Delirium detection tools show varying completion rates and positive score rates when used at scale in routine practice in general hospital settings: A systematic review

Applying an Agile Science Roadmap to Integrate and Evaluate Ethical Frameworks Throughout the Lifecycle and Use of Artificial Intelligence Tools in the Intensive Care Unit

This article summarizes existing ethical frameworks for healthcare artificial intelligence (AI) and ambient sensing technology, such as computer vision, and examines their application to improve patient outcomes in the intensive care unit (ICU). Integrating ethical considerations such as privacy, fairness, and autonomy into the lifecycle of an AI tool is necessary to fully harvest AI's potential to deliver safe, high-quality, personalized, and low-cost healthcare services that provide positive experiences for patients, families, and clinicians while improving health outcomes. Drawing from agile science, the article proposes a practical roadmap for clinician and researcher use to identify, integrate, and monitor ethical considerations throughout the lifecycle of an AI tool with the intention to improve patient care. A use case illustrates the application of the agile science-informed roadmap that details the development of a passive digital marker for delirium severity.

Delirium prevalence and management in general wards, emergency departments, rehabilitation centres and nursing homes in Germany, Austria and Switzerland (DACH countries): A secondary analysis of a worldwide point prevalence study

Background

Delirium is a common neuropsychiatric syndrome associated with an increased risk of mortality and length of stay. Current delirium prevalence, assessments and management practices of delirium in DACH countries are unknown.

Objective

To examine the delirium point prevalence, assessment, management practices in general wards, emergency departments, rehabilitation centres and nursing homes in DACH countries.

Design

Secondary data analysis from a prospective, cross-sectional, worldwide one-day point delirium prevalence study (registered in the German Registry for Clinical Trials, DRKS00030002).

Settings

General hospital wards, emergency departments, rehabilitation centres and nursing homes excluding operating rooms, ambulatory, high acuity, intermediate care and intensive care units.

Participants

In total, 172 wards (majority were general wards; 91.3 %, n = 157) from Germany, Austria and Switzerland participated.

Methods

Descriptive analysis of a 39-questions online survey with aggregated routine patient and facility data completed by healthcare professionals, administrators, and researchers on World Delirium Awareness Day, March 15th, 2023. Data on delirium prevalence were collected at 8:00 A.M. and P.M. (± 4 h). Use of delirium assessments, delirium awareness structures, presence of care protocols, and barriers to delirium management structures were reported.

Results

Overall delirium prevalence was 7.1 % (n = 143/2,028) at 8:00 A.M. and 7.2 % (n = 133/1,842) at 8:00 P.M. There was no statistically significant difference between the delirium prevalence assessed with valid (p = .770) or non-valid assessment (p = .643). The most frequent delirium assessments were the Nursing Delirium Screening Scale (16.3 %, n = 28/172), the Confusion Assessment Method (15.7 %, n = 27/172) and the Delirium Observation Screening Scale (9.3 %, n = 16/172). The most reported interventions to provide delirium awareness and education were "delirium is mentioned in handovers" (53.5 %, n = 92/172), "availability of delirium experts" (51.2 %, n = 88/172) and "delirium education during the last year" (48.3 %, n = 83/172). An existing delirium management protocol was present in 76.7 % (n = 132/172) of participating wards. The most frequently reported barriers to delirium care were "shortage of staff" (45.3 %, n = 78/172), "patients who are difficult to assess" (32.6 %, n = 56/172), and "communication gaps between professions" (29.1 %, n = 50/172). As non-pharmacological interventions, "mobilization" (92.4 %, n = 159/172), "pain management" (87.8 %, n = 151/172), and "adequate fluids" (83.7 %, n = 144/172) were mostly reported.

Conclusions

Delirium is a frequent complication in patients in DACH countries. More than three quarter of participating wards reported a delirium management protocol suggesting awareness of published guidelines and best practice recommendations. Improved staffing, education on delirium assessment, and interprofessional communication could be helpful to improve the usage of valid delirium assessments and addressing barriers to delirium management.

Brain Pro-TCT: a prospective, quasi-experimental study on early delirium detection with Delirium Observation Screening Scale vs. single-channel EEG after cardiac surgery in patients aged over 70 years

AIMS

Delirium is common in patients aged over 70 years after cardiac surgery. Screening to detect delirium in high-risk patients is important; yet, hypoactive delirium is often missed in nurse-reported screening. Polymorphic delta waves are associated with delirium, and can be detected with single-channel electroencephalography (SC-EEG). The aim of the study is to assess whether SC-EEG as a screening instrument for delirium will increase the detection rate of post-operative delirium and reduce hospital stay of delirious patients.

METHODS AND RESULTS

A prospective quasi-experimental study compared Delirium Observation Screening Scale (DOSS) screening (442 patients) to SC-EEG screening (462 patients) to detect post-operative delirium in cardiac surgery patients aged over 70 years. Delirium was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders 5th edition. Detection of delirium was higher in the SC-EEG group (20%) compared with DOSS group (14%), P = 0.016. A difference in length of stay for delirious patients was attributed to baseline differences as pneumonia and longer cardiopulmonary bypass time, but not delirium screening method. Length of stay for all patients was -0.11 (95% CI -0.18 to -0.04) night shorter for SC-EEG cohort patients compared with DOSS cohort patients, P = 0.002.

CONCLUSION

Screening with SC-EEG increased delirium detection after cardiac surgery. Only length of stay for all patients was significantly reduced in the SC-EEG cohort. This reduction in hospital stay is small, yet relevant for high volume cardiac surgery centres and should be further studied in other centres.

REGISTRATION

International Clinical Trials Registry Platform: NL-OMON27069.

Epidemiology and assessments of delirium in nursing homes and rehabilitation facilities: a cross-country perspective

PURPOSE

Delirium represents a significant healthcare challenge in long-term care settings. This study aims to investigate the epidemiology of delirium in long-term care facilities (LTCFs) across various countries, examining point prevalence and assessment methods.

METHODS

This descriptive analysis included data from 94 surveys conducted in LTCFs on World Delirium Awareness Day (WDAD), March 15th, 2023. Group comparisons were made between rehabilitation facilities (RFs) and nursing homes (NHs).

RESULTS

Of the participating units/wards, primarily from Europe and Australia, 65 were RFs and 29 were NHs. The overall reported delirium point prevalence was approximately 12%, with higher rates in RFs than in NHs. While most units/wards reported using a validated delirium detection tool, notable differences emerged in the frequency of assessments, the personnel conducting them, and delirium awareness interventions across settings.

CONCLUSION

Despite the well-documented impact of delirium on residents, the international variability in clinical practices within LTCFs highlights the current inadequacy in adopting effective and consistent strategies to address this condition.

A survey of perioperative medicine services with a focus on provision for older surgical patients in the UK and Republic of Ireland: SNAP-3

BACKGROUND

Perioperative medicine aims to improve care for high-risk patients, and is endorsed by national guidelines in the UK and Republic of Ireland (ROI). However, comprehensive perioperative medicine services are not yet uniformly available. This survey addressed the current state of perioperative medicine services for older surgical patients in the UK and ROI and how these services align with current national guidance.

METHODS

A survey was distributed electronically to all publicly administered UK and ROI hospitals performing surgical procedures. The survey examined perioperative care against national recommendations regarding service organisation and conduct.

RESULTS

Of 339 eligible hospitals, 54.9% (186/339) responded. A hospital frailty lead was appointed in 54% (101/186) of hospitals, and 9% (16/186) had a designated anaesthetist for cognitive impairment. Hospital anaesthetic services outside the theatre were focused on preoperative assessment clinics (146/172), with few reporting routine postoperative involvement (17/166). Nurse-led preoperative assessments of frailty, cognition, and delirium risk were conducted in 49.5% (90/182), 44.3% (78/176), and 13.7% (24/175) of hospitals, respectively. The Clinical Frailty Scale was used in 87.0% (147/169) of hospitals for frailty screening. The 4 'A's Test (45.7% [85/186]) and Abbreviated Mental Test (43.0% [80/186]) were the preferred cognitive assessment tools.

CONCLUSIONS

The survey highlights the variation in perioperative medicine services that exist for older surgical patients despite national guidelines advocating their widespread implementation. Opportunity exists to develop interspecialty perioperative services further and promote identification of frailty, cognitive impairment, and delirium, all of which negatively impact postoperative outcomes for older surgical patients.

Delirium assessment, management and barriers to effective care across Scotland: A secondary analysis of survey data from World Delirium Awareness Day 2023

INTRODUCTION

Delirium is a common, severe neuropsychiatric syndrome in hospitalised older adults. We evaluated use of validated delirium assessment tools, adherence to national guidelines and prevalence and management of delirium across Scotland, identifying barriers to effective care.

METHODS

Secondary analysis of national survey data, collected by participating clinicians on World Delirium Awareness Day (15 March 2023).

RESULTS

Among 120 responses (3,257 patients), the 4AT was the most frequently used assessment tool (75%), while 14% of units reported using clinical judgement alone. The delirium assessment rate was 74%, with a prevalence of 22% at 8 am. Management protocols varied, with frequent routine non-pharmacological interventions including pain management (88%), hydration (87%) and open family visiting (80%). Barriers to delirium care included insufficient staffing and training.

CONCLUSION

While many hospital settings follow national delirium guidelines, some still rely on clinical judgement for assessment, with variability in management protocols and practices. We have highlighted key barriers to effective delirium care in Scotland.

Pilot implementation of an electronic diagnostic support tool (AiD-DST) designed to identify the cause(s) of delirium

OBJECTIVE(S)

The identification of cause(s) of delirium remains a clinical challenge within medicine. Our group have previously successfully developed and tested the Aetiology in Delirium-Decision Support Tool (AiD-DST). The AiD-DST is designed to help medical professionals close the gap on the detection of cause(s) of delirium. Here, we report on use of AiD-DST in the real-world setting.

METHODS

A real-world implementation study of the AiD-DST within a general medical ward of a metropolitan hospital was conducted over a 10-week period. A mixed method evaluation was performed based upon the RE-AIM Framework that incorporates reach, effectiveness, adoption, implementation and maintenance of an intervention.

RESULTS

Reach: fifty-three out of 87 (61%) eligible doctors consented to participation in the study.

EFFECTIVENESS

A mean of 4.3 diagnoses were generated per patient with no difference in frequency when compared with historical control (z = 1.36; p = .17). Average usability score was 5.86 (SD = 1.15) on a 7-point scale, with 93% of respondents being satisfied with the AiD-DST. Free text feedback comprised themes of accessibility, ergonomics, diagnostic accuracy and applicability of AiD-DST to related conditions.

IMPLEMENTATION

Instrument completion rate was 98% (n = 49/50), with a median completion time of 90 s. Maintenance: Sixty-seven % of uses of AiD-DST occurred in the second half of the study (p = .3). Following the initiation period there was an increase in use (r = .79; p = 02).

CONCLUSION

Proof of principle was demonstrated for local implementation of a diagnostic support tool (AiD-DST).

A world-wide study on delirium assessments and presence of protocols

BACKGROUND

Delirium is a common complication of older people in hospitals, rehabilitation and long-term facilities.

OBJECTIVE

To assess the worldwide use of validated delirium assessment tools and the presence of delirium management protocols.

DESIGN

Secondary analysis of a worldwide one-day point prevalence study on World Delirium Awareness Day, 15 March 2023.

SETTING

Cross-sectional online survey including hospitals, rehabilitation and long-term facilities.

METHODS

Participating clinicians reported data on delirium, the presence of protocols, delirium assessments, delirium-awareness interventions, non-pharmacological and pharmacological interventions, and ward/unit-specific barriers.

RESULTS

Data from 44 countries, 1664 wards/units and 36 048 patients were analysed. Validated delirium assessments were used in 66.7% (n = 1110) of wards/units, 18.6% (n = 310) used personal judgement or no assessment, and 10% (n = 166) used other assessment methods. A delirium management protocol was reported in 66.8% (n = 1094) of wards/units. The presence of protocols for delirium management varied across continents, ranging from 21.6% (on 21/97 wards/units) in Africa to 90.4% (235/260) in Australia, similar to the use of validated delirium assessments with 29.6% (29/98) in Africa to 93.5% (116/124) in North America. Wards/units with a delirium management protocol [n = 1094/1664, 66.8%] were more likely to use a validated delirium test than those without a protocol [odds ratio 6.97 (95% confidence interval 5.289-9.185)]. The presence of a delirium protocol increased the chances for valid delirium assessment and, likely, evidence-based interventions.

CONCLUSION

Wards/units that reported the presence of delirium management protocols had a higher probability of using validated delirium assessments tools to assess for delirium.

Risk stratification and predictive modeling of postoperative delirium in chronic subdural hematoma

Background- Postoperative delirium is a common complication associated with the elderly, causing increased morbidity and prolonged hospital stay. However, its risk factors in chronic subdural hematoma patients have not been well studied. Methods- A total of 202 consecutive patients with chronic subdural hematoma at Peking University Third Hospital between January 2018 and January 2023 were enrolled. Various clinical indicators were analyzed to identify independent risk factors for postoperative delirium using univariate and multivariate regression analyses. Delirium risk prediction models were developed as a nomogram and a Markov chain. Results- Out of the 202 patients (age, 71 (IQR, 18); female-to-male ratio, 1:2.7) studied, 63 (31.2%) experienced postoperative delirium. Univariate analysis identified age (p < 0.001), gender (p = 0.014), restraint belt use (p < 0.001), electrolyte imbalance (p < 0.001), visual analog scale score (p < 0.001), hematoma thickness (p < 0.001), midline shift (p < 0.001), hematoma side (p = 0.013), hematoma location (p = 0.018), and urinal catheterization (p = 0.028) as significant factors. Multivariate regression analysis confirmed the significance of restraint belt use (B = 7.657, p < 0.001), electrolyte imbalance (B = -3.993, p = 0.001), visual analog scale score (B = 2.331, p = 0.016), and midline shift (B = 0.335, p = 0.007). Hematoma thickness and age had no significant impact. Conclusion- Increased midline shift and visual analog scale scores, alongside restraint belt use and electrolyte imbalance elevate delirium risk in chronic subdural hematoma surgery. Our prediction models may offer reference value in this context.