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      Incidence of delirium in the Canadian emergency department and its consequences on hospital length of stay: a prospective observational multicentre cohort study

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          Abstract

          Objective

          We aim to determine the incidence of delirium and describe its impacts on hospital length of stay (LOS) among non-delirious community-dwelling older adults with an 8-hour exposure to the emergency department (ED) environment.

          Design

          This is a prospective observational multicentre cohort study (March–July 2015). Patients were assessed two times per day during their entire ED stay and up to 24 hours on hospital ward.

          Setting

          The study took place in four Canadian EDs.

          Participants

          338 included patients: (1) aged ≥65 years; (2) who had an ED stay ≥8 hours; (3) were admitted to hospital ward and (4) were independent/semi-independent.

          Main outcome(s) and measure(s)

          The primary outcomes of this study were incident delirium in the ED or within 24 hours of ward admission and ED and hospital LOS. Functional and cognitive status were assessed using validated Older Americans Resources and Services and the modified Telephone Interview for Cognitive Status tools. The Confusion Assessment Method was used to detect incident delirium. Univariate and multivariate analyses were conducted to evaluate outcomes.

          Results

          Mean age was 76.8 (±8.1), 17.7% were aged >85 years old and 48.8% were men. The mean incidence of delirium was 12.1% (n=41). Median IQR ED LOS was 32.4 (24.5–47.9) hours and hospital LOS was 146.6 (75.2–267.8) hours. Adjusted mean hospital LOS was increased by 105.4 hours (4.4 days) (95% CI 25.1 to 162.0, P<0.001) for patients who developed an episode of delirium compared with non-delirious patient.

          Conclusions

          An incident delirium was observed in one of eight independent/semi-independent older adults after an 8-hour ED exposure. An episode of delirium increases hospital LOS by 4 days and therefore has important implications for patients and could contribute to ED overcrowding through a deleterious feedback loop.

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          Most cited references 32

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          Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions.

          We sought to synthesize the literature on patterns of use of emergency services among older adults, risk factors associated with adverse health outcomes, and effectiveness of intervention strategies targeting this population. Relevant articles were identified by means of an English-language search of MEDLINE, HealthSTAR, CINAHL, Current Contents, and Cochrane Library databases from January 1985 to January 2001. This search was supplemented with literature from reference sections of the retrieved publications. A qualitative approach was used to synthesize the literature. Compared with younger persons, older adults use emergency services at a higher rate, their visits have a greater level of urgency, they have longer stays in the emergency department, they are more likely to be admitted or to have repeat ED visits, and they experience higher rates of adverse health outcomes after discharge. The risk factors commonly associated with the negative outcomes are age, functional impairment, recent hospitalization or ED use, living alone, and lack of social support. Comprehensive geriatric screening and coordinated discharge planning initiatives designed to improve clinical outcomes in older emergency patients have provided inconclusive results. Older ED patients have distinct patterns of service use and care needs. The current disease-oriented and episodic models of emergency care do not adequately respond to the complex care needs of frail older patients. More research is needed to determine the effectiveness of screening and intervention strategies targeting at-risk older ED patients.
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            Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability.

            To prospectively develop and validate a predictive model for delirium based on precipitating factors during hospitalization, and to examine the interrelationship of precipitating factors and baseline vulnerability. Two prospective cohort studies, in tandem. General medical wards, university teaching hospital. For the development cohort, 196 patients aged 70 years and older with no delirium at baseline, and for the validation cohort, 312 comparable patients. New-onset delirium by hospital day 9, defined by the Confusion Assessment Method diagnostic criteria. Delirium developed in 35 patients (18%) in the development cohort. Five independent precipitating factors for delirium were identified; use of physical restraints (adjusted relative risk [RR], 4.4; 95% confidence interval [CI], 2.5 to 7.9), malnutrition (RR, 4.0; 95% CI, 2.2 to 7.4), more than three medications added (RR, 2.9; 95% CI, 1.6 to 5.4), use of bladder catheter (RR, 2.4; 95% CI, 1.2 to 4.7), and any iatrogenic event (RR, 1.9; 95% CI, 1.1 to 3.2). Each precipitating factor preceded the onset of delirium by more than 24 hours. A risk stratification system was developed by adding 1 point for each factor present. Rates of delirium for low-risk (0 points), intermediate-risk (1 to 2 points), and high-risk groups (> or equal to 3 points) were 3%, 20%, and 59%, respectively (P < .001). The corresponding rates in the validation cohort, in which 47 patients (15%) developed delirium, were 4%, 20%, and 35%, respectively (P < .001). When precipitating and baseline factors were analyzed in cross-stratified format, delirium rates increased progressively from low-risk to high-risk groups in all directions (double-gradient phenomenon). The contributions of baseline and precipitating factors were documented to be independent and statistically significant. A simple predictive model based on the presence of five precipitating factors can be used to identify elderly medical patients at high risk for delirium. Precipitating and baseline vulnerability factors are highly interrelated and contribute to delirium in independent substantive, and cumulative ways.
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              A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics.

              To prospectively develop and validate a predictive model for the occurrence of new delirium in hospitalized elderly medical patients based on characteristics present at admission. Two prospective cohort studies done in tandem. University teaching hospital. The development cohort included 107 hospitalized general medical patients 70 years or older who did not have dementia or delirium at admission. The validation cohort included 174 comparable patients. Patients were assessed daily for delirium using a standardized, validated instrument. The predictive model developed in the initial cohort was then validated in a separate cohort of patients. Delirium developed in 27 of 107 patients (25%) in the development cohort. Four independent baseline risk factors for delirium were identified using proportional hazards analysis: These included vision impairment (adjusted relative risk, 3.5; 95% Cl, 1.2 to 10.7); severe illness (relative risk, 3.5; Cl, 1.5 to 8.2); cognitive impairment (relative risk, 2.8; Cl, 1.2 to 6.7); and a high blood urea nitrogen/creatinine ratio (relative risk, 2.0; Cl, 0.9 to 4.6). A risk stratification system was developed by assigning 1 point for each risk factor present. Rates of delirium for low- (0 points), intermediate- (1 to 2 points), and high-risk (3 to 4 points) groups were 9%, 23%, and 83% (P < 0.0001), respectively. The corresponding rates in the validation cohort, in which 29 of 174 patients (17%) developed delirium, were 3%, 16%, and 32% (P < 0.002). The rates of death or nursing home placement, outcomes potentially related to delirium, were 9%, 16%, and 42% (P = 0.02) in the development cohort and 3%, 14%, and 26% (P = 0.007) in the validation cohort. Delirium among elderly hospitalized patients is common, and a simple predictive model based on four risk factors can be used at admission to identify elderly persons at the greatest risk.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2018
                8 March 2018
                : 8
                : 3
                Affiliations
                [1 ] departmentAxe Santé des populations et pratiques optimales en santé , Centre de recherche du CHU de Québec-Université Laval , Québec, Canada
                [2 ] departmentDépartement de médecine d’urgence , CHU de Québec-Université Laval , Québec, Canada
                [3 ] departmentMedicine , Université Laval , Québec, Canada
                [4 ] Centre d’excellence sur le vieillissement de Québec , Québec, Canada
                [5 ] Centre de recherche sur les soins et les services de première ligne de l’Université Laval , Québec, Canada
                [6 ] Centre interdisciplinaire de recherche en réadaptation et intégration sociale , Québec, Canada
                [7 ] departmentNursing , Université Laval , Québec, Canada
                [8 ] Centre Intégré de Santé et de Services Sociaux de Lanaudière , Joliette, Canada
                [9 ] Centre Hospitalier Régional de Trois-Rivières , Trois-Rivières, Canada
                [10 ] Centre de recherche de l’Hôpital du Sacré-Cœur de Montréal , Montréal, Canada
                [11 ] departmentMedicine , Université de Montréal , Montréal, Canada
                [12 ] Centre de recherche du Centre hospitalier de l’Université de Montréal , Montréal, Canada
                [13 ] Centre hospitalier de l’Université de Montréal , Montréal, Canada
                [14 ] Institut de gériatrie de l’Université de Montréal , Montréal, Canada
                [15 ] CSSS de Trois-Rivières , Trois-Rivières, Canada
                [16 ] Centre Intégré Universitaire de Services Sociaux et de Santé de la Capitale-Nationale , Québec, Canada
                [17 ] departmentDepartment of Family and Community Medicine , University of Toronto , Toronto, Canada
                [18 ] Sunnybrook Health Sciences Center , Toronto, Canada
                Author notes
                [Correspondence to ] Dr Marcel Émond; marcel.emond@ 123456fmed.ulaval.ca
                Article
                bmjopen-2017-018190
                10.1136/bmjopen-2017-018190
                5855334
                29523559
                © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                Product
                Funding
                Funded by: Fond Québécois de Recherche en Santé;
                Categories
                Emergency Medicine
                Research
                1506
                1691
                Custom metadata
                unlocked

                Medicine

                delirium, emergency department, community seniors, cognitive status, functional status

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