Objectives

Unrecognized delirium is associated with significant adverse outcomes. Despite decades of effort and educational initiatives, validated screening tools have not improved delirium recognition in the emergency department (ED). There remains a fundamental knowledge gap of why it is consistently missed. The objective of this study was to explore the perceptions of ED physicians and nurses regarding factors contributing to missed delirium in older ED patients.

Methods

We conducted a qualitative descriptive study at two academic tertiary care EDs in Toronto, Canada. Emergency physicians and nurses were interviewed by a trained qualitative researcher using a semi-structured interview guide. We coded transcripts with an iteratively developed codebook. Interviews were conducted until thematic saturation occurred. Thematic data analysis occurred in conjunction with data collection to continuously monitor emerging themes and areas for further exploration.

Results

We interviewed 26 ED physicians and nurses. We identified key themes at four levels: clinical practice, provider attitudes, systematic processes, and education. The four themes include: (1) there are varied approaches to delirium recognition and infrequent use of screening tools; (2) delirium assessment is perceived as overly time consuming and of lower priority than other symptoms and syndromes; (3) it is unclear whose responsibility it is to recognize delirium; and (4) there is a need for a deeper or “functional” understanding of delirium that includes its consequences.

Conclusions

Our findings demonstrate a need for ED leadership to identify clear team roles for delirium recognition, standardize use of delirium screening tools, and prioritize delirium as a symptom of an acute medical emergency.

中文翻译：

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理解为什么老年急诊科患者经常遗漏谵妄：一项定性描述性研究

目标

未被识别的谵妄与严重的不良后果有关。尽管经过数十年的努力和教育举措，经过验证的筛查工具并未提高急诊科 (ED) 对谵妄的识别率。关于为什么它一直被遗漏，仍然存在基本的知识差距。本研究的目的是探讨 ED 医生和护士对导致老年 ED 患者遗漏谵妄的因素的看法。

方法

我们在加拿大多伦多的两个学术三级医疗急诊室进行了定性描述性研究。一位训练有素的定性研究人员使用半结构化访谈指南对急诊医生和护士进行了访谈。我们使用迭代开发的密码本对成绩单进行编码。访谈一直进行到主题饱和为止。专题数据分析与数据收集相结合，以持续监测新出现的主题和领域以供进一步探索。

结果

我们采访了 26 名急诊科医生和护士。我们确定了四个层面的关键主题：临床实践、提供者态度、系统过程和教育。这四个主题包括：(1) 谵妄识别方法多种多样，筛查工具的使用频率较低；(2) 谵妄评估被认为过于耗时且优先级低于其他症状和综合征；(3) 谵妄的认定责任不明确；(4) 需要对包括其后果在内的谵妄有更深入或“功能性”的理解。

结论

我们的研究结果表明，急诊领导层需要明确识别谵妄的团队角色，标准化谵妄筛查工具的使用，并将谵妄作为紧急医疗紧急情况的症状进行优先排序。