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Understanding why delirium is often missed in older emergency department patients: a qualitative descriptive study

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Abstract

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.

Résumé

Objectifs

Le délire non reconnu est associé à des résultats négatifs importants. Malgré des décennies d'efforts et d'initiatives éducatives, les outils de dépistage validés n'ont pas amélioré la reconnaissance du délire au service des urgences (SU). Il reste une lacune fondamentale dans la connaissance des raisons pour lesquelles elle est systématiquement manquée. L’objectif de cette étude était d’explorer les perceptions des médecins et des infirmières de l’urgence au sujet des facteurs contribuant au délire manqué chez les patients âgés des urgences.

Méthodes

Nous avons mené une étude qualitative descriptive dans deux urgences universitaires de soins tertiaires à Toronto, au Canada. Les médecins et les infirmières des urgences ont été interrogés par un chercheur qualitatif formé à l'aide d'un guide d'entretien semi-structuré. Nous avons codé les transcriptions à l'aide d'un livre de codes développé de manière itérative. Les entretiens ont été menés jusqu'à saturation thématique. L'analyse thématique des données s'est déroulée conjointement avec la collecte des données afin de surveiller continuellement les thèmes émergents et les domaines à explorer davantage.

Résultats

Nous avons interrogé 26 médecins et infirmières des urgences. Nous avons identifié des thèmes clés à quatre niveaux : la pratique clinique, les attitudes des prestataires, les processus systématiques et l'éducation. Les quatre thèmes abordés sont les suivants : 1) les approches de la reconnaissance du délire sont variées et les outils de dépistage peu utilisés ; 2) l'évaluation du délire est perçue comme prenant trop de temps et moins prioritaire que d'autres symptômes et syndromes ; 3) il n'est pas clair à qui revient la responsabilité de reconnaître le délire ; et 4) il est nécessaire d'avoir une compréhension plus profonde ou "fonctionnelle" du délire, qui inclut ses conséquences.

Conclusions

Nos résultats démontrent la nécessité pour les responsables des urgences de définir clairement les rôles de l'équipe pour la reconnaissance du delirium, de normaliser l'utilisation des outils de dépistage du delirium et d'accorder la priorité au delirium en tant que symptôme d'une urgence médicale aiguë.

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Acknowledgements

Dr. Jacques S. Lee is supported by the Schwartz/Reisman Emergency Medicine Institute (SREMI) Inaugural Research Chair in Geriatric Emergency Medicine. Dr. Katie N. Dainty is supported by the North York General Hospital Research Chair in Patient-Centred Outcomes.

Funding

Canadian Association of Emergency Physicians (CAEP) 2019 Junior Investigators Grant.

Author information

Authors and Affiliations

  1. Department of Emergency Medicine, Royal Alexandra Hospital, University of Alberta, Edmonton, AB, Canada

    Rebecca Schonnop

  2. Schwartz/Reisman Emergency Medicine Institute, Sinai Health, ON, Toronto, Canada

    Rebecca Schonnop, Shelley L. McLeod, Don Melady & Jacques S. Lee

  3. North York General Hospital, Toronto, ON, Canada

    Katie N. Dainty

  4. Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

    Katie N. Dainty

  5. Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada

    Shelley L. McLeod & Don Melady

  6. Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada

    Jacques S. Lee

  7. Division of Emergency Services, Sunnybrook Research Institute, Toronto, ON, Canada

    Jacques S. Lee

Authors
  1. Rebecca Schonnop
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  2. Katie N. Dainty
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  3. Shelley L. McLeod
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  4. Don Melady
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Contributions

JSL, RS and KD conceived the study and designed the methods. All authors contributed to the grant application to obtain research funding. RS led recruitment, conduction of the interviews, and data management. Under the guidance of KD, RS completed the data analysis; KD provided expertise on study design and assisted in data analysis. RS drafted the manuscript. All authors contributed substantially to editing the manuscript and approved the final submission. RS takes responsibility for the paper as a whole.

Corresponding author

Correspondence to Rebecca Schonnop.

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RS, KND, SLM, DM, and JSL report no conflict of interest.

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Schonnop, R., Dainty, K.N., McLeod, S.L. et al. Understanding why delirium is often missed in older emergency department patients: a qualitative descriptive study. Can J Emerg Med 24, 820–831 (2022). https://doi.org/10.1007/s43678-022-00371-4

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