Tuesday, January 14, 2014

Diagnosing and Adequately Treating Delirium Vital for Patient Recovery

As many as two out of every three patients in hospital settings with delirium may not be recognized as such by health care professionals. This is due in part to of a lack of validated tools for properly managing delirious patients and because some practitioners may not recognize the condition, according to an article in MedPage Today.

A major barrier to assessing delirium in emergency departments (ED) is the lack of a rapid assessment tool specifically designed for such a fast-paced environment. Relying on past experience and the patients’ behavior is not enough.  In fact, using clinical gestalt to diagnose delirium can result in providers missing up to 83 percent of cases, particularly in patients where the symptoms are more subtle.

The impact on the patient of a missed diagnosis can be dire. Generally, patients with delirium should receive adequate oxygenation, hydration, nutrients, pain treatment if necessary, and judicious drug intervention if needed. They should not be restrained, and should be kept awake and alert, according to experts quoted in the article.

Jin Han, MD, MSc, of the Vanderbilt University School of Medicine in Nashville, Tenn, and colleagues developed a two-step, validated diagnostic of delirium for ED patients age 65 and older: the Brief Confusion Assessment Method and Delirium Triage Screen. The screens have 82 percent sensitivity and 95.8 percent specificity when used together, Han wrote in an article published in the Annals of Emergency Medicine. Delirium assessment tools currently available often take as much as five minutes to complete, while Han’s Brief Confusion Assessment method takes only one minute, an important time difference in the ED.

However, Han noted that there is still much work to be done in screening methodology. "I don't think there is a one-size-fits-all approach to delirium screening," he said. "Different clinical environments will have different expertise, time constraints, and goals for the patients."

An INQRI-funded study led by Michele Balas and William Burke, explored the high risk for delirium and weakness for patients on ventilators in hospital intensive care units (ICU). The study found that a bundle of practices, employed by a nurse-led interprofessional team of health care providers, could help ICU patients avoid delirium and weakness. The study was published in Critical Care Nurse.

Researchers examined a “bundle” of evidence-based practices called the Awakening, and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility bundle (ABCDE bundle), which uses the best available evidence on delirium, immobility, sedation and analgesia, and ventilator management in the ICU. The bundle is founded on three primary principles: improving communication among members of the ICU team; standardizing care processes; and breaking the cycle of over-sedation and prolonged attachment to a ventilator that can lead to delirium and weakness.

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