Impact on delirium detection of using a sensitive instrument integrated into clinical practice
Introduction
Delirium is a common and challenging psychiatric complication occurring during hospitalization in geriatrics, orthopedics, intensive care and oncology units [1], [2], [3], [4]. Although daily fluctuation is a cardinal symptom of delirium according to the Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV) [5], early delirium symptoms frequently go unnoticed [6] since, in general, only irregular or once-daily delirium clinical evaluations are performed. Promptly detecting delirium using continuous and sensitive assessment, thereby allowing immediate diagnosis and therapeutic actions [7], [8], can improve the efficiency of delirium screening, by decreasing the number of undetected patients and by reducing the delay in delirium recognition. The Nursing Delirium Screening Scale (Nu-DESC) is a simple observational instrument that can be used to assess delirium status on a continuous basis with a high level of sensitivity and accuracy [9]. The Nu-DESC was derived from the Confusion Rating Scale (CRS) [10] to improve its sensitivity to delirium without compromising its ease of use. We used this increased sensitivity to study how delirium detection can be improved. The objectives of this study were to determine delirium prevalence and incidence in oncology and to quantify the impact of using a continuous and sensitive delirium instrument on (1) the decrease in delirium underrecognition and (2) the reduction in time to delirium detection.
Section snippets
Method
This study is a secondary analysis of data collected in the validation study of a new delirium screening instrument, the Nu-DESC. The CRS comprises four items that are operationalized for on-site use: (1) disorientation (verbal or behavioral manifestation of not being oriented to time or place or of misperceiving persons in the environment), (2) inappropriate behavior (behavior inappropriate to place and/or for the person, e.g., pulling at tubes or dressings, attempting to get out of bed when
Results
Based on the validation study [9], the difference between Nu-DESC and CRS FNRs was 0.381 (95% CI, 0.173–0.589), for an absolute NNS of 2.6 (95% CI, 1.73–5.89). Relative NNS calculations for various overall delirium prevalences are presented in Table 1.
Overall prevalence of delirium based on the Nu-DESC was 35/134 (26.1%) and 29/134 (21.6%) based on the CRS. Nine cases were prevalent on admission according to the Nu-DESC compared to seven according to the CRS, and 26 patients were incident cases
Discussion
This study determined delirium prevalence and incidence in oncology and quantified the impact of using a continuous and sensitive delirium instrument on the decrease in delirium underrecognition and the reduction in time to delirium detection.
Acknowledgments
This research was supported by a grant from the Sociobehavioural Cancer Research Network (SCRN), funded through the National Cancer Institute of Canada's (NCIC) Centre for Behavioural Research and Program Evaluation, with funds from the Canadian Cancer Society. J.D. Gaudreau is the recipient of a Fonds d'Enseignement et de Recherche Award from the Faculty of Pharmacy, Laval University and of a Canadian Institutes of Health Research (CIHR) — NCIC award from the Strategic Training Program in
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2013, British Journal of AnaesthesiaCitation Excerpt :There are no studies documenting its performance in the PACU setting, but given its validation in patients receiving sedation and mechanical ventilation, evaluation for use in the PACU and postoperative inpatient setting is appropriate. The Nursing Delirium Symptom Checklist (NuDESC) delirium tool was validated in 59 oncology/internal medicine inpatients, with a sensitivity and specificity of 86 and 87%, respectively, when using a scoring threshold of ≥2.13 14 The NuDESC also has been used in the ICU, with a sensitivity and specificity of 83 and 81%, respectively.15
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2013, European Journal of Cancer, SupplementCitation Excerpt :In the validation study by Gaudreau et al [8], the NuDESC proved sufficiently sensitive to be used as a screening tool in oncology, although recently a study on the detection of postoperative delirium in the elderly showed that sensitivity was too low in this population [9]. Still, a more careful and systematic approach [10] adopted by the nursing staff is a reasonable strategy and is to be recommended in oncology and particularly in palliative care settings such as a hospice. The diagnosis finally relies on the DSM criteria and requires specific expertise.
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