Electronic Medical Records May Be Key to Diagnosing Delirium in Geriatric Emergency Patients

Dedicated to improving the rapid detection and long-term outcomes of older patients with delirium, Cleveland Clinic geriatricians have spent several years studying more efficient ways to manage this special population in the emergency department (ED), where many of these cases first arise. Now, researchers are reporting significant progress in the identification and assessment of at-risk patients with the use of electronic medical records (EMRs) during triage.

In 2019, when the original study first began, elderly ED patients were not being routinely screened for acute confusion, despite the widespread understanding that geriatric patients with delirium are at increased risk for prolonged hospitalization, poorer outcomes, greater costs and long-term institutionalization, explains Saket Saxena, MD, co-director of Cleveland Clinic’s geriatric emergency department.

“We knew that most elderly patients who come to the hospital initially arrive by way of the ED,” he says. “We also knew that identifying delirium early was the key to improving care and treatment. But, although we had a good delirium assessment process in place for the rest of the hospital, the same wasn’t true in the ED. That gap – the fact that acute confusion was seldom detected until after an elderly patient had already been admitted – was what we wanted to address.”

Expediting the diagnosis

One of the first studies undertaken by Dr. Saxena and his team evaluated the use of the 4AT, a rapid screening tool for delirium in the ED. The study found that the test, which takes approximately 60 seconds to complete, could detect delirium with a positivity rate of 14%, an incidence rate consistent with the general population. Also of note, about 7% of those determined to have delirium did not initially present with a complaint of altered mental status. Patients were flagged for additional screening if they were medically complex and older than 65 years; all patients aged 80 years and older were screened.

The 4AT was chosen, says Dr. Saxena, because it was easy to implement and didn’t require much training, both important factors in the ED setting.

“Things move really, really fast in the ED, where clinicians – particularly our nursing colleagues – often have to make important decisions with very little information. Because of this, we were mindful about the patients we selected for screening, so as not to squander time or resources,” he explains.

By May 2023, Dr. Saxena and his team were confident that the 4AT could be a valuable screening tool for delirium in geriatric patients, regardless of their mental status on arrival in the ED. In a paper presented at the 2023 American Geriatric Society’s Annual Scientific Meeting and recently published in the Journal of Geriatric Emergency Medicine, the team’s conclusion was clear: All high-risk geriatric patients – as identified by prior medical history, number of outpatient medications, and ED visits and hospitalizations in the preceding year – should be screened for delirium or cognitive impairment with the 4AT at the time of triage.

Putting documentation to work

Dr. Saxena notes that integrating the clinic’s EMR system into the process was a game changer. By generating a “best practice alert” during triage in the ED, the EMR can prompt the geriatrics team to further assess an at-risk patient.

For this purpose, a group of subject matter experts developed criteria to define high-risk geriatric characteristics that could be captured by the EMR. Those factors included:

• Age greater than 80 years
• Fall complaint
• Documented dementia history
• Polypharmacy, meaning 10 or more listed medications
• High ED utilization, meaning more than five visits in one year
• Positive 4AT delirium screening

According to a descriptive feasibility study set to be published later this year in the Journal of the American Medical Informatics Association, Dr. Saxena and his team have been able to demonstrate two critical findings regarding the use of the EMR. First, it is feasible to use structured EMR data to identify older adults at risk for poor outcomes during triage, eliminating the need for additional resources, including more staff, to perform such screenings. And second, it is possible to narrow down and define the group of patients who might benefit from a more comprehensive assessment by a geriatric medicine provider. “Both of these findings are critical for optimizing limited resources in the high-acuity, high-volume ED environment and [are] achievable by leveraging readily available discrete EMR data fields,” the paper notes.

“This has changed the whole process of assessing for delirium in our EDs,” Dr. Saxena says. “The EMR will prompt triage nurses to do a delirium assessment on any high-risk patient, even if there is no prima facie evidence of a change in mental status. We are continuing to learn and are ready to expand our screening to a larger audience.”

The new screening process is being implemented throughout the Cleveland Clinic healthcare system, he explains. “The processes we’re talking about affect the entire enterprise: Northeast Ohio, Florida, and anywhere else there is a Cleveland Clinic ED. We are unique in using our advanced EMR to identify patients who might be at risk, and thousands of patients are being already being touched by this process every day.”

Harnessing data to improve outcomes

Now that the feasibility of identifying elderly ED patients with delirium has been established, Dr. Saxena is preparing for the next step: finding ways to use that data to improve patient care.

“Our job is to show that if you detect acute confusion earlier in the presentation, you may be able to improve the care of these patients as they move forward in the hospital system,” he explains, noting that the process could result in payoffs like decreased need for antipsychotic medications, less deconditioning, better nutrition, fewer pressure ulcers and shorter length of stay.

“We now have a process in place to identify delirium soon after a patient arrives, so now the question becomes: What can we do about it?” says Dr. Saxena. “We hope that ongoing research will continue to provide answers. We’re moving forward with the expectation of positively influencing the clinical picture for older patients.”