1. Early detection of delirium in older people in the emergency department
Group N°6
Els DEVRIENDT (Belgium)
Camilla GÖRAS (Sweden)
Sara LEVATI (Italie)
Laura-Maria MURTOLA (Finland)
Sebastien KEREVER (France)
Nijmegen 5th July 2013

2. safety and quality of care impairment
Background
Delirium: disturbance of consciousness, attention, cognition, and perception that appears after a short period of time (usually hours to days) and tends to fluctuate during the course of the day
Prevalence of delirium: 8-10% of older patients (≥70 yo) admitted to the Emergency Departement, underdiagnosed in 57% to 83% of the cases
Multifactorial problem associated with a increasing of:
Hospital mortality
Hospital length of stay
Healthcare costs
Long-term functional and cognitive decline
Missing delirium detection  Missing diagnosis
safety and quality of care impairment
Barron EA & Al, 2013; NICE, 2010; Han & Al , 2010; Innoye & Al, 1990; Press & Al, 2009.

3. Question
What is the impact of an e-learning program on nurses to improve the early detection of delirium in older patients in an emergency department?
Setting: Belgium University hospital in leuven

4. Methods MRC METHODS 1. Developement Evidence base Systematic Review
Qualitative studies: Focus groups
Identifying Theory
Competency framework
Modelling intervention
Expert Pannel Meeting
2. Feasibility/piloting
Testing procedures
Before/After Pilot study
Qualitative feasibility study
Estimation of recruitment/retention
Review of the litterature + a priori information
Number of subject needed for the pilot study
Sample size determination
Inclusion rate estimation

5. Ishikawa - fishbone flowchart (Cause & Effect Diagram)
Environement
Competences
Underdetection of delirium in older patients in ED
TODO check SR and add fishbone
Aim SR
Screening tool
Documentation
Ishikawa K , “Introduction to quality control”, 1990.

6. Theoretical framework%
Focus Group:
Qualitative part
Skills
Knowledge
Attitudes
Behavior
Quantitative part
Proportion
Distribution
Functional Competence (Skills)
Ethical Competence (Attitudes)
Personal Competence (Behavior)
Cognitive Competence (Knowledge)
Knowledge complex problem delirium
Skills eg delirium managing
Skills: using screeningsinstruments
Focusgroup to identify and quantify the problem of underrecognition of delirium in the ED influencing competence. We want to do that before the intervention. % % %
Cheetham G & Al, “Towards a holistic model of professional competence”, J Eur Indus Training, 1996

7. Intervention development
Educational program
Philosophy: self constructive program
Methods: e-learning platform (modules and toolbox)
Content:
Skills: using the CAM screening tool, how to deal with the target population
Knowledge: incidence, risk factors, consequences, screening methods
Attitudes: organisational culture, climate within the team, attitudes towards the population, safety, motivation
Behavior: emotional control (aggresivity)
Competence tests (part of the e learning)
Modelling
Expert panel meeting: geriatric and emergency team.
Components of the intervention can be ….
We will propose this intervention to a group of experts

8. Methodology – Pilot study
Model
Monocentric prospective quasi experimental before and after pilot study
Primary outcome: proportion of delirium documented during the first 72h at the ED (%)
Secondary outcome: Increased competence (questionnaire, nurse competence scales, vignette study)
Sample size
Attended effect Δ + 20% (systematic review & previous study)
α = 5%, power = 90%, two tailed
n = 260
Inclusion rate
Rate of patient 2/days with delirium (≥ 70 yo)
Length 8 months (3 before, 2 teaching, 3 after)
n = 360 (+ 40%, refusal, withdraw, dementia, lost to follow up, missing)
Cost euros
Sample size based on observational study on 442 patients in leuven

9. Future Perspectives Meta analysis
Risk factors (HR), Mortality
Multicentric international cluster RCT
Long term mortality
Long term e-learning
Cost Effectiveness Study
E learning vs. Cost of avoid delirium

10. Why Us ?
Conclusion: “Delirium is a significant concern in the ED, with many delirious patients not identified by physicians. To improve delirium outcomes and hospital management, measures must include mechanisms to improve detection” Barron & Al, 2013
The team experience
Els DEVRIENDT (Geriatric and Emergency Room)
Camilla GÖRAS (Safety & Quality of care)
Sara LEVATI (Complex Intervention & net work tools)
Laura-Maria MURTOLA (ICU, management, care organisation)
Sebastien KEREVER (ICU, Methodology, Biostatistic)
The results
Improving Patient outcome
Saving institutional money
Increase Nursing Competence