者：
Ely, E. Wesley
中科院分区：
文献类型：
--
作者：
Han, Jin H.;Wilson, Amanda;Vasilevskis, Eduard E.;Shintani, Ayumi;Schnelle, John F.;Dittus, Robert S.;Graves, Amy J.;Storrow, Alan B.;Shuster, John;Ely, E. Wesley
妄想是急性脑功能障碍的一种常见形式，具有预后意义。护理老年急诊科(ED)患者的卫生保健专业人员遗漏了大约75%的病例。这一错误是由于缺乏可以足够快地执行以纳入临床实践的可用措施。因此，我们开发和评估了一种新的两步法来监测ED的精神错乱。这项前瞻性观察性研究是在65岁≥患者的学术ED中进行的。一名研究助理(RA)和一名医生进行了妄想症分类筛查(DTS)和简明混淆评估方法(BCAM)，前者是一种高度敏感的排除试验，后者是一种高度特异的妄想症纳入试验。精神错乱的参考标准是使用《精神疾病诊断和统计手册》第四版文本修订版(DSM-IV-TRR)标准进行的综合精神病学家评估。所有评估都是在彼此相隔3小时内独立进行的。计算敏感度、特异度和似然比及其95%可信区间(95%CI)。在406例入选患者中，有50例(12.3%)按照精神病学家的参考标准诊断为精神错乱。DTS的敏感性为98.0%(95%CI：89.5%-99.5%)，对两个评价者的预期特异性约为55%。两个评价者的DTS阴性似然比均为0.04(95%CI：0.01~0.25)。作为补充，BCAM的特异度分别为95.8%(95%CI：93.2%~97.4%)和96.9%(95%CI：94.6%~98.3%)，敏感性分别为84.0%(95%CI：71.5%~91.7%)和78.0%(95%CI：64.8%~87.2%)。BCAM的阳性似然比分别为19.9(95%CI：12.0~33.2)和25.2(95%CI：13.9~46.0)。如果对RA DTS进行BCAM检查，其敏感性为84.0%(95%CI：71.5%~91.7%)，特异性为95.8%(95%CI：93.2%~97.4%)。如果RA同时进行DTS和BCAM，这两种方法的敏感性为78.0%(95%CI：64.8%-87.2%)，特异性为97.2%(95%CI：94.9%-98.5%)。如果医生同时进行DTS和BCAM检查，这两种检查的敏感性为82.0%(95%CI：69.2%-90.2%)，特异性为95.8%(95%CI：93.2%-97.4%)。在老年ED患者中，这种两步法(高度敏感的DTS和高度特异的BCAM)可能使医疗专业人员无论临床背景如何，都能有效地筛查精神错乱。需要更大规模的多中心试验来证实这些发现，并确定这些评估对ED中的精神错乱识别的影响。
Delirium is a common form of acute brain dysfunction with prognostic significance. Health care professionals caring for older emergency department (ED) patients miss delirium approximately 75% of cases. This error results from a lack of available measures that can be performed rapidly enough to be incorporated into clinical practice. Therefore, we developed and evaluated a novel two-step approach to delirium surveillance for the ED. This prospective observational study was conducted at an academic ED in patients ≥ 65 years old. A research assistant (RA) and physician performed the Delirium Triage Screen (DTS), designed to be a highly sensitive rule-out test, and the Brief Confusion Assessment Method (bCAM), designed to be a highly specific rule-in test for delirium. The reference standard for delirium was a comprehensive psychiatrist assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria. All assessments were independently conducted within 3 hours of each other. Sensitivities, specificities, and likelihood ratios with their 95% confidence intervals (95%CI) were calculated. Of 406 enrolled patients, 50 (12.3%) had delirium diagnosed by the psychiatrist reference standard. The DTS was 98.0% (95%CI: 89.5% – 99.5%) sensitive with an expected specificity of approximately 55% for both raters. The DTS’ negative likelihood ratio was 0.04 (95%CI: 0.01 – 0.25) in both raters. As the complement, the bCAM had a specificity of 95.8% (95%CI: 93.2% – 97.4%) and 96.9% (95%CI: 94.6% – 98.3%) and a sensitivity of 84.0% (95%CI: 71.5% – 91.7%) and 78.0% (95%CI: 64.8% – 87.2%) when performed by the physician and RA, respectively. The positive likelihood ratios for the bCAM were 19.9 (95%CI: 12.0 – 33.2) and 25.2 (95%CI: 13.9 – 46.0), respectively. If the RA DTS was followed by the physician bCAM, the sensitivity of this combination was 84.0% (95%CI: 71.5% – 91.7%) and the specificity was 95.8% (95%CI: 93.2% – 97.4%). If the RA performed both the DTS and bCAM, this combination was 78.0% (95%CI: 64.8% – 87.2%) sensitive and 97.2% (95%CI: 94.9% – 98.5%) specific. If the physician performed both the DTS and bCAM, this combination was 82.0% (95%CI: 69.2% – 90.2%) sensitive and 95.8% (95CI: 93.2% – 97.4%) specific. In older ED patients, this two-step approach (highly sensitive DTS followed by highly specific bCAM) may enable healthcare professionals, regardless of clinical background, to efficiently screen for delirium. Larger, multi-centered trials are needed to confirm these findings and to determine the impact of these assessments on delirium recognition in the ED.
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影响因子：
38.9
作者：
Ely, EW;Truman, B;Bernard, GR
通讯作者：
Bernard, GR
影响因子：
8.8
作者：
Ely, EW;Margolin, R;Inouye, SK
通讯作者：
Inouye, SK
影响因子：
6.2
作者：
Hustey, FM;Meldon, SW
通讯作者：
Meldon, SW
影响因子：
6.2
作者：
Han, Jin H.;Shintani, Ayumi;Eden, Svetlana;Morandi, Alessandro;Solberg, Laurence M.;Schnelle, John;Dittus, Robert S.;Storrow, Alan B.;Ely, E. Wesley
通讯作者：
Ely, E. Wesley
DOI：
10.1197/jamia.m2489
发表时间：
2008-03-01
影响因子：
6.4
作者：
Aronsky, Dominik;Ones, Ian;Slonvis, Corey M.
通讯作者：
Slonvis, Corey M.