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

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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.