Improving Delirium Screening and Detection for Older Adults Presenting to the Emergency Department (ED): A Novel ED Delirium Screening and Detection Program

在美国，每年有超过2300万老年人到急诊室（艾德）就诊， 然而，据估计，超过75%的艾德谵妄病例是在 错过了.未能系统地筛查和检测艾德谵妄影响临床管理（例如，使用 化学和物理约束）和结果（例如，增加死亡率和痴呆症）。艾德障碍 谵妄检测包括缺乏筛查工具的使用，竞争的优先事项，以及广泛的知识 赤字即使是经过验证的筛选工具（例如，简明混淆评估方法（bCAM） 并整合到护理工作流程中，它们很少在临床实践中一致或准确地使用，导致 精神错乱检测的缺失我们的长期目标是实施和传播一个全面的艾德谵妄 检测计划（ED-DDP），将改善老年人艾德谵妄的筛查、检测和管理 成年人了我们的团队以前已经开发并测试了创新的DDP在重症监护室（ICU- DDP）。ICU-DDP采用“培训培训员”模式，包括：1）多组分一天谵妄 冠军讲习班; 2）通过远程医疗（远程谵妄）进行实时直接观察、培训和强化 （3）由冠军训练护士。ICU-DDP将谵妄检出率从9.1%提高到 30.1%（p = 0.005）。随后，我们通过半结构化改进了艾德的ICU-DDP（ED-DDP）。 访谈艾德利益相关者和艾德远程谵妄培训试点。艾德利益相关者访谈显示 参与ED-DDP是高度优先、可接受和可行的。这项工作的首要目标是， 建议是确定ED-DDP用于改善艾德谵妄筛查、检测 和管理，同时还评估ED-DDP的实施结果， 冠军和护士我们建议：1）进行一项初步的阶梯式楔形分组随机试验（SW-CRT）， 3种不同ED的ED-DDP，以确定ED-DDP的初步疗效;以及2）使用混合- 评估RE-AIM实施结果的方法（范围、有效性、采用、实施， 和维护）的ED-DDP。我们的团队拥有谵妄，急诊医学，医院基础 干预措施和实施科学，准备好完成以下2个具体目标：1）行为 在3个艾德研究中心进行了一项试验性SW-CRT，以确定ED-DDP改善谵妄的初步疗效 在到艾德就诊的老年人中进行筛查、检测和管理; 2）以RE-AIM为基础 我们将采用混合方法对ED-DDP的实施结果进行评估， 冠军和护士。该提案解决了改善艾德谵妄筛查、检测 和管理，这将改善数百万老年人的结果，提出了艾德每年。 我们的研究结果将：通知方法，以确保程序的保真度;使验证和完善的艾德- DDP;并估计ED-DDP后续全尺寸SW-CRT的效应量。

Over 23 million older adults present to the Emergency Department (ED) each year in the United States, and up to 20% will experience delirium while in the ED. Yet, it is estimated that over 75% of ED delirium cases are missed. Failure to systematically screen and detect ED delirium affects clinical management (e.g., use of chemical and physical restraints) and outcomes (e.g., increased mortality and dementia). Barriers to ED delirium detection consist of a lack in screening tool use, competing priorities, and wide-ranging knowledge deficits. Even when validated screening tools (e.g., brief confusion assessment method, bCAM) are prioritized and integrated into nursing workflow, they are rarely used consistently or accurately in clinical practice, leading to lack of delirium detection. Our long-term goal is to implement and disseminate a comprehensive ED Delirium Detection Program (ED-DDP) that will improve screening, detection, and management of ED delirium in older adults. Our group has previously developed and tested the innovative DDP in the intensive care unit (ICU- DDP). The ICU-DDP utilizes a “train-the-trainer” model, and consists of: 1) a multicomponent one-day delirium champion workshop; 2) real-time direct observation, training, and reinforcement via telehealth (tele-delirium training); and 3) training of nurses by champions. The ICU-DDP improved delirium detection from 9.1% to 30.1% (p = 0.005). Subsequently, we refined the ICU-DDP for the ED (ED-DDP) through semi-structured interviews with ED stakeholders and a pilot of ED tele-delirium training. ED stakeholder interviews revealed that participation in the ED-DDP was of high priority, acceptable, and feasible. The overarching aim of this proposal is to determine the preliminary efficacy of the ED-DDP for improving ED delirium screening, detection, and management in older adults, while also evaluating implementation outcomes of the ED-DDP for champions and nurses. We propose to: 1) conduct a pilot stepped wedge cluster randomized trial (SW-CRT) of the ED-DDP across 3 diverse EDs to determine preliminary efficacy of the ED-DDP; and 2) use a mixed- methods approach to assess RE-AIM implementation outcomes (Reach, Efficacy, Adoption, Implementation, and Maintenance) of the ED-DDP. Our team with expertise in delirium, emergency medicine, hospital-based interventions, and implementation science, is well-poised to complete the following 2 Specific Aims: 1) Conduct a pilot SW-CRT across 3 ED sites to determine the preliminary efficacy of the ED-DDP for improving delirium screening, detection, and management in older adults presenting to the ED; and 2) Grounded in the RE-AIM framework, we will use mixed methods to conduct implementation outcome assessments of the ED-DDP for champions and nurses. The proposal addresses a critical need for improving ED delirium screening, detection, and management, which will improve outcomes for the millions of older adults presenting to the ED each year. Our findings will: inform approaches to ensure program fidelity; enable validation and refinement of the ED- DDP; and estimate effect sizes for a subsequent full-scale SW-CRT of the ED-DDP.