Targeted Delirium Screening in At-risk Older Adults in the Emergency Department Improves Screening Rates

Objectives Delirium is prevalent yet underrecognized in the emergency department (ED). Timely identification of delirium is a priority, but results from systematic implementation of targeted delirium screening in the ED are limited. Methods This study analyzes delirium screening rates, positivity rates, and distribution of screening scores before and after implementation of an electronic medical record (EMR)-based risk stratification at ED triage. In the baseline period, delirium screening was based on age (65+ years) and clinical concern for altered mental status (AMS). In the intervention period, eligibility for delirium screening was based on an automated EMR-based risk stratification. The 4AT was used as a delirium screening tool in both periods. Results In the baseline period, only 3267 (3.0%) of patient encounters were noted to have AMS and were eligible for delirium screening; 2241 patients received the screening; 1901 screenings resulted in a positive 4AT. In the intervention period using EMR-based targeted screening, 39,065 encounters were eligible for delirium screening; 14,125 patients received the screening, resulting in 2016 positive 4AT. Conclusion This multicenter study demonstrates the feasibility of EMR-based risk stratification to target encounters for delirium screening at ED triage. The clinical judgment approach resulted in lower screening rates and a greater percentage of high-positive 4AT scores. The risk-stratified approach resulted in a 6-fold increase in number of screenings and identification of low-positive 4AT scores, detecting more patients with subtle delirium. An approach that leverages risk-stratified screening, complemented by screening based on clinical judgment, could capture a wider range of patients with delirium.