INcidence and impact measurement of DElirium induced by ED stay



Principal Investigator: Marcel Émond, MD, MSc, Centre de Recherche du CHU de Québec- Université Laval

Co-investigators: Berthelot, S; Daoust, R; Lamontagne, ME; Lemire, S; Moore, L; Morin, J; Voyer, P

Collaborators: Pelletier, M; Duval, M; Le Sage, N; Lee, J; McCusker, J; Morin, M; Rheault, M; Minh Vu, TT; Juneau, L; Émond, D

Local research coordinator:  Valérie Boucher

Marianne Giroux, occupational therapist and Masters student in epidemiology: her project focuses on the association between delirium in the emergency department and cognitive and functional decline in elderly patients.
Antoine Laguë, medical extern: his project focuses on the use of the Bergman-Paris question for the identification of cognitive disorders in the emergency department.
Catherine Bédard, nurse and psychology student: her project focuses on the Ottawa 3DY.
Anne-Julie Gagné, psychology student: her project focuses on 4AT.
Samuel Charland-Larivière: kinesiologist and bachelor’s degree student in physiotherapy: he is interested in the impact of polypharmacy and pain control on the incidence of delirium in the emergency department

Granting agency: Fonds de Recherche du Québec – Santé (FRQ-S)

In 2011, the first members of the “baby-boomer” generation turned 65 y.o. By 2031, the proportion of the population greater than 65 will nearly double, with the largest increases occurring among those 85 years of age and older.

Care of older patients in the ED is particularly challenging. Inouye et al. demonstrated that an ED stay of 12 hours or more was one of the strongest independent predictor of subsequent delirium in older patients. This is of increasing concern, as ED wait times is quite significant. To date no data exist on the incidence of ED-induced delirium following the recent « senior-friendly approach era ».

Objectives: The primary objective of this study is to fill a basic knowledge gap regarding the incidence, severity and impacts of ED-induced delirium among older ED patients who have prolonged ED stays (> 12 hours). Specifically, we will: A) Measure the incidence rate of ED-induced B) Evaluate and compare the incidence of delirium at different sites considering their “Senior-Friendly approach level”. C) Measure the length of stay of patient with ED-induced delirium episode and compare to non-delirious patient and potential impacts on ED overcrowding. D) Evaluate potential clinical and administrative predictors of ED-induced delirium episode. E) Measure and compare the rate of unplanned return to the ED and functional decline within 60 days of discharge from hospital.

Methods: A prospective cohort study design will be used. Five Quebec ED will recruit participant in the project. Eligible patients will be identified using the Hospital or Emergency Department Information System patient tracking software. Inclusion Criteria: patient will be eligible to participate if they’re aged ≥ 65 years, admitted to any hospital ward and screened non-delirious at ED admission. All patient will be exposed to a minimal 12 hours of ED stay before being include in the study. Patient will be excluded if they become delirious within the first 12 h ED stay; are unable to provide medical information or speak French/ English; are critically ill. Patient with delirium before arrival to ED will be excluded.

Primary Outcome: Incidence of ED-induced delirium will be assessed with the validated Confusion Assessment Method (CAM) and severity will be measured with the delirium index. Secondary Outcomes: Assessing the impact of the delirium incidence will be measured using total LOS from ED admission to hospital discharge. Functional status and unplanned ED returns will be assessed at 60 days after hospital discharge.

Data Collection: Research assistants will assess patient with a standardized data collection tools at baseline and follow patient daily up to 72h to assess outcomes. Standardized follow-up phone interview will be done at 60 days following discharge. Data Analysis Plan: Simple proportions will be tested using the Chi-square statistic.  Comparison of incidence between sites will be tested and delay in onset will be reported with univariate analyses. LOS will be log-transform and linear regression will be compared between the delirium positive and delirium negative. Adjustment will be made for age, admission diagnosis, co-morbidity and « senior-friendly measures ».

Study relevance: This prospective study will address the knowledge gap regarding the incidence rate of ED-induced delirium (ED throughput) and the related- impacts on ED output (i.e. length of stay on the ward). ED services need to measure their adaption to older patient care and modify practice according to best available evidence. The proposed study will also provide crucial information for planning future trial that will assess the impact of a delirium on ED management and prevention intervention on incidence, severity and duration of delirium.