List of Tables - University of Edinburgh - Delirium vs encephalopathy in coding

The 4 “A”s Test (4AT) delirium assessment instrument: qualitative evaluation and diagnostic accuracy studyAlasdair MacLullich,1 Susan Shenkin,1 Steve Goodacre,2 Mary Godfrey,3 Janet Hanley,4 Antaine Stiobhairt,1 Elizabeth Lavender,3 Julia Boyd,5 Jacqueline Stephen,5,6 Christopher Weir,5,6 Allan Macraild,7 Jill Steven,7 Polly Black,7 Katharina Diernberger,6,7 Peter Hall,5 Zo? Tieges,1 Christopher Fox,8 Atul Anand,1 John Young,9 Najma Siddiqi,10 Alasdair Gray6,71Geriatric Medicine, University of Edinburgh, Edinburgh, UK; 2Emergency Medicine, University of Sheffield, Sheffield, UK3Health and Social Care, Institute of Health Sciences, University of Leeds, Leeds, UK 4Health and Social Care, Edinburgh Napier University, Edinburgh, UK.5Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK6Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.7Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK. 8Norwich Medical School, University of East Anglia, Norwich, UK9Elderly Care and Rehabilitation, University of Leeds, Leeds, UK.10Psychiatry, University of York, York, Hull York Medical School; York and Bradford District Care NHS Foundation Trust, Bradford, UK. *Corresponding AuthorProfessor Alasdair MJ MacLullich Professor of Geriatric Medicine, University of EdinburghHonorary Consultant in Geriatric Medicine, Royal Infirmary of EdinburghGeriatric Medicine Unit, University of EdinburghRoom S1642, Royal Infirmary of Edinburgh51, Little France Crescent, Edinburgh EH16 4SATel: 0131 242 6481Fax: 0131 242 6370Email: a.maclullich@ed.ac.ukThe authors declare no competing interests.The protocol can be obtained from the corresponding author.Funder: National Institute of Health Research, ref. 11/143/01. The funder specified that the any new delirium assessment tool should be compared against the Confusion Assessment Method, but had no other role in the study design or conduct of the study.Word count (main body): 43262.Abstract BackgroundDelirium is a common and serious neuropsychiatric syndrome usually triggered by illness or drugs. It remains under detected. One reason is lack of brief, pragmatic assessment tools. The 4 “A”s test (Arousal, Attention, Abbreviated Mental Test 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost.MethodsPhase 1 The usability of the 4AT in routine practice was measured by two surveys and two qualitative studies of healthcare professionals, and a review of current clinical use and presence in guidelines and reports.Phase 2 The diagnostic accuracy of the 4AT was assessed in newly-admitted acute medical patients aged >=70. Its performance was compared with the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items were related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks, and outcomes. Methods were: a prospective double blind diagnostic test accuracy study in emergency departments or acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment, and was randomised to assessment also with 4AT (N=421) or CAM (N=420). A health economic analysis was also conducted.ResultsPhase 1 found evidence of increasing delirium awareness, but need for education on delirium in general and the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use in the UK and beyond. No changes were considered necessary.Phase 2 involved 785 individuals with data for analysis: mean age 81.4 (SD 6.4) years, 45% male, 99% white, 9% known dementia diagnosis. The 4AT (N=392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (>3) had specificity of 95% (95% CI 92-97%) and sensitivity of 76% (95% CI 61-87%) for reference standard delirium. The CAM (N=382) had a specificity of 100%, (95% CI 98-100%) and a sensitivity of 40% (95% CI 26-57%) in the subset of participants in whom is was assessable.Patients with positive 4AT had longer lengths of stay (median 5 days (IQR 2.0-14.0) than negative 4AT (median 2 days (IQR1.0 to 6.0) and higher 12 weeks mortality: 16.1% v 9.2% respectively. The estimated 12-week costs of the initial inpatient stay for patients with delirium were more than double those without, e.g. in Scotland (?7559 (?7362-7755) v. ?4215 (4175, 4254). The estimated cost for false positive cases was ?4653, for false negatives ?8956, and from a missed diagnosis ?2,067.LimitationsPatients were aged >=70 and assessed early in their admission, limiting generalisability. Treatment of patients per reference standard diagnosis limited the ability to assess comparative cost-effectiveness.ConclusionsThese findings support use of the 4AT as a rapid delirium assessment instrument. It has acceptable diagnostic accuracy for acute older patients aged over 70. Future workFurther research should address real-world world implementation of delirium assessment. The 4AT should be tested in other populations.Study registrationInternational standard randomised controlled trial number (ISRCTN) 53388093. Funding detailsNational Institute of Health Research Technology Assessment Programme (NIHR HTA) grant number 11/143/01. KeywordsDelirium, dementia, acute hospitals, 4AT, diagnostic accuracy, CAMTable of Contents TOC \o "1-2" \h \z \u List of Tables PAGEREF _Toc521141283 \h 10List of Figures PAGEREF _Toc521141284 \h 12Alphabetical list of abbreviations/glossary PAGEREF _Toc521141285 \h 13Plain English Summary PAGEREF _Toc521141286 \h 16Scientific Summary PAGEREF _Toc521141287 \h 171General Introduction PAGEREF _Toc521141288 \h 261.1Delirium: background PAGEREF _Toc521141289 \h 261.2Under-detection of delirium PAGEREF _Toc521141290 \h 271.3The need for a new assessment tool PAGEREF _Toc521141291 \h 291.4Overview of project PAGEREF _Toc521141292 \h 312Surveys of Current Practice PAGEREF _Toc521141293 \h 332.1General Introduction PAGEREF _Toc521141294 \h 332.2Methods PAGEREF _Toc521141295 \h 342.3Results PAGEREF _Toc521141296 \h 372.4Discussion PAGEREF _Toc521141297 \h 483Clinical Use and Examples of Clinical Service Evaluations PAGEREF _Toc521141298 \h 553.1Introduction PAGEREF _Toc521141299 \h 553.2Inclusion of the 4AT in policy, guidelines, and advisory documents and websites PAGEREF _Toc521141300 \h 563.3Use of the 4AT in clinical practice PAGEREF _Toc521141301 \h 583.4Field testing of 4AT Item 1 (level of alertness) PAGEREF _Toc521141302 \h 623.5Conclusions PAGEREF _Toc521141303 \h 634Implementing Delirium Screening PAGEREF _Toc521141304 \h 644.1Introduction PAGEREF _Toc521141305 \h 644.2Research design PAGEREF _Toc521141306 \h 654.3Methods PAGEREF _Toc521141307 \h 664.4Findings PAGEREF _Toc521141308 \h 734.5Discussion PAGEREF _Toc521141309 \h 1045Diagnostic Accuracy of the 4AT PAGEREF _Toc521141310 \h 1115.1Introduction PAGEREF _Toc521141311 \h 1115.2Study objectives and hypotheses PAGEREF _Toc521141312 \h 1135.3Methods PAGEREF _Toc521141313 \h 1145.4Results PAGEREF _Toc521141314 \h 1285.5Discussion PAGEREF _Toc521141315 \h 1415.6Conclusions PAGEREF _Toc521141316 \h 1466Health economics PAGEREF _Toc521141317 \h 1486.1Introduction PAGEREF _Toc521141318 \h 1486.2Methods PAGEREF _Toc521141319 \h 1496.3Results PAGEREF _Toc521141320 \h 1596.4Health Economic Model – Cost Effectiveness Analysis PAGEREF _Toc521141321 \h 1626.5Discussion PAGEREF _Toc521141322 \h 1687General discussion PAGEREF _Toc521141323 \h 1717.1Research implications PAGEREF _Toc521141324 \h 1757.2Clinical implications PAGEREF _Toc521141325 \h 1768Acknowledgements PAGEREF _Toc521141326 \h 1778.1Contributions of authors PAGEREF _Toc521141327 \h 1778.2Data Sharing Statement PAGEREF _Toc521141328 \h 1809References PAGEREF _Toc521141329 \h 18110Appendices PAGEREF _Toc521141330 \h 20210.1Appendix 1. Survey A PAGEREF _Toc521141331 \h 20210.2Appendix 2. Survey B PAGEREF _Toc521141332 \h 22210.3Appendix 3. Survey B: respondent characteristics PAGEREF _Toc521141333 \h 24210.4Appendix 4. Survey B: assessment tools used and the frequency of use among respondents PAGEREF _Toc521141334 \h 24310.5Appendix 5. User opinions of the 4AT from Survey B PAGEREF _Toc521141335 \h 24410.6Appendix 6. Interviewees by hospital and department in qualitative study PAGEREF _Toc521141336 \h 24810.7Appendix 7. Interviewees by profession and seniority in qualitative study PAGEREF _Toc521141337 \h 24910.8Appendix 8: Topic guide for qualitative staff interviews. Identifying delirium: knowledge, screening practices and barriers to identifying delirium in acute hospitals PAGEREF _Toc521141338 \h 25010.9Appendix 9. Comments and examples of suggested changes to the 4AT. PAGEREF _Toc521141339 \h 25410.10Appendix 10: STARD flow diagrams of recruitment at each site PAGEREF _Toc521141340 \h 25610.11Appendix 11. Receiver Operator Characteristic Curve for 4AT diagnostic accuracy PAGEREF _Toc521141341 \h 26210.12Appendix 12. Diagnostic Test Accuracy of 4AT versus CAM for diagnosis of delirium PAGEREF _Toc521141342 \h 26310.13Appendix 13. Diagnostic test accuracy of individual items of 4AT for diagnosis of delirium PAGEREF _Toc521141343 \h 26410.14 Appendix 14. Scatterplot of DRS-R98 scores and 4AT score PAGEREF _Toc521141344 \h 26610.15Appendix 15. Kaplan Meier Plot for 4AT and length of stay PAGEREF _Toc521141345 \h 26710.16Appendix 16. Costs of tests – health economics analysis PAGEREF _Toc521141346 \h 26810.17Appendix 17. Community health service costs PAGEREF _Toc521141347 \h 26910.18Appendix 18. Costs of additional activities PAGEREF _Toc521141348 \h 27110.19Appendix 19. Health economics survey PAGEREF _Toc521141349 \h 27310.20Appendix 20. Model Parameters PAGEREF _Toc521141350 \h 28310.21Appendix 21. Results from the Health Economic Model PAGEREF _Toc521141351 \h 28510.22Appendix 22. Tornado plot: difference in costs PAGEREF _Toc521141352 \h 28610.23Appendix 23. Tornado plot: difference in effectiveness PAGEREF _Toc521141353 \h 28710.24Appendix 24: Cost-effectiveness plane PAGEREF _Toc521141354 \h 28810.25Appendix 25. Cost-effectiveness-acceptability curve (CEAC) PAGEREF _Toc521141355 \h 289 PAGEREF _Toc521141356 \h 289List of Tables TOC \h \z \c "Table" Table 1. Survey A: respondent characteristics PAGEREF _Toc521141242 \h 38Table 2. Survey A: respondents’ answers when asked to indicate which of three tasks different professional groups should consider their own duty in regards to delirium detection PAGEREF _Toc521141243 \h 41Table 3. Survey B: the extent to which respondents thought various barriers were preventing the 4AT from being used more regularly in their units PAGEREF _Toc521141244 \h 45Table 4. Reference standard assessment for delirium PAGEREF _Toc521141245 \h 120Table 5. The 4 “A”s Test (4AT) PAGEREF _Toc521141246 \h 121Table 6. Confusion Assessment Method (CAM): pre-scoring cognitive testing procedure PAGEREF _Toc521141247 \h 122Table 7. Baseline characteristics stratified by delirium status PAGEREF _Toc521141248 \h 130Table 8. Cross tabulation of index test results (4AT and CAM) by results of reference standard PAGEREF _Toc521141249 \h 132Table 9. Diagnostic test accuracy of 4AT for diagnosis of delirium (defined by reference standard assessment) PAGEREF _Toc521141250 \h 133Table 10. Individual components of 4AT cognitive items stratified by dementia status, defined as a documented history of dementia and/or a score of >=3.44 on the IQCODE PAGEREF _Toc521141251 \h 135Table 11. Diagnostic test accuracy of 4AT cognitive components for diagnosis of dementia, defined as a documented history of dementia and/or a score of >=3.44 on the IQCODE PAGEREF _Toc521141252 \h 136Table 12. 4AT as a predictor of clinical outcomes PAGEREF _Toc521141253 \h 139Table 13: Scottish hospital cost estimates PAGEREF _Toc521141254 \h 153Table 14: English hospital cost estimates PAGEREF _Toc521141255 \h 156Table 15: Costs at 12 weeks for delirium versus no delirium by original researcher assessments PAGEREF _Toc521141256 \h 160Table 16: Costs at 12 weeks for delirium versus no delirium by the final reference standard ascertainments PAGEREF _Toc521141257 \h 161Table 17: Survey B: respondent characteristics PAGEREF _Toc521141258 \h 242Table 18: Survey B: assessment tools used and the frequency of use among respondents PAGEREF _Toc521141259 \h 243Table 19: Interviewees by hospital and department in qualitative study PAGEREF _Toc521141260 \h 248Table 20: Interviewees by profession and seniority in qualitative study PAGEREF _Toc521141261 \h 249Table 21: Diagnostic Test Accuracy of 4AT versus CAM for diagnosis of Delirium PAGEREF _Toc521141262 \h 263Table 22: Diagnostic test accuracy of individual items of 4AT for diagnosis of delirium PAGEREF _Toc521141263 \h 264Table 23: Costs of tests – health economics analysis PAGEREF _Toc521141264 \h 268Table 24: Community health service costs PAGEREF _Toc521141265 \h 269Table 25: Costs of additional activities PAGEREF _Toc521141266 \h 271Table 26: Model Parameters PAGEREF _Toc521141267 \h 283Table 27: Differences in Costs and Effectiveness and ICERs PAGEREF _Toc521141268 \h 285List of Figures TOC \h \z \c "Figure" Figure 1. Page views per year on the website between 2011 and 2017. Source: Google Analytics PAGEREF _Toc521141269 \h 59Figure 2: Diagnostic accuracy study: overview flowchart PAGEREF _Toc521141270 \h 125Figure 3: STARD diagram of flow of participants through the study (total across all three sites) PAGEREF _Toc521141271 \h 129Figure 4: Decision Tree PAGEREF _Toc521141272 \h 163Figure 5: STARD diagram of flow of participants through the Edinburgh site PAGEREF _Toc521141273 \h 257Figure 6: STARD diagram of flow of participants through the Sheffield site PAGEREF _Toc521141274 \h 258Figure 7: STARD diagram of flow of participants through the Edinburgh site PAGEREF _Toc521141275 \h 259Figure 8: Receiver Operator Characteristic Curve for 4AT diagnostic accuracy PAGEREF _Toc521141276 \h 262Figure 9: Scatterplot of DRS-R98 scores and 4AT scores PAGEREF _Toc521141277 \h 266Figure 10: Kaplan Meier Plot for 4AT and length of stay PAGEREF _Toc521141278 \h 267Figure 11: Tornado plot: difference in costs PAGEREF _Toc521141279 \h 286Figure 12: Tornado plot: difference in effectiveness PAGEREF _Toc521141280 \h 287Figure 13: Cost-effectiveness plane PAGEREF _Toc521141281 \h 288Figure 14: Cost-effectiveness-acceptability curve (CEAC) PAGEREF _Toc521141282 \h 289Alphabetical list of abbreviations/glossary4AT4 “A”s TestAMTAbbreviated Mental TestAMT4Abbreviated Mental Test – 4AMT10Abbreviated Mental Test (same as AMT, different name)CAMConfusion Assessment MethodCAM-ICUConfusion Assessment Method for the ICUCEACCost-Effectiveness Acceptability Curve CQUINCommissioning for Quality and InnovationCRFCase Record FormDDOTDelirium Dementia Outreach TeamDADDelirium and Dementia teamDRS-R98Delirium Rating Scale – Revised – 98DSM-III-RDiagnostic and Statistical Manual of Mental Disorders, 3rd Edition - RevisedDSM-IVDiagnostic and Statistical Manual of Mental Disorders, 4th EditionDSM-5Diagnostic and Statistical Manual of Mental Disorders, 5th Edition EAUElderly Assessment UnitEDEmergency Department (Accident and Emergency)FAIR Find, Assess, Investigate, ReferFNFalse NegativeFPFalse PositiveHCAHealthcare AssistantHSWHealth Support WorkerICDInternational Classification of DiseaseICERIncremental Cost-Effectiveness Ratio ICUIntensive Care UnitIQCODEInformant Questionnaire for Cognitive Decline in the ElderlyISDInformation Services Division, NHS ScotlandMAUMedical Assessment UnitMDTMulti-disciplinary teamMMSEMini-Mental Status ExaminationNPVNegative Predictive ValueNU-DESC Nursing Delirium ScaleOPACOlder People in Acute Care PPVPositive Predictive ValuePSAProbabilistic Sensitivity AnalysisPSSRU Personal Social Services Research Unit (NHS costs)QALY Quality-Adjusted Life YearROCReceiver Operating CharacteristicSAU Surgical Assessment UnitTNTrue NegativeTPTrue PositiveUPRUnitary Patient Record Plain English SummaryDelirium is the sudden onset of confusion that can happen when someone is unwell. It is common when older people go in to hospital, and upsetting for both patients and their families. It is important to diagnose because people with delirium do less well than those without, and it is often treatable. The ideal way to diagnose it is with a full assessment by a specialist, but this is expensive and time consuming. We therefore developed a short test, the Four A’s Test (4AT). The four A’s stand for Arousal, Attention, Abbreviated Mental Test, and Acute change,First we interviewed hospital staff about delirium and the 4AT. We found that the 4AT was already widely used, and people found it easy to use. We then tested how the 4AT performed in practice. 785 recently admitted, over 70 year olds, of whom around one in eight had delirium, participated. A researcher did the full standard delirium assessment on each patient. Then a different nurse did the 4AT. A normal 4AT score reliably ruled out delirium. An abnormal score was also reasonably effective in detecting it, but staff still needed to follow up such patients with a full assessment. People with higher 4AT scores stayed in hospital longer, were more likely to die, and their treatment was more expensive. We conclude that the 4AT is a useful test to rule out delirium, or to see if more detailed testing is required. It could help treat patients correctly and quickly. This would save money, and improve outcomes. (254 words)Scientific SummaryBackground Delirium is significantly under-detected in the acute hospital, and there is a need for short, easy to administer screening tools that can be used by non-experts. The 4 “A”s Test (4AT), a four-item bedside assessment test (see Table 5), was developed for this purpose. This project assessed the need for further development of the 4AT, and then tested its diagnostic accuracy compared to an alternative, older test with longer administration time called the Confusion Assessment Method (CAM). A health economics analysis was also undertaken.Objectives Phase 1: What is the usability of the 4AT in clinical practice?Are any changes needed in the current structure and scoring of the 4AT?Phase 2:Primary objective:What is the diagnostic accuracy of the 4AT for delirium detection?Secondary objectives: 2a) To compare the performance of the 4AT with the CAM2b) To examine the performance of the cognitive test items in the 4AT in detecting general cognitive impairment2c) To determine if the 4AT predicts length of stay, new institutionalisation, mortality at 12 weeks2d) To examine the contribution of individual items of the 4AT to overall delirium diagnosis2e) To estimate the costs of delirium in the study populationMethods: Phase 1SurveysWe performed two online surveys (A and B). We invited healthcare practitioners across multiple healthcare settings by social media and email. Items were presented in a fixed order and included multiple choice, ranking, 5-point Likert scale and open comment response formats. Survey A was of general aspects of knowledge of and attitudes to delirium assessment in medical practitioners, nurses, occupational therapists and physiotherapists in UK. Survey B was tailored to those healthcare practitioners who had previously used the 4AT to identify any potential changes to instrument.. Qualitative studyWe performed a qualitative, mixed methods study comprising interviews with health professionals and observation of practice in different locations along the patient journey; and in selected acute wards in three sites: two English sites where the 4AT was not in use, and one Scottish site where the 4AT was widely used. Interviews and ethnographic observations were analysed using grounded theory.Current use in clinical practiceWe explored current clinical usage of the 4AT by searching for published studies and on-line reports, presence of the 4AT in clinical guidelines, pathways and websites, and by contacting networks of clinicians active in delirium, and requests via social media. Phase 2Diagnostic Test Accuracy StudyWe performed a multicentre prospective diagnostic test accuracy study. We recruited older patients in Emergency Departments or acute general medical wards in three UK sites from Oct 2015 to Dec 2016. Inclusion criteria: age >=70, within 12h of admission to the Emergency Department (ED) or 96 hours of admission to medical unit. Exclusion criteria: coma, acute life-threatening illness, severe communication impairment. Consent was sought from patients or legal proxies when patients lacked capacity. Each patient underwent 1) a reference standard delirium diagnostic assessment, and 2) were randomised to assessment (by a a different researcher) with either a) the 4AT (range 0-12; score >= 4 indicating ‘possible delirium’) or b) the CAM (scores are either negative or positive). The order of reference standard and 4AT/CAM was computer-randomised. We administered the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) for prior cognitive impairment. Length of stay, institutionalisation, and mortality at 12 weeks were measured.A statistical analysis plan was agreed prior to database lock, blinded to randomised allocations. We calculated positive and negative predictive values, sensitivity and specificity (with exact binomial 95% confidence interval) for 4AT versus delirium reference standard. We constructed a receiver operating characteristic (ROC) curve. We tested differences in proportions and 95% confidence interval of sensitivity, specificity, positive and negative predictive values by Fisher’s exact test. The overall performance of 4AT and CAM was summarised using Youden’s Index (sensitivity minus false positive rate) and the odds ratio of sensitivity to specificity. We used logistic regression modelling to predict mortality; and Kaplan-Meier curves and Cox proportional hazards models (adjusted for age, gender and presence of dementia) to predict hospital length of stay. Health economic analysis 1) Cost analysis using data collected within the study. Research nurses collected patients’ use of hospital services from the Health Economics Questionnaire at the 12 week outcome assessment and using length of stay on different hospital wards from the clinical notes. We calculated observed mean (95% CIs) of costs occurring within the 12 weeks. Unit costs were assigned to inpatient stays specific to the admitting specialty. Inpatient, day case, outpatient or rehabilitation costs were summed, and then costs from community services were calculated and added to generate the total cost per patient. Alternative costing perspectives were taken for Scotland and England. 2) Cost-effectiveness analysis generated through a health economic model. We developed a health economic model to compare the cost effectiveness of 4AT and CAM: a decision tree with pathways representing reference standard diagnosis of delirium and non-delirium, divided into branches dictated by sensitivity and specificity. The model was parameterised with costs and Quality Adjusted Life Years (QALYs) to calculate the Incremental Cost Effectiveness (ICER). Results Phase 1: What is the usability of the 4AT in clinical practice?Are any changes needed in the current structure and scoring of the 4AT?SurveysSurvey A (n=2306: 47.7% medical, 29.0% nursing, 11.7% OT, 11.5% physiotherapy)): 83% reported increasing awareness of delirium amongst hospital staff. Only 20% of respondents reported delirium detection rates of >80% in their unit. Respondents stated that 64% of units had guidelines for delirium detection, although only 20% reported that they were ‘almost always/always followed’. The vast majority (91%) of respondents agreed or strongly agreed that formal diagnosis of delirium is important; 93% that distinguishing between delirium and dementia was important, and 89% that delirium treatment improves patient care.In Survey B (n=100: 64% medical, 32% nursing, 3% OT, 1% physiotherapy), 69% reported the 4AT as routinely used in their clinical area, and 52% used the 4AT frequently. Respondents generally viewed the 4AT as a useful, rapid, and practical tool. No consistent problems with the content or administration of the 4AT emerged. Qualitative studyWe performed 19 interviews and 10 informant discussions in 4AT ‘virgin’ sites, and 23 interviews in the experienced site, in the Emergency Department, Medical Assessment Unit, Elderly/Frailty Assessment Unit and Surgical Assessment Unit (SAU). SAU staff generally had a low level of understanding and awareness of delirium. Knowledge and understanding of the significance of delirium, including its impact on patient distress and outcomes, were critical to the engagement of staff in delirium detection. A simple, easy to use standardised tool like the 4AT was felt to be useful. Staff needed to understand what action would result from completion of a delirium detection tool.In the ED the place of work, and the impact of the admission event and process on patients made determination of ‘acute confusion’ difficult and uncertain. In the Medical Assessment Unit (MAU) detection of delirium was considered important, but the busy environment was felt to be a barrier to screening for and managing delirium. In the experienced site nursing staff completed the 4AT, and medical staff conducted further formal cognitive testing. The lack of clarity about how the tool was used to inform action planning was a factor in the priority attached to completing it. In the Elderly Assessment Unit (EAU)/Frailty Assessment Unit staff appeared more knowledgeable about delirium. Collaboration between medical and nursing staff led to a culture where delirium identification and action was owned by staff across disciplines as part of routine practice. Current use in clinical practiceBy December 2017, the 4AT was present in multiple local, national and international policy, guidelines, advisory documents and websites, and used in clinical practice in a range of medical and surgical units in the UK and other countries. was accessed 61,269 times in the year beginning June 2016. Phase 2:Diagnostic test accuracy study843 patients were recruited of 5696 screened, 2 withdrew, therefore 841 have data for analysis, of whom 785 participants had a positive or negative reference standard assessment (delirium present = 95 (12.1%), absent = 690 (87.9%). Delirium prevalence was 12.1% as assessed by the reference standard. Those with delirium were older (mean age 83.5 years v 81.1 years), more likely to be from a minority ethnic group (4.2% v 1.2%), and more likely to have a diagnosis of dementia (26.3% v 6.7%) Primary objective:What is the diagnostic accuracy of the 4AT for delirium detection?The 4AT had an area under the receiver operating characteristic curve (AUROC) of 0.90. A positive 4AT score (>3) had specificity of 95% (95% CI 92-97%) and sensitivity of 76% (62-87%), with a PPV of 66% (52-78%) and NPV of 96% (94-98%) for detecting delirium. Secondary objectives: 2a) To compare the performance of the 4AT with that of the CAMIn the n=384 who had a valid CAM, the prevalence of reference standard delirium was 11% (n=42) as assessed by the reference standard, and delirium prevalence using the CAM was 5% (n=18). In the n=392 who had a valid 4AT score, the prevalence of delirium was 12.5% (n=49) as assessed by the reference standard, and delirium prevalence using the 4AT was 14% (n=56). The CAM had a specificity of 100% (98-100%) and a sensitivity of 41% (26-57%) in the subset of participants in whom it was assessable. Youden’s index (sensitivity minus specificity, plus one) of CAM was 0.40 and 4AT was 0.70. The odds ratio of sensitivity to specificity for CAM was 232 (30-1812), for 4AT 53 (24-117).2b) To examine the performance of the cognitive test items in the 4AT in detecting general cognitive impairmentThe Abbreviated Mental Test – 4 item (AMT4) and attention (Months Backwards_ cognitive test items of the 4AT did show some relationships - high specificity but low-moderate sensitivity - with general cognitive impairment as ascertained in the reference standard assessment by a documented prior diagnosis of dementia and/or positive IQCODE score (specificity AMT4 score of 2: 97% (94-98%); attention score of 2: 98% (96-99%); sensitivity AMT4 score of 2: 47% (32-62%; attention score of 2: 23% (12-38%), high NPV but low PPV, for a diagnosis of dementia (documented history, or IQCODE of >=3.44). 2c) To determine if the 4AT predicts length of stay, new institutionalisation, mortality at 12 weeks Patients with 4AT >3 had longer lengths of stay (median 5 day (IQR 2.0-14.0) than those with scores <=3 (median 2 days (IQR 1.0-6.0). Hazard ratio of time to discharge 0.64 (95% CI 0.46-0.88). Positive 4AT scores were also significantly associated mortality: 16.1% of those with 4AT >3 had died by 12 week follow-up compared to 9.2% of those with 4AT<=3. The odds ratio of mortality for 4AT>3 was higher at, 2.00 (0.85-4.70). New institutionalisation within 12 weeks was too infrequent for analysis.2d) To examine the contribution of individual items of the 4AT to overall delirium diagnosisThe alertness test item of the 4AT showed high specificity (99% (98-100%) and low sensitivity (31% (18-45%) for delirium. Two or more errors (including untestable) on the AMT4 had high specificity (96% (94-98%) and low sensitivity 41% (27-56%) for delirium. Attention (months of the years backwards) score of 1 or 2 (less than 7 months correct, refuses to start or untestable) versus 0 (7 or more months correct) had specificity of 79% (CI 74-83%) and sensitivity of 71% (57-83%). A score of 2 (untestable) versus 1 or 0 had identical performance to alertness. The acute change/fluctuating course item had high specificity (96% (93-98%) and low sensitivity (76% (61-87%) for delirium. Almost all positive cases on 4AT scored positively on ‘acute change or fluctuating course’. Health economic analysis2e) To model the costs of delirium in the study populationUsing data collected within the study, a diagnosis of delirium was associated with higher costs regardless of the costing perspective or diagnosis method. Using original researcher delirium ascertainment, costs in Scotland for the initial stay were ?2810 (95% CI 2734, 2886) with delirium and ?1277 (1267, 1287) without; at 12 weeks (?7559 (7362, 7755) with; ?4215 (4175, 4254) without; England initial stay ?2810 (2734, 2886) with and ?1277 (1267, 1287) without; at 12 weeks ?5216 (5107, 5326) with; ?4320 (4295, 4346) without. A similar pattern for patients with delirium as assessed by centrally ascertained reference standard diagnosis: costs for patients with delirium (Scotland at 12 weeks ?2934 (95% CI 2862, 3006); England ?2934 (2862, 3006)) were higher than for those without delirium (Scotland ?1239 (95% CI ?1229, 1249; England ?4264 (95% CI ?4239, 4290)).Cost-effectiveness analysis generated through a health economic model The result of the economic model were found to be highly dependent on underlying assumptions that were informed by expert opinion. In the base-case analysis the difference in costs between 4AT and CAM was -?90.35, representing lower 12 week healthcare costs for 4AT. The difference in QALYs was -0.00053 representing very similar health outcomes using 4AT compared to CAM over 12 weeks. The base-case ICER was ?170,533 (meaning that for each QALY lost ?170,533 would be saved), but the ICER varied considerably depending on model assumptions. In the scenario analysis with English costs at the best estimate of parameters from expert elicitation the difference in costs was ?-61.52. The difference in QALYs remains the same as in the base case, yielding an ICER of ?116,133. As in the base case, this would be considered cost-effective at conventional thresholds.Scenario analysis using the lowest and highest values of parameters estimated from expert opinion, elicitation was undertaken. At the lowest estimates, the ICER was ?24,289 per QALY gained, which is in a range in which 4AT may be considered cost effective. At the highest estimates 4AT dominates CAM, being more effective and less expensive.The model estimated the 12 week cost incurred by patients with a false positive diagnosis of delirium to be ?4653. For patients with a false negative diagnosis the cost was ?8955.70.Conclusions The 4AT is already in widespread and growing clinical use internationally, and cited in many guidelines, pathways and websites. This study supports the ongoing clinical use of the 4AT as a rapid delirium assessment instrument in older acute hospital patients. It detects delirium with high specificity, and reasonable sensitivity. Subscores within the 4AT (AMT4 score of 2 or attention score of 2) have high specificity but low-moderate sensitivity for general cognitive impairment. The qualitative studies indicate, however, that improving delirium detection relies not only on an effective assessment tool but also on adequate training in delirium and its assessment, and an understanding of the action plan resulting from a positive delirium diagnosis. Thus, use of the 4AT has to be embedded as part of wider education about delirium and dementia with the result of the test directly affecting the patient’s care pathway visible to staff involved. Further research should address real-world implementation of delirium assessment. Delirium is associated with higher costs, with undetected delirium possibly costing more, though this needs to be studied further. The 4AT shows clear potential to be cost-effective, but further research is needed to prove this definitively. Improved detection of delirium has the potential to produce large cost savings within the health care system.International standard randomised controlled trial number (ISRCTN) 53388093. General Introduction Delirium: backgroundDelirium is a severe and distressing neuropsychiatric syndrome which is characterised by acute deterioration in attention and other mental functions. The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) criteria for delirium are, in summary: a disturbance of consciousness (that is, reduced ability to focus, sustain or shift attention), and a change in cognition. The mental status deterioration develops over short periods of time (usually hours to days) and it tends to fluctuate. ADDIN EN.CITE <EndNote><Cite><Author>American Psychiatric Association</Author><Year>2000</Year><RecNum>2095</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>2095</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">2095</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>American Psychiatric Association,</author></authors></contributors><titles><title>Diagnostic and statistical manual of mental disorders : DSM-IV-TR</title></titles><edition>4th</edition><keywords><keyword>Mental illness Classification Handbooks, manuals, etc.</keyword><keyword>Mental illness Diagnosis Handbooks, manuals, etc.</keyword><keyword>Mental Disorders classification.</keyword><keyword>Mental Disorders diagnosis.</keyword></keywords><dates><year>2000</year></dates><pub-location>Washington, DC</pub-location><isbn>0890420246 (casebound alk. paper)0890420254 (pbk. alk. paper)</isbn><accession-num>11905196</accession-num><call-num>Reference - Science Reading Room (Adams, 5th Floor) RC455.2.C4; D536 2000Jefferson or Adams Building Reading Rooms RC455.2.C4; D536 2000</call-num><urls></urls></record></Cite></EndNote>1 The newer DSM-5 criteria (published in 2013) are similar, though with some terminological differences. ADDIN EN.CITE <EndNote><Cite><Author>American Psychiatric Association</Author><Year>2013</Year><RecNum>3544</RecNum><DisplayText><style face="superscript">2</style></DisplayText><record><rec-number>3544</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505369966">3544</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>American Psychiatric Association,</author></authors></contributors><titles><title>Diagnostic and Statistical Manual of Mental Disorders</title></titles><edition>5th</edition><dates><year>2013</year></dates><pub-location>Washington, DC.</pub-location><urls></urls></record></Cite></EndNote>2 Delirium is commonly precipitated by acute illness, trauma, or the side-effects of drugs. The presence of a ‘general medical condition’ is also part of the DSM-IV and DSM-5 criteria, though in practice this is usually assumed rather than specified in each case. 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ADDIN EN.CITE.DATA 9, 20 The economic burden of delirium derived from 2008 U.S. data estimates the one-year health care costs to be $38-$152 billion.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZXNsaWU8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS

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PjwvRW5kTm90ZT5=

ADDIN EN.CITE.DATA 21 Detection of delirium is vital because it indicates acute systemic or central nervous system illness, physiological disturbance and drug intoxication or withdrawal; indeed, failure to detect delirium in the acute setting is associated with worse outcomes.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYWt1bWE8L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFyPjxS

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Pn==

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Pn==

ADDIN EN.CITE.DATA 22 Specific management of delirium is of obvious and immediate benefit to patients in many clinical situations, e.g. in reversing opioid toxicity, treatment of peripheral infections which have presented with delirium, alleviating distress caused by anxiety and disorientation as well as directly by frightening delusions and hallucinations,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXJ0cmlkZ2U8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFy

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ADDIN EN.CITE.DATA 13, 23-25 and in prompting more thorough assessment and treatment of symptoms. ADDIN EN.CITE <EndNote><Cite><Author>Aligeti</Author><Year>2016</Year><RecNum>3646</RecNum><DisplayText><style face="superscript">26</style></DisplayText><record><rec-number>3646</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505813599">3646</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Aligeti, S.</author><author>Baig, M. R.</author><author>Barrera, F. F.</author></authors></contributors><auth-address>Department of Psychiatry,University of Texas Health Science Center,San Antonio,Texas.Audie L. Murphy VA Hospital,South Texas Veterans Health Care System,San Antonio,Texas.School of Medicine,University of Texas Health Science Center,San Antonio,Texas.</auth-address><titles><title>Terminal delirium misdiagnosed as major psychiatric disorder: Palliative care in a psychiatric inpatient unit</title><secondary-title>Palliat Support Care</secondary-title></titles><periodical><full-title>Palliat Support Care</full-title></periodical><pages>307-10</pages><volume>14</volume><number>3</number><keywords><keyword>Delirium</keyword><keyword>Dementia</keyword><keyword>Depression</keyword><keyword>End-of-life care</keyword><keyword>Terminal delirium</keyword></keywords><dates><year>2016</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1478-9523 (Electronic)1478-9515 (Linking)</isbn><accession-num>26490485</accession-num><urls><related-urls><url> For example, some studies have found that surgical patients with delirium receive less analgesia than those with normal cognition; ADDIN EN.CITE <EndNote><Cite><Author>Adunsky</Author><Year>2002</Year><RecNum>2196</RecNum><DisplayText><style face="superscript">27</style></DisplayText><record><rec-number>2196</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">2196</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Adunsky, A.</author><author>Levy, R.</author><author>Mizrahi, E.</author><author>Arad, M.</author></authors></contributors><auth-address>Department of Orthopedic-Geriatric Medicine, Bitan 38, Sheba Medical Center, Tel Hashomer 52621, Israel. eadunsky@</auth-address><titles><title>Exposure to opioid analgesia in cognitively impaired and delirious elderly hip fracture patients</title><secondary-title>Arch Gerontol Geriatr</secondary-title><alt-title>Archives of gerontology and geriatrics</alt-title></titles><periodical><full-title>Arch Gerontol Geriatr</full-title></periodical><alt-periodical><full-title>Archives of Gerontology and Geriatrics</full-title><abbr-1>Arch. Gerontol. Geriatr.</abbr-1></alt-periodical><pages>245-51</pages><volume>35</volume><number>3</number><edition>2004/02/07</edition><dates><year>2002</year><pub-dates><date>Nov-Dec</date></pub-dates></dates><isbn>0167-4943 (Print)0167-4943 (Linking)</isbn><accession-num>14764363</accession-num><urls><related-urls><url> this matters not only because pain treatment is an end in itself but because pain is itself a cause of delirium. Delirium management also includes communication of the diagnosis of patients and carers; in the latter case, it is well-known that delirium causes substantial distress to carers.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb3JhbmRpPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48

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ADDIN EN.CITE.DATA 8 Detection of dementia has recently been highlighted in the Dementia Commissioning for Quality and Innovation (CQUIN) framework; ADDIN EN.CITE <EndNote><Cite><Year>2012</Year><RecNum>2407</RecNum><DisplayText><style face="superscript">30</style></DisplayText><record><rec-number>2407</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">2407</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Department of Health,</author></authors></contributors><titles><title>Using the Commissioning for Quality and Innovation (CQUIN) payment framework: Guidance on new national goals for 2012-13</title><tertiary-title> of Health</publisher><urls></urls></record></Cite></EndNote>30 crucially, establishing if the patient has a ‘clinical diagnosis of delirium’ is a central element in the FAIR (Find, Assess, Investigate, Refer) algorithm at the heart of this framework.Under-detection of deliriumAmple evidence shows that in medical, surgical, emergency department and palliative care settings, the majority of delirium is not diagnosed.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db2xsaW5zPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48

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ADDIN EN.CITE.DATA 7, 31-33 It is unclear why detection rates are so low. A variety of types of studies including surveys of practitioners’ attitude and knowledge, studies of the content of practitioners’ education and training, and qualitative studies have attempted to understand why such a common and serious condition remains so neglected in modern healthcare. One of the commonly identified issues is that staff are not certain about the diagnostic criteria for delirium, and related to this, what screening and/or diagnostic tools should be used. In a 2009 survey of 784 UK trainee physicians, only 21% stated that they had good knowledge of the diagnostic criteria for delirium; and only 8% reported using specific screening tools for delirium. ADDIN EN.CITE <EndNote><Cite><Author>Davis</Author><Year>2009</Year><RecNum>3285</RecNum><DisplayText><style face="superscript">34</style></DisplayText><record><rec-number>3285</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1422608685">3285</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Davis, D</author><author>MacLullich, A</author></authors></contributors><titles><title>Understanding barriers to delirium care: a multicentre survey of knowledge and attitudes amongst UK junior doctors</title><secondary-title>Age and Ageing</secondary-title></titles><periodical><full-title>Age and Ageing</full-title></periodical><pages>559-563</pages><volume>38</volume><number>5</number><num-vols>0002-0729</num-vols><dates><year>2009</year><pub-dates><date>SEP 2009</date></pub-dates></dates><accession-num>WOS:000269193800014</accession-num><urls></urls><electronic-resource-num>10.1093/ageing/afp099</electronic-resource-num></record></Cite></EndNote>34 A similar survey repeated recently showed some improvements but broadly similar results. ADDIN EN.CITE <EndNote><Cite><Author>Jenkin</Author><Year>2016</Year><RecNum>3447</RecNum><DisplayText><style face="superscript">35</style></DisplayText><record><rec-number>3447</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1504334205">3447</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jenkin, R. P.</author><author>Al-Attar, A.</author><author>Richardson, S.</author><author>Myint, P. K.</author><author>MacLullich, A. M.</author><author>Davis, D. H.</author></authors></contributors><auth-address>Department for the Care of Older People, Whittington Hospital, London, UK.Department of Medicine for the Elderly, St Mary's Hospital, London W2 1NY, UK.Institute of Neuroscience, Newcastle University, Newcastle Upon Tyne, UK.School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland AB25 2ZD, UK.Geriatric Medicine, University of Edinburgh, Edinburgh EH16 4SA, UK.MRC Unit for Lifelong Health and Ageing, University College London, London, UK.</auth-address><titles><title>Increasing delirium skills at the front door: results from a repeated survey on delirium knowledge and attitudes</title><secondary-title>Age Ageing</secondary-title></titles><periodical><full-title>Age Ageing</full-title></periodical><pages>517-22</pages><volume>45</volume><number>4</number><keywords><keyword>delirium</keyword><keyword>education</keyword><keyword>older people</keyword><keyword>questionnaire</keyword><keyword>survey</keyword></keywords><dates><year>2016</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1468-2834 (Electronic)0002-0729 (Linking)</isbn><accession-num>27118700</accession-num><urls><related-urls><url> A recent survey of undergraduate medical education found that though delirium was included in teaching, the approach was highly heterogeneous, likely leading to inconsistent knowledge.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GaXNoZXI8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS

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AG==

ADDIN EN.CITE.DATA 37, 38 Prior work shows that there are many reasons for delirium under-detection which act at many levels from undergraduate education training to whole systems. These findings have pointed to several remediable factors. However, there is ongoing uncertainty around the present state of practice in the UK in relation to delirium assessment. In particular, how different disciplines approach to detection is underexplored.One obvious conclusion from the existing literature is that to achieve consistently high rates of delirium detection in routine care, many practitioner and systems elements or building blocks need to be present and operating effectively. One of the essential elements is the availability of assessment tools that validated, and practical for the context in which they are to be used, and which are implemented consistently. There are many diagnostic instruments that operationalise the DSM/ICD criteria but despite this these have largely remained research tools. For example, the short Confusion Assessment Method (CAM) is commonly advocated in pathways and guidelines, but it requires specific training and takes 5-10 minutes to complete because it is preceded by cognitive assessment and brief interview. In many clinical units, the duration of such a test is too long for practical use.Rapid assessment of delirium presents several challenges, one of which is that patients show a wide range of levels of severity: many patients in acute settings are too unwell, sleepy, or agitated to undergo cognitive testing or interview.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGVzdGVyPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48

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ADDIN EN.CITE.DATA 39-44 This problem of ‘untestability’ is likely to be another important factor in delirium under-detection. Most cognitive or screening tools do not make explicit how these patients should be classified; the result is that mental status assessments are often simply left uncompleted in most of these patients, and no diagnosis, and often no specific treatment, is applied.Finally, given the time pressures in acute settings, it is challenging to implement a separate delirium screening instrument in addition to any existing general cognitive screening instruments. The lack of a combined instrument allowing screening for both general cognitive impairment and delirium may therefore contribute to the lack of specific delirium detection.The need for a new assessment toolGiven the multiple constraints of the acute environment, the range of staff who might be expected to screen for delirium, the common co-existence of delirium and dementia, and the heterogeneity of patients, we judged that a screening tool should have these features: 1.Short (less than 2 minutes)2.Easy to learn3.Easy to administer and score4.Can be used by professional-level healthcare staff from a variety of disciplines5.Allows scoring of patients who are too drowsy or agitated to undergo cognitive testing or clinical interview6.Takes account of informant history7.Can be administered through written questions to people with severe hearing impairment8.Can be administered to patients with visual impairments9.Does not require subjective judgements based on bines delirium screening with general cognitive screening11.Does not need a quiet environment for administration12.Does not require physical responses such as drawing figures or clocksThere are multiple instruments for delirium screening, diagnosis, severity assessment, and monitoring.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYWxsPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48UmVj

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AG==

ADDIN EN.CITE.DATA 45-48 Before deciding to design a new screening tool, we therefore examined each of the available tools against the above criteria, focusing on screening tools such as the CAM. We also searched the literature systematically, including conference proceedings, books, and book chapters, for any newly-published tools as well as to examine the study data for each tool. Most scales were excluded on grounds of duration alone. The remaining scales lacked features such as general cognitive screening, and other important features. We thus found that, in late 2010, no existing tool fulfilled the above requirements, and because of this we decided to design a new test. This conclusion was supported by the NICE Guidelines on Delirium ADDIN EN.CITE <EndNote><Cite><Year>2010</Year><RecNum>1950</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>1950</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">1950</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>NICE,</author></authors></contributors><titles><title>Delirium: diagnosis, prevention and management.</title></titles><number>1 Dec 2017</number><dates><year>2010</year></dates><urls><related-urls><url>.uk/CG103</url></related-urls></urls></record></Cite></EndNote>4 which emphasised the need for research on a screening tool for delirium suitable for routine use.The subsequent design process involved scrutiny of each of the nearly 30 published (in 2010) delirium assessment tools, evaluating the performance of each, including subtests, in published studies and, in most cases, through direct clinical or research experience of their use. Because we had decided to incorporate general cognitive screening into the new instrument, to avoid the need to have separate instruments for cognitive screening and delirium screening, we also reviewed the broader literature on brief tests for general cognitive impairment (including dementia). In the context of designing a screening tool for the acute hospital, it is important to note that delirium generally causes cognitive impairment detectable on the kinds of tests used for dementia screening.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5KYWNrc29uPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48

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ADDIN EN.CITE.DATA 43, 49-51 Therefore, abnormal test results may indicate delirium and/or dementia (as well as other causes of cognitive impairment, such as learning disability). It is clinically essential to know if any such impairment is acute, that is, delirium, but also important to identify underlying general (acute or chronic) cognitive impairment. A tool designed exclusively to detect cognitive impairment will not lead to delirium detection without another step, and a tool designed only to detect delirium may miss general cognitive impairment. In this light, we decided that the new test should include cognitive screening sensitive to general cognitive impairment, but also including items on altered level of alertness and change in mental status, both of which are strong indicators of delirium. The new test was named the 4 “A”s Test or 4AT, with the “A”s standing for Alertness, the Abbreviated Mental Test – 4 (AMT4), Attention (the Months of the Year Backwards test), and determination of Acute Onset (see Table 5 and ). The first version of the 4AT was drafted and tested informally by colleagues, changes were made based on feedback, and updated versions tested again. After several iterations involving 20 doctors and nurses of varying levels of experience, the final version was produced. An initial audit (unpublished) in 30 inpatients found encouraging results. Since the 4AT was launched, locally and through the website, it has been adopted in clinical units in several centres in the UK and internationally, with generally positive feedback from users (see Chapter 3). Feedback from these sites has been positive. Several validation studies have been published, showing supportive results, with satisfactory diagnostic accuracy (see Chapter 5).PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWVzPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA 52-57 An additional study also assessed the usability of the 4AT in the palliative care setting, finding positive results. ADDIN EN.CITE <EndNote><Cite><Author>Baird</Author><Year>2017</Year><RecNum>3561</RecNum><DisplayText><style face="superscript">58</style></DisplayText><record><rec-number>3561</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505400710">3561</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Baird, Lucy</author><author>Spiller, Juliet Anne</author></authors></contributors><titles><title>A quality improvement approach to cognitive assessment on hospice admission: could we use the 4AT or Short CAM?</title><secondary-title>BMJ Open Quality</secondary-title></titles><periodical><full-title>BMJ Open Quality</full-title></periodical><volume>6</volume><number>2</number><dates><year>2017</year></dates><urls></urls><electronic-resource-num>10.1136/bmjoq-2017-000153</electronic-resource-num></record></Cite></EndNote>58 However, there is still a need for further diagnostic accuracy studies to inform clinicians as to which tools to use in which contexts, especially given the large number of tools and validation studies such tools available. Health economicsIn this study we also wished to compare the implications of any differences in diagnostic accuracy between the CAM and the 4AT with respect to healthcare costs. Delirium is known to be economically costly,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZXNsaWU8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 60, 61 Overview of project This project has the overarching goal of assessing the need for further development and then testing the diagnostic accuracy of the 4AT delirium assessment tool. The work is divided into two phases, and there is a health economics project which ran in parallel with the second phase. Phase 1 uses practitioner surveys, qualitative studies and information from existing use of the 4AT in clinical practice to assess usability and to determine the need for any changes in the current structure and scoring of the tool. The aims of Phase 1 were specifically to understand more about knowledge of and attitudes to delirium assessment among healthcare practitioners using survey and qualitative study methodology. We also specifically surveyed practitioners with experience of use of the 4AT. The main aims of Phase 1 were to determine if there need to be changes to the 4AT in advance of Phase 2.Phase 2 is a diagnostic accuracy study with the primary objective of determining the diagnostic accuracy of the 4AT for delirium detection. The secondary objectives of Phase 2 are to compare the performance of the 4AT with that of the CAM (because the CAM is recommended in some guidelines, and it is of value to know if the 4AT performs similarly whilst being shorter), to examine the performance of the cognitive test items in the 4AT in detecting general cognitive impairment, to determine if the 4AT predicts length of stay, new institutionalisation, mortality at 12 weeks, and to examine the contribution of individual items of the 4AT to overall delirium diagnosis. In the health economics study, conducted in parallel with Phase 2, we wished to estimate the economic implications of differences in diagnostic accuracy between the 4AT and the CAM. This was based on first estimating the costs of delirium care over 12 weeks. From this the costs of true positives, true negatives, false positives and false negatives were estimated, and these were applied in the context of a model to the diagnostic test accuracy results of the 4AT.Surveys of Current PracticeGeneral IntroductionAlthough the severe impacts of delirium are becoming clearPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYXZpczwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 7, 16, 31-33, 65-70 There are many possible reasons for this. Surveys on practice and knowledge among professionals have helped to shed some light on these reasons.IG51bWVyaWNhbCBkYXRhPC9rZXl3b3JkPjxrZXl3b3JkPlRyZWF0bWVudCBPdXRjb21lPC9rZXl3

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ADDIN EN.CITE.DATA 34, 36, 71-91 The surveys vary considerably in the mix of professionals being studied, the focus of the questions, healthcare setting, and so on. The majority of published surveys relate to ICUs alone, with relatively small numbers involving healthcare practitioners from other settings. Most surveys have primarily focused on the attitudes, clinical practice and knowledge of various healthcare practitioners with respect to delirium management rather than attention on delirium detection and assessment. Some notable findings from the surveys relevant to detection assessment follow. Most respondents across disciplines believe that delirium is underdiagnosed PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FbHk8L0F1dGhvcj48WWVhcj4yMDA0PC9ZZWFyPjxSZWNO

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dGU+AG==

ADDIN EN.CITE.DATA 72, 76, 81, 87 Yet surveys frequently indicate that basic knowledge of delirium is inadequate.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYXZpczwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 34-36, 75, 88, 89, 91, 92 In one study, 42% of nursing and medical staff working in one of three Scottish ICUs did not know that delirium was associated with increased 6 month mortality and 44% had never received training on ICU delirium.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FbGxpb3R0PC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48

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ADDIN EN.CITE.DATA 75 In a survey of UK surgical training doctors, only 2% were familiar with the diagnostic criteria for delirium.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGlwd2F5PC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48

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ADDIN EN.CITE.DATA 88 Published guidelines in the UK recommend daily screening in ICUs using validated delirium screening tools. ADDIN EN.CITE <EndNote><Cite><Author>NICE</Author><Year>2010</Year><RecNum>1950</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>1950</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">1950</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>NICE,</author></authors></contributors><titles><title>Delirium: diagnosis, prevention and management.</title></titles><number>1 Dec 2017</number><dates><year>2010</year></dates><urls><related-urls><url>.uk/CG103</url></related-urls></urls></record></Cite></EndNote>4 Despite this, surveys generally indicate that a small minority of practitioners routinely screen for delirium using tools.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FbHk8L0F1dGhvcj48WWVhcj4yMDA0PC9ZZWFyPjxSZWNO

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ADDIN EN.CITE.DATA 34, 75, 76, 80, 81, 83-85, 87, 91, 92 Greater knowledge of attitudes and clinical practice with respect to detection and assessment is essential in identifying factors that contribute to the under-detection of delirium and could help in the development of effective screening tools, education and clinical implementation strategies. Currently, although the existing surveys provide useful information, there remains a lack of understanding of the specifics of delirium assessment in general settings and in different disciplines. In this chapter we describe two different survey studies. The first, Survey A, had the aim of gaining more understanding of knowledge of and attitudes to delirium in general. The survey was of four practitioner groups (medical practitioners, nurses, occupational therapists and physiotherapists) working in a variety of inpatient and outpatient settings in the UK. The second survey, Survey B, was distinct from Survey A in that it had specific aim of gauging attitudes and potential issues around the use of the 4AT. This addressed practical use and other aspects. The aim of was to identify any potential changes to instrument or its guidance notes which could improve usability of the instrument prior to its evaluation in the diagnostic accuracy study. There was some conceptual overlap with Survey A, but Survey B was specifically aim at understanding more about use of the 4AT.MethodsSurvey developmentThe surveys (Survey A is in Appendix 1, and Survey B is in Appendix 2) were developed in multiple stages. They were initially drafted in web form and revised by AS, AM and SS based on previous literature and personal clinical experience of delirium. The revised surveys were then reviewed by members of the study team, who assessed face validity, structure and clarity. Further revisions were then made. Subsequently, Survey A was piloted with 19 additional healthcare practitioners outside of the study and Survey B on 5. In each case participants were asked to comment on content and any technical problems. Minor amendments were made to both. In both surveys items were presented in a fixed order (with no randomisation) and included multiple choice, ranking, 5-point Likert scale and open-comment response formats. Response options including ‘N/A’, ‘don’t know’ and ‘other (please specify)’ were provided throughout the survey and the majority of questions were optional in order to minimise response coercion and attrition. The surveys began with six demographic items, two of which (career stage, and specialty) were only presented to respondents with a primary qualification in medicine. There were some additional questions administered to those with this qualification (see Appendix 1). Both surveys finished with an open-comments box in which respondents were invited to “comment on any of the issues raised in this survey or additional issues surrounding the detection and assessment of delirium that have not been addressed”. No incentives were offered for survey completion.The surveys were considered to be service evaluations as the participants were anonymous healthcare practitioners and the surveys were of current practice, thus formal research ethical approval was not required. The surveys were hosted on the internet using Survey Monkey (). Invitation recipients who clicked on the hyperlinked URL included in the email were initially presented with a webpage which described the study in greater detail, explained that participation was anonymous, that no computer location information or cookies would be collected, and that the results would be published and may involve direct quotes. Potential respondents were then presented with the question: “Do you agree to participate in this survey and consent to the potential use of your anonymised responses as described above?”. Those who chose “I agree” proceeded to the survey, while those who chose “I do not agree” were directed to a page which explained that they must agree if they wished to participate. As it was anonymised, the survey did not allow for checking for multiple responses from single users. No time-stamp data for individuals were analysed.ParticipantsFor Survey A healthcare practitioners of interest were medical practitioners, nurses, occupational therapists and physiotherapists working in the UK that come into contact with delirium as part of their daily routine. These professional groups were selected as being numerically large and in frequent contact with patients with delirium. A list of email addresses of potential respondents was generated through networks of study authors and through internet searches focused on, but were not limited to, emergency departments, ICUs, acute/medical assessment units, elderly care, orthopaedics, oncology, stroke units and palliative care as delirium is common in these settings. Contact details for relevant associations/societies and Trusts/Health Boards were also obtained through internet search engines. A standard invitation email was distributed to individual practitioners on 30/09/2014. Amended versions of this email were sent to Trusts/Health Boards across the UK, and relevant societies/associations (geriatrics, psychiatry, acute medicine, nursing, palliative care, etc.). All recipients were asked to forward the email to relevant practitioners in their own contacts list and to consider displaying an A4 poster highlighting the survey in their staff areas. Reminder emails were sent on 21/10/2014 and 18/11/2014. Each of the study collaborators forwarded the email to their contacts informally throughout this period. The survey was closed on 03/01/2015 when participation had tapered off.Survey B was intended for any healthcare practitioners worldwide who had used the 4AT to screen patients for delirium. A convenience sample of suitable practitioners was obtained through multiple methods. A standard invitation email was distributed to practitioners working in units where the 4AT was known to be in use on 4/11/2014. Practitioners who completed Survey A (Delirium Detection and Assessment in Clinical Practice) confirmed that they had used the 4AT and provided their email address were emailed on 06/11/2014. All recipients were asked to forward the email to 4AT users in their own contacts list and to consider displaying an A4 poster highlighting the survey in their staff areas. Reminder emails was sent on 02/12/2014. Each of the study collaborators forwarded the email to their contacts informally throughout this time. Posters were also displayed in staff areas of units in the Royal Infirmary of Edinburgh that use the 4AT and paper slips containing the link were handed to practitioners informally. The survey was closed on 22/01/2015 when participation had tapered off.Data analysisQuantitative data were analysed using R version 3.0.2 (R Core Team, 2013). The majority of the data had non-normal distributions and heterogeneous variance across groups; therefore medians and inter-quartile ranges are reported throughout and non-parametric statistical tests were used. For comparative data in Survey A the threshold for statistical significance was p < 0.05. Between-group analyses were carried out using Chi-squared tests where both variables were categorical, using Kruskal-Wallis tests with Holm corrections followed by Mann-Whitney U tests. For items where responses were made via five-point Likert scales, verbal responses were converted to the corresponding numeric responses 1 – 5 to facilitate between-group analyses and analysed as continuous variables. Mean scores and standard deviations were reported for these converted responses as the median and inter-quartile range rarely varied from 3 and 2 – 4 respectively due to the restricted scoring range of 1 – 5. Between-group analyses involving work settings were carried out on participants who worked in single inpatient settings only, in order to avoid the possible confounding effects of working in multiple settings. Due to the large number of significant pairwise comparisons, details of significant effects were not reported in text where effect size r < 0.15, but were included in tables only. Unanswered items and sample attrition resulted in missing data and fluctuating sample sizes across and within items, therefore the results are based on the total number of responses for each item, excluding cases of missing data and where respondents chose “N/A” or “Don’t know”, unless stated otherwise. No statistical corrections were applied. Qualitative data submitted through open-comments fields was reviewed informally and the decision on which quotes to report was based on what was judged to contribute to improved implementation or refinement of the 4AT.ResultsSurvey AA total of 2671 practitioners agreed to participate in the survey. Of those, 172 stopped before completing the core demographic questions; 137 completed these questions but did not continue; 12 worked outside the UK; 41 had a primary professional qualification in an area other than medicine, nursing, occupational therapy or physiotherapy; the primary professional qualification could not be verified for two; and one was retired. These cases were excluded. Data from 2306 respondents (86%) were retained. A summary of respondent characteristics is shown in Table 1. Table SEQ Table \* ARABIC 1. Survey A: respondent characteristicsAll estimates relate to frequency of respondents except where stated otherwise. Cells for settings are not equal to the total sample size as respondents could choose multiple settings.Medicine (tertiles of years of experience)NursingOccupational TherapyPhysiotherapyTotalUnknownLowerMidUpperOverallFrequency (% of sample)51452716801101 (47.75)668 (28.97)271 (11.75)266 (11.54)2306 (100)Years qualified (Mdn(IQR))16 (8 – 26)2 (1 – 3)8 (6 – 10)19.50 (14 – 25)14 (7 – 22)21 (12.75 – 30)10 (5 – 16)12 (6 – 20)15 (8 – 24)SettingAcute inpatient medical1831242534612241621551002Emergency department13096183310271420371Intensive care 110188111090225227Rehabilitation 03124459354662202Surgical ward (exc. ortho.)2682440551125131Palliative care0132024284359Psychiatry114166091832012206Other*219241391842147575548Acute inpatient medical = acute assessment/medical assessment unit, medicine of the elderly, orthopaedics, oncology, stroke, internal medicine specialist ward (e.g. cardiology, respiratory, gastroenterology, nephrology, endocrinology, neurology); Surgical ward (exc. ortho.) = surgical ward not including orthopaedics.* 436/548 chose ‘other’ alone. Of these, 201 worked in the community (GP = 48, mental health = 58, rehabilitation = 12, various = 84), 50 worked in inpatient settings (mental health = 13, anaesthetics = 10, high dependency unit = 5, various = 22), 24 worked in outpatient settings (rehabilitation = 3, various = 21). For the remaining 160 respondents it was unclear whether they worked in inpatient, outpatient or community settings (mental health = 49, research = 10, intermediate care = 10, various = 89).Awareness of deliriumRespondents were asked whether they thought there had been an increase in awareness of delirium among colleagues in their speciality in the last three years or not; a large majority of 83% (1392/1680) said ‘yes’. Post hoc analysis revealed significant differences across inpatient settings (X2 (6) = 84.9, p < 0.001): increased awareness was reported most frequently by respondents working in intensive care (95%, 149/157) and acute inpatient medical settings (90%, 534/593), and least frequently by those working in emergency departments (68%, 141/208) and rehabilitation units (67%, 28/42). The majority perceived increased mentioning of delirium in professional domains such as professional conferences (77%, 1076/1391), clinical journals (77%, 1101/1426), clinically-related websites (77%, 1043/1351), training events (76%, 1221/1603) and training curriculums (71%, 1010/1406). In contrast, much lower proportions perceived an increase in general media coverage (e.g. BBC News, newspapers; 30%, 440/1489) and in social media (in respondents who were users) such as Twitter (35%, 203/575) and Facebook (13%, 88/675). Responses given in an open-comments field following this question focused on increased awareness of delirium in the workplace with references to the promotional work of individuals or teams, internal teaching sessions, in-house/on-the-job training, information displayed in clinical areas, and awareness raised indirectly through educational drives for sepsis and frailty. The remaining comments focussed on increased awareness gained through NICE guidelines and e-learning modules.Detection of deliriumWhen respondents were asked their opinion on what percentage of patients with delirium in their unit have their delirium diagnosed and documented, using the following bandings ‘0 – 20%’, ‘21 – 40%’, ‘41 – 60%’ ’61 – 80%’ and ’81 – 100%’, the responses were 14% (275/2010), 18% (352/2010), 22% (449/2010), 26% (526/2010) and 20% (408/2010), respectively. This suggests that those surveyed suggest that there is substantial under-diagnosis of delirium, with a minority of units perceived to be achieving at least 80% (estimated) diagnosis rates. Estimates of rates of diagnosis differed significantly by clinical areas, with emergency departments showing the lowest estimates (mean=2.6 (SD 1.12)), and acute inpatient medical and rehabilitation settings showing higher estimates (mean=3.45 (SD 1.22), mean=3.6 (SD 1.3), respectively). Overall, respondents believed that the largest contributor to the under-diagnosis of delirium in their units was ‘difficulty discriminating delirium from dementia’ with 44% (907/2072) stating that it made a ‘large’ or ‘very large’ contribution. This was followed by ‘lack of staff confidence in assessment’ (39%, 809/2050) and ‘lack of staff knowledge of delirium’ (39%, 817/2083). Notably, the difference between all of these contributors is limited to a range of 11% and more than one-third of respondents considered each of the listed contributors to have a ‘large’ or ‘very large’ effect, indicating that a complex combination of factors is considered by respondents to be responsible for the under-diagnosis of delirium. Regarding the role of different disciplines in ‘flagging potential cases’, ‘screening high risk patients’, and ‘making a formal diagnosis’, responses indicated that doctors were considered by virtually the whole sample to be responsible for diagnosis, with other disciplines considered to have a much smaller role in this. Nurses were considered to have the most important role in screening high risk patients, whereas physiotherapists and occupational therapists were considered to have their main responsibility in ‘flagging potential cases’ (Table 2).Attitudes to the importance of making a formal diagnosis of deliriumRespondents were asked to indicate their agreement with three statements concerning delirium care. When asked to indicate their agreement with the statement “making a formal diagnosis of delirium is important to provide good delirium care”, 5% (92/1999) of respondents chose ‘strongly disagree’ or ‘disagree’ and 5% (98/1999) chose ‘neither agree nor disagree’, while 91% (1809/1999) chose ‘agree’ or ‘strongly agree’. When asked to indicate their agreement with the statement “distinguishing between delirium and dementia is important in providing good care”, 4% (73/2001) chose ‘strongly disagree’ or ‘disagree’ and 3% (69/2001) chose ‘neither disagree nor agree’, while 93% (1859/2001) chose ‘agree’ or ‘strongly agree’. Finally, when asked to indicate their agreement with the statement “delirium treatment improves patient outcomes”, 4% (76/2000) chose ‘strongly disagree’ or ‘disagree’, 7% (146/2000) chose ‘neither disagree nor agree’, while a vast majority of 89% (1778/2000) chose ‘agree’ or ‘strongly agree’. Table SEQ Table \* ARABIC 2. Survey A: respondents’ answers when asked to indicate which of three tasks different professional groups should consider their own duty in regards to delirium detectionFlagging potential cases Screening high risk patients Making a formal diagnosisDoctors43% (868/2004)56% (1113/2004)96% (1926/2004)Nurses67% (1322/1983)78% (1553/1983)23% (451/1983)Occupational Therapists83% (1619/1947)46% (887/1947)10% (191/1947)Physiotherapists88% (1738/1984)32% (633/1984)7% (130/1984)All Estimates as shown in % (proportion) of the total responses for each practitioner typePersonal practiceWhen respondents were asked to rate their level of confidence in their own ability to detect delirium, 15% (303/2064) stated ‘very low’ or ‘low’, 78% (1600/2064) stated ‘moderate’ or ‘high’, and 8% (161/2064) stated ‘very high’. Post hoc analysis revealed significant differences in mean scores (very low = 1; low = 2; moderate = 3; high = 4; very high = 5) between inpatient settings (X2 (6) = 102.6, p < 0.001). Respondents working in both psychiatry (n = 165, mean = 3.8, SD = 0.84) and intensive care (n = 163, mean = 3.7, SD = 0.76) were more confident than those in surgical wards (n = 66, M = 3.0, SD = 0.93; p < 0.001 for both) and rehabilitation units (n = 49, mean = 2.8, SD = 0.9; p < 0.001 for both). When respondents were asked whether they had ever used a tool (that is, a specific tool or cognitive test) to detect delirium, 54% (1103/2061) stated ‘yes’. Significant differences were also revealed between inpatient settings (X2 (6) = 116.3, p < 0.001), where 90% (147/163) of respondents working in intensive care, 65% (107/164) working in psychiatry and 58% (425/729) working in acute inpatient medical settings reported having used a tool to detect delirium. Rates of tool use ranged from 33% to 47% among respondents working in other settings. The most-used delirium screening tools used were the CAM (61%, 630/1041), the 4AT (60%, 625/1043) and the CAM-ICU (42%, 430/1044). The most widely used cognitive tests were ‘orientation to time, place, person’ (91%, 940/1028), followed by AMT-10 (75%, 770/1026) and MMSE (74%, 762/1028) respectively. When medical practitioners were asked whether they thought patients need to have a sufficiently high level of consciousness to produce verbal responses in order to allow bedside assessment for delirium, 72% (769/1073) stated ‘yes’. A majority of medical practitioners (88% (947/1077)) reported that they ‘frequently’ or ‘almost always/always’ sought a history of mental status from collateral sources (e.g. family, GP, etc.) for patients with cognitive impairment. Both individual and organisational practice in recording delirium varied, with a range of terms being used for patients likely to have delirium. When asked whether guidelines for delirium detection exist in their units or not, 64% (1021/1605) reported that they did exist. Of those who said that guidelines existed, 22% (211/953) thought they were ‘never/rarely’ or ‘sometimes’ followed, 58% (554/953) thought they were followed ‘about half of the time’ or ‘frequently’, and 20% (188/953) thought they were ‘almost always/always’ followed. Terminology Medical practitioners were asked to indicate which term they would be most likely to apply in practice to a patient who “presents with recent onset drowsiness and is not producing verbal responses but is responding intermittently to one-stage commands”. The term ‘delirium’ was chosen by one third of respondents (35%, 386/1090). This was followed by ‘obtundation’ (23%, 248/1090), ‘stupor’ (15%, 166/1090), ‘encephalopathy’ (4%, 41/1090) and ‘coma’ 3% (36/1090). Among the 20% (213/1090) of medical practitioners who chose to specify their own term, a majority (n = 136) said altered, decreased or fluctuating ‘consciousness’ or said they would make reference the patients score on the Glasgow Coma Scale. Other repeated terms included ‘confusion’, ‘acute confusion’ or ‘acute confusional state’ (n = 12). Twenty-seven respondents stated that they would need for further information on the wider clinical context in order for a judgement to be made and nine stated that they would not apply a label at all, but rather would describe the patients’ symptoms. While almost 2/3 medical practitioners chose a term other than delirium, in a follow-up question 2/3 (66%, 732/1101) stated that the same patient is ‘likely’ or ‘very likely’ to have delirium, indicating that terms are considered somewhat interchangeably by 1/3 medical practitioners. In contrast, 6% (67/1101) stated ‘very unlikely’ or ‘unlikely’, and 26% (288/1101) stated that it was ‘neither likely nor unlikely’ that this patient had delirium.The term used most often in respondents’ units to describe patients with “acute deterioration in cognition or other mental functions caused by an acute medical problem, drug side-effects or other acute causes” was ‘confusion’, with 61% (1250/2046) stating that it is ‘frequently’ or ‘almost always/always’ used in their unit. This was followed by ‘acute confusional state/acute confusion’ (45%, 1032/2306), ‘delirium’ (33%, 682/2058) and ‘septic encephalopathy’ (2%, 48/1951) respectively. The majority of the 129 participants that chose to report alternatives recorded informal descriptions such as ‘agitated’, ‘knocked-off’, ‘muddled’, ‘disorientated’, ‘withdrawal’ and ‘drowsy’. Specific terms reported included: ‘acute on chronic confusion’, ‘cognitive impairment’, ‘acute cognitive impairment’, and ‘dementia’, with some practitioners stating that these terms are often misused in their units. Survey BA total of 117 practitioners agreed to participate in the survey. Fourteen stopped before completing the core demographic questions (items 1 – 4) and three stated that they had never used the 4AT in clinical practice. These cases were excluded, giving a final sample of 100 (88%) respondents. The geographical distribution was Scotland (n = 62), England (n = 28), Italy (n = 5), the USA, (n = 3) and Australia (n = 2). See Appendix 3 for a summary of respondent characteristics. In addition to the 4AT, a large proportion of respondents also reported having used the Confusion Assessment Method (68%, 61/90). Of the 28 respondents that named additional tools they had used, the Abbreviated Mental Test (n = 15) or Mini Mental State Examination (n = 8) were the two most commonly mentioned (Appendix 4).Respondents reported having at least moderate confidence in their ability to detect delirium: moderate (28%, 28/100), ‘high’ (52%, 52/100) or ‘very high’ (20%, 20/100). The interval from which the 4AT was first used by the individual to the time of completing the survey varied across the sample (‘<1 month’ = 10% (9/90); ‘1 – 6 months’ = 21% (19/90); ‘7 – 12 months’ = 18% (16/90); and ‘>1 year’ = 51% (46/90).A detailed summary of user opinions on the 4AT collected as part Survey B is provided in Appendix 5. Regarding general opinions on the 4AT, 84% (59/70) had positive views, 14% (10/70) had neutral or mixed views and one (1/70) had a negative view. When respondents were asked how often they use the 4AT in patients at risk of delirium, 33% (30/90) stated ‘never/rarely’ or ‘sometimes’, 14% (13/90) said ‘about half of the time’ and 52% said ‘frequently’ or ‘almost always/always’. When respondents were asked if they thought that use of the 4AT as part of routine assessment was feasible in their unit, most (95% (81/85) said ‘yes’, with many referring to the ease (39%, 15/38) and speed of use (29%, 11/38). One question addressed the extent of knowledge of delirium respondents thought necessary in order for healthcare practitioners to use the 4AT effectively: 7% (6/84) stated ‘none/very little’, 58% (49/84) stated ‘some’ or ‘a moderate amount’, and 35% (29/84) stated ‘quite a bit’ or ‘an extensive amount’. With respect to specific training in use of the 4AT in order for healthcare practitioners to use the tool effectively, 17% (14/84) stated ‘none/very little’, 60% (50/84) stated ‘some’ or ‘a moderate amount’, and 24% (20/84) stated ‘quite a bit’ or ‘an extensive amount’.When respondents were asked whether the 4AT was used as part of routine assessment by them or others in their unit 69% (57/83) said ‘yes’, with two respondents commenting that they are currently carrying out audits of 4AT use in their units. Regarding barriers to use of the 4AT in respondents’ units, several factors were identified (Table 3). The use of an alternative tool was not considered by most to be a significant barrier. Opinions on other barriers showed a broad distribution across the sample, suggesting that implementation of delirium assessment tools is complex. Two particular comments from the free text comments emphasised that the extent of 4AT use depends on broad systemic and cultural factors and not simply on the merits of its utility: “We tried it but then moved back to AMT + CAM as AMT already performed by Nursing staff as part of basic assessment” (Consultant, ED/MAU)“We have done some improvement work with it but there was some resistance from colleagues about using it as a screening tool” (ST3+, MAU/MoE)Table SEQ Table \* ARABIC 3. Survey B: the extent to which respondents thought various barriers were preventing the 4AT from being used more regularly in their unitsVery small%(frequency)SmallModerateLargeVery largeTime constraints9.64(8/83)36.15(30/83)27.71(23/83)15.66(13/83)10.84(9/83)Existing use of / familiarity with an alternative tool37.35(31/83)24.10(20/83)24.10(20/83)12.05(10/83)2.41(2/83)Lack of staff confidence in using the tool8.43(7/83)28.92(24/83)34.94(29/83)19.28(16/83)8.43(7/83)Lack of perceived need to use a delirium screening tool7.23(6/83)16.87(14/83)32.53(27/83)37.35(31/83)6.02(5/83)Lack of staff knowledge of delirium6.02(5/83)28.92(24/83)40.96(34/83)21.69(18/83)2.41(2/83)To gather information about ease of use of the 4AT, respondents were presented with descriptions for three patient groups and asked to indicate their typical experience in using the 4AT with each group (see Appendix 2). For “drowsy patients who cannot produce verbal responses”, 51% (36/70) reported ‘very easy’ or ‘easy’, 17% (12/70) reported ‘neither easy nor difficult’, and 31% (22/70) reported ‘difficult or ‘very difficult’. For “patients with dementia who are alert and able to converse”, 77% (60/78) reported ‘very easy’ or ‘easy’, 17% (13/78) reported ‘neither easy nor difficult’, and 6% (5/78) reported ‘difficult’ or ‘very difficult’. For “patients who are agitated and distressed”, 44% (33/75) reported ‘very easy’ or ’easy’, 20% (15/75) reported ‘neither nor difficult’, and 36% (27/75) reported ‘difficult’ or ‘very difficult’. Respondents were also asked how long 4AT Items 1 – 3 typically take to complete: 12% (10/81) stated ‘<1 minute’, 54% (44/81) stated ‘1 – 2 minutes’, and 33% (27/81) stated ‘3+ minutes’. Some respondents added that the time taken is “affected by deafness”, that they usually have a “conversation at the same time” and that “longer time usually hints at worse performance”. Most of those who commented explained that the time taken to obtain collateral history from patients’ family, carers, GP or medical records was highly variable. These findings confirm the brevity of the bedside components in most patients but that Item 4 can be time-consuming.A detailed account of responses to Survey B questions along with examples of free text responses is reported in Appendix 3. Additional to feedback on the 4AT itself, respondents were asked whether they would suggest making any changes to the 4AT. The majority did not propose any changes, with 6-10 comments on each item and the guidance notes. Respondents’ comments could be grouped into the following themes: changes to item content, clarity, visual presentation, the scoring system and general comments. Examples are shown in Box 1. There were also some queries about validity and diagnostic accuracy of the individual items. Similarly a small number of respondents suggested including ‘time’ alongside the four items of the AMT4. The findings of Survey B were discussed with members of the study team, and considered in the light of other information, including additional external validation studies that had been published, the clinical service evaluations that had been collected as part of the study process, and other feedback from outside of the study about the 4AT. The team decided that in the absence of consistent feedback concerning a potential specific change to the 4AT, that the study process had determined that no change to the 4AT was required in advance of the forthcoming diagnostic accuracy study. 6934200Box 1: Examples of suggested changes to 4AT from free text comments in Survey BChanges to item contentA number of respondents suggested making changes to the content of the items. One respondent proposed using the AVPU scale for ‘Alertness’. Others suggested greater specificity “’Clearly abnormal’ automatically scores ‘possible delirium’. Perhaps break this down to, for example, 'comatose, drowsy, agitated' and provide relevant scores”(FY1 – 2, surgical ward)“There should be a box for hyperactive/over stimulated behaviour”(Nurse (30 yrs), MoE)Some respondents reported having experienced difficulties when asking patients to state the months of the year backwards and suggested including an alternative measure of attention:“Make other suggestions for different types of attention questions as some patient are illiterate and can’t do the months of the year backwards”(Nurse (10 yrs), MoE)“advice on test to use in non verbal or aphasic patients or in non english speaking patients” (Consultant, MoE)“people sometimes refuse to do, so I resort to using 20-1”(Consultant, MAU/Immediate care)ClarityIn reference to item 1, multiple respondents pointed out that there are no examples for what constitutes ‘clearly abnormal’. Some respondents felt that item 4 needs to be clearer about what exactly is being assessed and how it should be assessed:“More emphasis on 'is this their normal behaviour or has there been a change'”(Consultant, MoE/Stroke)“A lot of staff think its an acute and fluctuating change in their physical condition not the cognition! Maybe it needs to be explained more or maybe its a teaching problem we need to take on board”(Nurse (10 yrs), MoE) “I would change the description from over the ‘last 2 weeks’ to ‘in the last few days or weeks’. … to take account of those with a delirium who have been treated in the community but have not improved.”(Nurse (30 yrs), MoE) “There is a need to be explicit about what to do if there is no one to give a history.” (Nurse (30 yrs), MoE)Visual PresentationA number of comments focussed specifically on the visual presentation of information on the document for example, “I'd put [item 1] as Item 3 or 4 - I assess it throughout rather than as a stand-alone item at the start. Rarely am I just doing the 4AT, usually it's part of a more general assessment” (Consultant, MoE)Scoring systemSome respondents suggested making changes to the current scoring system for example. “I wonder if the timeline of 2 weeks would capture most/all cases of delirium esp if there has been a longer duration of the index episode. Could a breakdown of the absolute point score of '4' currently given for a 'Yes' response, be subdivided into a score of '2' for between 2 - 4 weeks; and perhaps as score of '4' for <2 weeks?”(Consultant, MoE/Rehab.)“Alertness - 0,0,1,3. Feels more realistic and reflective of variation. AMT4 - 0,0,1,2,3. I do not believe that 1 mistake deserves a score at all. It would be fairly easy with normal brain function even in young patients to make a single mistake. A score of 2 would be from my AMT5 (including 'time' to nearest hour)”(ST3+, MAU/MoE)General commentsOne respondent suggested the need to provide more information about the clinical significance of the results in the guidance notes: “There is some confusion about repeated testing and if this means the delirium is resolving. Capturing that would be very helpful, like a MEWS” (Consultant, MoE/Stroke)Another respondent highlighted an issue which might be of growing concern as hospitals gradually go ‘paper-light’. In reference to item 4 they stated:“This part of the test is frequently the most inaccurately completed part of the test. However this is due to the trust version of the test has been created on a computer and the guidance sentence underneath is not present.”(Nurse (5 yrs), MoE)00Box 1: Examples of suggested changes to 4AT from free text comments in Survey BChanges to item contentA number of respondents suggested making changes to the content of the items. One respondent proposed using the AVPU scale for ‘Alertness’. Others suggested greater specificity “’Clearly abnormal’ automatically scores ‘possible delirium’. Perhaps break this down to, for example, 'comatose, drowsy, agitated' and provide relevant scores”(FY1 – 2, surgical ward)“There should be a box for hyperactive/over stimulated behaviour”(Nurse (30 yrs), MoE)Some respondents reported having experienced difficulties when asking patients to state the months of the year backwards and suggested including an alternative measure of attention:“Make other suggestions for different types of attention questions as some patient are illiterate and can’t do the months of the year backwards”(Nurse (10 yrs), MoE)“advice on test to use in non verbal or aphasic patients or in non english speaking patients” (Consultant, MoE)“people sometimes refuse to do, so I resort to using 20-1”(Consultant, MAU/Immediate care)ClarityIn reference to item 1, multiple respondents pointed out that there are no examples for what constitutes ‘clearly abnormal’. Some respondents felt that item 4 needs to be clearer about what exactly is being assessed and how it should be assessed:“More emphasis on 'is this their normal behaviour or has there been a change'”(Consultant, MoE/Stroke)“A lot of staff think its an acute and fluctuating change in their physical condition not the cognition! Maybe it needs to be explained more or maybe its a teaching problem we need to take on board”(Nurse (10 yrs), MoE) “I would change the description from over the ‘last 2 weeks’ to ‘in the last few days or weeks’. … to take account of those with a delirium who have been treated in the community but have not improved.”(Nurse (30 yrs), MoE) “There is a need to be explicit about what to do if there is no one to give a history.” (Nurse (30 yrs), MoE)Visual PresentationA number of comments focussed specifically on the visual presentation of information on the document for example, “I'd put [item 1] as Item 3 or 4 - I assess it throughout rather than as a stand-alone item at the start. Rarely am I just doing the 4AT, usually it's part of a more general assessment” (Consultant, MoE)Scoring systemSome respondents suggested making changes to the current scoring system for example. “I wonder if the timeline of 2 weeks would capture most/all cases of delirium esp if there has been a longer duration of the index episode. Could a breakdown of the absolute point score of '4' currently given for a 'Yes' response, be subdivided into a score of '2' for between 2 - 4 weeks; and perhaps as score of '4' for <2 weeks?”(Consultant, MoE/Rehab.)“Alertness - 0,0,1,3. Feels more realistic and reflective of variation. AMT4 - 0,0,1,2,3. I do not believe that 1 mistake deserves a score at all. It would be fairly easy with normal brain function even in young patients to make a single mistake. A score of 2 would be from my AMT5 (including 'time' to nearest hour)”(ST3+, MAU/MoE)General commentsOne respondent suggested the need to provide more information about the clinical significance of the results in the guidance notes: “There is some confusion about repeated testing and if this means the delirium is resolving. Capturing that would be very helpful, like a MEWS” (Consultant, MoE/Stroke)Another respondent highlighted an issue which might be of growing concern as hospitals gradually go ‘paper-light’. In reference to item 4 they stated:“This part of the test is frequently the most inaccurately completed part of the test. However this is due to the trust version of the test has been created on a computer and the guidance sentence underneath is not present.”(Nurse (5 yrs), MoE)DiscussionSurvey ASurvey A had a substantial number of respondents and is to our knowledge the largest survey on delirium to date. Because of the nature of the recruitment process, respondents were likely to have an interest in delirium, and/or be interested in the management of cognitive impairment more generally. Nevertheless, given the sample size, the results do suggest that there is increasing awareness of delirium amongst hospital staff in the UK. Additionally, respondents indicated that the majority of units in which they worked had guidelines for delirium detection. These findings indicate potentially positive trends in improving delirium detection and therefore care in UK. However, other findings suggest that substantial challenges remain.Nine in 10 of respondents agreed or strongly agreed that formal diagnosis of delirium is important, that distinguishing between delirium and dementia was important, and that delirium treatment improves patient care. Although these data are from a potentially biased sample of healthcare professionals, they support the notion that a substantial proportion of practitioners believe that delirium is worth diagnosing. This view in the context of the well-documented poor rates of delirium detection demonstrates a challenging paradox in mainstream clinical practice.Some of the findings of this study help to address the question of why this paradox exists. One of the striking results is the range of terminology used to describe a patient with "recent onset drowsiness" who is "not producing responses but is responding intermittently to one stage commands". This clinical scenario is clearly consistent with a diagnosis of delirium according to DSM-5 criteria and the accompanying guidance notes, especially considering how much more common delirium is than potential alternative diagnoses. Yet, only one third of respondents favoured the term delirium being applied to this case, with several non-diagnostic, ill-defined terms such as "obtundation" collectively being suggested more often than the formal term delirium. Notably, a follow-up question asked respondents if the patient described at the beginning of this paragraph had delirium, and two thirds of respondents then stated that patient was "likely" or "very likely" to have delirium. Additionally, a different question directed at medical practitioners found that 72% believed that the patient needed to be able to produce verbal responses to allow bedside assessment for delirium; this view is not aligned with DSM-5, in which non-comatose patients with acute mental status disturbance who are incapable of speech are deemed assessable for delirium. These findings indicate that there is remarkable inconsistency in the terms used to describe clinical states which are most compatible with an initial diagnosis of delirium. The results in relation to the variable terminology used in the organisations of respondents parallel the findings from individual practitioners. The consequences of using inconsistent terminology are potentially serious, including failure to apply agreed treatment pathways, impaired communication among staff, and absence of adequate communication of the diagnosis to patients and carers. Moreover, an incoherent approach to diagnosis among senior staff makes attempts to provide effective training to junior practitioners and students much more challenging. Thus, these findings have broad implications for education and training, including continuing professional development.Practitioners showed a range of levels of confidence with respect to their own ability to detect delirium. Given that the sample is likely biased towards those with an interest in the condition, it is of concern that at least a substantial minority of respondents, including medical practitioners, have very low to moderate confidence. Given that delirium is very common, for example affecting at least one in eight hospital patients, unfamiliarity with the condition is not the source of this lack of confidence; rather it is likely insufficient education and training. The general incoherence around approaches to delirium detection may also contribute to the lack of confidence in many practitioners. The findings showed that just over half of respondents had ever used a specific delirium detection tool; non-specific cognitive tests were more widely used. Related to this, although around two thirds of units had delirium guidelines, respondents reported that in only a minority of these units were the guidelines followed.Another informative finding concerns perceptions around responsibilities of different disciplines with respect to delirium. In particular, respondents mostly had the opinion that nurses held the responsibility of screening for delirium but not diagnosing it. The restriction of diagnosis to medical staff alone in such a common condition in which the diagnosis can mostly be made readily with bedside assessment and informant history (or personal knowledge of the patient) is not a rational or pragmatic position. On the contrary, it can be argued that nurses with appropriate training (including awareness of DSM-5 criteria) are in a strong position in which to make a diagnosis, because they have the most direct contact with the patient of any healthcare practitioner. Notably, prompt diagnosis of delirium is advocated by many policymakers such as Healthcare Improvement Scotland. This finding has implications for both policy and clear decision-making around explicit roles of doctors and nurses in detecting delirium and initiating early care. With respect to physiotherapists and occupational therapists, awareness of the main features of delirium, perhaps coupled with use of a screening tool like the 4AT could lead to reporting of potential delirium to colleagues qualified to make a diagnosis. LimitationsSome limitations of the Survey A study should be acknowledged. This study did not have a population sample. The nature of the survey likely means that there was a higher proportion of practitioners with an active interest in delirium who responded compared with the whole population of practitioners in the UK. Emails were initially only sent to practitioners for whom an email address was available and recipients then decided whether to participate or not, and also to forward the email to colleagues. Although the core distribution list contained practitioners from 165 Trusts/Boards, 112 palliative care services and each of the authors and multiple organisations were asked to forward the invitation email to relevant practitioners in their contacts list, this snowball distribution method likely resulted in clusters of respondents in particular locations. The ratio of practitioners in the sample from each UK nation does not reflect the true ratio of practitioner distributed across the UK. In particular, Scotland is over-represented relative to England, and this is relevant because of promotional efforts in NHS Scotland from the government body Healthcare Improvement Scotland around delirium care that began in 2012. Although efforts were made not to lead respondents, use of the term ‘delirium’ in the invitation email and study title may have primed respondents and introduced bias when asking about the terms used by them and others in their units’. As such, use of the term ‘delirium’ is potentially over-reported in this survey in comparison to practice in general. While the survey was reviewed by all of the authors on two occasions for face validity, clarity and structure then piloted on 19 healthcare practitioners, neither test-retest nor inter-rater reliability were assessed. Anonymous participation precluded calculations of reliability for the study sample; however rough estimates could have been generated from pilot participants. The analysis was mainly purely descriptive. Group comparisons among professions were conducted post-hoc. Given this, and also that the sample was not representative, no strong conclusions can be drawn from the results with respect to differences among professional groups. Nevertheless, the findings provide some evidence that practitioner expectations around delirium diagnosis are different.Survey BSurvey B was directed at respondents with experience of using the 4AT. The final sample size was 100 and comprised mostly doctors and nurses. A large majority of respondents reported carrying out delirium assessments ‘frequently’ or ‘almost always/always’, meaning that this is a sample which likely includes a substantial proportion of professionals experienced in delirium assessment. In addition to the structured survey questions, multiple free text comments were provided. Taking the findings as a whole, respondents generally viewed the 4AT as a useful, rapid, and practical tool. Several comments were made around potential changes. However, no clear problem with the 4AT emerged consistently. Many of the issues raised do not relate to the 4AT specifically but to general challenges in the assessment of delirium, such as the availability of informant history and the time it can sometimes take to get this history, and basic knowledge of the features of the syndrome itself. Other issues relate to possible modifications of the cognitive tests used, the timeframe over which altered mental status is considered to indicate delirium, and so on. Many of these suggestions are reasonable and reflective of variations in accepted, mainstream practice. However, given that current version of the 4AT is in wide use, supported by several validation studies, and mentioned in several policy statements and guidance (see chapter 3), in the absence of strong positive evidence in favour of these modifications being introduced, retaining the current version is the most pragmatic option. Around one third of practitioners reported that it was ‘difficult or ‘very difficult’ to complete the 4AT in “drowsy patients who cannot produce verbal responses”. Items 2 and 3 in the 4AT allow for scoring of such ‘untestable’ patients, and Item 1 allows for scoring drowsy patients. This finding does suggest that education on the features of delirium with respect to reduced level of arousal would be helpful, and specific training on the 4AT concerning this issue would reduce the level of uncertainty that some practitioners have reported. With respect to training, most respondents stated that at least some training in use of the 4AT would be needed to use the tool effectively. The proportions of respondents stating this were similar to those responding to the question about whether training in delirium in general would be required to use the tool. Although the 4AT was designed to be simple and practical, and usable without specific training, findings of the survey suggest that users must have a basic understanding of delirium if using the 4AT. This should include understanding that reduced level of arousal is commonly seen in delirium and contributes to diagnosis. A number of comments suggested that more guidance is needed about what to ask carers or contacts about changes to behaviour. This knowledge is best classed as part of a practitioner’s general information around delirium detection; nevertheless given the lack of other approaches to delirium detection in routine care, more information on how this should be done in the context of using the 4AT would be valuable. Additionally, in conjunction with this, some training in the use of the 4AT would appear to be beneficial in promoting its effective use. Given the lack of space on the one page 4AT form, such additional education and training on delirium in general and on the 4AT would best be provided by content on easily accessible websites including .There were some queries about the scoring of the cognitive test items. Cognitive tests used in hospital practice show variable diagnostic accuracy for dementia and delirium,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5KYWNrc29uPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48

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ADDIN EN.CITE.DATA 43, 49, 93, 94 and no single test provides sufficiently good performance for use in all contexts. In addition, cognitive tests performed in isolation inform clinical judgement, but cannot perform as diagnostic tests alone. Therefore, practitioners using the AMT4 and Months Backwards tests need to have an awareness of both the value and limitations of information provided from the test results. With respect to practitioners seeking further information about the cognitive test items in the 4AT, the URL of the 4AT website () is present on the form (and indeed is readily identifiable through an Internet search, and an up-to-date list of specific 4AT validation studies as well as relevant studies relating to the cognitive test items is provided on that website).A need for both the scoring and guidance to be present on the paper or electronic documentation was also identified. This sometimes seems to have been lost when the 4AT has been incorporated into a larger assessment, incorporated into electronic patient assessment forms. This could be addressed by providing clearly identifiable links to the 4AT guidance notes or the 4AT website . The current findings emphasise the fact that use of the 4AT is not based solely on the utility of the tool itself, but is also depends on broader systemic and cultural factors. All those participating in Survey B had some experience of delirium assessment, and yet there was some evidence of lack of knowledge of some general aspects of delirium, which had an adverse effect on understanding how to use the 4AT. Furthermore, respondents identified factors external to themselves which hinder use of the 4AT, and presumably any other delirium assessment tool. LimitationsSurvey B had some limitations that must be acknowledged. The sample size was relatively small, and most participants were based in UK with a disproportionate number from Scotland. This limits the generalisability of the findings. The sample was not representative of all users of the 4AT; rather it likely was biased towards those with experience of its use, and possibly a more favourable opinion of the tool than users of the 4AT as a whole. Respondents were mostly medical practitioners, thus limiting information from nursing staff and other disciplines. The free text comments were not subjected to formal analysis such as content analysis. Nevertheless, the study yielded considerable useful information regarding opinions on the use of the 4AT from both the structured questions and the free text comments.Conclusions and implicationsTwo major issues were addressed in these surveys. The first was to develop a deeper understanding of broader issues around delirium assessment in the UK healthcare practitioners. The results from Survey A provided valuable insights into the many barriers that prevent effective detection of delirium in mainstream care. These include variable knowledge of delirium and its features among practitioners, a lack of confidence in ability to detect delirium in many practitioners, chaotic use of terminology, lack of compliance with guidelines, and varying opinions on the roles of different healthcare staff in detecting delirium. These findings have implications for education policy in relation to education at the undergraduate, and professional levels, as well as the design of effective systems, and creating an organisational culture which facilitates delirium detection. The organisational issues are explored in more detail in the qualitative studies which also form part of phase 1 of this project. The second major issue addressed by this part of the project was a specific survey examining opinions on the 4AT, looking in particular at the issue of whether there was a need to modify the 4AT in advance of the diagnostic accuracy studies in the second part of this project. Respondents were generally positive about the 4AT. There were some suggestions as to how it could be modified, but in the absence of a consistent message to do with these potential modifications the team decided that no changes were necessary. However, Survey B did yield important information concerning the need for general delirium education and pointed towards the benefits of providing education on use of the 4AT to enhance its effectiveness. Clinical Use and Examples of Clinical Service EvaluationsIntroductionThe 4AT was initially developed as a practical clinical tool as described in the introductions to Chapters 1 and 5. At the time of submission of the main grant application funding the present project, the 4AT had already started being used as a clinical tool in some settings and two diagnostic test accuracy studies had been published. Since that time, the clinical use of the 4AT nationally and internationally has expanded rapidly. It also has now a substantial presence in multiple policy, guidelines and advisory documents and websites. It has been translated into Arabic, Thai, Russian, German, Spanish, French, Italian, Dutch, and Norwegian (with active plans for Japanese, Serbo-Croat, Hebrew). In addition to the 4AT being the subject of several diagnostic accuracy studies it is also in use as a tool in some other studies of delirium.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb3JhbmRpPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48

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ADDIN EN.CITE.DATA 95-97 This brief chapter has the purposes of (a) providing an overview of current knowledge as to the clinical use of the 4AT, including its presence in policy and guidelines documents, and (b) providing examples of clinical service evaluations including field testing of 4AT Item 1. Issues around item changes for example Item 4 (acute onset and fluctuating course) were explored in the qualitative studies and surveys, and the conclusion of the study team was that no changes to the 4AT were required. Inclusion of the 4AT in policy, guidelines, and advisory documents and websitesThe 4AT is included in multiple local, national and international policy, guidelines, advisory documents and websites, and reports of use in clinical practice. Some examples are provided here. Websites were accessed on 5 Dec 2017.Policy websites and documents including the 4ATScottish Standards of Care for Hip Fracture Patients 2016. Scottish Government. The 4AT is the recommended delirium assessment tool. Improvement Scotland Delirium Toolkit. Scottish Government. The 4AT is the recommended delirium assessment tool. Falls and Fractures in Care Homes for Older People – good practice resource. Revised edition. Care Inspectorate and NHS Scotland. 2016. The 4AT is the recommended delirium assessment tool. Revealed: What Primary Care Needs to Know. A Primer for General Practice. Department of Health, England, 2014. The 4AT is included as one of the recommended tools. for Cognitive Impairment in Older People: Clinical Audit 2014-15. Royal College of Emergency Medicine. The 4AT is one of the recommended tools. and fracture consensus statement: Resource pack. Resources for commissioners and strategic leads with a remit for falls prevention, bone health and healthy ageing. Public Health England. The 4AT now included in the list of “Quality metrics required to pass best practice tariff”. Major Trauma System: Management of elderly major trauma patients. London Clinical Networks, NHS England (London region). 2017. The 4AT is one of two recommended delirium assessment tools. Department of Veterans Affairs (website). Delirium information for Professionals. The 4AT is among the recommended tools for delirium assessment. Nurses Association. Select Delirium Resources. The 4AT is one of the included tools for delirium assessment. Identification and Initial Management of Delirium in the Emergency Department /Acute Medical Assessment Unit. Irish Government. The 4AT is included as the main delirium assessment tool. Clinical Care Standard. Australian Commission on Safety and Quality in Health Care. Australian Government. The 4AT is included as a recommended tool. Navigator website, New Zealand. Website providing clinical information for clinicians in New Zealand. The 4AT is the recommended delirium assessment tool. of the 4AT in clinical practiceThere is no central record of which screening tool is used in different hospitals, therefore it is impossible to determine where it is currently used, but through requests on social media, and contacts with members of the Scottish and European Delirium Associations, we have determined that it has been rapidly adopted throughout the UK. In England, it has been widely adopted as a screening tool to fulfil the CQUIN target, for example at Guy’s and St Thomas’s hospital, Kings College Hospital, York Teaching Hospital NHS Foundation Trust, Sunderland NHS Trust, Northampton General Hospital (see case studies below). It is also widely used throughout Scotland for screening of cognition on admission. Older People in Acute Care (OPAC) in Health Improvement Scotland report that there is no nationwide collection of data on the 4AT, but it is being used in the majority of NHS boards (e.g. Royal Infirmary of Edinburgh and Western General Hospital NHS Lothian, Royal Victoria Hospital, Dundee), and options are being explored for testing its use in care homes and community hospitals. Additional information regarding use of the 4AT in clinical practice includes findings from Survey A in this report (Chapter 2). Indirect evidence for clinical use of the 4AT in clinical practice also comes from the number of hits on the 4AT website (). This website was launched in February 2011. The number of page views has increased from 1254 in the year beginning June 2011 (the point at which analytical data are first available) to 61,269 in the year beginning June 2016 (see Figure 1). The top five countries recorded are: UK, Australia, USA, Ireland, and Canada. center24533700Figure SEQ Figure \* ARABIC 1. Page views per year on the website between 2011 and 2017. Source: Google AnalyticsHere we provide some examples of websites and documents relevant to the clinical use of the 4AT are provided, then following this we provide two case studies of clinical use. The case studies were selected based on knowledge of members of the study team of centres with established 4AT use.Examples of websites and documents documenting 4AT use in clinical practiceIdentifying critical success factors for improved outcomes for people with dementia and their carers in acute care. A focus on NHS Grampian. Report on improvements in care in NHS Grampian, Scotland. 2017. Quality improvement work on use of the 4AT is reported. Older People’s Acute Care. Impact Report. Healthcare Improvement Scotland. 2016. Summary report of multiple quality improvement projects including delirium in several hospitals in Scotland, involving use of the 4AT. Hip Fracture Database (NHFD) Annual Report. 2016. The 4AT is documented as having been introduced as a standard clinical tool for delirium detection in hip fracture patients. Delirium: Recognition of delirium in an acute medical unit. 2016. Clinical audit, Ninewells Hospital, Dundee, showing improvement in delirium detection following introduction of the 4AT. Identification and Management of Delirium in the Orthopaedic Trauma Unit. 2014. Quality improvement project on increasing the use of the 4AT in an acute hip fracture ward. Teaching Hospitals NHS Foundation Trust Annual Report and Accounts 2015/16. The report documents that the 4AT was introduced to improve delirium detection. study: City Hospitals Sunderland NHS Trust City Hospitals Sunderland NHS Trust is a large District General Hospital with ~900 beds, of which ~200 are acute Care of the Elderly. The 4AT is embedded in the Trust (since 2013), used for all acute admissions, and in the Emergency Department for automatically appearing in the nursing admission documentation for completion for all admissions aged 65+ years. Score distribution is approximately 65% score 0, 20% score 1-3 and 15% score >3. All patients scoring >=1, (and patients in whom there is a clinical concern) are reviewed by the specialist Delirium Dementia Outreach Team (DDOT) comprising 4 Band 7 practitioners (3 nurses, 1 physio), a 0.5WTE senior pharmacist, 0.5WTE Band 3 admin, supervision from 1.5 consultant geriatricians. The team assesses 300-400 new and 100-200 review patients each month (total N to June 2017 = 1218, mean age 78.1 years, range 61 to 102). This has resulted in improvement in achievement of the CQUIN target, and delirium diagnosis recording, with a reduction in referrals to the Mental Health Liaison Team. Of note, approximately 75% of patients seen by the DDOT team are picked up after a positive score on the 4AT, but 25% are also referred by clinical staff due to concerns. The majority of these scored ‘0’ on the 4AT, but on review where confused, and/or drowsy, and therefore the score was likely to have been inaccurate. Written feedback from the team was provided: in summary, the 4AT has been widely adopted, is considered easy to use, and quick to complete. Scores of ‘0’ may be ‘under-scored’: local review has concluded that this is a staff training issue, rather than requiring a change in the tool. Case study: Kings College Hospital NHS Foundation Trust, LondonKings College Hospital NHS Foundation Trust is a large acute care teaching hospital with 950 beds. The 4AT is embedded as the screening test for all acute admissions. A Delirium and Dementia team (DAD) was established to review patients who screened positively on the 4AT (see report to Royal College of Psychiatrists ). It has been difficult to validate due to difficulty in retrieving accurate information from primary care. However, there is a good correlation between higher 4AT scores and delirium features. Just over 80% of individuals screened go on to receive a diagnosis of dementia or delirium at follow up. Written feedback from the team is that the 4AT is easy to use and score.Field testing of 4AT Item 1 (level of alertness)The main purpose of this subproject was to assess agreement between raters for Item 1 (level of alertness). The reason for assessing this item alone was because the study team considered that the brief cognitive test items (items 2 and 3) were well-studied and relatively simple tests with less need for assessment of agreement, whereas a binary judgement of level of alertness was more likely to be prone to disagreement, and potentially therefore to require to be changed in advance of Phase 2. This subproject was conducted using paired assessors using the 4AT in routine clinical practice in the Royal Infirmary of Edinburgh. In the acute hip fracture ward, patients are commonly reviewed by a pair of practitioners (either two doctors, or a doctor and a nurse). For this clinical evaluation, when practitioners were assessing patients in pairs, one would perform the 4AT and the other would record their responses to each item, blind to the other rater’s scores. We performed 50 paired observations, scored as either negative or positive for the presence of abnormal level of alertness. Where there was disagreement, raters discussed this (without changing the ratings), recording their opinions as to why there had been disagreement. The number of positive observations was 16 out of the total of 100. There were four instances of disagreement across the 50 paired assessments. This yielded a Cohen’s Kappa statistic of 0.70, which indicates substantial agreement. On two occasions raters disagreed as to whether the patient had agitation, and on two occasions whether the reduced level of arousal was low enough to trigger a positive score. On all four occasions both raters noted that where there was disagreement between raters, altered arousal was relatively mild. In summary, the field testing showed that there will be some differences of interpretation regarding whether mildly altered level of alertness (whether this is restlessness or sleepiness) is considered to be abnormal or not. This is an inherent problem in using a binary scoring system. An item involving more gradations would likely lead to greater agreement. However, the additional time cost and complexity of using an item with multiple levels conflicts with the need for a tool that is not only rapid but also easy to understand and use in a busy clinical context. On balance, the evidence suggests that Item 1 in the 4AT performs at an acceptable level.ConclusionsSince its release in 2011, the 4AT has become a widely used instrument for delirium detection in clinical practice nationally and internationally. This has been driven by the apparent need for such a tool, as identified in the 2010 NICE Guidelines on delirium, ADDIN EN.CITE <EndNote><Cite><Year>2010</Year><RecNum>1950</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>1950</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">1950</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>NICE,</author></authors></contributors><titles><title>Delirium: diagnosis, prevention and management.</title></titles><number>1 Dec 2017</number><dates><year>2010</year></dates><urls><related-urls><url>.uk/CG103</url></related-urls></urls></record></Cite></EndNote>4 in combination with the simplicity of the 4AT and initial evidence that it has sufficient validity. Although it is difficult to get precise estimates of use of different tools in clinical practice, the 4AT is likely now one of the leading tools for delirium assessment in current use in the NHS in the UK. Information from clinical service evaluations and uptake by major policy makers demonstrates that, overall, the 4AT is considered a practical and valuable tool. Implementing Delirium ScreeningIntroductionThis chapter reports on the qualitative sub-study, part of Phase 1 of the research. The purpose of the exploratory study was to provide insight into the practice of delirium screening and assessment in acute NHS settings from the perspective of different health professionals. As discussed in Chapter 1, despite the fact that delirium is a common complication of acute illness particularly in older people and incurs considerable costs at human, clinical, service and societal levels, the problem of under-detection persists. Although surveys have shed important light on knowledge of, and attitudes to delirium among health professionals in different health systems (Chapter 2), there is limited research on the practice of delirium recognition and assessment in the real life context of healthcare delivery across different service delivery locations within the acute hospital.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZWxhbmdlcjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+

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ADDIN EN.CITE.DATA 98-106 Most such published studies relate to the work of nurses only;PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZWxhbmdlcjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+

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ADDIN EN.CITE.DATA 103, 104 in medical/surgical ADDIN EN.CITE <EndNote><Cite><Author>Lou</Author><Year>2002</Year><RecNum>3674</RecNum><DisplayText><style face="superscript">105</style></DisplayText><record><rec-number>3674</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1513155545">3674</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lou, M. F.</author><author>Dai, Y. T.</author></authors></contributors><auth-address>School of Nursing, College of Medicine, National Taiwan University. mfalou@ha.mc.ntu.edu.tw</auth-address><titles><title>Nurses' experience of caring for delirious patients</title><secondary-title>J Nurs Res</secondary-title></titles><periodical><full-title>J Nurs Res</full-title></periodical><pages>279-90</pages><volume>10</volume><number>4</number><keywords><keyword>Adaptation, Psychological</keyword><keyword>Adult</keyword><keyword>*Attitude of Health Personnel</keyword><keyword>Delirium/*nursing/psychology</keyword><keyword>Female</keyword><keyword>Health Knowledge, Attitudes, Practice</keyword><keyword>Humans</keyword><keyword>Interprofessional Relations</keyword><keyword>Models, Psychological</keyword><keyword>Nurse's Role</keyword><keyword>Nurse-Patient Relations</keyword><keyword>Nursing Assessment</keyword><keyword>Nursing Methodology Research</keyword><keyword>Nursing Staff, Hospital/*psychology</keyword><keyword>Pilot Projects</keyword><keyword>Qualitative Research</keyword><keyword>Safety Management</keyword><keyword>Social Support</keyword><keyword>Surveys and Questionnaires</keyword><keyword>Taiwan</keyword><keyword>Workload</keyword></keywords><dates><year>2002</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>1682-3141 (Print)1682-3141 (Linking)</isbn><accession-num>12522741</accession-num><urls><related-urls><url> and older peoplePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Hb2RmcmV5PC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48

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ADDIN EN.CITE.DATA 100, 101, 106 wards); and in different countries. The main conclusions are that nurses experience discomfort and lack knowledge and understanding in working with and responding to patients with delirium; and that focus is often on disruptive behaviours to be managed than on investigating and treating a medical syndrome. Negative attitudes and knowledge and skills gaps at individual and professional levels have been implicated in under-detection of delirium and poor treatment. However, knowledge, skill gaps and work practices are not separate from, but are located in cultural, organisational and inter-professional contexts. Yet few studies have examined barriers to delirium screening, assessment and management at these levels.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CcmFkbGV5PC9BdXRob3I+PFllYXI+MjAwNDwvWWVhcj48

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ADDIN EN.CITE.DATA 37, 38, 100, 107-109 In this study, we sought to provide insight into delirium knowledge, the value attached to delirium identification, and how both are shaped by professional role, organisational purpose and routines in different settings along the patient journey into and through hospital in the UK NHS. This was to inform understanding of the factors implicated in implementation of a screening tool for delirium in practice. Research designResearch objectivesThe study objectives were to:1.Examine screening practices for delirium at particular locations in the patient journey into and through hospital;2.Explore staff knowledge of delirium, the value attached to identifying delirium, and the strategies called forth to manage it, at these same service delivery locations;3.Determine the organisational, environmental and system level barriers at locations over the patient journey that impact systematic identification of patients with possible delirium;4.Consider staff use of screening tools generally and the 4AT specifically, the contexts in which the 4AT is used, speed and ease of use and value attached to use.We performed a multimethod, qualitative, mixed method study comprising in-depth interviews with health professionals, and observation of practice in different locations along the patient journey from the Accident & Emergency Department (ED), Medical, Surgical and Elderly Assessment Units (MAU, SAU and EAU); and in selected acute wards. The rationale for combining interviews and observation was that whereas interviews can explore staff understanding of delirium and the meaning of, and value attached to delirium screening in particular settings, observation provides a picture of what staff actually do, in the real life context of healthcare delivery in time and space. This includes what people take for granted or are unable to articulate. The overall aim of the study therefore was to provide a descriptive and explanatory account of how hospital staff from different disciplines and at different levels of seniority understood, made sense of, and attached value to identifying patients with delirium, in context of the organisation of work within settings intended to achieve different purposes. MethodsSampling strategyHospitalsWe sought to include hospitals in which the 4AT was in routine use as a screening tool (4AT ‘experienced’ site), and where it was not (4AT ‘virgin’ sites). Initial findings from the survey of health professionals in the four countries of the UK (England, Scotland, Wales and Northern Ireland) (Chapter 2) had indicated that apart from a small number of hospitals in England, the 4AT was primarily used routinely in Scottish hospitals at that time. Further, among the majority of respondents from other UK countries, there was no consistent use of any specific screening tool for delirium. We purposively selected three general hospitals (two in England and one in Scotland). Two were part of large, acute foundation trusts located in urban centres in the North of England and were 4AT ‘virgin’ sites (Avonfield and Cranford). Neither had adopted specific delirium guidelines for the detection and management of delirium at a whole hospital level, although in both initiatives had occurred at elderly care directorate and ward levels to improve detection, management and prevention of delirium, drawing on NICE Guidelines (93). Neither hospital had adopted a single delirium screening tool, although one (Cranford) was considering implementing the SQiD, a single prompt question which asks: ‘Is this patient more confused than before?’ The third hospital, Denbury is in an urban area of Scotland, within a large Health Board spanning metropolitan areas and a rural hinterland. Here, the 4AT had been introduced across the hospital along with local guidelines on the detection and management of delirium. All three hospitals are attached to medical schools. Pseudonyms are given for each site. ParticipantsWithin each hospital, we adopted a multi-layered approach to securing engagement in the study. Initially, we arranged meetings with departmental managers, clinical leads for delirium and dementia and senior medical and nursing staff in order to introduce the study, gauge interest in participation, and secure access. Staff provided orienting guidance on the process of screening and assessment, identified key informants and offered a point of contact for each department. Within each department/service location, we approached the senior clinician/manager to discuss the study, seek permission to conduct observation and interview staff from different disciplines and at different levels of seniority. We provided information leaflets and posters to advertise the study. In some settings, we were able to attend team meetings and explain the research; in others information leaflets were distributed to staff. Interest was in identifying and approaching individuals who played a specific role in the process of assessment, information gathering and diagnosis. In all settings, a senior clinician was invited to take part in an interview and then suggested others in different roles to contact. Observation also served to identify key practitioners to approach; for example, an informant conversation with an individual about their work on occasion resulted in an invitation to take part in a formal interview. All those approached agreed to take part in the study.Data Collection InterviewsWe conducted qualitative interviews with a purposive sample of staff from each service location (ED), different types of assessment unit (AU) and acute wards), from different disciplines, and with varying experience and seniority. On each site, we discussed participation in the study through meetings with departmental managers, clinical leads for delirium and dementia, senior medical and nursing staff in order to introduce the study, gauge interest in participation, and secure access. Staff provided orienting guidance on the process of screening and assessment, identified key informants and offered a point of contact for each department. A total of 19 health professionals within the 4AT ‘virgin sites’ took part in a formal interview: eleven based at Avonfield Hospital, and eight at Cranford. Additionally, a further ten staff participated in lengthy informant discussions in the course of observation during which detailed notes were made and subsequently written up. In the 4AT ‘experienced’ site, 24 interviews were conducted. In total, 43 interviews and ten informant discussions were carried out. The number of interviewees at each organisational setting and their seniority and discipline within the ‘virgin’ and ‘experienced’ sites are shown in Appendices 6 and 7.Interviews were conducted using a topic guide (Appendix 8). The topic guide was employed as an aide-memoire and interviewees were invited to discuss issues of relevance to their professional role, task and work setting. 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ADDIN EN.CITE.DATA 100 and discussion with clinical colleagues within the wider research team including the Chief Investigator and co-applicants working in varied clinical settings. Focus was on how staff perceived their role within the setting and the nature and pattern of their work routine; the context in which they were involved in identifying patients with delirium; their current strategies for detecting delirium, including triggers; what actions or investigations might be prompted following screening and assessment of probable delirium; and issues pertaining to the treatment and management of patients with delirium. This line of questioning permitted further exploration of individuals’ knowledge and understanding of delirium; strategies for dealing with it specific to their role or department; and features of the setting that facilitated or inhibited understanding, identification of, and action on delirium. This set the context for asking respondents for their general views on delirium screening tools and on their specific views about the 4AT. The mean length of interviews was 50 minutes (range: 35 to 65 minutes duration). They were mainly conducted in a private space (office or meeting room), although they were frequently subject of interruptions and then resumed.ObservationsEthnographic observation including shadowing members of staff was employed to develop understanding of the rhythm and pattern of routine activity in each organisational setting; how the work of assessment and care delivery was accomplished; and how delirium screening, assessment and management fitted into this. During observation, researchers engaged staff in informant conversations in order to clarify aspects of practice and work organisation. These ranged from chats to clarify an event, activity or professional role, to lengthy exchanges to provide insight into sequences of action and work processes. Locating respondents’ comments in the contexts in which they were made, facilitated deeper understanding of their meaning. Additionally, we collected documents relating to procedures (for example, care pathways, use of structured assessment tools) and processes (assessment, diagnostics and action planning).A total of 45 hours observation took place across the three hospitals, each session lasting around three hours at a time. Observation initially cantered on the ED, intentionally replicating the starting point of the patient journey, since the ED might be considered to be a key location for early detection of delirium. At the same time, the pace and complexity of the practices and processes in ED required a longer period of observation in that setting to better understand staff roles and routines. Then, we moved on to the next point in the patient journey – the AUs. These included three MAUs, two EAUs/Frailty units (dedicated assessment units for older people), and one SAU. Finally, we moved on to acute wards, mainly care of older people but also stroke, cardio-thoracic, orthopaedic trauma and post-surgical wards. Not all patients will follow such a linear path; some will bypass the assessment unit and will be directly admitted to a ward; others will go straight to an Intensive Care Unit (ICU). However, the assessment unit is an important staging point for more detailed assessment of patients and decision-making about acute admission or diversion elsewhere. Selection of a range of types of assessment units and wards was to ensure inclusion of settings where staff would likely vary in their knowledge of delirium (and dementia). We did not include Intensive Care Units (ICUs) in the study: observation in this setting was considered intrusive and the research timescale did not permit the detailed negotiation that such participation would require. Data AnalysisAll audio-recorded interviews were anonymised and transcribed verbatim. As our focus was on interview content, transcription notations were used only to indicate pauses, cross-talking, and hesitations. Researchers conducting the interviews listened to the audio-recording alongside the transcribed text for accuracy of transcription. They also completed a pro-forma for each interviewee which included their salient characteristics (profession, grade/seniority, gender, organisational setting/ward type). A summary was produced as soon as possible after the interview including the main issues raised, the research questions on which the contact focused most centrally, new ideas generated to pursue in the next interview, and/or areas that were insufficiently explored. Audio-recordings, transcriptions and summaries were shared and discussed within each local team; transcriptions and summaries were shared across the two local teams. We did not send transcriptions to interviewees for comment. 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ADDIN EN.CITE.DATA 110-112 The researchers’ impressions and reactions to what they had seen and heard were recorded separately in a chronological journal. All datasets were stored electronically and organised by site and setting. Research teams involved in the English and Scottish sites respectively met regularly to discuss the emerging data, what to make of it and to compare and contrast findings within and across sites; team members also maintained regular email and telephone communication. Data from all sources were analysed using grounded theory methods, ADDIN EN.CITE <EndNote><Cite><Author>Charmaz</Author><Year>2014</Year><RecNum>3683</RecNum><DisplayText><style face="superscript">113</style></DisplayText><record><rec-number>3683</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1513169908">3683</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Charmaz, K.</author></authors></contributors><titles><title>Constructing grounded theory.</title></titles><dates><year>2014</year></dates><pub-location>Thousand Oaks CA.</pub-location><publisher>Sage.</publisher><urls></urls></record></Cite></EndNote>113 including simultaneous data collection and analysis, constant comparison, search for negative cases and memo-writing. Multiple readings of all interview transcripts, summaries and fieldnotes by team members individually, familiarised researchers with the data, including its variability and range within and across settings and at individual and organisational levels. Through discussion, we developed tentative ideas captured in memos on what was going on at both levels. For example, what were the distinctive features of clinical work undertaken in different organisational settings; how did these inform the delirium-related work carried out by individual staff; how did delirium knowledge across sites and settings influence the value attached to the work of delirium identification, assessment and action?Datasets (transcripts and fieldnotes) relating to each organisational setting were subject of initial open coding by local research team members, individually and together. This first phase involved synthesising, integrating and organising data segments into named meaning units on hard data copies, with each data source examined on its own terms. In this way, we sought to retain the coded segments in context of the whole interview or fieldnote. Initial codes were provisional, primarily descriptive, close to the data and were aimed at understanding participants’ meanings, accounts and actions. Coded transcripts were shared, compared and discussed across the research team: differences in interpretation often giving rise to new insights. For example, participants in Denbury often prefaced their accounts of action on delirium in terms of what they should do, suggesting the need to examine how normative practices relating to delirium identification were introduced, and what was shared, subverted or sustained over time.From initial codes, we agreed which to pursue for more in-depth focused coding. The open code ‘knowledge of delirium’, for instance, was developed as an analytic category during focused coding comprising several components (formal knowledge of diagnostic criteria; practice knowledge based on exposure to patients with delirium and its effects on them; and tacit knowledge from practice experience, emotions, insights and observation). Analytic categories, components, descriptors and the research objectives they related to, were displayed and managed in Word files organised by site and setting. With regard to knowledge for example, we compared and contrasted different forms of knowledge to examine how they variously shaped meaning and action on delirium identification between settings, professionals and across sites, and created diagrams of these relationships. These were captured in memos and further tested out with the data.In addition to coding and categorising data, we explored the data narratively to examine processes and context systematically. For example, regarding delirium identification, we perused larger sections of transcripts and notes to examine the narrative structure of accounts– what preceded a particular account/incident and what followed from it to capture the processes involved. Comparing and contrasting narratives between settings cast light on how features of organisational context affected these processes. Each stage of analysis involved discussion within the research team: codes and categories were reviewed, memos and diagrams shared; and explanations developed were refined and verified moving iteratively between the empirical data and sense making in relation to it. Research TeamTwo investigators (EL and AS) conducted the interviews and observation with academic support of MG and JH (both experienced qualitative researchers). Organised as two local teams, EL and MG pursued the research in the English sites and AS and JH in the Scottish site. They came from different disciplinary backgrounds: psychology (EL, AS), sociology (MG) and nursing (JH); and from varied research areas: applied health and social care research relating to older people, including with cognitive impairment (MG), adult mental health (EL), learning disability and delirium (AS), and the introduction of new health technologies particularly in primary and community care (JH). None were medical practitioners. Their varied backgrounds and perspectives generated openness to exploring different ways of considering issues and problems. The whole team met together for a day at critical points: at the beginning of the research to develop the fieldwork plan; during fieldwork to reflect on emerging data, consider variation within and between sites and what shaped it, and identify new lines of enquiry; and during analysis to discuss and refine codes, categories, analytic concepts and narrative content. Regular telephone conversations, email discussions and sharing memos, diagrams and matrices occurred between investigators in an ongoing dialogue and to ensure consistency of analytic approach in the three sites. Within local teams, formal meetings and informal discussion took place approximately weekly. EthicsEthical approval for the study in the two English sites was obtained from the National Research Ethics Committee (Ref: 14/SW/1095). The main ethical issue was not seeking formal consent for general observations of routine practice. As observations were unobtrusive, carried out in public or semi-public spaces, and did not identify individual staff, patients or visitors by name, we considered it would be impractical and likely more intrusive to seek formal written consent from all those present. Instead, we sought informal, verbal consent. At the beginning and end of each observation, the researcher ‘signed in’ and ‘signed out’ with a senior staff member. No difficulties were encountered in any of the sites. Advice from National Research Ethics Committee in Scotland was that as focus was on examining the 4AT in use, the study was more appropriately characterised as audit and therefore only required local clinical governance approvals; these were obtained. The conduct of the study in this site conformed to the same ethical principles as informed research in the English sites.FindingsThe findings are organised as follows. We examine each setting separately, their organisational and care environments and the views and experiences of different professionals within them pertaining to their knowledge and practice regarding delirium detection. We consider how the context and purpose of each setting impacts the value attached to delirium screening. Then we compare and contrast findings across settings and between professionals to consider the barriers to delirium screening with focus on the pattern of variation between 4AT ‘virgin’ and ‘experienced’ hospital sites. Finally, we draw out the implications for understanding delirium screening implementation and practice. In Appendix 9 we report some views of staff on the 4AT screening tool within the ‘virgin’ sites as they ‘thought aloud’ on its use in context of their particular setting; and similarly in the 4AT ‘experienced’ sites. Each setting is introduced with a snapshot drawn from observation of the organisational context in which the work of delirium screening and assessment occurred. This is to convey the type and pace of activity within the department, the speed of routine processes, and how staff worked together to accomplish their role and purpose. The Emergency Department (ED)Studies examining recognition, detection and delirium occurrence in EDs have been a particular focus of research interest on delirium. EDs are both the first point of entry of patients into general hospitals and a location in which decisions about appropriateness of acute care are initially made. From systematic reviewsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYXJyb248L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 114, 115 of observational and prospective studies over two decades, there exists yawning gap between the occurrence of delirium among older patients in EDs as assessed by researchers using various measurement tools, and what is identified by ED physicians, typically based on review of charts/documents. Primarily conducted in North America and Canada, study findings suggest the presence of delirium in approximately 7% to 10% of older people admitted to the ED; lower in some studies ADDIN EN.CITE <EndNote><Cite><Author>Lewis</Author><Year>1995</Year><RecNum>3686</RecNum><DisplayText><style face="superscript">116</style></DisplayText><record><rec-number>3686</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1513170050">3686</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lewis, L. M.</author><author>Miller, D. K.</author><author>Morley, J. E.</author><author>Nork, M. J.</author><author>Lasater, L. C.</author></authors></contributors><auth-address>Emergency Medicine Division, St. Louis University Health Sciences Center, MO.</auth-address><titles><title>Unrecognized delirium in ED geriatric patients</title><secondary-title>Am J Emerg Med</secondary-title></titles><periodical><full-title>Am J Emerg Med</full-title></periodical><pages>142-5</pages><volume>13</volume><number>2</number><keywords><keyword>Aged</keyword><keyword>Cohort Studies</keyword><keyword>Delirium/classification/*diagnosis</keyword><keyword>Emergency Service, Hospital</keyword><keyword>*Geriatric Assessment</keyword><keyword>Humans</keyword><keyword>Neuropsychological Tests</keyword><keyword>Nursing Assessment</keyword><keyword>Patient Admission</keyword><keyword>Patient Discharge</keyword><keyword>Sensitivity and Specificity</keyword></keywords><dates><year>1995</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0735-6757 (Print)0735-6757 (Linking)</isbn><accession-num>7893295</accession-num><urls><related-urls><url>(95)90080-2</electronic-resource-num></record></Cite></EndNote>116 and considerably higher among sub-groups of older people, such as those who are older, in long-term care or living with dementia.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYW48L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFyPjxSZWNO

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bmROb3RlPn==

ADDIN EN.CITE.DATA 32 Further, delirium is missed in between half and three-quarters of cases comparing rates of delirium as measured by researchers with detection rates based on chart review.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYWt1bWE8L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 114, 115 it is also likely that contextual factors are implicated. ED: An observational snapshot EDs were variously calm and chaotic; either eerily empty and anticipatory, or alarmingly active and noisy. The general atmosphere in reception was steadily busy yet reassuringly calm. Walk-in patients checked-in at reception, and were directed to minor injuries or ‘See and Treat’ waiting. Time passed slowly here. The low hum of a TV screen appeared to offer people some distraction as they waited for attention. Passing from reception into the main treatment area, sound and commotion intensified. There was an impression of constant movement. Staff walked quickly between treatment areas; patients were wheeled in and out of assessment cubicles; family members entered, looking lost and anxious; porters, therapists and non-medical staff searched for patients; other visitors to the department - paramedics, police, social care workers - attempted to attract the attention of relevant practitioners and sometimes patients. This noisy, chaotic, disorientating atmosphere concealed the composed coordination of the operation beneath. ED staff faced an unremitting stream of incoming patients and tasks to be carried out, yet appeared to work steadily, each playing their part in the overall purpose, namely accomplishing timely and appropriate throughput of patients. In the centre of observed departments were large computer tracking screens on which each patient’s location, assessments, test results and time since arrival served as a constant reminder and additional pressure.Staff greeted incomers, taking each case in succession, filtering and processing patients onwards, and drawing on different sources of information to effect appropriate movement, all the while conscious of the clock ticking and the steady accumulation of incoming patients. Porters transported sometimes confused, upset, or unwell patients to x-ray or to bays for further investigation; technicians took blood samples; nurses and junior doctors traced patients’ progression through investigatory staging posts; picked up observations and carried out detailed assessments. Amidst the mêlée were the patients, sometimes accompanied, often alone as they were guided through and onwards. Staff – primarily medical and nursing - carried out their tasks systematically, concurrently and collaboratively, constructing a picture of the patient, a clinical case. Flow and processing were paramount; efficiency and accuracy crucial. Sporadically this pattern was interrupted by an incoming emergency. Alerted by an alarm, senior doctors and nurses gathered, ready to respond, primed to act, then melting away back to their patients and paperwork when no longer needed. Ambulance patients’ arrived through the back door accompanied by paramedics and sometimes by a relative or friend. Paramedics waited to handover their charge, usually to a senior doctor or nurse, who took the patient’s information including a brief history of the precipitating medical event, biographical details and medication taken; conducted a rapid assessment; ordered appropriate tests and further investigations. With an experienced clinician at handover, the process took about ten minutes per patient. Sites varied in the type of professional undertaking this task (in Avonfield, for example, this was a senior doctor; and in Cranford, a senior nurse practitioner). Their early involvement appeared to aid efficiency as long as staff in the bays could respond to the pace. The specific aim at handover was rapid, accurate movement of patients to the appropriate next location, whether for immediate treatment in resuscitation for those who were very unwell or further assessment and information gathering by staff in the bays. Here, nursing staff conducted clinical observations, gathered information about the person, including social circumstances, functional abilities, health and well-being; while medical staff, typically junior doctors, carried out clinical assessments, interpreted test results, and drawing on the multiple sources of information and discussion with nurses, developed a possible differential diagnosis and plan of action for review with senior staff. Patients were discharged or admitted, the ultimate aim of ED being the effective direction of the patient either onward through acute care or discharged home. A marked feature of the process of decision-making regarding movement of patients between one assessment space and another and within each space was vertical and horizontal collaboration between staff. Even so, there were times when the sheer numbers of patients coming in, constrained the smooth flow. Location of resources at the ‘front’ door of the hospital had potential to facilitate further observation and assessment of those deemed medically fit for discharge but who might need support to ensure a ‘safe discharge’. Distinctive and common features of ED organisation to achieve its clinical and service purposes were: the temporal frame within which the work was organised; the division of labour in designated spaces where particular types of action and interaction occurred (e.g. Triage, Pitstop, Resuscitation); systems and processes to achieve collaborative and coordinated team working to appropriately respond to patients’ immediate clinical needs, pursue investigations and information gathering to determine where next for the patient; and maintain pace and flow.ED: Knowledge and understanding of delirium and delirium detectionRespondents to Survey A (Chapter 2) generally reported increased awareness of delirium primarily attributing this to greater exposure through professional journals and conferences, prompted by NICE guidance ADDIN EN.CITE <EndNote><Cite><Author>NICE</Author><Year>2010</Year><RecNum>1950</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>1950</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">1950</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>NICE,</author></authors></contributors><titles><title>Delirium: diagnosis, prevention and management.</title></titles><number>1 Dec 2017</number><dates><year>2010</year></dates><urls><related-urls><url>.uk/CG103</url></related-urls></urls></record></Cite></EndNote>4 and initiatives such as ‘THINK Delirium’ in Scotland. Nevertheless, also evident from the survey, was wide variation in awareness of, knowledge about and attitudes to delirium among staff in different organisational settings and across different disciplines. In particular, the perception of general increased awareness of delirium amongst staff was not shared by survey respondents working within EDs. However, interviews with ED staff convey a more nuanced picture as considered below. Types of knowledgeSenior ED doctors in ‘virgin’ sites suggested that they had heightened knowledge of delirium and of the consequences of undetected delirium, meaning that they were more attuned to the importance of identifying it. Further, understanding of the delirium trajectory, including its deleterious consequences for patients in the immediate and longer term, increased the salience of work to detect it. The combination of clinical knowledge and experience meant that senior staff were able to quickly recognise a particular constellation of factors in the patient which made them think of delirium. This tacit knowledge of delirium aligned with the clinical presentation, sensitised such professionals to note and interpret observational cues to construct a clinical picture; There comes a point in a senior doctor’s life where the database of thousands and thousands of patients that I have seen is sufficient for me to be able to recognise certain clinical patterns both from history and examination and that’s often brief… but it’s quite common to get the key points of the history that will point towards the diagnosis.… so recommending a comprehensive history and a full physical examination …in the first place, and then targeting investigations to those most relevant… there’s a number of different things that can cause it.Consultant, ED, Avonfield 04Importantly, these different types of knowledge were not shared by all staff within the ED. A common view expressed by senior doctors was that while staff generally were ‘more willing to consider delirium as part of the clinical picture’, they lacked knowledge of the profound negative effects of undetected delirium. Do they understand it? No, I don’t think they appreciate it. I think that people are getting better at picking it up but do I think that they recognise the significant mortality rate … that’s associated with it? No I don’t think so. I think they might vaguely be aware but… I think the numbers would startle them.Consultant, ED, Avonfield 01Consequently, it was suggested that such staff might be less focused on delirium detection, according it of lesser significance in the overall assessment process and in the construction of the differential diagnosis. Lack of clinical experience with patients with delirium as well was seen as a barrier to the development of tacit knowledge.The enhanced understanding of delirium that accompanied knowledge and experience meant that senior staff were often able to quickly recognise a particular constellation of factors in the patient which made them think of delirium. By incorporating knowledge of delirium with the clinical presentation, such professionals noted and interpreted observational cues to construct a clinical picture; further, understanding of the delirium trajectory increased the salience of detecting it. Less experienced staff, or those with different professional roles, might only have some elements of this delirium knowledge, leaving them less able to recognise its presentation and its meaning for the patient. Introduction of a screening tool might, some suggested, improve recognition of delirium, but only if the pattern of signs presented by the patient offered a signal or trigger to the practitioner to consider delirium as a possibility. This in turn was seen to require at least some knowledge of the circumstances in which delirium typically developed. The corollary was that senior staff might perceive use of a screening tool as less relevant; focusing instead on assessment using a range of clinical tools among those patients who exhibited signs of probable delirium. Inconsistency of knowledgeAmong junior staff, the pattern of awareness and knowledge of delirium was inconsistent, partly shaped by training and partly by prior experience in a setting in which delirium was prevalent. One interviewee described how knowledge of delirium gained through geriatric experience in a care of older people ward in addition to taught sessions, had helped him to better understand delirium, and to develop a proactive approach towards cognitive screening which carried over into his practice in potentially less delirium prevalent settings. I imagine that if I’d not come from a ward, a base ward, where there was very much a focus on cognitive screening, I think I would have had much more of a hit and miss approach to the deployment of cognitive screening and I wouldn’t have easily recognised its importance and prioritised doing it above other things for the patient.Junior doctor, ED, Avonfield 06 Several others indicated that their knowledge of delirium only developed into deeper understanding when they connected their theoretical learning with practical experience of patients with delirium and its effects on them. Thus:At medical school you are taught that delirium is a medical emergency, that it’s an acute medical problem that needs treatment straightaway. But as much as I understand the seriousness of it, I generally appreciate finding out the source of it. ….It’s more that this patient has delirium because they’ve got sepsis. I need to treat the sepsis, so that’s what worries me more to be honest…. So if I’m worried that…the patient is kind of disoriented to time and place, confused, then I’ll go down that avenue in terms of what I should be looking for in the collateral history.Junior doctor, ED, Avonfield 11Awareness of the significance of delirium therefore enhanced sensitivity to observational cues that might indicate potential delirium. Further, it translated into a line of exploration in history-taking and information gathering as part of the process of developing a differential diagnosis. The conception of understanding the significance of delirium as a factor in prioritising it to arrive at a differential diagnosis is further evident in the following account. Here, a junior doctor with interests in psychiatry and emergency medicine and a recent rotation in psychiatry described how he would elicit information from an older patient, among those ‘presenting an extra challenge’: I tend to ask open questions to start off with because you can just gauge whether the patient is completely oriented and knows what’s going on and if I’m worried that I don’t think that patient is kind of oriented to time and places, confused, then I’ll go down a completely different avenue in terms of what I’ll be looking for in the collateral history; if anybody’s with them at the time, and chatting to them about what’s happened. And I also tend to go through the AMT [cognitive assessment tool] with patients like that as well… it’s very difficult to know what’s new for them because sometimes you’ll turn around to the relatives and you’ll say, you know, “Is this a new amount of confusion do you think?” and they’ll be like, “I’m not really sure to be honest,” and...you have to treat it as it’s new…but trying to figure out a source of that confusion as well…And then depending on how well that patient is and whether there’s an obvious source and what their home circumstances are like, you know, sometimes you can get them back home with a course of antibiotics, other times you need to admit them because it’s not safe to send them home, given their kind of social support, and the fact that they’re just very confused. …More often than not I’ve ended up admitting people that have come in acutely confused, because they’ve just not been well enough to go home… and there’s been other issues like they’ve been tachycardic or hypotensive, and so they’ve needed to stay in clinically.Junior doctor, ED, Avonfield 07It is notable here that use of the terms ‘confusion’ or ‘acute confusion’ did not necessarily denote lack of knowledge of delirium. The terms in this context were employed as descriptive labels drawn from the patient’s history and observational cues which opened up lines of investigation to probe the source, which might conclude with a diagnosis of ‘probable delirium.’ Where such a cause was not evident, this was generally viewed as a reason for admission in both 4AT ‘virgin sites.I think anyone who’s acutely confused and that you haven’t … got an easily reversible cause… I think they would need admission really… Junior doctor, ED, Cranford 01And, I would imagine that a lot of patients with confusion get admitted and it’s left at a later point for people to work out if their confusion is new, the extent to which it’s new….I would think it’s difficult to arrange the speedy discharge of an A&E attender when you can’t clarify the history of confusion.Junior doctor, ED, Avonfield 06A key issue emerging from the findings from these 4AT ‘virgin’ sites i.e. where there was no systematic, routine delirium screening tool in use, including the 4AT, is that assigning value to delirium detection is at least partly contingent on experiential knowledge of delirium and its impact on patients, as well as learned knowledge. Professionals with such multi-level knowledge of delirium, we have characterised as ‘delirium knowledgeable’.It might be anticipated that routine use of a delirium screening tool would enhance delirium awareness, if not knowledge of delirium, which in turn would result in its more consistent detection. The relationship was appeared to be less straightforward, as suggested by interviewees in an ED setting within a 4AT ‘experienced’ site. Here, although the 4AT had been introduced into the ED more than a year previously, it was not currently in routine use in this setting. Delirium knowledge was described as patchy.So I think it’s still under-recognised…and you’ll maybe get a handover from triage that the patient’s agitated, or… they could be septic, that’s another term. So they might have a high temperature, and it’s only really picked up that they’re delirious I think if someone is familiar with the concept…and that’s usually after they’ve seen a doctor or an experienced nurse who’s maybe done some geriatric training. But even then it can slip through the net. Consultant, ED, Denbury 17‘Delirium knowledgeable’ staff, however were likely to ‘see’ behaviours as possible indicators of delirium, requiring further investigation. Similar to ‘delirium knowledgeable’ participants in the 4AT ‘virgin’ sites, it appeared that knowledge of delirium among some ED staff enhanced their sensitivity to indicators of probable delirium in taking a patient’s history. From the account below it is evident that the process of eliciting understanding involved a combination of strategic questioning, interpretation based on tacit knowledge of risk factors for delirium and experience and sensitivity to the meaning of observational cues. Within a few minutes of speaking to them, I’ll appreciate whether they’ve got an understanding as to where they are, why they’re here… their presenting complaint would be one for me… the story of their presentation would make me think. Before I go in to see somebody I often have a very quick look in their medical history. So anything there … that they’ve been in before with confusional states, they’ve had UTIs, they may already have a diagnosis of cognitive impairment. So I may have that information before even going to the room. And also just how I see them. What they look like as I’m approaching them… all of those little things would trigger in my head…what’s going on here… And I would note on the history ‘have you considered… [Delirium]; ‘does the patient need this’. But it would be the area the patient goes to for their management that should be the area that does the 4AT. Senior nurse, ED, Denbury 16Among ‘delirium’ knowledgeable staff, although the type of work involved in eliciting and noting the presence of delirium in the ED is described in this account, nevertheless systematic screening of delirium was viewed as problematic in this setting. To understand why this was the case, we consider the specific ED context and purpose.ED: Context, purpose and their impact on the value attached to delirium screeningContextual factors pertaining to the nature of the care environment in the ED were viewed as impinging on both the capacity and value attached to delirium screening and detection. These were of three broad types and operated across 4AT ‘virgin’ and ‘experienced’ sites: the fast pace of work (and rapid turnover of patients) within a short, delimited time period; the impact of the admission process on patients; and the purpose of the work in the ED. Pace of work in the EDAcross all sites, the pace of work was uniformly perceived as a barrier to delirium screening.The problem is that it’s such a rapid turnover there’s probably a lot of concern from staff that they don’t want to fill in another score sheet or another tool…I’ve had similar problems trying to institute scores for frailty …no one really wants to have more work to take on …it’s probably quite a short-sighted view …the scores we have on the triage sheet at the moment are vastly under-completed even for such questions as: ‘what’s the patient’s early warning score’ and ‘do you think the patient’s septic?’ Senior doctor, ED, Cranford 02Two specific features of the criticality of time in the ED were raised: the short time-frame for work with each patient to arrive at a decision about immediate action; and accessing relevant information to address key features of probable delirium, namely whether ‘confusion’ was of recent origin and fluctuating. Time in the ED to achieve purpose: decision-making on immediate action appropriate to the clinical presentation of the patient was short; within four hours to meet the performance target and manage the pressure of demand. Even a screening tool described as brief and concise, such as the 4AT, was considered impractical or at least not conceived of as a priority to complete in this context, as a nurse in the 4AT ‘experienced’ site indicated: It’s not consistently completed particularly on days like today, when you are extremely busy. It’s probably not one of the first things that you would prioritise… because of staffing more than anything… it’s not something that people automatically think about.Staff nurse, ED, Denbury 18This pattern was corroborated by interviewees working on the MAU and acute wards in this site who reported that the 4AT was rarely completed in respect of patients coming to them. Typically, documentation from ED comprised a patient history, acute presentation and differential diagnosis. Even so, staff acknowledged that an accurate assessment of cognitive impairment was difficult to secure in the ED environment on account of the impact of the admission and the event that gave rise to it (see below).A key feature of delirium is its fluctuating course and recent onset. Time and context in the ED was perceived as a barrier to accessing relevant information to address what is an apparently simple question. Thus: The acute…and fluctuating course … that’s so difficult in ED … when this is done, within four hours of them coming in. Unless we’ve got the family there or we know them well, I think that it’d be really difficult to get a judgement on that….unless you’ve got a really good history from someone else I don’t think you’d be able to… score that very accurately. Junior doctor, Care of older people ward, Denbury 13Impact of the admission process on patientsFeatures of delirium, for example ‘alertness’ were viewed as affected by time and context: the busy, dynamic environment making it difficult for patients to concentrate. It was also argued that the trauma attached to the event giving rise to admission meant that patients required reassurance and support, and ‘tests’ that were aimed at identifying deficits might add to the patient’s anxiety. For ‘delirium knowledgeable’ practitioners, reassuring conversations with patients employing ‘comforting’ strategies to alleviate distress could elicit understanding of cognitive impairment as part of a whole picture.I think when people come in and their either in pain or distressed or, you know, that they’ve had a journey by ambulance, they’re excited, they’re you know, upset by that… It’s a busy noisy department and so concentration possibly is an issue for patients. It’s probably not the best time …to be asking them to count backwards, or you know ‘tell me the numbers from’…We would all struggle with no cognitive impairment under those circumstances…So I do get that … just informally, chatting to them can give you quite a lot of information without putting them through the added sort of almost ‘examination’ stress, of doing a formalised test. Senior nurse, ED, Denbury 16The approach conveyed here offers a partial explanation of how ‘knowledgeable delirium practitioners’ are sensitive to, and take account of delirium risk as part of their overall assessment yet eschew use of a screening tool. Purpose of ED workSeveral participants described the ED as a ‘blank canvas’ insofar as the work was unpredictable. The primary purpose of the work was viewed as obtaining a differential diagnosis to inform decision-making on an immediate course of action within a designated timeframe. The process was conceived of as ‘layers of decision-making’: firstly, deciding if the patient was seriously ill; second, whether to admit or not, cognoscente of the gatekeeping function of ED; and third, whether a probable diagnosis fitted the overall patient picture. Prioritisation of delirium screening in this setting was influenced by its perceived value in contributing to such decision-making. Even where delirium detection in itself was valued, unless it influenced decision-making it might not be prioritised.The icing on the cake almost is where a diagnosis fits into that because you may not know precisely what the diagnosis is…you might have a list of differential diagnoses …so that for the person in front of you, you don't actually know what the cause of their problem is but you know that they can’t go home…Consultant, ED, Avonfield 01Across all sites, it was suggested that more consistent use of a screening tool (whether the 4AT or other tool) would be more likely to ensue if staff understood why it was important to do it, they could see tangible benefits for patients and if screening was seen to make a difference to patient outcomes in this particular setting. It's a good concept. The problem is that trying to change people’s behaviour is very difficult if they don't understand why they are doing something… What we kind of want to know, in the emergency department, is…if by doing this score are we making a difference? And, you know, how many, what effect is this having on patients dying or on saving patients from getting unnecessary treatment. Consultant, ED, Denbury 17Even so, assessment of benefit would likely involve consideration of the nature of the ED environment and the challenges of context and time within that setting. Additionally, we noted that experienced and ‘delirium aware’ ED staff considered delirium risk as a factor in their overall assessment, albeit this drew on pattern recognition through multiple sources of information including interpretation of observational cues. Non-delirium ‘aware’ staff, by contrast were unlikely to ‘see’ and interpret such information. Paradoxically, all other things being equal, knowledge of delirium in the ED context might obviate the value attached to the use of a screening tool; whilst lack of delirium knowledge similarly contributed to non-use of such a tool. Assessment Units: Medical Assessment Unit (MAU); Elderly/Frailty Assessment Unit (EAU); Surgical Assessment Unit (SAU)In contrast to the ED, there is a paucity of research on delirium prevalence and detection in Assessment Units. Generic assessment units are similar to EDs in that they manage demand and flow near the point of entry to the hospital within a relatively short timescale and with a diverse patient profile in age and clinical presentation. Dedicated assessment units for older people, however, although subject of the same time and pace pressures, are more likely to be staffed by those with interest and expertise in care of older people.AU: An observational snapshot These varied types of assessment unit operate at the next point of the patient journey from the ED. These are short-stay facilities (usually for between 24 and 48 hours or up to 72 hours) to enable further observation, investigations and decision-making in order to develop a management plan for the patient. The work here includes determining the most appropriate course of action and destination for patients: acute ward admission, discharge to an alternative setting (intermediate care, community hospital, hospital at home) or discharge home; and mobilising the necessary support and resources to achieve the intended outcome. Whereas assessment units within two hospital sites included dedicated units for older people or those with frailty (EAU); the third operated as a generic unit (MAU) within which patients with medical needs irrespective of age were accommodated. In one site, we included a surgical assessment unit (SAU).The physical environments of assessment units in the study had a similar layout to acute wards with varied combinations of male and female bays and single rooms; and a work station in which medical and nursing staff congregated, checking computers, working the phones, examining case notes. The rhythm of the daily routine was shaped by purpose: engagement in clinical observations and multiple investigations to determine destination outcome; and provision of medical, personal and emotional care for patients with variable levels of acute need. Both lines of work contributed to an intense, noisy, busy, and fast- paced care environment, albeit one that was typically somewhat less frenetic than that in the ED. An area of high patient flow, the impression of MAU/EAU was of continuous movement – of patients and staff – and a cacophony of sound. New patients were brought in on trolleys by porters; others sat, dressed by their beds waiting to be discharged; yet others were wheeled away to acute wards. Medical and nursing staff moved between patients and clinical stations variously carrying out examinations, ordering investigations, perusing results, conducting observations and eliciting relevant clinical and biographical information from patients. Nurses in particular spent considerable time on the telephone checking out information on medical history, service use and patient background with primary and community care professionals and family members. Ward rounds, several times daily, drew on these multiple sources of information, to achieve pace and flow. The orderliness of the process could be deceptive: conversations with individual patients were disrupted as staff were called away to respond to the sound of a buzzer, a patient calling out or a newly admitted patient needing to be settled in. The flow was such that a staff member down or a very ill patient could transform what might be construed as organised chaos into a chaotic care environment. In contrast to typical acute wards, patient movement in and through the setting continued through the night.The clinical rhythm was punctuated by the care regimen – mealtimes, physical care (washing, assistance with toileting, mobilising) and housekeeping tasks (bed-making, distributing drinks, cleaning). Here, Health Care Assistants (HCAs) moved quickly through the bays and rooms cleaning, turning, washing, toileting, serving meals and conversing with patients, creating multiple opportunities to notice slight changes in the patient’s condition, the communication of which relied on a verbal exchange with nursing or medical colleagues.There were similarities and differences in MAU organisation to achieve its clinical and service purpose compared to the ED. Similar to the ED was the temporal frame within which the work was organised, although it was over a longer period of time. Extending from 12 to 48 hours meant that the work encompassed tasks relating to personal care, bodywork and nurture (nutrition and hydration) as well as clinical observations, investigations and more detailed information gathering from diverse sources. Observation of patients over different times of the day and night, ongoing direct patient contact through care routines aligned with enhanced knowledge of the person’s usual state through the information-gathering process made assessment of ‘fluctuating’ and ‘new onset’ easier. AU: Knowledge and understanding of delirium and delirium detection MAULike their ED colleagues, members of the multi-disciplinary team within assessment units were required to draw on their knowledge of a wide range of conditions to pursue an investigatory strategy to develop and refine their diagnosis and implement a management plan for the patient. Importantly, and in contrast to the ED, the lengthier period for assessment meant that ascertaining relevant knowledge of the patients’ biography and medical history was more feasible, albeit time was also regarded as a scarce resource. Similar to the ED, some senior doctors in this setting conveyed a breadth of clinical experience through which they had acquired knowledge and understanding of delirium: they were ‘delirium knowledgeable’. Additionally, specific local initiatives which were directed at enhancing awareness of delirium among staff as in Cranford, had, it was suggested, improved delirium knowledge among MAU professionals.Nurses here are fairly switched on as far as delirium goes. We don’t have so many patients here as we do on elderly care who have fluctuating confusion, but we do get it here and nurses deal with it. I trust them.Senior doctor, MAU, Cranford 02In Denbury, implementation of the 4AT in the MAU was regarded as having enhanced awareness of delirium. This was symbolised in the language employed: explicit use of the term ‘delirium’ from ‘cognitively impaired’ or ‘not quite right’. Its introduction had been supported by a short information session on use and the significance of delirium. Nursing staff were designated as responsible for screening for delirium and completing the tool; the 4AT being incorporated as part of the nursing assessment. Even so, evident from interviews was that multi-level delirium knowledge among MAU staff on this site was variable. ‘Delirium knowledgeable’ interviewees in Denbury MAU described the process of identifying patients with probable delirium as similar to that proffered by delirium ‘knowledgeable’ participants in 4AT ‘virgin’ sites. Thus, it was seen to involve more than completing a score on the tool. It involved ‘empathic connection’ with the patient’s sense of distress and anxiety as a result of the event giving rise to the admission, history-taking in a ‘comforting’ conversational style to help relax the person and eliciting information ‘almost like a chat’ to ascertain whether the person might have a cognitive impairment. Discrepant accounts on the part of the patient were described as ‘red flags’, triggering questions such as: what is going on here? Is this normal? These also posed the need for further information gathering. Completion of the tool by these nurses in this context formalised what might in the past have been a comment to the doctor that the patient was ‘really confused but it isn’t normal for her’. They regarded screening for delirium as a necessary and legitimate part of the habitual work of assessment in MAU. A positive screen also directed and prescribed action: I would check what bloods have been done in Accident and Emergency and probably add a few more tests because we’re looking at a confusion screen…widening the screen …and should help get a diagnosis quicker [of possible infection] and work out the appropriate antibiotic.Staff nurse, MAU, Denbury 04Whereas delirium knowledge and its management enabled nursing staff to take the initiative and act on the results of screening, for others the perceived value of screening for patient care was not self-evident. This had a knowledge dimension: if staff did not understand the significance of delirium, they were less motivated to use the tool. It also had an action dimension: if the pathway from detection to action was unclear, sustaining engagement in screening could be compromised.I think there’s an assumption that we’ll just carry on with this person who has got known cognitive impairment and we’ll carry on observing it, which I suppose is what the 4AT is for… But what are we doing with it? … Are we doing anything about a known cognitive impairment when they’re scoring one to three? I don’t know.Staff Nurse, MAU, Denbury 08 Several nurses indicated that when under time constraints, they would prioritise specific assessments over the 4AT: skin/pressure assessments were specifically mentioned as being more visible indicators of performance and care quality. Whilst noting that they had used the delirium screening tool on only a few occasions, they also acknowledged that “others do it more often”. Yet others prefaced their accounts of use by reference to what ‘should be done’: it was what was expected of them. Variable knowledge of delirium and lack of clarity on the pathway from detection could affect consistency in use of the screening tool.SAUWe conducted the study in only one SAU; therefore the picture that emerged of a low level of understanding and awareness of delirium from comments of interviewees may not be typical of such units. Even so, it echoes accounts of the care of older people liaison team on orthopedic wards in Denbury. Within the SAU in Cranford, the delirium knowledge deficit was acknowledged by senior nursing staff, and viewed as problematic in light of the high level of risk among one group of their patients, namely older people with hip fracture. Even though information gathering did not include use of a screening tool for delirium, the nursing assessment pro-forma contained four questions relating to risk factors for delirium based on NICE Guidelines (current hip fracture; 65 years and over; cognitive impairment; and severe illness). For those at risk of delirium, a pro-forma delirium prevention care plan was to be completed (for example, action on hydration, nutrition, pain, medication review). Both were introduced to wards as part of a drive to increase awareness of delirium and delirium prevention (although without explanation, training or support in use). Interviewees here were unclear about how these risk factors were established and about the content and purpose of the delirium prevention plan. Unsurprisingly, they reported that the pro-forma was not completed on the unit. Supportive of the conception of delirium knowledge as enabling staff to ‘see’ the value of identifying delirium, a senior nurse welcomed the introduction of a short, easy to use tool like the 4AT but went on to suggest that in order to trigger use in this setting, staff needed to understand why they should invest in it and what action would be called forth as a consequence: It looks pretty user-friendly and that it won’t take too long to do which is the key, you know, ‘cos otherwise people just won’t do it. But then obviously we need to know why we’re doing it and what to do once they trigger a certain score as well.Senior nurse practitioner, SAU, Cranford 06EAU/Frailty UnitWithin EAUs/Frailty Units, staff presented as experienced and knowledgeable about the multiple needs of older people, including those arising from a cognitive impairment. Among their patients, delirium was common. Identifying, assessing and developing a management plan for those with delirium was conceived of as a routine part of their work albeit how this was accomplished differed between the two 4AT ‘virgin’ sites. In Cranford EAU, although the patient assessment form used did not include a delirium screening tool, it was commented that experience in caring for older people meant that ‘acute confusion’ was at the forefront of thinking and that any indication of inattention would sensitise staff to look for ‘reversible causes’. In this site, the perceived skill of staff in noting and making sense of changes in the patient contributed to the low value attached to screening tools: confidence in observation and reporting of changes meant that medical staff could proceed to assessment and investigation of factors contributing to delirium. Moreover, since the purpose of the setting was to develop a management plan, tools were indicative of a problem but the view was that they did not in themselves inform such a plan. As a geriatrician what you are doing is looking at the whole picture to inform the most appropriate management plan… you are using your observational skills as a doctor; you are also drawing on cues from staff from their knowledge of the patient. Nursing staff will also know – but they may not use the word ‘delirium’. They’ve observed that the patient has become more muddled, more confused as they’ve seen them on the ward; or the relative has said they are more confused now than they were at home. Consultant, EAU, Cranford 05In Avonfield, the AMT10 (a tool to identify cognitive impairment) was conducted with all patients as a case-finding tool for dementia with a flowchart to delineate action consequent on the outcome of the screen. Aligned with the collateral history, this was also used to identify a new, acute confusion. The rationale for this approach was the co-occurrence of delirium and dementia and to engage staff in thinking about the link between them.The pattern observed previously in ED, that understanding and knowledge of delirium meant that staff were more sensitive to picking up on observational cues that might for example indicate change in alertness and perceptual disturbances, was evident in both units. Understanding of risk factors and direct, routine involvement with patients meant that nursing and care staff were seen to play a crucial role in ascertaining if a patient did not seem to be ‘quite right’. Both doctors and nurses interviewed emphasised their joint and collaborative endeavour in identifying delirium: “they appreciate that it means something’s going on that needs investigating”. Medical staff were seen to note and act on the information communicated by nursing and care staff; the latter in turn felt valued and confident in communicating their observations in multi-disciplinary team meetings, in ward rounds and informally with medical colleagues.MAU/EAU: Context and purpose: impact on the value attached to delirium screeningTwo contextual features of the care environment that impacted on delirium screening and detection in MAU/EAU settings as in the ED were the pace of work and the perceived alignment of organisational purpose with delirium detection and assessment. Other features more specific to this setting were: the systems in place for integrating delirium detection into the care culture and the processes established to legitimise the contribution of different groups of staff. Pace of work A feature of MAU/EAU settings was that in comparison to the ED, staff had a longer and more sustained period of time in which to observe, collect collateral information and review patients’ progress. As patients were admitted at all times of the day and night, the constant busyness and noise of the unit was disturbing of those trying to rest or sleep. Among some staff, the continuous hum of activity and merging of day and night meant that it was a ‘bad environment’ in which to screen for delirium. Further, it was considered that patients would likely be disoriented and distressed, particularly those admitted during the night, both on account of the medical event which precipitated hospital admission and the admission itself. Generally, although the nature of the care environment in MAU might make it difficult to obtain an accurate baseline picture on which to determine delirium, the general consensus was that it did not create an insurmountable barrier. ?Systems for integrating delirium detection into routine practiceWithin the 4AT ‘experienced’ MAU setting, participants described the work engaged in to implement the 4AT into ward routines. It was incorporated into the Unitary Patient Record (UPR) which comprised multiple screening and assessment tools and was intended to be completed by nursing staff for all new admissions along with documentation of ‘care rounding’. The latter involved daily, regular interval review and documentation by nurses of skin/pressure areas, mobilisation, toileting, continence and catheter care hygiene, analgesia, pain, fluid balance and care plans. Direct, ongoing engagement of nursing (and care) staff with patients meant that they were seen as being well placed to observe change and fluctuations. A division of labour was in place such that nurses were responsible for completing the delirium screening tool and junior doctors conducted the cognitive assessments (Abbreviated Mental Test (AMT) and Mini-Mental State Examination (MMSE)) as part of the clerking process. There were aspects of the system to implement delirium screening in Denbury that were not universally regarded as meaningful. A senior nurse questioned the value of screening everyone who met specific age criteria. It should be more flexible and draw on tacit knowledge and expertise in respect of delirium risk: ‘use your head’. Thus, it was argued observation and conversation with patients should inform which patients were ‘at risk’ of delirium and therefore subject of screening. Such an approach was however predicated on in-depth knowledge of delirium and delirium risk.In our paperwork it says over 65 years…we’re trying to make it ‘use your head, basically. If they’re 55 but they’re ill enough that you’re concerned that they’ve got some sort of delirium/sepsis, use the tool… But the lady in bed [bed number], who is over 65, so technically we should be doing the 4AT. She’s all with it. She’s in for cardiac reasons. She’s no side-symptom of infection. And I just explained it to her by ‘it’s a screening tool we have for anyone over 65, do you mind?’, ‘no’, but she laughed all through it…. I was a bit embarrassed about her but … that’s the first time I kind of thought ‘why am I doing this?’Senior Nurse, MAU, Denbury 04Within a MAU context, responding to the heterogeneity of patient need across age groups and with multiple and varied presentations, posed particular issues for some staff with regard to use of the 4AT delirium screening tool. Highlighted was the way in which staff with knowledge of particular conditions employed their specific knowledge and skills as a lens to make sense of, or contextualise observational cues and behaviours. The extended narrative account below in respect of toxicology is illustrative of how the overall pattern of presentation confers meaning. It also suggests how practitioners may judge routine screening for patients as unnecessary without consideration of delirium risk or for whom alternative explanations for symptoms might be available drawing on knowledge and skills in a different field of medicine. For the younger age group you …look for the obvious first. If they’ve just drunk a bottle of vodka you’re looking at intoxication. What’s the chance of this person … having a delirious state before coming in? If there’s no history of it look at the obvious and deal with it from there…Or …if there’s a history of an on-going affective disorder or something else going on from a psychiatry point-of-view I would think psychiatry rather than a delirium. And if you get the history then it’s going to show up…. So the history taking is going to give you the indication. The 4AT is a bit of a snapshot when they arrive; you need a bit more of a history. So regarding the criterion: ‘has there been a kind of sudden onset?’ Well your history taking is going to show you that. So it’s part of it from there. But if you… get a 3 out of 4 on 4AT… is it going to change? And it’s just another number where you think ‘fine’, but that could be explained by the fact that they’ve just drank a huge amount of alcohol four hours ago. You’re giving yourself a reason why there’s a four. You don’t necessarily need to be think that… we’re looking at delirium; no, we’re looking at an intoxication.Senior nurse, MAU, Denbury 08Legitimising the contribution of different staff groupsAmong some nurses, the value of the standardised tool was two-fold. It gave credence to nursing observations and enabled the exercise of professional autonomy to pursue investigatory action, without deferring to medical colleagues to endorse it. Understanding of delirium in context of a perceived valued professional role in detection and action contributed to ownership of the process and sustained ongoing use. Screening, from this perspective was not simply a ‘tick-box’ exercise. It involved knowledge informed interpretation and decision making on the part of nursing staff. Others questioned whether medical colleagues accorded value to the work of nurses in the detection of delirium. If their work within the overall process of detection and action on delirium was neither understood nor accorded value, this could also inhibit sustained participation. Doctors aren’t coming to say ‘4AT, we’re acting on it, we’ve done this… And there’s not enough of: ‘what we are doing next, are we responding to a sepsis or are we responding to…’ It’s a multi-disciplinary team thing at the end of the day…. Staff nurse, MAU, Denbury 07Overall, delirium screening and assessment was viewed as consistent with the purpose of assessment units, namely to develop a patient management plan within a more extended timescale than available in the ED. Nevertheless, as evident from all sites knowledge of delirium affected the significance attached to delirium detection and assessment in formulating a plan of care. From accounts provided by ward staff interviewed, there were relatively high 4AT completion rates from MAU (reported as 60-70%). Factors contributing to variability included: uneven knowledge of delirium which negatively affected the value attached to identifying it, and uncertainty as to whether screening was followed by action and therefore accorded value by members of the multi-disciplinary team. Moreover, although the delirium screening tool appeared simple and an ‘objective’ indicator of probable delirium, interpretation of some items, such as ‘recent’ and ‘fluctuating’, were not regarded as straightforward; rather they made sense as part of an overall pattern in context. Similarly, presenting features that might indicate probable delirium, could, depending on the context, be interpreted as meaning something else.Acute WardsThe occurrence of delirium on acute wards varies with illness severity and the age profile of patients. This pattern is evident in a study that uniquely examined prevalence and incidence of delirium across acute wards in a large, tertiary hospital using a common suite of screening and diagnostic tools PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SeWFuPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA 117. Whereas an overall prevalence of 20.7% represented the burden of delirium in the hospital, this varied between wards, being highest among patients on medical, neurosurgical and orthopaedic wards and lowest in general surgical wards. Further those in advanced older age – 80 years and over had nearly 35% delirium prevalence – compared to around 5% among patients less than 50 years; and over half of patients with delirium had a pre-existing cognitive impairment. These findings underscore the significance of delirium detection and management as a major focus of clinical and care work on particular acute wards; the importance of detection and assessment of both delirium and cognitive impairment; and consideration of their reciprocal impact on treatment and recovery. Acute ward: An observational snapshotThe organisation of space in acute wards was not dissimilar to that of assessment units. There were varied combinations of 4- and 6- bed bays and single rooms, clinical areas, and differently sized staff working spaces. Policy initiatives in the UKPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EZXBhcnRtZW50IG9mIEhlYWx0aDwvQXV0aG9yPjxZZWFy

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ADDIN EN.CITE.DATA 118-120 have directed attention to the need for environmental changes on acute hospital wards to create easier navigable spaces for patients with a cognitive impairment. This has included colour coded bays and signage on toilets and bathrooms to help orient people with a cognitive impairment. Most care of older people wards in the study (but not other medical wards) had pursued such changes although their nature and extent varied considerably, for example, space for patients to engage in activities or interact socially with each other was very limited. Similar to assessment units, the daily rhythm of acute wards was shaped by purpose of the setting: clinical observations and dispensing of medication, ward rounds and multi-disciplinary team (MDT) meetings to develop and review treatment plans, progress, discharge readiness and destination; and provision of medical, personal and emotional care for patients with variable levels of acute need. The daily routine and tasks that comprised it had a similar shape and content on all study acute wards, although timing and degree of flexibility varied. The routine working day for ward staff began early: handover from the night to the day shift around 7am, followed by patient related tasks such as dispensing medication and assistance with personal care such as washing and toileting and organising and supporting patients with breakfast. Such tasks were often opportunities for conversations with patients and to develop knowledge about biography and preferences. The period following breakfast to late morning was a flurry of activity and cacophony of sounds as members of the ward team (therapists, doctors, nurses, care staff and ward clerk) and off-ward staff (phlebotomists, pharmacists and porters) went about their work. For nursing and care staff, work with individual patients was often interrupted as they responded to others buzzing for assistance or calling out in distress. Mid-day and the round of mealtimes, toileting and dispensing of medication resumed. On several wards, open visiting from late morning saw a trickle of visitors, often encouraged to assist their relative/friend with eating. On most, visiting times were scheduled for up to 2 hours from 2pm, and up to 2 hours from 6.30 pm. In practice, there was considerable flexibility: where patients were very ill, when visitors had come a distance, or had simply arrived early. The steady stream of visitors in the afternoon altered the ward rhythm as movement and noise emanated from patients and visitors. Their departure heralded repetition of routine tasks: meal, clinical observations, toileting and then visiting again. The exiting of visitors in the evening was the signal for commencing night work. Visiting times were often a period during which nurses sought out, or were approach by, relatives to give or elicit information. Formal handover from day to night staff reversed the sequence of the early morning: and another busy period of putting patients to bed, toileting, and medications began. For patients, dimming of the central lights in the bays signalled the days end, although movement within bays and between beds, bays and toilets continued into the night. In summary, the rhythm of acute wards in comparison to the ED and MAU appeared more orderly and less frenetic, although for staff there was no let-up in a round of activity that involved continuous movement. Nevertheless, there were opportunities within their daily routines for staff to observe and converse with patients and to develop knowledge about what was ‘normal’ for them in terms of presentation and behaviour. Acute wards: Knowledge and understanding of delirium From the findings relating to the ED and MAU, one would anticipate that awareness and knowledge of delirium and the value attached to identifying it would vary greatly depending on the ward patient profile. This was broadly substantiated albeit depth of knowledge of delirium among staff on care of older people wards was also variable.Care of older people wardsAs noted earlier, delirium and dementia often co-occur in older patients and the prevalence of delirium on care of older people wards is high. Most of the wards in the study were care of older people wards. Although medical and nursing staff on these wards had experience of ‘seeing’ and responding to patients with both delirium and delirium on dementia, knowledge of delirium embraced the spectrum from ‘limited’ or ‘general awareness’ to ‘delirium knowledgeable’ as characterised above, namely in-depth understanding of its heterogeneous presentation, trajectory, distress caused to patients and anxiety of relatives. The 4AT ‘virgin’ care of older people wards in this study were in some respects atypical of care of older people wards generally in their knowledge of delirium and in the value attached to identifying and managing it. The Avonfield ward was designated for patients with dementia and delirium; and the Cranford ward had been involved in research on delirium prevention. On both wards, knowledge of delirium and the significance attached to it were viewed as sensitising staff to observable signs of change. Thus: The wards I work on staff understand the value of identifying delirium…they appreciate that it means something’s going on that needs assessing…and even hypoactive delirium, you know, they notice if someone’s not waking up for them and taking their medication … they do pick it up and I feel they do know to act on it…Consultant, Frailty Assessment Unit and Care of older people ward, Avonfield 02The close working environment and frequent interaction between staff, patients and caregivers, were seen as enabling staff to develop a shared understanding of what was ‘normal’ for the patient and to work with the patient as a person: I think perhaps in terms of a general experience point of view I suppose it is good to have because I don’t know where else you’d get this experience because [delirium] is a common problem, especially in older people….you are treating the patient as a whole rather than just the illness that they’ve come in with which is good. Junior doctor, Care of older people ward, Avonfield 05Healthcare assistants (HCAs), nurses, doctors and therapists conveyed a deep understanding of people with a cognitive impairment. There was an expectation on nursing and care staff that they spend time with patients and acquire personally meaningful knowledge of them as individuals. You get to know your patients when they’re not right: ‘oh Elsie’s not right today…she’s sleeping more than usual…not communicating as she would normally…we spend a lot of time with patients so we notice changes when you’re washing or bed-bathing the person…and because everybody’s different…it’s really important that you know the person as an individual and what they’re like on a daily basis…we talk about those changes at handover.Health support worker, Care of older people ward, Avonfield 09Personally meaningful knowledge acquired by HCAs through their direct contact with patients was valued, communicated, listened to and shared in multi-disciplinary fora.In care of older people 4AT ‘experienced’ wards, nursing staff reported that the introduction of local guidelines for delirium aligned with organisational impetus on screening with 4AT implementation had brought delirium further to the front of awareness; and that this was in context of a pre-existing knowledge gap. Thus:Interviewer: …what sort of training have you had in the past on delirium? Interviewee: [shakes head]…none [then goes on] …I have looked at information websites for myself…and there has been a big drive on delirium just now in the hospital as well as a sepsis drive, to increase detection of delirium and get us to distinguish between delirium and dementia…Staff nurse, Care of older people ward, Denbury 02Knowledge of the significance of delirium conferred priority on detection and action. …the recognition of delirium is crucial ‘cos it’s like any acute medical condition it needs to be addressed as importantly as you would do the rest, the heart attack or anything else…we’re all getting better at identifying it earlier…and there’s quite a focus on it in care of older people…now it should impact their medical care, their nursing care and whether they will have the ability to engage with physio or OT so it has to be part of reviewing their progress or their medical condition…Clinical fellow, Care of older people ward, Denbury 09Awareness of delirium, it was suggested, meant that ‘problem’ behaviour of patients ‘kicking, spitting, and aggressive’ was understandable in context of the condition, facilitating empathic connection with the patient as a person.It makes it, in your head, more acceptable, because you know that [normally] they would never act that way, they wouldn’t…Staff nurse, Care of older people ward, Denbury 21The level of awareness and attention on delirium on care of older people wards was in marked contrast to that reported among staff in other medical and surgical wards. Junior doctors in particular from their experience of multiple rotations in various surgical and medical specialties offered a wide comparative perspective. The prevalence of delirium (or cognitive impairment) on specific surgical wards, as for example cardiothoracic, was viewed as very low in comparison with care of older people wards. The profile of patients (younger) and clinical purpose (mainly elective procedures) suggested low risk, seen to explain why neither cognitive nor delirium screening appeared on clerk-in sheets, also justified on the basis of very low prevalence. On orthopedic wards, high prevalence of delirium among sub-groups of patients, particularly older people with hip fracture had been addressed via a liaison care of older people team to provide support for these patients. Although working closely with nurses and junior doctors on these wards, a division of labour existed such that there was little involvement with senior surgical staff whose focus was on surgical aspects of treatment and care. From a comparative perspective, then, staff on care of older people wards had heightened awareness of delirium given their exposure to patients at risk of, and experiencing delirium. Moreover, nursing and care staff were in a powerful position to note change in patients on account of more direct and prolonged contact with them. Description of practice, however, revealed uncertainty among some staff as to what to do as a consequence of identifying delirium in this setting.Acute wards: Context and purpose: impact on the value attached to delirium screeningThe features of context in respect of the acute ward that operated as barriers to, or were facilitative of, delirium detection, were: systems for integrating delirium detection into routine care management and inter-disciplinary working practices legitimising the contribution of different groups of staff. These were in turn aligned with the primary purpose of work in acute ward settings, namely to provide treatment and care to effect recovery and appropriate discharge in conditions where risk of cognitive impairment including delirium, was high among patients. Systems for integrating delirium identification into care management in routine practiceOur study was focused on delirium detection. What emerged from interviews with staff on care of older people acute wards was that there was an intimate relationship between knowledge of delirium, the value attached to detection and the processes in place for the subsequent management of patients with delirium. In Denbury, study participants came from three different care of older people wards. From staff interviews in each ward, there was some ambiguity as to which professionals were responsible for detecting new cases of delirium and the use of the 4AT in that process; how detection impacted the management of patients identified with delirium, including those for whom a positive screen had been completed in MAU; and what systems were in place to review recovery from delirium. It is possible that the disparate findings reflect the fact that interviews took place during the period in which considerable movement of staff was happening: junior medical staff had just begun their new rotation, which also coincided with the recruitment and induction of nurses into the department. Thus, findings may pertain to local, temporal features of care delivery. Even so, they pose organisational issues relevant to embedding new practices on delirium into work routines. Delirium detection: division of labour or disconnection?There was consensus among junior doctors interviewed from Denbury care of older people wards, that as part of the clerking-in process, it was their responsibility to ensure that a cognitive assessment was conducted, typically using the AMT10 tool. The 4AT on the other hand was for nurses to complete, consistent with the system operating on the MAU. From the doctors perspective, their cognitive assessments informed a plan of treatment which was then reviewed by a senior doctor in which ‘it's the AMT we refer to’. The 4AT, on the other hand, was in the nursing profile (on their assumption that it was completed by nursing staff) and not something to which they would refer or look at: Whereas the AMT because it’s in our…booklet…that is what we look at…the medical team don't use the 4AT very much...I don't think many people would go into the nursing notes to find the 4AT score…I’ve never had one of the nurses flag the 4AT score to me. They might flag that they think the patient is confused…I’ve never had anybody say: ‘oh we’re worried about…and this was their score’.Junior doctor, Care of older people ward, Denbury 03Among doctors, the rationale for use of the AMT10 was two-fold: it was the preferred tool on the wards and on their clerking-in checklist; and it was familiar: “I know it by heart; I don't need to refer to it”. The 4AT on the other hand was unfamiliar and the meaning of the score as representation of the patient’s presentation was not obvious. Generally, the picture conveyed by nursing staff was that if the 4AT was completed on MAU, it was not repeated on admission to the ward; only in its absence would it be done on ward admission. 'Delirium knowledgeable’ nurses emphasised their reliance on behavioural cues that might indicate change and a probable new episode of delirium; the formal system for delirium detection with the 4AT did not feature. I think the nurses would go to the doctors…and say ‘we think’ or during a ward round …or one of the rapid rundowns we would say: ‘overnight this…[happened]…’what do you think, we’ve sent urine…blood’. A lot of the time we do take the initiative…if we think there’s an infective source.Staff nurse, Care of older people ward, Denbury 02These nurses would take the initiative in pursuing investigations to seek out the source of the observed changes, drawing on tacit knowledge, “deep down you can distinguish delirium from dementia”, and on learned and experience-based knowledge: they did not wait for medical endorsement of the decision to act.Among staff generally, it was reported that serial use of the 4AT did not occur, or even that it was appropriate: It’s almost by the time [the patient gets to the ward] I suspect we’ve already got all the information that a 4AT would capture and so we should be doing more than just a 4AT…it gives us a baseline…then it’s not just screening … it becomes an investigation doesn’t it?... Occupational therapist, Care of older people ward, Denbury 22Among some senior doctors, the interface between detection and management of patients with delirium posed challenges that required further work to address: I think everybody should be screened, but then it’s knowing what to do after the screening tests, and how to do it… it’s then the follow-up, and I think that’s what we struggle with …that's a general problem [not unique to us]. We should reassess things …[some patients with delirium] might well have an undiagnosed dementia that we can’t diagnose yet because they’ve got delirium… and for [new cases] is a different approach needed? Consultant, Care of older people ward, Denbury 15Integrating detection with the work of managementIn MAU, the purpose of delirium detection using the 4AT was broadly understood by staff, and there were systems in place to include it within the nursing UPR, thereby establishing clear lines of accountability for completing it as part of the nursing assessment. By contrast, ward nursing staff conveyed considerable uncertainty as to the purpose of the 4AT in this setting. Although it was included in the nursing assessment, medical staff assumed the lead in assessing cognitive impairment and forming an action plan in relation to it and nursing staff seen to provide a supporting role in feeding back observational cues that might be indicative of delirium. Senior staff on Denbury wards referred to routine multi-disciplinary team meetings (MDT) as arenas through which progress of recovery from an episode of delirium was discussed and new cases of delirium identified. This included decision-making on whether a patient was safe enough to move to another ward or to engage with rehabilitation or for the team to assess the person’s progress with recovery. They saw nursing staff as playing a critical role in such decision-making as a consequence of their more direct and ongoing interaction with patients. Even so, for nurses, the question posed was where the tool fitted into routine practice. Aspects of how the work of delirium management was accomplished on Avonfield care of older people ward are also illustrative of how integration of delirium detection and management and co-ordination of inter-disciplinary work practices. Similar to Denbury wards, delirium was initially identified within the EAU, using the AMT10. People with delirium then underwent routine investigations to examine aetiology. As part of the process of admission to the ward, a joint treatment plan was discussed within the MDT. The ward care culture prioritised spending time with patients, also drawing on families’ own knowledge of the person and engaging in practices which were regarded as the ‘good nursing aspects of delirium management’. These included such non-pharmacological strategies as attention to hydration and nutrition, sleep hygiene, mobilising patients and stimulation. Nursing and care staff reported that knowledge of patients, aligned with understanding of delirium meant that they were sensitive to what was ‘normal’ for the person, communicating observations formally and informally through such forums as MDTs and handovers. Person-knowledge informed how staff worked with patients to effect a calm and supportive environment:Some of our patients with delirium we have to provide one-to-one nursing which makes it difficult for the rest of the ward ‘cos that takes one whole person off the ward team … so a patient we had recently, he just wanted you to walk around and hold his hand all the time, otherwise, you know, he’d get distressed or fall or something, so it was doing that. Or it’s observing somebody from a bit of a distance ‘cos some patients get overwhelmed if somebody’s with them all the time. It’s just like I say, it’s just assessing each patient individually.Senior nurse, Care of older people ward, Avonfield 08Ongoing review of progress in relation to treatment plans, supported through systematic observation of patients’ emotional, behavioural and relational action and interaction and involvement of families, contributed to evaluation of progress. The work was conceived of as a joint and shared enterprise involving all members of the multi-disciplinary team. It was the consistency in the way in which joint work was pursued that reinforced the sense of value in each other’s particular disciplinary expertise. DiscussionThe novel features of this study were firstly, exploration of the relationship between knowledge of delirium among health professionals, the value attached to detecting it, and practices engaged in to identify and manage it; and secondly, examination of how knowledge and practice relating to delirium plays out at different points in the patient journey into and through the acute hospital. Although current evidence from systematic reviewsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYXJyb248L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 99-105 reports attitudes to, and knowledge about delirium among nurses in various acute wards, there is a paucity of studies that have addressed how knowledge is distributed between settings and professionals and how organisational context shapes the value attached to delirium screening and practices.Multi-level knowledge of deliriumKnowledge and understanding of the significance of delirium, including its impact on patient distress and outcomes, were critical to the engagement of staff in delirium detection. Across all settings, delirium detection and the value attached to it were contingent on a particular type of knowledge held by professionals. This was more than ‘awareness’ of the syndrome, including its diagnostic features. Although important, such awareness was insufficient for staff to invest time and effort to systematically carry out the work of identification and action in relation to it. Also required was more in-depth knowledge of how delirium impacted on patients, the distress that ensued as a consequence of the delirium and its immediate and longer term effects on clinical and service outcomes. Acquisition of this multi-level knowledge meant that staff were able to recognise particular constellations of factors in the patient situation which made them think of delirium. This tacit knowledge aligned with the clinical presentation, sensitised professionals to note and interpret observational cues to construct a clinical picture. This was build up collaboratively employing a comprehensive investigatory approach combining observational cues, patient assessments, collateral history, medical notes and nursing observations, in a process referred to elsewhere as horizontal and not vertical use of expertise. ADDIN EN.CITE <EndNote><Cite><Author>Teodorczuk</Author><Year>2015</Year><RecNum>3661</RecNum><DisplayText><style face="superscript">37</style></DisplayText><record><rec-number>3661</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505822393">3661</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Teodorczuk, A.</author><author>Mukaetova-Ladinska, E.</author><author>Corbett, S.</author><author>Welfare, M.</author></authors></contributors><auth-address>School of Medical Education, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK, Andrew.Teodorczuk@ncl.ac.uk.</auth-address><titles><title>Deconstructing dementia and delirium hospital practice: using cultural historical activity theory to inform education approaches</title><secondary-title>Adv Health Sci Educ Theory Pract</secondary-title></titles><periodical><full-title>Adv Health Sci Educ Theory Pract</full-title></periodical><pages>745-64</pages><volume>20</volume><number>3</number><keywords><keyword>*Delirium</keyword><keyword>*Dementia</keyword><keyword>England</keyword><keyword>Female</keyword><keyword>Focus Groups</keyword><keyword>Health Personnel/education</keyword><keyword>*Hospitalization</keyword><keyword>Humans</keyword><keyword>Interviews as Topic</keyword><keyword>Male</keyword><keyword>Quality of Health Care</keyword></keywords><dates><year>2015</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1573-1677 (Electronic)1382-4996 (Linking)</isbn><accession-num>25354660</accession-num><urls><related-urls><url> The significance of multi-level knowledge is reinforced from studies of the experiences of people with delirium and the staff caring for them. In a synthesis of qualitative studies of patients and nurses experiences of delirium, ADDIN EN.CITE <EndNote><Cite><Author>Belanger</Author><Year>2011</Year><RecNum>3666</RecNum><DisplayText><style face="superscript">98</style></DisplayText><record><rec-number>3666</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1513153725">3666</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Belanger, L.</author><author>Ducharme, F.</author></authors></contributors><auth-address>University of Montreal, Chemin Queen-Mary, Quebec, Canada. louise.belanger.2@umontreal.ca</auth-address><titles><title>Patients' and nurses' experiences of delirium: a review of qualitative studies</title><secondary-title>Nurs Crit Care</secondary-title></titles><periodical><full-title>Nurs Crit Care</full-title></periodical><pages>303-15</pages><volume>16</volume><number>6</number><keywords><keyword>Adult</keyword><keyword>Critical Care</keyword><keyword>Delirium/*nursing/*psychology</keyword><keyword>Geriatric Nursing</keyword><keyword>Humans</keyword><keyword>*Nurse-Patient Relations</keyword><keyword>Qualitative Research</keyword></keywords><dates><year>2011</year><pub-dates><date>Nov-Dec</date></pub-dates></dates><isbn>1478-5153 (Electronic)1362-1017 (Linking)</isbn><accession-num>21999421</accession-num><urls><related-urls><url> the authors concluded that patients who had suffered delirium experienced safety and comfort from being understood, supported, believed and responded to with reassurance and care and were able to distinguish the quality of care delivery from how they were acted on, spoken to and touched. 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ADDIN EN.CITE.DATA 98, 99, 101-106 have emphasised the importance of staff attitudes and responsiveness to the emotional needs of patients with delirium. We found that the introduction of an easy to use screening tool had potential to raise awareness of delirium, when accompanied by learning and changes to, or modification of existing systems for information gathering, for example, inclusion of the tool as an integral component of the assessment process. However, insofar as delirium knowledge remained patchy, the outcomes poorly understood and the benefits of detection not visible to practitioners, the practice of delirium detection was inconsistent given competing demands of the setting, findings echoed in other studies.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UZW9kb3JjenVrPC9BdXRob3I+PFllYXI+MjAxNTwvWWVh

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ADDIN EN.CITE.DATA 37, 38, 99, 101-106, 109 Thus, van den Steeg et alPEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gZGUgU3RlZWc8L0F1dGhvcj48WWVhcj4yMDE0PC9Z

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ADDIN EN.CITE.DATA 109 concluded that poor delirium knowledge and skills among nurses acted as barriers to delirium guidance adherence, including systematic use of a risk screening instrument. Problems of adherence in turn undermined belief in the benefits and goals of screening; the consequence was that nurses viewed screening as simply another form, completion of which took time away from patient care delivery. Health professionals (irrespective of role) with extensive clinical experience and/or exposure to delirium risk patients, and those with expertise in the care of people with a cognitive impairment, were more likely to understand the significance of delirium detection, be sensitive to observational indicators of ‘something not being quite right,’ and pursue lines of information gathering, investigation and interpretation to make sense of symptom patterns. Such ‘delirium knowledgeable’ clinicians spanned professional disciplines. They were commonly found among those with extensive clinical experience and/or with specific skill and expertise in the care of older people, and had additionally made the connection between the diagnostic features of delirium and its significance for patient outcomes. ‘Delirium knowledgeable’ nurses, for example, would initiate diagnostic investigations to ascertain the source of delirium without deferring to medical staff. That ‘delirium knowledgeable’ practitioners were found across settings provides partial explanation of variability in identifying and responding to delirium. The paradox was that for ‘delirium knowledgeable’ practitioners in some settings, the value of a screening tool as an aide memoire for practice was seen as unnecessary, although among ‘delirium knowledgeable’ nurses in the 4AT ‘experienced’ site, the tool reinforced their expertise vis a vis medical staff.Service delivery context, purpose and value attached to delirium screeningThe second feature of the study findings relates to how delirium knowledge and practice played out at different points in the patient journey into and through the acute hospital. The value and priority attached to delirium detection varied with clinical purpose and organisational context. Within an ED environment, the purpose of the setting – obtaining a differential diagnosis to inform decision-making on an immediate course of action within a very short timeframe – did not make formal delirium detection salient at this point in the patient journey. The question posed by ‘delirium knowledgeable’ practitioners was whether systematic detection of delirium in this context with its attendant problems (difficulty of ascertaining a baseline picture; time constraints; and pace and flow pressures) would make a difference to patient outcomes? On the one hand, ‘delirium knowledgeable’ clinicians described their approach to practice as being sensitive to observational signs of ‘acute confusion, then engaging in a comprehensive assessment process drawing on multiple sources of information to guide investigations and action, suggested that there was value in this work. Action for example on identifying and responding to infection as a cause of delirium meant that treatment could be speedily initiated with benefit for patients. More problematic was introducing a detection tool for all patients meeting specific criteria (for example, age). It was notable that although the 4AT had been introduced into the ED in Denbury some time prior to this study, the consensus, not just from ED interviewees but from staff in MAU and wards, was that it was no longer completed. Knowledge and purpose then were key factors in variability of delirium recognition in the ED. Although some contextual features of MAU settings were conceived of as barriers to delirium detection, it was generally agreed that identifying delirium was consistent with their organisational and clinical purpose: to enable further observation, investigations and decision-making to develop a management plan for the patient. Here too, knowledge and understanding of delirium were critical in engaging staff in the work of delirium detection, creating the conditions for staff to invest in it. Even so, organisational factors including systems for integrating detection in routine care delivery; attention on mechanisms for legitimising and valuing the role and contributions of different professionals; and clarity about how delirium detection informed treatment and care, were also necessary to embed delirium detection in care routines. Critical also was that the outcomes of investigations and determination of actions arising out of them were clearly communicated to those charged with the task of carrying them through at the next point in the patient journey. The ward was the main site for both ongoing management of patients with delirium and for identifying new cases. In high delirium prevalence settings, such as care of older people wards, staff were more aware of and knowledgeable about delirium. Junior doctors, nursing and care staff reported greater awareness of delirium than colleagues in other medical and surgical wards; they also conveyed greater consistency in their understanding of delirium and ability to distinguish it from dementia, a commonly cited reason for under-detection. Even so, practice in managing delirium was variable. From this study as from other research,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UZW9kb3JjenVrPC9BdXRob3I+PFllYXI+MjAxNTwvWWVh

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AG==

ADDIN EN.CITE.DATA 37, 38 critical to the integration of delirium detection and management on acute wards, in addition to multi-level knowledge of delirium were: working practices that placed value on person-centred approaches with patients and acknowledged the expertise of different groups of staff, and systems in place for coordinating, evaluating, communicating and sharing progress on recovery. Our findings do not offer grounds for complacency as evidence from other studies attests.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Hb2RmcmV5PC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48

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ADDIN EN.CITE.DATA 100, 101, 106 Person-centred approaches to practice in respect of people on acute wards living with dementia (and delirium) are the exception and not the norm, as reported in national audits carried out in NHS hospitals in England. ADDIN EN.CITE <EndNote><Cite><Author>Royal College of Psychiatrists</Author><Year>2011</Year><RecNum>3693</RecNum><DisplayText><style face="superscript">121, 122</style></DisplayText><record><rec-number>3693</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1513172307">3693</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Royal College of Psychiatrists,</author></authors></contributors><titles><title>Report of the National Audit of Dementia Care in general hospitals</title></titles><dates><year>2011</year></dates><pub-location>London</pub-location><publisher>Royal College of Psychiatrists</publisher><urls></urls></record></Cite><Cite><Author>Young</Author><Year>2013</Year><RecNum>3101</RecNum><record><rec-number>3101</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">3101</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Young, J.</author><author>Hood, C.</author><author>Gandesha, A.</author><author>Souza R</author></authors></contributors><titles><title>National Audit of Dementia Care in General Hospitals 2012-2013: Second round audit report and update.</title></titles><dates><year>2013</year></dates><pub-location>London</pub-location><publisher>HQIP</publisher><urls></urls></record></Cite></EndNote>121, 122 A recent study of practice in respect of people with a cognitive impairment on ten care of older people and orthogeriatric wards in hospitals in three English regions ADDIN EN.CITE <EndNote><Cite><Author>Godfrey</Author><Year>in press</Year><RecNum>3695</RecNum><DisplayText><style face="superscript">123</style></DisplayText><record><rec-number>3695</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1513173546">3695</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Godfrey, M.; Young, J.; Shannon, R.; Skingley, A; Woolley, R,; Arrojo, F.</author></authors></contributors><titles><title>A multi-site evaluation of the Person, Interactions & Environment Programme (PIE) to improve person-centred care for people with dementia admitted to hospital wards. </title><secondary-title>NIHR Journals Library</secondary-title></titles><periodical><full-title>NIHR Journals Library</full-title></periodical><dates><year>in press</year></dates><urls></urls></record></Cite></EndNote>123 found that knowledge and understanding of delirium was variable and that consistent collection of data on delirium only occurred on a minority of wards where staff had both knowledge of delirium and valued ongoing assessment and review as a means to effect and evaluate better management of it. It is perhaps surprising given the co-occurrence of delirium and dementia that policy emphasis on dementia in the UK ADDIN EN.CITE <EndNote><Cite><Author>NHS Wales</Author><Year>2010.</Year><RecNum>3691</RecNum><DisplayText><style face="superscript">119-121</style></DisplayText><record><rec-number>3691</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1513171819">3691</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>NHS Wales,</author></authors></contributors><titles><title>1000 Lives +: Improving Dementia Care.</title></titles><number>1 Dec 2017</number><dates><year>2010.</year></dates><urls><related-urls><url>1000livesplus.wales.nhs.uk/mh-dementia. </url></related-urls></urls><access-date>10 July 2016</access-date></record></Cite><Cite><Author>Scottish Government</Author><RecNum>3692</RecNum><record><rec-number>3692</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1513172025">3692</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Scottish Government,</author></authors></contributors><titles><title>Scotland’s National Dementia Strategy 2013-2016</title></titles><number>10 July 2016.</number><dates></dates><urls><related-urls><url><style face="normal" font="default" size="11"> . </style></url></related-urls></urls></record></Cite><Cite><Author>Royal College of Psychiatrists</Author><Year>2011</Year><RecNum>3693</RecNum><record><rec-number>3693</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1513172307">3693</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Royal College of Psychiatrists,</author></authors></contributors><titles><title>Report of the National Audit of Dementia Care in general hospitals</title></titles><dates><year>2011</year></dates><pub-location>London</pub-location><publisher>Royal College of Psychiatrists</publisher><urls></urls></record></Cite></EndNote>119-121 and reflected in performance targets relating to it, has not also accorded more visibility to delirium. Across all sites and settings professional roles and expertise shaped knowledge and action, although the purpose of the setting and inter-disciplinary practice were also key. Generally, medical staff assumed primary responsibility for diagnostics and overall treatment planning but nursing and care staff played a pivotal role in noting and communicating change in patients and in pursuing work practices implicated in non-pharmacological delirium prevention and management interventions. In this respect, inter-disciplinary working practices contributed to the establishment of a culture of care in which delirium detection and management were integrated into the broader work of supporting patients with a cognitive impairment in acute care.LimitationsThis was an exploratory study and its limitations should be acknowledged. It was performed in three sites only; the number of interviews conducted in each site was small; as was the number of interviewees drawn from different organisational settings across the patient journey from ED through to the ward. At ward level, the majority of those interviewed worked in care of older people wards. Thus, the findings are likely to overstate engagement of staff in delirium screening compared to wards in which knowledge and salience of delirium was low. At the level of assessment units, the study revealed different forms of service organisation from generic units to surgical units to designated units for older people and those with frailty. In the context of this study, although the findings are suggestive of how different organisational cultures shape the salience attached to delirium detection and practice, the full import of these different organisational forms on strategies to improve practice, require further systematic exploration. Conclusions and implicationsFrom this study, it is helpful to consider improvement in the identification and care of people with delirium as involving several interacting layers. At the individual level, multi-level knowledge of delirium creates the conditions in which delirium detection and action in relation to it is understood as meaningful and invested in, with regard to the time and skill to engage with it. The second layer refers to the existence of systems, mechanisms and processes to collectively engage and co-ordinate the work of different groups of staff to implement and sustain delirium detection and management in routine practice. This includes appropriate tools for identification of delirium. The third layer relates to the organisational purpose of the setting, namely how far and to what extent can work practices and the division of labour through which these are carried out be modified or adapted to enhance delirium detection and achieve clinical and organisational outcomes. This poses a particular challenge for the ED. Considerable further research is needed to address these multiple challenges.Diagnostic Accuracy of the 4AT IntroductionIt is essential that delirium, and any cognitive impairment (e.g. due to dementia, depression or learning disability) is detected early, to allow identification and management of any underlying conditions, ADDIN EN.CITE <EndNote><Cite><Author>Adunsky</Author><Year>2002</Year><RecNum>2196</RecNum><DisplayText><style face="superscript">27</style></DisplayText><record><rec-number>2196</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">2196</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Adunsky, A.</author><author>Levy, R.</author><author>Mizrahi, E.</author><author>Arad, M.</author></authors></contributors><auth-address>Department of Orthopedic-Geriatric Medicine, Bitan 38, Sheba Medical Center, Tel Hashomer 52621, Israel. eadunsky@</auth-address><titles><title>Exposure to opioid analgesia in cognitively impaired and delirious elderly hip fracture patients</title><secondary-title>Arch Gerontol Geriatr</secondary-title><alt-title>Archives of gerontology and geriatrics</alt-title></titles><periodical><full-title>Arch Gerontol Geriatr</full-title></periodical><alt-periodical><full-title>Archives of Gerontology and Geriatrics</full-title><abbr-1>Arch. Gerontol. Geriatr.</abbr-1></alt-periodical><pages>245-51</pages><volume>35</volume><number>3</number><edition>2004/02/07</edition><dates><year>2002</year><pub-dates><date>Nov-Dec</date></pub-dates></dates><isbn>0167-4943 (Print)0167-4943 (Linking)</isbn><accession-num>14764363</accession-num><urls><related-urls><url> to ensure appropriate care pathways are followed, capacity is reviewed, and families and legal guardians are kept informed. At least two-thirds of cases are missed in Emergency Department and general medical settings.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db2xsaW5zPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48

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ADDIN EN.CITE.DATA 7, 31, 32, 124 There are multiple general reasons underlying this including inadequate education and training, lack of a culture that facilitates delirium detection, time constraints and so on. However, another key reason may be the lack of a very rapid, simple, validated assessment tool there is usable without specific training. ADDIN EN.CITE <EndNote><Cite><Author>Davis</Author><Year>2009</Year><RecNum>3285</RecNum><DisplayText><style face="superscript">34</style></DisplayText><record><rec-number>3285</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1422608685">3285</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Davis, D</author><author>MacLullich, A</author></authors></contributors><titles><title>Understanding barriers to delirium care: a multicentre survey of knowledge and attitudes amongst UK junior doctors</title><secondary-title>Age and Ageing</secondary-title></titles><periodical><full-title>Age and Ageing</full-title></periodical><pages>559-563</pages><volume>38</volume><number>5</number><num-vols>0002-0729</num-vols><dates><year>2009</year><pub-dates><date>SEP 2009</date></pub-dates></dates><accession-num>WOS:000269193800014</accession-num><urls></urls><electronic-resource-num>10.1093/ageing/afp099</electronic-resource-num></record></Cite></EndNote>34The short Confusion Assessment Method (CAM) ADDIN EN.CITE <EndNote><Cite><Author>Inouye</Author><Year>1990</Year><RecNum>2763</RecNum><DisplayText><style face="superscript">125</style></DisplayText><record><rec-number>2763</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">2763</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Inouye, S. K.</author><author>van Dyck, C. H.</author><author>Alessi, C. A.</author><author>Balkin, S.</author><author>Siegal, A. P.</author><author>Horwitz, R. I.</author></authors></contributors><auth-address>Yale University School of Medicine, New Haven, Connecticut.</auth-address><titles><title>Clarifying confusion: the confusion assessment method. A new method for detection of delirium</title><secondary-title>Ann Intern Med</secondary-title></titles><periodical><full-title>Ann Intern Med</full-title><abbr-1>Annals of internal medicine</abbr-1></periodical><pages>941-8</pages><volume>113</volume><number>12</number><edition>1990/12/15</edition><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Algorithms</keyword><keyword>Confusion/*diagnosis</keyword><keyword>Delirium/*diagnosis</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Prospective Studies</keyword><keyword>*Psychiatric Status Rating Scales</keyword><keyword>Questionnaires</keyword><keyword>Reproducibility of Results</keyword><keyword>Sensitivity and Specificity</keyword></keywords><dates><year>1990</year><pub-dates><date>Dec 15</date></pub-dates></dates><isbn>0003-4819 (Print)0003-4819 (Linking)</isbn><accession-num>2240918</accession-num><urls><related-urls><url> is the most-studied short delirium assessment tool. ADDIN EN.CITE <EndNote><Cite><Author>Shi</Author><Year>2013</Year><RecNum>3546</RecNum><DisplayText><style face="superscript">126</style></DisplayText><record><rec-number>3546</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505371545">3546</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shi, Q.</author><author>Warren, L.</author><author>Saposnik, G.</author><author>Macdermid, J. C.</author></authors></contributors><auth-address>Health and Rehabilitation Sciences, Western University, London, Ontario, Canada ; Stroke Outcomes Research Center, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.</auth-address><titles><title>Confusion assessment method: a systematic review and meta-analysis of diagnostic accuracy</title><secondary-title>Neuropsychiatr Dis Treat</secondary-title></titles><periodical><full-title>Neuropsychiatr Dis Treat</full-title></periodical><pages>1359-70</pages><volume>9</volume><keywords><keyword>confusion assessment method</keyword><keyword>delirium</keyword><keyword>diagnostic accuracy</keyword><keyword>meta-analysis</keyword><keyword>systematic review</keyword></keywords><dates><year>2013</year></dates><isbn>1176-6328 (Print)1176-6328 (Linking)</isbn><accession-num>24092976</accession-num><urls><related-urls><url> It comprises a four-feature diagnostic algorithm based on DSM-III-R, where each feature is scored following a brief bedside interview and cognitive assessment such as the Mini-Cog.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Cb3Jzb248L0F1dGhvcj48WWVhcj4yMDAwPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 4, 46, 129-134 The variability in sensitivity across studies appears partly to relate to the professional background of the rater, and the degree of training of the rater; in the studies showing lower sensitivities raters have tended not to be medically qualified and/or have not had specific training in the use of the CAM. Additionally, validation studies of the CAM have been performed in varying settings, with different populations, and different exclusion criteria. As a tool for mainstream routine use for detection of delirium, the CAM may not be ideally suited to all settings. Because of the need for a bedside interview and brief cognitive test before scoring, it generally takes 5-10 minutes to complete. Also, many acutely unwell patients have a reduced level of arousalPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qcnl0aGVyY2g8L0F1dGhvcj48WWVhcj4yMDEwPC9ZZWFy

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ADDIN EN.CITE.DATA 39, 44, 135 and are unable to undergo cognitive testing or even a simple interview. The CAM has an algorithmic structure such that Feature 1 (acute onset and fluctuating course) and Feature 2 (inattention) must both be positive before proceeding to score Feature 3 (disorganised thinking) and Feature 4 (altered level of arousal). A patient with a severely reduced level of arousal (for example, if they are only responding a to verbal stimulation with slight movement) cannot readily be assessed for inattention according to the guidance in the CAM manual, ADDIN EN.CITE <EndNote><Cite><Author>Inouye</Author><Year>2014</Year><RecNum>3554</RecNum><DisplayText><style face="superscript">136</style></DisplayText><record><rec-number>3554</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505388706">3554</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Inouye, S. K.</author></authors></contributors><titles><title>The Short Confusion Assessment Method (ShortCAM): Training Manual and Coding Guide.</title></titles><dates><year>2014</year></dates><pub-location>Boston</pub-location><publisher>Hospital Elder Life Program</publisher><urls></urls></record></Cite></EndNote>136 and thus such patients cannot be scored positive for delirium. Additionally, early in the hospital stay positive evidence for acute onset or fluctuating course is often not available. ADDIN EN.CITE <EndNote><Cite><Author>Hendry</Author><Year>2016</Year><RecNum>3552</RecNum><DisplayText><style face="superscript">56</style></DisplayText><record><rec-number>3552</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505376908">3552</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hendry, K.</author><author>Quinn, T. J.</author><author>Evans, J.</author><author>Scortichini, V.</author><author>Miller, H.</author><author>Burns, J.</author><author>Cunnington, A.</author><author>Stott, D. J.</author></authors></contributors><auth-address>Glasgow Royal Infirmary, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.Department of Medical Sciences and Community Health, University of Milan, Milan, Italy.Department of Medicine for the Elderly, Glasgow Royal Infirmary, Glasgow, UK.Greater Glasgow and Clyde NHS-Geriatrics, Glasgow, UK.</auth-address><titles><title>Evaluation of delirium screening tools in geriatric medical inpatients: a diagnostic test accuracy study</title><secondary-title>Age Ageing</secondary-title></titles><periodical><full-title>Age Ageing</full-title></periodical><pages>832-837</pages><volume>45</volume><number>6</number><keywords><keyword>acute care</keyword><keyword>cognitive impairment</keyword><keyword>delirium</keyword><keyword>dementia</keyword><keyword>geriatrics</keyword><keyword>older people</keyword></keywords><dates><year>2016</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1468-2834 (Electronic)0002-0729 (Linking)</isbn><accession-num>27503794</accession-num><urls><related-urls><url> Again, in such circumstances, the CAM cannot be scored positive. A further issue is the need for subjective, binary assessments of aspects of mental status such as inattention. Such assessments are less reliable and more challenging for staff, particularly non-specialists, than more objective tests. For example, one study found a kappa of 0.66 for the CAM inattention item when measured by trained assessors. ADDIN EN.CITE <EndNote><Cite><Author>Simon</Author><Year>2006</Year><RecNum>1608</RecNum><DisplayText><style face="superscript">137</style></DisplayText><record><rec-number>1608</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">1608</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Simon,S.E.</author><author> Bergmann,M.A.</author><author> Jones,R.N.</author><author> Murphy,K.M.</author><author> Orav,E.J.</author><author> Marcantonio,E.R.</author></authors></contributors><titles><title>Reliability of a structured assessment for nonclinicians to detect delirium among new admissions to postacute care</title><secondary-title><style face="normal" font="System" size="100%">Journal of the American Medical Directors Association</style></secondary-title></titles><periodical><full-title>J Am Med Dir Assoc</full-title><abbr-1>Journal of the American Medical Directors Association</abbr-1></periodical><pages>412-415</pages><volume>7</volume><number>7</number><keywords><keyword>ADMISSION</keyword><keyword>CARE</keyword><keyword>delirium</keyword><keyword>RELIABILITY</keyword></keywords><dates><year>2006</year></dates><isbn>1525-8610</isbn><urls></urls></record></Cite></EndNote>137 Another challenge is that according to the CAM training manual, those using the tool should undergo specific training; this training takes several hours and it may not be feasible to provide this to all users in a given healthcare setting.The 4As Test (4AT)PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZWxsZWxsaTwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+

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ADDIN EN.CITE.DATA 53 (see ) was developed in 2010 as a screening tool for delirium, and to identify pre-existing cognitive impairment. The development was prompted by the need for improved detection in the first authors’ institution, a need identified as part of a larger planned programme of improved care for delirium. Although at that time there were multiple delirium assessment tools already published, after extensive searching and trials of some available tools, the authors took the view that none of the available tools had the required characteristics. These included that the tool be short, easy to learn, administer and score, be usable in patients unable to produce verbal responses, be as inclusive as possible, and be usable by health professionals from a range of disciplines. The tool also had to include general cognitive screening items so as to avoid requiring two separate instruments. The test was initially drafted then assessed for practicality and usability in clinical use, and redrafted and reassessed, with several iterations of this process. An audit (unpublished) of the completed version in 30 inpatients comparing clinical use of 4AT with independent reference standard DSM-IV ADDIN EN.CITE <EndNote><Cite><Author>American Psychiatric Association</Author><Year>2000</Year><RecNum>2095</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>2095</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">2095</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>American Psychiatric Association,</author></authors></contributors><titles><title>Diagnostic and statistical manual of mental disorders : DSM-IV-TR</title></titles><edition>4th</edition><keywords><keyword>Mental illness Classification Handbooks, manuals, etc.</keyword><keyword>Mental illness Diagnosis Handbooks, manuals, etc.</keyword><keyword>Mental Disorders classification.</keyword><keyword>Mental Disorders diagnosis.</keyword></keywords><dates><year>2000</year></dates><pub-location>Washington, DC</pub-location><isbn>0890420246 (casebound alk. paper)0890420254 (pbk. alk. paper)</isbn><accession-num>11905196</accession-num><call-num>Reference - Science Reading Room (Adams, 5th Floor) RC455.2.C4; D536 2000Jefferson or Adams Building Reading Rooms RC455.2.C4; D536 2000</call-num><urls></urls></record></Cite></EndNote>1 assessment found 100% sensitivity (CI 69-100) and 90% specificity (CI 68-99). The tool was then published on as a means to facilitate local institutional use. Following this, the 4AT began to be adopted in clinical units in several centres in the UK and internationally. A validation study in geriatrics inpatients (n=234) found a sensitivity of 0.9 and a specificity 0.84 for delirium.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZWxsZWxsaTwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+

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ADDIN EN.CITE.DATA 52 However, given the limitations of prior tools, and the promising early diagnostic accuracy evaluations and increasing clinical adoption of the 4AT, it was considered necessary to proceed to a larger validation study. The present study was funded in 2013, and commenced recruitment in 2015. Since the funding award for the present study, some other studies evaluating the 4AT have been published.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5JbmZhbnRlPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48

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ADDIN EN.CITE.DATA 139 for reporting diagnostic accuracy studies. The study was registered: International standard randomised controlled trial number (ISRCTN) 53388093. UK Clinical Research Network ID: 19502, and the protocol was accepted for publication in advance of any database locking and any statistical analyses. ADDIN EN.CITE <EndNote><Cite><Author>Shenkin</Author><Year>2017</Year><RecNum>3562</RecNum><DisplayText><style face="superscript">140</style></DisplayText><record><rec-number>3562</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505401722">3562</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shenkin, Susan D.</author><author>Fox, Christopher</author><author>Godfrey, Mary</author><author>Siddiqi, Najma</author><author>Goodacre, Steve</author><author>Young, John</author><author>Anand, Atul</author><author>Gray, Alasdair</author><author>Smith, Joel</author><author>Ryan, Tracy</author><author>Hanley, Janet</author><author>MacRaild, Allan</author><author>Steven, Jill</author><author>Black, Polly</author><author>Boyd, Julia</author><author>Weir, Christopher J.</author><author>MacLullich, Alasdair M. J.</author></authors></contributors><titles><title>Protocol for validation of the 4AT, a rapid screening tool for delirium: a multicentre prospective diagnostic test accuracy study</title><secondary-title>BMJ Open</secondary-title></titles><periodical><full-title>BMJ Open</full-title><abbr-1>BMJ open</abbr-1></periodical><dates><year>2017</year><pub-dates><date>3/17</date></pub-dates></dates><isbn>2044-6055</isbn><work-type>Article</work-type><urls></urls></record></Cite></EndNote>140 EthicsThis study was granted ethical approval prior to data collection in Scotland (Scotland A NHS Research Ethics Committee REC 15/SS/0071) and England (Yorkshire and The Humber – Bradford Leeds NHS Research Ethics Committee REC 15/YH/0317). Study design: overviewPatients aged 70 or over in Emergency Departments or acute general medical wards were prospectively recruited in three sites (Edinburgh, Bradford, and Sheffield). The total target number of patients was 900 (all sites). Each patient underwent (a) a reference standard delirium assessment lasting up to 20 minutes, and (b) either the 4AT or the CAM (lasting up to 10 minutes). Randomisation was used to allocate participants to the 4AT or the CAM and to determine the ordering of the reference standard and 4AT or CAM assessments. A questionnaire on pre-admission cognitive function was administered to an appropriate informant (if one was available). At 12 weeks data on clinical outcomes including length of stay, institutionalisation, and mortality, and resource utilisation were collected from medical and social care records or from patients if the records did not provide sufficient information.Inclusion and exclusion criteriaInclusion criteria: Aged 70 or overAcutely admitted to the Emergency Department (ED) (within 12 hours of attending) or acute general medical and geriatrics units (within 96 hours of admission to the ward). ED patients were only recruited from those who were brought in by ambulance as an emergency or through their general practitioner, to ensure that recruited patients were representative of those likely to be admitted to hospital as well as having a similar profile of underlying cognitive impairment or other co-morbidities.Exclusion criteria: Acute life-threatening illness requiring time-critical intervention e.g. ST-elevation myocardial infarction; septic shock; severe pulmonary oedema. Coma (‘Unresponsive’ on the AVPU scale (Alert, Responsive to Verbal Stimulation, Responsive to Pain, Unresponsive) ADDIN EN.CITE <EndNote><Cite><Author>McNarry</Author><Year>2004</Year><RecNum>3302</RecNum><DisplayText><style face="superscript">141</style></DisplayText><record><rec-number>3302</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1422608699">3302</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McNarry, A. F.</author><author>Goldhill, D. R.</author></authors></contributors><auth-address>Royal London Hosp, Barts & London NHS Trust, Dept Anaesthesia & Crit Care, London E1 1BB, England.McNarry, AF (reprint author), Royal London Hosp, Barts & London NHS Trust, Dept Anaesthesia & Crit Care, Alexandra Wing, London E1 1BB, England.</auth-address><titles><title>Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the Glasgow Coma scale</title><secondary-title>Anaesthesia</secondary-title></titles><periodical><full-title>Anaesthesia</full-title></periodical><pages>34-37</pages><volume>59</volume><number>1</number><keywords><keyword>intensive care</keyword><keyword>consciousness, assessment, bedside</keyword><keyword>ACDU scale</keyword><keyword>AVPU</keyword><keyword>scale</keyword><keyword>Glasgow Coma Scale (GCS)</keyword><keyword>team</keyword><keyword>Anesthesiology</keyword></keywords><dates><year>2004</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0003-2409</isbn><accession-num>WOS:000187343100007</accession-num><work-type>Article; Proceedings Paper</work-type><urls><related-urls><url><Go to ISI>://WOS:000187343100007</url></related-urls></urls><electronic-resource-num>10.1111/j.1365-2044.2004.03526.x</electronic-resource-num><language>English</language></record></Cite></EndNote>141Unable to communicate in English, severe dysphasia.Previous enrolment in the 4AT studySample sizeA total of 900 patients were planned to be randomised, 450 to assessment by 4AT and 450 to CAM. Of the 450 patients within each group, 15% (N=67) would be expected to have delirium ADDIN EN.CITE <EndNote><Cite><Author>Siddiqi</Author><Year>2006</Year><RecNum>1599</RecNum><DisplayText><style face="superscript">3</style></DisplayText><record><rec-number>1599</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">1599</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Siddiqi,N.</author><author> House,A.O.</author><author> Holmes,J.D.</author></authors></contributors><titles><title>Occurrence and outcome of delirium in medical in-patients: a systematic literature review</title><secondary-title>Age and Ageing</secondary-title></titles><periodical><full-title>Age and Ageing</full-title></periodical><pages>350-364</pages><volume>35</volume><number>4</number><keywords><keyword>delirium</keyword><keyword>INPATIENTS</keyword><keyword>MEDICAL INPATIENTS</keyword><keyword>OUTCOME</keyword><keyword>review</keyword></keywords><dates><year>2006</year></dates><isbn>0002-0729</isbn><urls></urls></record></Cite></EndNote>3. The specificity of each triage tool would be estimated based on the 85% (383) without delirium; sensitivity would be estimated from the 67 with delirium. This sample size would allow precise estimation of specificity and moderately precise estimation of sensitivity. Based on analysis using the normal approximation to the binomial distribution, the two-sided 95% confidence interval width for specificity would range from ±0.030 to ±0.050, for true specificity ranging from 0.90 to 0.50. The corresponding confidence interval widths for sensitivity would range from ±0.072 to ±0.120.For the secondary objective comparing 4AT and CAM, based on analysis by continuity corrected chi-squared test, we have 83% power to detect a difference in specificity of 0.10, assuming a null hypothesis of specificity=0.70 for both tests and a 5% significance level. The difference detectable for sensitivity (null hypothesis sensitivity=0.70 on both tests) would be 0.224 (80% power).RecruitmentPatients were recruited between 0800 and 2200. Eligibility screening was carried out by a member of the clinical team, yielding sets of names of potentially eligible patients. Patients were screened in alphabetical order from study opening in October 2015 until July 2016 This recruitment strategy was from that point on (5 months duration) because analyses suggested that patients at lower risk of delirium (i.e., those not requiring capacity assessment) were more likely to be recruited than those with impaired capacity. We thus adopted a pragmatic approach so as to facilitate some oversampling of patients at higher risk of delirium. adopted. From the lists patients identified as per the original strategy, patients considered at higher risk of delirium on clinical grounds (egg, older age, likelihood of admission, a higher degree of comorbidities) were approached first, rather than in alphabetical order. This change was approved by the funder and the Trial Steering Committee Potentially eligible participants (n=4,928) were identified as those without critical illness or coma, in the Emergency Department within 12 hours of attendance, or acute medical wards within 96 hours of attendance, in three sites (Edinburgh, Bradford, Sheffield: see Appendix 9 for numbers screened, eligible and consented for each site). Study recruitment commenced on 19th October 2015, and completed on 30 December 2016, with final follow-up data collection and locking of the database on 29 June 2017. In total 843 patients were randomised.ConsentParticipants were eligible for this study whether they had capacity to consent or not. 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ADDIN EN.CITE.DATA 142 Test methodsReference standard assessment for deliriumThe reference standard assessment for delirium (Table 4) was based on a combination of the Delirium Rating Scale-Revised-98 (DRS-R98) ADDIN EN.CITE <EndNote><Cite><Author>Trzepacz</Author><Year>2001</Year><RecNum>1741</RecNum><DisplayText><style face="superscript">143</style></DisplayText><record><rec-number>1741</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">1741</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Trzepacz,P.T.</author><author> Mittal,D.</author><author> Torres,R.</author><author> Kanary,K.</author><author> Norton,J.</author><author> Jimerson,N.</author></authors></contributors><titles><title>Validation of the Delirium Rating Scale-revised-98: Comparison with the Delirium Rating Scale and the Cognitive Test for Delirium</title><secondary-title>Journal of Neuropsychiatry and Clinical Neurosciences</secondary-title></titles><pages>229-242</pages><volume>13</volume><number>2</number><keywords><keyword>cognitive</keyword><keyword>COGNITIVE TEST</keyword><keyword>consistency</keyword><keyword>delirium</keyword><keyword>DEMENTIA</keyword><keyword>depression</keyword><keyword>INTERRATER RELIABILITY</keyword><keyword>ITEM</keyword><keyword>longitudinal</keyword><keyword>longitudinal studies</keyword><keyword>longitudinal study</keyword><keyword>NEUROLOGY</keyword><keyword>PSYCHIATRY</keyword><keyword>RATING-SCALE</keyword><keyword>RELIABILITY</keyword><keyword>SCALE</keyword><keyword>SCHIZOPHRENIA</keyword><keyword>SCORES</keyword><keyword>SENSITIVITY</keyword><keyword>Sensitivity and Specificity</keyword><keyword>SEVERITY</keyword><keyword>SPECIFICITIES</keyword><keyword>SPECIFICITY</keyword><keyword>SYMPTOM</keyword><keyword>SYMPTOMS</keyword><keyword>VALIDATION</keyword></keywords><dates><year>2001</year></dates><isbn>0895-0172</isbn><urls></urls></record></Cite></EndNote>143 and several neuropsychological assessments used together to inform a binary ascertainment of delirium present or absent based on DSM-IV criteria. The DRS-R98 is a well-validated scale which assesses multiple dimensions of mental status change and quantifies delirium severity. The DRS-R98 includes 16 domains, which are divided into two parts. The first part comprises 13 domains of mental status assessment which are rated according to their presence according to a three-point severity scale, or are absent. The second part comprises 3 items which are concerned with the diagnosis of delirium, namely ‘Temporal Onset of Symptoms’, ‘Fluctuation of Symptom Severity’ and ‘Physical Disorder’. The first two of these three require information on change from baseline. As per the instruction manual, the DRS-R98 was supplemented by short neuropsychological assessments of attention and other domains, including Digit Span, ADDIN EN.CITE <EndNote><Cite><Author>Simon</Author><Year>2006</Year><RecNum>1608</RecNum><DisplayText><style face="superscript">137</style></DisplayText><record><rec-number>1608</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">1608</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Simon,S.E.</author><author> Bergmann,M.A.</author><author> Jones,R.N.</author><author> Murphy,K.M.</author><author> Orav,E.J.</author><author> Marcantonio,E.R.</author></authors></contributors><titles><title>Reliability of a structured assessment for nonclinicians to detect delirium among new admissions to postacute care</title><secondary-title><style face="normal" font="System" size="100%">Journal of the American Medical Directors Association</style></secondary-title></titles><periodical><full-title>J Am Med Dir Assoc</full-title><abbr-1>Journal of the American Medical Directors Association</abbr-1></periodical><pages>412-415</pages><volume>7</volume><number>7</number><keywords><keyword>ADMISSION</keyword><keyword>CARE</keyword><keyword>delirium</keyword><keyword>RELIABILITY</keyword></keywords><dates><year>2006</year></dates><isbn>1525-8610</isbn><urls></urls></record></Cite></EndNote>137 the Observational Scale for Level of Arousal,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UaWVnZXM8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 144 and the DelApp computerised objective attentional assessment test. ADDIN EN.CITE <EndNote><Cite><Author>Tieges</Author><Year>in press</Year><RecNum>3224</RecNum><DisplayText><style face="superscript">145</style></DisplayText><record><rec-number>3224</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1422027344">3224</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tieges, Z.; Stiohbhairt, A.; Scott, K.; Suchorab, K.; Weir, A.; Parks, S.; Shenkin, S.D.; MacLullich, A.M.J.;</author><author> </author></authors></contributors><titles><title>Development of a smartphone application for the objective detection of attentional deficits in delirium </title><secondary-title>International Psychogeriatrics</secondary-title></titles><periodical><full-title>International Psychogeriatrics</full-title></periodical><dates><year>in press</year></dates><urls></urls></record></Cite></EndNote>145 The final DSM-IV ascertainment of delirium used a standardised process utilising the above assessment results with final verification by the Chief Investigator and two independent adjudicators (ZT and SDS) by consensus, blind to the 4AT or CAM results. Cases judged as indeterminate on final verification were excluded from analyses. DSM-IV was used rather than DSM-5 ADDIN EN.CITE <EndNote><Cite><Author>American Psychiatric Association</Author><Year>2013</Year><RecNum>3544</RecNum><DisplayText><style face="superscript">2</style></DisplayText><record><rec-number>3544</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505369966">3544</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>American Psychiatric Association,</author></authors></contributors><titles><title>Diagnostic and Statistical Manual of Mental Disorders</title></titles><edition>5th</edition><dates><year>2013</year></dates><pub-location>Washington, DC.</pub-location><urls></urls></record></Cite></EndNote>2 because of the timing of the study protocol and application in relation to the launch of DSM-5, including the fact that DSM-IV is long-established whereas DSM-5 criteria were untested in research at around the time that study protocols were being finalised. DSM-IV are DSM-5 criteria are not markedly different, however.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWFnaGVyPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48

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ADDIN EN.CITE.DATA 146 The main difference is in the terminology used in Criterion A, with DSM-IV stating, “ Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, shift or sustain attention).” and DSM-5 stating, “A disturbance in attention (i.e. reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).” How these features should be operationalised is not precisely covered in either manual. Therefore, how a test like the 4AT performs in relation to a DSM-IV or DSM-5 reference standard will depend to some extent on how the reference standard operationalises the criteria included in DSM-IV or DSM-5.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYXZpczwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 147 If similar processes are used to inform Criterion A for both DSM-IV and DSM-5, these criteria will score similar numbers of patients as delirium positive.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWFnaGVyPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48

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ADDIN EN.CITE.DATA 1464 “A”s Test (4AT) The 4AT (Table 5) comprises 4 items. Item 1 concerns an observational assessment of level of alertness. The next two items are brief cognitive tests: the Abbreviated Mental Test – 4 (AMT4) ADDIN EN.CITE <EndNote><Cite><Author>Swain</Author><Year>2000</Year><RecNum>2291</RecNum><DisplayText><style face="superscript">148</style></DisplayText><record><rec-number>2291</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">2291</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Swain, D. G.</author><author>O'Brien, A. G.</author><author>Nightingale, P. G.</author></authors></contributors><auth-address>Department of Elderly Medicine, Yardley Green Hospital, Birmingham Heartlands and Solihull NHS Trust, UK.</auth-address><titles><title>Cognitive assessment in elderly patients admitted to hospital: the relationship between the shortened version of the Abbreviated Mental Test and the Abbreviated Mental Test and Mini-Mental State Examination</title><secondary-title>Clin Rehabil</secondary-title></titles><pages>608-10</pages><volume>14</volume><number>6</number><edition>2000/12/29</edition><keywords><keyword>Aged</keyword><keyword>Cognition Disorders/*diagnosis</keyword><keyword>*Geriatric Assessment</keyword><keyword>*Hospitalization</keyword><keyword>Humans</keyword><keyword>Mental Status Schedule</keyword><keyword>Middle Aged</keyword><keyword>Predictive Value of Tests</keyword><keyword>*Psychiatric Status Rating Scales</keyword></keywords><dates><year>2000</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>0269-2155 (Print)0269-2155 (Linking)</isbn><accession-num>11128735</accession-num><urls><related-urls><url> which asks the patient to state their age, their date of birth, the current year, and the place they are in; and attention testing with Months Backwards, in which the patient is asked to state the months of year in reverse order, starting with December. Only items 1-3 are done at the bedside, and the typical duration is under 2 minutes. Item 4 concerns acute change in mental status, a core diagnostic feature of delirium; this information is obtained from the casenotes, the GP letter and/or from an informant, that is, from any of, or a combination of these sources.Confusion Assessment Method (CAM)The CAM ADDIN EN.CITE <EndNote><Cite><Author>Inouye</Author><Year>1990</Year><RecNum>2763</RecNum><DisplayText><style face="superscript">125</style></DisplayText><record><rec-number>2763</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">2763</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Inouye, S. K.</author><author>van Dyck, C. H.</author><author>Alessi, C. A.</author><author>Balkin, S.</author><author>Siegal, A. P.</author><author>Horwitz, R. I.</author></authors></contributors><auth-address>Yale University School of Medicine, New Haven, Connecticut.</auth-address><titles><title>Clarifying confusion: the confusion assessment method. A new method for detection of delirium</title><secondary-title>Ann Intern Med</secondary-title></titles><periodical><full-title>Ann Intern Med</full-title><abbr-1>Annals of internal medicine</abbr-1></periodical><pages>941-8</pages><volume>113</volume><number>12</number><edition>1990/12/15</edition><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Algorithms</keyword><keyword>Confusion/*diagnosis</keyword><keyword>Delirium/*diagnosis</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Prospective Studies</keyword><keyword>*Psychiatric Status Rating Scales</keyword><keyword>Questionnaires</keyword><keyword>Reproducibility of Results</keyword><keyword>Sensitivity and Specificity</keyword></keywords><dates><year>1990</year><pub-dates><date>Dec 15</date></pub-dates></dates><isbn>0003-4819 (Print)0003-4819 (Linking)</isbn><accession-num>2240918</accession-num><urls><related-urls><url> is a diagnostic algorithm drawn from the DSM-III-R delirium definition ADDIN EN.CITE <EndNote><Cite><Author>American Psychiatric Association</Author><Year>1987</Year><RecNum>3697</RecNum><DisplayText><style face="superscript">149</style></DisplayText><record><rec-number>3697</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1513432897">3697</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>American Psychiatric Association,</author></authors></contributors><titles><title>Diagnostic and Statistical Manual of Mental Disorders</title></titles><edition>3rd, revised</edition><dates><year>1987</year></dates><pub-location>Washington DC</pub-location><publisher>American Psychiatric Association</publisher><urls></urls></record></Cite></EndNote>149. In the CAM the tester rates the following four DSM-III-R features as present or absent: 1. Acute Change and Fluctuating Course; 2. Inattention; 3. Disorganised Thinking; and 4. Altered Level of Consciousness. The CAM algorithm requires that Features 1 and 2 are both positive; if they are positive then Features 3 and 4 are assessed and if one or both of Features 3 or 4 is positive, then the whole CAM is positive, indicating the presence of delirium. The tester scores the features by a combination of interview with the patient, cognitive testing (the CAM requires that a cognitive test be performed before the features are scored), examining the casenotes, and seeking informant history if required. Note that the questionnaires used to assess cognition are not specified by the CAM manual, though some suggested tests are provided. Feature 1 is assessed by the same process as Item 4 in the 4AT. Feature 2 is assessed by the tester giving a positive or negative rating to the question, "Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?” Feature 3 is assessed by the tester giving a positive or negative rating to the question, "Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?” Feature 4 is similar to item 1 in the 4AT. In this study, for the pre-CAM cognitive assessment we used a set of questions covering the cognitive domains represented in the suggested tests in the CAM manual, including Days of the Week Backwards, counting from 20 down to 1, orientation questions, three-word recall, and clock-drawing (Table 6). All of these questions are used in routine clinical practice at the rmant Questionnaire for Cognitive Decline in the Elderly (IQCODE)The (IQCODE) ADDIN EN.CITE <EndNote><Cite><Author>Jorm</Author><Year>1994</Year><RecNum>802</RecNum><DisplayText><style face="superscript">150</style></DisplayText><record><rec-number>802</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">802</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jorm,A.F.</author></authors></contributors><titles><title>A Short-Form of the Informant Questionnaire on Cognitive Decline in the Elderly (Iqcode) - Development and Cross-Validation</title><secondary-title><style face="normal" font="System" size="100%">Psychological Medicine</style></secondary-title></titles><periodical><full-title>Psychological Medicine</full-title><abbr-1>Psychol. Med.</abbr-1></periodical><pages>145-153</pages><volume>24</volume><number>1</number><keywords><keyword>cognitive</keyword><keyword>COGNITIVE DECLINE</keyword><keyword>CROSS-VALIDATION</keyword><keyword>DECLINE</keyword><keyword>elderly</keyword><keyword>INFORMANT QUESTIONNAIRE</keyword><keyword>IQCODE</keyword><keyword>QUESTIONNAIRE</keyword></keywords><dates><year>1994</year></dates><urls></urls></record></Cite></EndNote>150 was used to assess if a patient had prior cognitive impairment. The IQCODE is a very widely-used validated questionnaire, including in delirium studies,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5KYWNrc29uPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48

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ADDIN EN.CITE.DATA 151-154 which allows estimation of whether an individual has pre-existing cognitive impairment. The recommended cut-off of 3.44 was used. ADDIN EN.CITE <EndNote><Cite><Author>Jorm</Author><Year>2004</Year><RecNum>3705</RecNum><DisplayText><style face="superscript">155</style></DisplayText><record><rec-number>3705</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1528100584">3705</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jorm, A. F.</author></authors></contributors><auth-address>Centre for Mental Health Research, Australian National University, Canberra, Australia. Anthony.Jorm@anu.edu.au</auth-address><titles><title>The Informant Questionnaire on cognitive decline in the elderly (IQCODE): a review</title><secondary-title>Int Psychogeriatr</secondary-title></titles><periodical><full-title>Int Psychogeriatr</full-title><abbr-1>International psychogeriatrics / IPA</abbr-1></periodical><pages>275-93</pages><volume>16</volume><number>3</number><keywords><keyword>Aged</keyword><keyword>Cognition Disorders/*diagnosis</keyword><keyword>Dementia/diagnosis</keyword><keyword>Humans</keyword><keyword>Mass Screening/methods</keyword><keyword>Neuropsychological Tests</keyword><keyword>Reproducibility of Results</keyword><keyword>*Surveys and Questionnaires</keyword></keywords><dates><year>2004</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>1041-6102 (Print)1041-6102 (Linking)</isbn><accession-num>15559753</accession-num><urls><related-urls><url> It is administered to the nearest relative or carer and takes five minutes to complete. Consent was sought from the nearest relative or carer before the IQCODE was administered. Appropriate informants are not always available; thus reasonable efforts were made to identify such informants within four weeks of patient recruitment. Table SEQ Table \* ARABIC 4. Reference standard assessment for deliriumReference standard assessment for deliriumBinary ascertainment of delirium based on DSM-IV criteriaInformed by:Delirium Rating Scale-Revised-98 (DRSR98) ADDIN EN.CITE <EndNote><Cite><Author>Trzepacz</Author><Year>2001</Year><RecNum>1741</RecNum><DisplayText><style face="superscript">143</style></DisplayText><record><rec-number>1741</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">1741</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Trzepacz,P.T.</author><author> Mittal,D.</author><author> Torres,R.</author><author> Kanary,K.</author><author> Norton,J.</author><author> Jimerson,N.</author></authors></contributors><titles><title>Validation of the Delirium Rating Scale-revised-98: Comparison with the Delirium Rating Scale and the Cognitive Test for Delirium</title><secondary-title>Journal of Neuropsychiatry and Clinical Neurosciences</secondary-title></titles><pages>229-242</pages><volume>13</volume><number>2</number><keywords><keyword>cognitive</keyword><keyword>COGNITIVE TEST</keyword><keyword>consistency</keyword><keyword>delirium</keyword><keyword>DEMENTIA</keyword><keyword>depression</keyword><keyword>INTERRATER RELIABILITY</keyword><keyword>ITEM</keyword><keyword>longitudinal</keyword><keyword>longitudinal studies</keyword><keyword>longitudinal study</keyword><keyword>NEUROLOGY</keyword><keyword>PSYCHIATRY</keyword><keyword>RATING-SCALE</keyword><keyword>RELIABILITY</keyword><keyword>SCALE</keyword><keyword>SCHIZOPHRENIA</keyword><keyword>SCORES</keyword><keyword>SENSITIVITY</keyword><keyword>Sensitivity and Specificity</keyword><keyword>SEVERITY</keyword><keyword>SPECIFICITIES</keyword><keyword>SPECIFICITY</keyword><keyword>SYMPTOM</keyword><keyword>SYMPTOMS</keyword><keyword>VALIDATION</keyword></keywords><dates><year>2001</year></dates><isbn>0895-0172</isbn><urls></urls></record></Cite></EndNote>143 scored via interview, information from casenotes and informant history, and cognitive tests including Digit Span ADDIN EN.CITE <EndNote><Cite><Author>Simon</Author><Year>2006</Year><RecNum>1608</RecNum><DisplayText><style face="superscript">137</style></DisplayText><record><rec-number>1608</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">1608</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Simon,S.E.</author><author> Bergmann,M.A.</author><author> Jones,R.N.</author><author> Murphy,K.M.</author><author> Orav,E.J.</author><author> Marcantonio,E.R.</author></authors></contributors><titles><title>Reliability of a structured assessment for nonclinicians to detect delirium among new admissions to postacute care</title><secondary-title><style face="normal" font="System" size="100%">Journal of the American Medical Directors Association</style></secondary-title></titles><periodical><full-title>J Am Med Dir Assoc</full-title><abbr-1>Journal of the American Medical Directors Association</abbr-1></periodical><pages>412-415</pages><volume>7</volume><number>7</number><keywords><keyword>ADMISSION</keyword><keyword>CARE</keyword><keyword>delirium</keyword><keyword>RELIABILITY</keyword></keywords><dates><year>2006</year></dates><isbn>1525-8610</isbn><urls></urls></record></Cite></EndNote>137, the Observational Scale for Level of Arousal PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UaWVnZXM8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 144, the Vigilance A test ADDIN EN.CITE <EndNote><Cite><Author>Hart</Author><Year>1996</Year><RecNum>660</RecNum><DisplayText><style face="superscript">156</style></DisplayText><record><rec-number>660</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">660</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hart,R.P.</author><author> Levenson,J.L.</author><author> Sessler,C.N.</author><author> Best,A.M.</author><author> Schwartz,S.M.</author><author> Rutherford,L.E.</author></authors></contributors><titles><title>Validation of a cognitive test for delirium in medical ICU patients</title><secondary-title><style face="normal" font="System" size="100%">Psychosomatics</style></secondary-title></titles><periodical><full-title>Psychosomatics</full-title></periodical><pages>533-546</pages><volume>37</volume><number>6</number><keywords><keyword>cognitive</keyword><keyword>COGNITIVE TEST</keyword><keyword>delirium</keyword><keyword>VALIDATION</keyword></keywords><dates><year>1996</year></dates><urls></urls></record></Cite></EndNote>156, the DelApp objective attentional assessment PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UaWVnZXM8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 157, and simple object naming and orientation questions. DRS-98 includes inspection of case notes and informant history Predefined positivity cut-offDelirium (DSM IV criteria) present or absent by consensus among the Chief Investigator and two adjudicators (SS and ZT) based on above assessments as recorded in the Case Record Form.Time taken: 20 minutesTable SEQ Table \* ARABIC 5. The 4 “A”s Test (4AT)4AT itemsScore1. Alertness Normal Mild sleepiness Clearly abnormal 2. AMT4 (Date of birth, current age, place patient is in now, current year) No mistakes 1 mistake 2 or more mistakes/untestable 3. AttentionMonths of the year backwards7 or more correct <7 or refuses to start Untestable 4. Acute change or fluctuating course No Yes 01401201204Maximum score (sum of scores from each Items12Predefined positivity cut-off (for secondary analysis 0-12 as severity marker, and 1-3 as indicator of cognitive impairment)0-3 No delirium4-12 DeliriumTime taken: 1-2 minutesPre-scoring cognitive testing procedureAll participants underwent a brief interview (asking them to discuss their hospital stay, etc.), then the following cognitive testing procedure.1. Days of the week backwards2. Counting from 20 down to 13. Orientation (What is the day today?; Is it day or night just now?; What is the year?; What was your last meal?; How long have you been in hospital? What city are we in?; What is the name of the hospital?; What floor are we on?)4. Memory registration: three words stated then participant asked to recall these. Up to three trials until all three words recalled or three trials repeated.5. Clock drawing: asked to draw a clock with hands at ‘ten past eleven’; if participant unable to do the test, 30 second interval with conversation used as gap instead.6. Delayed recall. Recall of the three words from question 4.Predefined positivity cut-off As per the CAM manual, once the cognitive testing had been completed, and information about onset gathered, raters used observation during the interview, and information from casenotes and informants to score each feature of the CAM positive or negative, then reached a delirium positive or negative score according to the CAM algorithm.Time taken: ~10 minutesTable SEQ Table \* ARABIC 6. Confusion Assessment Method (CAM): pre-scoring cognitive testing procedureOrdering of reference standard delirium assessment, 4AT and CAMThe reference standard assessment for delirium was administered to all patients by the researcher who conducted the capacity assessment and consenting process. A different researcher performed either the 4AT or the CAM. The rationale for this is that the capacity and consenting process provides information to the researcher which exceeds what the 4AT or CAM provide. This is not a concern for the reference standard assessment, which is aimed at providing a thorough assessment to optimise diagnostic accuracy. The order of the two assessments ([4AT or CAM assessment] and reference standard assessment) was randomised in the ratio 1:1. Participants were also randomised in the ratio 1:1 to be assessed using the 4AT or CAM. Randomisation, using a secure online system, occurred immediately after consenting. Access to the secure system for each randomisation was via a unique username and password for each researcher; the full list of randomised allocations was held within the secure online system and concealed from researchers. The randomisation sequence was created using computer-generated pseudo-random numbers, and was stratified by study site, with block allocation. The two assessments took place within a maximum of two hours of each other, with a target interval of 15 minutes. Researchers were blinded to each other’s assessments. The result of the reference standard assessment was recorded in the casenotes, and communicated to the clinical team after the assessments were complete. See Figure 2 for the study assessment flowchart.The IQCODE (when possible) was administered following the above tests (within 4 weeks of the patient joining the study).Outcomes data and healthcare utilisation data at 12 weeksData on length of stay, institutionalisation, and mortality were recorded up to 12 weeks. Patient resource-use was derived from medical and social care records, where available, and if necessary via patient or carer self-report. In each case, records were retrieved or inspected in detail to extract the specified data. Standardised data collection forms were utilised, and were then entered into the main database Case Record Form. The optional self-report resource-use questionnaire, to be used if the required information was not available through the patient’s records, included questions on patient health and social care utilisation with a maximum recall period of 16 weeks. The self-report resource use questionnaire (Appendix 1) was developed for this study for use by patient or proxy-respondent using guidance from the Database of Instruments for Resource Use Measurement. ADDIN EN.CITE <EndNote><Cite><Author>Ridyard</Author><Year>2010</Year><RecNum>2766</RecNum><DisplayText><style face="superscript">158</style></DisplayText><record><rec-number>2766</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">2766</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ridyard, C. H.</author><author>Hughes, D. A.</author></authors></contributors><auth-address>Centre for Economics & Policy in Health, Institute of Medical and Social Care Research, Bangor University, Bangor, Gwynedd, UK.</auth-address><titles><title>Methods for the collection of resource use data within clinical trials: a systematic review of studies funded by the UK Health Technology Assessment program</title><secondary-title>Value Health</secondary-title></titles><pages>867-72</pages><volume>13</volume><number>8</number><edition>2010/10/16</edition><keywords><keyword>Biomedical Technology/*economics</keyword><keyword>Cost-Benefit Analysis</keyword><keyword>Economics, Pharmaceutical/*standards</keyword><keyword>Great Britain</keyword><keyword>Humans</keyword><keyword>Research Design/*standards</keyword><keyword>State Medicine</keyword></keywords><dates><year>2010</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>1524-4733 (Electronic)1098-3015 (Linking)</isbn><accession-num>20946187</accession-num><urls><related-urls><url>(11)71817-4 [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>158 If necessary, administration of the questionnaire was conducted at approximately 12 weeks by one of the researchers in the study team, face-to-face where patients are still hospitalised, or via telephone. Research staff and trainingResearchers were nurses or trained graduate clinical research associates. All underwent a systematic training process comprising three initial modules with reading material and videos covering (a) the patient and carer experience of delirium, (b) basic knowledge of the features of delirium, clinical diagnosis, and treatment approaches, and (c) specific coverage of delirium assessment, including cognitive testing, differentiating delirium from dementia, and the tools and tests used in the present study. These modules took 1-2 days each to complete. After these modules, researchers underwent face to face training with the Chief Investigator, and underwent role play practice and supervised bedside practice with hospitalised patients for the reference standard assessment (guided by and referring to the DRS-R98 manual ADDIN EN.CITE <EndNote><Cite><Author>Trzepacz</Author><Year>2001</Year><RecNum>1741</RecNum><DisplayText><style face="superscript">143</style></DisplayText><record><rec-number>1741</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">1741</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Trzepacz,P.T.</author><author> Mittal,D.</author><author> Torres,R.</author><author> Kanary,K.</author><author> Norton,J.</author><author> Jimerson,N.</author></authors></contributors><titles><title>Validation of the Delirium Rating Scale-revised-98: Comparison with the Delirium Rating Scale and the Cognitive Test for Delirium</title><secondary-title>Journal of Neuropsychiatry and Clinical Neurosciences</secondary-title></titles><pages>229-242</pages><volume>13</volume><number>2</number><keywords><keyword>cognitive</keyword><keyword>COGNITIVE TEST</keyword><keyword>consistency</keyword><keyword>delirium</keyword><keyword>DEMENTIA</keyword><keyword>depression</keyword><keyword>INTERRATER RELIABILITY</keyword><keyword>ITEM</keyword><keyword>longitudinal</keyword><keyword>longitudinal studies</keyword><keyword>longitudinal study</keyword><keyword>NEUROLOGY</keyword><keyword>PSYCHIATRY</keyword><keyword>RATING-SCALE</keyword><keyword>RELIABILITY</keyword><keyword>SCALE</keyword><keyword>SCHIZOPHRENIA</keyword><keyword>SCORES</keyword><keyword>SENSITIVITY</keyword><keyword>Sensitivity and Specificity</keyword><keyword>SEVERITY</keyword><keyword>SPECIFICITIES</keyword><keyword>SPECIFICITY</keyword><keyword>SYMPTOM</keyword><keyword>SYMPTOMS</keyword><keyword>VALIDATION</keyword></keywords><dates><year>2001</year></dates><isbn>0895-0172</isbn><urls></urls></record></Cite></EndNote>143) and the CAM (the latter training using instructions from the CAM training manual ADDIN EN.CITE <EndNote><Cite><Author>Inouye</Author><Year>2014</Year><RecNum>3554</RecNum><DisplayText><style face="superscript">136</style></DisplayText><record><rec-number>3554</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505388706">3554</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Inouye, S. K.</author></authors></contributors><titles><title>The Short Confusion Assessment Method (ShortCAM): Training Manual and Coding Guide.</title></titles><dates><year>2014</year></dates><pub-location>Boston</pub-location><publisher>Hospital Elder Life Program</publisher><urls></urls></record></Cite></EndNote>136). Researchers also underwent additional brief familiarisation sessions with the 4AT. Figure SEQ Figure \* ARABIC 2: Diagnostic accuracy study: overview flowchartAnalysis The detailed statistical analysis plan was agreed prior to database lock ADDIN EN.CITE <EndNote><Cite><Author>Shenkin</Author><Year>2017</Year><RecNum>3562</RecNum><DisplayText><style face="superscript">140</style></DisplayText><record><rec-number>3562</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505401722">3562</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shenkin, Susan D.</author><author>Fox, Christopher</author><author>Godfrey, Mary</author><author>Siddiqi, Najma</author><author>Goodacre, Steve</author><author>Young, John</author><author>Anand, Atul</author><author>Gray, Alasdair</author><author>Smith, Joel</author><author>Ryan, Tracy</author><author>Hanley, Janet</author><author>MacRaild, Allan</author><author>Steven, Jill</author><author>Black, Polly</author><author>Boyd, Julia</author><author>Weir, Christopher J.</author><author>MacLullich, Alasdair M. J.</author></authors></contributors><titles><title>Protocol for validation of the 4AT, a rapid screening tool for delirium: a multicentre prospective diagnostic test accuracy study</title><secondary-title>BMJ Open</secondary-title></titles><periodical><full-title>BMJ Open</full-title><abbr-1>BMJ open</abbr-1></periodical><dates><year>2017</year><pub-dates><date>3/17</date></pub-dates></dates><isbn>2044-6055</isbn><work-type>Article</work-type><urls></urls></record></Cite></EndNote>140, blinded to the randomised allocations. All analyses were performed by statisticians (JS, CW, VA). Methods: measures of diagnostic accuracyPrimary objective(a) We calculated positive and negative predictive values, sensitivity and specificity (with exact binomial 95% confidence interval) for 4AT versus delirium reference standard. We constructed a receiver operating characteristic (ROC) curve– and reported area under the curve and 95% confidence intervals to verify the appropriateness of the cut point of great than 3 on the 4AT score (this cut-point was used as it was specified in the original tool design).Secondary objectives(a) 4AT vs CAM: we estimated the differences in proportions (4AT – CAM) and its 95% confidence interval for each of sensitivity, specificity, positive and negative predictive values. Statistical significance of differences was assessed using Fisher’s exact test. The overall performance of 4AT and CAM were each summarised using Youden’s Index (sensitivity minus false positive rate) and the diagnostic odds ratio of sensitivity to specificity. (b) 4AT as a screen for general cognitive impairment: 4AT as index test with history of dementia and/or the Informant Questionnaire for Cognitive Decline in the Elderly as reference standard? (c) 4AT vs clinical outcomes: Descriptive statistics of clinical outcomes (length of stay, institutionalisation, and mortality) were calculated for the groups with and without 4AT scores above the cut point of 3. Logistic regression modelling was used to predict mortality and institutionalisation; Kaplan-Meier curves and Cox proportional hazards models were used to predict hospital length of stay. Logistic regression and Cox models also adjusted for age, gender and the presence of dementia(d) Individual items of the 4AT: individual items were investigated as a predictor of delirium diagnosis using the same methods as for the primary objective.(e) Delirium severity: The Spearman correlation and its 95% confidence interval were calculated between the total 4AT and DRS-R98 scores.Subgroup analysesPredefined subgroup analyses of measures of diagnostic accuracy for the primary objective and secondary objective (A) were performed to determine the impact of (i) time from presentation to recruitment before or after 4h (ED) or 24h (medical admissions), (ii) time between index test and reference standard less or more than 30 minutes. Sensitivity analyses Predefined sensitivity analyses of the primary objective and secondary objective (A) were performed where the reference standard was indeterminate. In turn, delirium was classified as being present, and then absent. Post hoc sensitivity analysis was also performed using the reference standard DRS-98 classification recorded at the time of the original bedside by the researchers, rather than the Chief Investigator consensus adjudicated assessment. A further post-hoc sensitivity analysis assumed that any patients with a missing result for the index test (4AT or CAM) had delirium. Missing dataIndividuals with missing data for the reference diagnostic test, CAM or 4AT were removed from formal statistical analysis. If items of the CAM or 4AT could not be assessed, an overall delirium diagnosis was derived where possible based on recorded items. There was no other imputation of missing delirium diagnoses. Individuals with missing data on an outcome variables were omitted from the analysis of that outcome. ResultsDescriptive statistics4928 patients were eligible, from whom 843 individuals (17.2%) were randomised across the three sites, and two withdrew, leaving 841 with data for analysis (Figure 3).The initial DRS-98 informed reference standard identified 96 (11.7%) as delirium present, and 723 (88.3%) as delirium absent (22 missing due to study withdrawal (n=18), discharged home (n=3), patient request (n=1)). Final delirium ascertainment by the consensus group reclassified 7 from delirium present to absent, and 17 from delirium absent to present. 32 were classified as indeterminate, and therefore excluded from analyses (and two additional records were excluded because of an incomplete assessment which was interrupted for clinical reasons, and because of an error in which researchers completed which part of the assessment resulting in an overall invalid assessment). Therefore analyses were performed on n=785, delirium present = 95 (12.1%), absent = 690 (87.9%). Descriptive data are presented in Table 7. Participants tested in Edinburgh n=372 (4AT n=187; CAM n=185, could not assess CAM score n=3); Sheffield n=125 (4AT n= 64; CAM n=61; missing 4AT n= 2); Bradford n = 279 (4AT n=141; CAM n=138; could not assess CAM n=2; missing 4AT n=1). Only a minority of IQCODE questionnaires were completed, with most (78%) unavailable.86241421600Figure SEQ Figure \* ARABIC 3: STARD diagram of flow of participants through the study (total across all three sites)Table SEQ Table \* ARABIC 7. Baseline characteristics stratified by delirium statusTotal (N=785)Delirium Present (N=95)Delirium Absent (N=690)P-valueAge?(Years)Mean (SD)81.4 (6.4)83.5 (6.9)81.1 (6.3)0.0007Median [Q1-Q3]81.0 [77.0-86.0]84.0 [78.0-89.0]81.0 [77.0-86.0]GenderMale349 (44.5%)34 (35.8%)315 (45.7%)0.0697Female436 (55.5%)61 (64.2%)375 (54.3%)Ethnicity*White773 (98.5%)91 (95.8%)682 (98.8%)0.0463Mixed or Multiple Ethnic Groups2 (0.3%)1 (1.1%)1 (0.1%)Asian, Asian Scottish or Asian British5 (0.6%)1 (1.1%)4 (0.6%)African1 (0.1%)0 (0.0%)1 (0.1%)Caribbean or Black4 (0.5%)2 (2.1%)2 (0.3%)Dementia?Diagnosis**Missing1 (.)0 ()1 (.)<0.0001Yes71 (9.1%)25 (26.3%)46 (6.7%)No713 (90.9%)70 (73.7%)643 (93.3%)IQCODE?>=3.44**Missing613 (.)56 (.)557 (.)<0.0001Yes70 (40.7%)29 (74.4%)41 (30.8%)No102 (59.3%)10 (25.6%)92 (69.2%)Location?of?First?AssessmentEmergency Department53 (6.8%)10 (10.5%)43 (6.2%)0.2624Acute Unit665 (84.7%)76 (80.0%)589 (85.4%)Hospital Ward67 (8.5%)9 (9.5%)58 (8.4%)Numbers?are?n(%)?or?mean?(SD).P-value?from?chi-squared?(categorical?variables)?or?t-test?(continuous).*P-value?from?Fisher's?exact?test?of?white?versus?other?ethnicity.**Missing?category?not?included?in?chi-squared?test.Primary objectiveDiagnostic test accuracy of 4ATOverall delirium prevalence as determined by the reference standard was 12.1% (n=95 of 785). Table 8 provides a cross-tabulation of the index test results. Reference standard delirium prevalence in the n=392 who had a valid 4AT assessment was 12.5% (n=49). The main diagnostic test accuracy tests are shown in Table 9. The area under the receiver operating characteristic (ROC) curve across all cutpoints on the 4AT was 0.90 (95% CI 0.84-0.96)(Appendix 10). Table SEQ Table \* ARABIC 8. Cross tabulation of index test results (4AT and CAM) by results of reference standardDelirium presentDelirium absentTotal4AT4AT score >337 (75.5%)19 (5.5%)56 (14.3%)4AT score <=312 (24.5%)324 (96.5%)336 (85.7%)Missing 4AT033CAMCAM-delirium17 (37.0%)1 (0.3%)18 (4.8%)CAM-no delirium25 (54.3%)341 (99.4%)366 (94.1%)Could not assess CAM4 (8.7%)1 (0.3%)5 (1.3%)Missing CAM011Numbers are n (%)Table SEQ Table \* ARABIC 9. Diagnostic test accuracy of 4AT for diagnosis of delirium (defined by reference standard assessment)SensitivitySpecificityPPVNPVAUC*4AT (>3)75.51% (61.13%,86.66%)94.46% (91.48%,96.63%)66.07% (52.19%,78.19%)96.43% (93.84%,98.14%)0.895Numbers?are?estimate?(95%?CI).Abbreviations:?CI,?confidence?interval;?PPV,?positive?predictive?value;?NPV,?negative?predictive?value;AUC,?area?under?receiver?operating?characteristic?curve.*AUC?refers?to?overall?area?under?the?curve?across?all?cut-points?on?the?4AT.Secondary objectives(a) Comparison between 4AT and CAMIn the n=384 who had a valid CAM, the prevalence of delirium was 10.9% (n=42) as assessed by the reference standard. Delirium prevalence using the 4AT only as a diagnostic test was 14.3% (n=56) and for CAM only as a diagnostic test was 4.8% (n=18).The CAM had a sensitivity of 40% (95% CI 27% to 57%) and a specificity of 100% (95% CI 98% to 100%) in the subset of participants in whom it was assessable. Youden’s Index of the CAM was 0.40 and of the 4AT was 0.70. The odds ratio of sensitivity to specificity for the CAM was 232 (95% CI 30 to 1812); for the 4AT it was 53 (95% CI 24 to 117).(b)4AT items as a predictor of general cognitive impairmentThe AMT4 and attention items of the 4AT showed high specificity but low sensitivity, high negative predictive value, but low positive predictive value, for a diagnosis of dementia (Tables 10 and 11). All patients were included in this analysis, regardless of delirium status.Table SEQ Table \* ARABIC 10. Individual components of 4AT cognitive items stratified by dementia status, defined as a documented history of dementia and/or a score of >=3.44 on the IQCODEDementia PresentDementia AbsentTotalAMT4Missing0 (.)3 (.)3 (.)No Mistakes15 (31.9%)287 (83.2%)302 (77.0%)1 Mistake10 (21.3%)47 (13.6%)57 (14.5%)2 Mistakes22 (46.8%)11 (3.2%)33 (8.4%)AttentionMissing0 (.)3 (.)3 (.)Achieves 7 months or more correctly12 (25.5%)273 (79.1%)285 (72.7%)Starts but scores <7 months / refuses to start24 (51.1%)65 (18.8%)89 (22.7%)Untestable11 (23.4%)7 (2.0%)18 (4.6%)Numbers?are?n(%)See Table 5 for details of 4AT scoring.ScoresSensitivitySpecificityPPVNPVYouden's IndexAMT4 (1 or 2 versus 0)68.09% (52.88%,80.91%)83.19% (78.82%,86.98%)35.56% (25.74%,46.35%)95.03% (91.94%,97.19%)0.51AMT4 (2 versus 1 or 0)46.81% (32.11%,61.92%)96.81% (94.37%,98.40%)66.67% (48.17%,82.04%)93.04% (89.89%,95.44%)0.44Attention (1 or 2 versus 0)74.47% (59.65%,86.06%)79.13% (74.46%,83.30%)32.71% (23.95%,42.45%)95.79% (92.76%,97.81%)0.54Attention (2 versus 1 or 0)23.40% (12.30%,38.03%)97.97% (95.86%,99.18%)61.11% (35.75%,82.70%)90.37% (86.92%,93.17%)0.21Numbers?are?estimate?(95%?CI).Abbreviations:?CI,?confidence?interval;?PPV,?positive?predictive?value;?NPV,?negative?predictive?value;Youden's?Index?is?equal?to?sensitivity+specificity-1,?a?value?of?zero?indicates?no?value,?and?a?value?of?1indicates?a?perfect?test.See Table 5 for details of 4AT scoring.Table SEQ Table \* ARABIC 11. Diagnostic test accuracy of 4AT cognitive components for diagnosis of dementia, defined as a documented history of dementia and/or a score of >=3.44 on the IQCODE(c)Diagnostic test accuracy of individual items of the 4AT for diagnosis of deliriumA score of 4 on Item 1 (abnormal alertness, scored either as 0 if the patient had normal alertness, or 4 if the patient had abnormal alertness) had a sensitivity of 31%, 95% CI 18% to 45%) and a specificity of 99% (95% CI 98% to 100%). Item 2 is the Abbreviated Mental Test – 4, in which patients are asked to state their date of birth, their age, the current year, and the place that they are currently in). Two or more errors (including untestable status)on this item, giving a score of 2, had a sensitivity of 41% (95% CI 27% to 56%) and a specificity of 96% (95% CI 94% to 98%) compared to one or no errors. One or more errors (including untestable status), giving a score of 1 or 2, had a sensitivity of 63% (95% CI 48% to 77%) and a specificity of 83% (95% CI 78% to 87%) compared to no errors.An Item 3 (Months Backwards test) score of 1 or 2, indicating that the patient was able to start reciting the months of the year backwards but not able to reach seven months correctly in sequence, or that they were able to convert but refused to do the test or were ‘untestable’, gave a sensitivity of 71% (95% CI 57% to 83%), and a specificity of 79% (95% CI 74% to 83%). A score of 2, indicating that the patient was ‘untestable’ had identical performance to that of Item 1. This is likely because a score of 2 on Item 3 is given when the patient is ‘untestable’, and in most cases this score is given when the patient is unable to respond because of altered arousal. Item 4 (acute change or fluctuating course) showed a sensitivity of 76% (95% CI 61% to 87%), and a specificity of 96% (95% CI 93% to 98%). These results are almost identical to the overall performance of the 4AT. None of other individual items of the 4AT showed good diagnostic test accuracy alone. These results indicate that, in this study, virtually all positive cases on the 4AT had a positive Item 4 (acute change or fluctuating course). The full results of the diagnostic test accuracy for the individual items are show in Appendix 11.(d)Delirium severityThe 4AT score correlated moderately (Spearman correlation coefficient 0.57 (95% CI 0.50 to 0.63) with the DRS-98 total score as a measure of delirium severity (See Appendix 12 for scatterplot).(e)OutcomesMortality was higher in patients with positive 4AT scores: 16.1% of those with 4AT>3 had died by 12 week follow up, compared to 9.2% of those with 4AT<=3, odds ratio higher at 2.00 (95% CI 0.85 to 4.70). The median length of stay was longer in patients with 4AT >3 (median 5 [IQ range 2.0 to 14.0] days) than those with 4AT<=3 (median 2 [IQR 1.0 to 6.0], P=0.0009), with a hazard ratio of time to discharge of 0.64 (95% CI 0.46 to 0.88). Patients with 4AT>3 had significantly greater length of stay and increased mortality than those with 4AT<=3 (Table 12; Kaplan Meier Plot in Appendix 13), adjusted for age, gender and dementia status. Numbers newly admitted to institutions within the 12-week period of analysis were too small to allow analysis.Table SEQ Table \* ARABIC 12. 4AT as a predictor of clinical outcomes4AT <=34AT >3Nn(%) or Median[Q1-Q3]Nn(%) or Median[Q1-Q3]TotalP-valueEffect (95% CI)*Length of Stay (days)3352.0 [1.0-6.0]555.0 [2.0-14.0]3.0 [1.0-7.0]0.00090.64 (0.46-0.88)Mortality33631 (9.2%)569 (16.1%)40 (10.2%)0.02612.00 (0.85-4.70)Institutionalisation2062 (1.0%)341 (2.9%)3 (1.3%)Abbreviations:?n,?number;?Q,?quartile;?CI,?confidence?interval.P-value?from?assessing?association?between?clinical?outcomes?and?total?4AT?score(Spearman?correlation/Mann-Whitney?Test).Cox?proportional?hazards?model?for?length?of?stay?(calculated?as?time?from?presentation?to?discharge,censored?at?12?week?follow-up?or?death)to?estimate?Hazard?Ratio?and?95%?CI.Logistic?regression?model?for?mortality?to?estimate?Odds?Ratio?and?95%?CI.Hazard?ratios?and?Odds?ratios?calculated?for?4AT?>3?versus?4AT<=3.?An?odds?ratio?greater?than?1?indicatesan?increase?in?the?odds?of?death.?A?hazard?ratio?of?less?than?1?is?a?negative?outcome,indicating?an?increased?time?to?discharge.No?analyses?performed?for?institutionalisation?due?to?amount?of?missing?data.*Adjusted?for?age,?gender?and?dementia?status.Subgroup analyses(i) Time from presentation to recruitment before or after 4h in ED or 24h in medical admissions There was no statistically significant difference in the diagnostic test accuracy of the 4AT between those recruited early and those recruited later after initial presentation. (Fisher’s Exact Test p-values: sensitivity p=0.19, specificity p=0.75, PPV p=0.47, NPV p=0.24).(ii) Time between index test and reference standard less or more than 30 minutes The proportion of participants assessed as delirium positive with a gap between index test and reference standard of less than 30 minutes was higher than at those assessed with a gap of more than 30 minutes, but there was no statistically significant difference in performance of either test between early and late assessment (Fisher’s Exact Test p-values: sensitivity p=0.16, specificity p=0.24, PPV p=1.00, NPV p=0.56).Post-hoc sensitivity analysesMissing index test:If delirium was scored as present where the index test result was missing, this did not substantially alter the diagnostic test accuracy of the 4AT or CAM. For the 4AT, the sensitivity was 76% (95% CI 61-87%), and the specificity 94% (95% CI 9149-964%). For the CAM, the sensitivity was 46% (95% CI 3146-6199%), and the specificity was 99% (95% CI 97-100%).Using the researcher reference standard as the DRS-98 classification, not the Chief Investigator adjudicated classification. If the DRS-R98 classification as performed by the researchers doing the reference delirium assessments was used as the reference standard, the sensitivity of the 4AT increased to 83% (95% CI 70-93) with little change in the specificity at 94% (95% CI 91-96%). The sensitivity (40% (95% CI 25-56%)) and specificity (99% (95% CI 98-100%) of the CAM did not change materially. DiscussionThe main objective of this study was to assess the diagnostic accuracy of the 4AT against a reference standard assessment. The main findings were that the 4AT showed reasonable sensitivity (76%), and high specificity (95%). The area under the curve was high at 0.90. The CAM showed lower sensitivity than the 4AT, at 40%. The specificity of the CAM was close to 100%. The cognitive test items of the 4AT did show some relationship with general cognitive impairment as ascertained in the reference standard assessment by a documented prior diagnosis of dementia and/or positive IQCODE score. However, the pattern of results was that these items had high specificity but moderate-good sensitivity, suggesting that an overall 4AT score of 1-3 (resulting from combinations of positive scores in the AMT4 and Attention items) should raise concern about the possibility of general cognitive impairment, but does not exclude such impairment. These findings are broadly consistent with those reported in a recent study. ADDIN EN.CITE <EndNote><Cite><Author>O'Sullivan</Author><Year>2017</Year><RecNum>3696</RecNum><DisplayText><style face="superscript">57</style></DisplayText><record><rec-number>3696</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1513180986">3696</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>O'Sullivan, D.</author><author>Brady, N.</author><author>Manning, E.</author><author>O'Shea, E.</author><author>O'Grady, S.</author><author>O. ' Regan N</author><author>Timmons, S.</author></authors></contributors><auth-address>Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland.Mercy University Hospital, Cork, Ireland.</auth-address><titles><title>Validation of the 6-Item Cognitive Impairment Test and the 4AT test for combined delirium and dementia screening in older Emergency Department attendees</title><secondary-title>Age Ageing</secondary-title></titles><periodical><full-title>Age Ageing</full-title></periodical><pages>1-7</pages><keywords><keyword>delirium</keyword><keyword>dementia</keyword><keyword>emergency department</keyword><keyword>older people</keyword><keyword>screening</keyword></keywords><dates><year>2017</year><pub-dates><date>Sep 1</date></pub-dates></dates><isbn>1468-2834 (Electronic)0002-0729 (Linking)</isbn><accession-num>28985260</accession-num><urls><related-urls><url> The bedside assessment items in the 4AT (Items 1-3) individually showed varying relationships with reference standard diagnosis, with the majority showing relatively low sensitivity and relatively high specificity. Scores on the 4AT were moderately correlated with the DRS–R98 severity score. Although the 4AT was not designed to assess severity, this analysis was included to determine if useful clinical information about delirium severity could be derived from 4AT scores. These results indicate that higher scores, which are generated in the presence of altered arousal and/or worse cognitive impairment, may to some extent indicate worse severity. The final secondary objective was to examine the relationship between 4AT scores and outcomes. Consistent with prior studies linking the presence of delirium with poor outcomes, positive 4AT scores were significantly associated with increased length of stay and mortality. The number of patients recorded as being institutionalised within the 12-week study period was small and did not permit formal analysis.At the time that the present study was commenced, there were two published diagnostic accuracy studies of the 4AT.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWVzPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA 52, 53 It was already in use in multiple centres, and initial clinical service evaluation reports provided informal feedback that the 4AT was considered useful in practice. Since the commencement of the present study, further external studies of the diagnostic accuracy of the 4AT have been published.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5JbmZhbnRlPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48

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ADDIN EN.CITE.DATA 54-56, 58, 138 The findings of the present study are broadly consistent with existing published studies, albeit with the present findings showing somewhat lower sensitivity and higher specificity than these published studies. The clinical use of the 4AT has continued to increase, with some centres reporting more than 10,000 uses of the tool (see Chapter 3). The website has had an increasing traffic, and the 4AT has been translated into multiple languages. The 4AT is also included in several national guidelines and position statements nationally and internationally. Diagnostic accuracy studies of delirium tools vary in multiple ways, and these differences can potentially affect the findings. Differences include the population studied, the stage of the admission at which the assessment was done, the inclusion and exclusion criteria (especially whether patients with reduced arousal are included or not with many studies excluding patients unable to communicate verbally ADDIN EN.CITE <EndNote><Cite><Author>Marcantonio</Author><Year>2014</Year><RecNum>3429</RecNum><DisplayText><style face="superscript">159</style></DisplayText><record><rec-number>3429</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1455035504">3429</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Marcantonio, E. R.</author><author>Ngo, L. H.</author><author>O'Connor, M.</author><author>Jones, R. N.</author><author>Crane, P. K.</author><author>Metzger, E. D.</author><author>Inouye, S. K.</author></authors></contributors><titles><title>3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium: a cross-sectional diagnostic test study</title><secondary-title>Ann Intern Med</secondary-title><alt-title>Annals of internal medicine</alt-title></titles><periodical><full-title>Ann Intern Med</full-title><abbr-1>Annals of internal medicine</abbr-1></periodical><alt-periodical><full-title>Ann Intern Med</full-title><abbr-1>Annals of internal medicine</abbr-1></alt-periodical><pages>554-61</pages><volume>161</volume><number>8</number><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Algorithms</keyword><keyword>Confusion</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Delirium/*diagnosis</keyword><keyword>Female</keyword><keyword>Hospitalization</keyword><keyword>Humans</keyword><keyword>Interviews as Topic</keyword><keyword>Male</keyword><keyword>*Neuropsychological Tests</keyword><keyword>Reproducibility of Results</keyword><keyword>Sensitivity and Specificity</keyword></keywords><dates><year>2014</year><pub-dates><date>Oct 21</date></pub-dates></dates><isbn>1539-3704 (Electronic)0003-4819 (Linking)</isbn><accession-num>25329203</accession-num><urls><related-urls><url>), and the reference standard used. The latter is likely an underestimated source of difference among studies. Neufeld and colleaguesPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OZXVmZWxkPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48

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ADDIN EN.CITE.DATA 160 found surprising variability in delirium reference standard assessments used in diagnostic accuracy studies of shorter delirium assessment tools. Some studies simply stated that the delirium reference standard was performed according to a standardised set of criteria such as DSM-IV, without providing any other information as to how this was achieved; other studies provided much more detail as to how the reference standard assessment was performed. Notably, many reference standard assessments in published studies did not use cognitive testing as part of the assessment process.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OZXVmZWxkPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48

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ADDIN EN.CITE.DATA 160 In the present study the reference standard used a standardised process which incorporated the best-validated detailed delirium assessment instrument, the DRS–R98, supplemented by several cognitive tests. The researcher performing the assessment gave an initial judgement as to the presence or absence of delirium according to DSM-IV following both the consenting process and the reference standard assessment (because the researcher doing the reference standard assessment was always the one who had performed the consenting). However, the final delirium ascertainment in all cases was performed by the chief investigator in combination with two other members of the study team based on the recorded findings of the DRS–R98 items and the cognitive tests and any notes from the assessors. This was to help ensure consistency of approach. The sensitivity of the 4AT was higher (83%) against the researcher assessment of delirium present or absent than the final delirium ascertainment (76%), with little difference in the specificities. It is possible that the researcher’s impression of delirium present or absent created a different sensitivity with respect to the 4AT because the objective assessments recorded in the reference standard did not fully capture other elements of the researcher’s interaction with the patient, including the consenting process. Indeed the researcher’s assessment might more closely reflect clinical practice than making a judgement based on remote inspection of cognitive test data. However, to some extent all delirium reference standard assessments involve arbitrary judgements as to thresholds for positivity on given features. Studies have shown that the prevalence of delirium in a given study varies according to how reference standard assessments are performed,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWFnaGVyPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48

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ADDIN EN.CITE.DATA 146 and notably the official diagnostic criteria themselves have changed over time ADDIN EN.CITE <EndNote><Cite><Author>Neufeld</Author><Year>2015</Year><RecNum>3577</RecNum><DisplayText><style face="superscript">161</style></DisplayText><record><rec-number>3577</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505570450">3577</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Neufeld, K. J.</author></authors></contributors><auth-address>Department of Psychiatry and Behavioral Sciences,Johns Hopkins University,Baltimore,USAEmail:kneufel2@jhmi.edu.</auth-address><titles><title>Delirium classification by the Diagnostic and Statistical Manual - a moving target</title><secondary-title>Int Psychogeriatr</secondary-title></titles><periodical><full-title>Int Psychogeriatr</full-title><abbr-1>International psychogeriatrics / IPA</abbr-1></periodical><pages>881-2</pages><volume>27</volume><number>6</number><keywords><keyword>Aged</keyword><keyword>Cognition Disorders/diagnosis</keyword><keyword>Delirium/*classification/diagnosis/psychology</keyword><keyword>*Diagnostic and Statistical Manual of Mental Disorders</keyword><keyword>Humans</keyword><keyword>Neuropsychological Tests</keyword></keywords><dates><year>2015</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1741-203X (Electronic)1041-6102 (Linking)</isbn><accession-num>25921878</accession-num><urls><related-urls><url> and when compared show different prevalences of delirium in the same populations.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWFnaGVyPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48

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ADDIN EN.CITE.DATA 146, 162-164 Therefore, given the sources of variability in diagnostic accuracy studies, it is reasonable to conclude that the present findings are broadly consistent with other studies of the 4AT, and thus that its use in clinical practice continues to be supported by the evidence base. The caveat with all such brief tools, however, is that they do not provide a diagnosis, and clinical judgement by a suitably qualified practitioner is always required. As judged against the reference standard used in the present study, the 4AT showed a sensitivity of 76%. Against this standard, some 4AT assessments resulted in false negatives. The consequences of false negatives with respect to delirium could include a failure to investigate and treat the acute causes of delirium. Another consequence is that the lack of a diagnosis means that inaccurate information is provided to patients and families. The implications of these findings are that staff involved in delirium screening involving the 4AT should be informed that the 4AT is a rapid assessment tool that may not always detect reference standard delirium, and that clinical judgement is required alongside use of the tool. The specificity of the 4AT was high in the present study (as judged against the reference standard). This means that the rate of false positives was low. A false positive delirium diagnosis can lead to unnecessary investigations and sometimes treatments (for example, the presence of delirium may alter the threshold at which treatment for possible infection is initiated). Additionally, a false positive diagnosis would lead to inaccurate information being given to patients and carers. Again, the implication of this is that staff need to use screening or assessment tools with the awareness that they do not provide a definitive diagnosis, and that judgement by a clinician of appropriate expertise is needed to provide this diagnosis.The 4AT includes some general cognitive testing items, the AMT4 and the Months Backwards test. Individually, these short tests have some scientific literature supporting their use as brief cognitive tests, albeit with mixed sensitivities and specificities across studies.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYXJlPC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA 56, 94, 148, 165-168 The present findings provide some support, albeit non-definitive, for the validity of these tests as indicators of general cognitive impairment including dementia. However, though as with the 4AT as a whole, in clinical practice further assessment is required before firm conclusions can be drawn. A further caveat is that in acute populations, even in the absence of delirium, there is often a degree of reversible cognitive dysfunction, ADDIN EN.CITE <EndNote><Cite><Author>Inouye</Author><Year>2006</Year><RecNum>753</RecNum><DisplayText><style face="superscript">169</style></DisplayText><record><rec-number>753</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">753</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Inouye,S.K.</author><author> Zhang,Y.</author><author> Han,L.</author><author> Leo-Summers,L.</author><author> Jones,R.</author><author> Marcantonio,E.</author></authors></contributors><titles><title>Recoverable cognitive dysfunction at hospital admission in older persons during acute illness</title><secondary-title><style face="normal" font="System" size="100%">Journal of General Internal Medicine</style></secondary-title></titles><pages>1276-1281</pages><volume>21</volume><number>12</number><keywords><keyword>ACUTE ILLNESS</keyword><keyword>ADMISSION</keyword><keyword>cognitive</keyword><keyword>COGNITIVE DYSFUNCTION</keyword><keyword>DYSFUNCTION</keyword><keyword>hospital</keyword><keyword>ILLNESS</keyword><keyword>OLDER</keyword><keyword>OLDER PERSONS</keyword></keywords><dates><year>2006</year></dates><isbn>0884-8734</isbn><urls></urls></record></Cite></EndNote>169 which limits the interpretability of cognitive tests in the acute setting in relation to chronic cognitive impairment.In this study the CAM showed low sensitivity and very high specificity. At 40%, the sensitivity was lower than in most published studies, though some studies have also shown low sensitivities. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qb21wZWk8L0F1dGhvcj48WWVhcj4xOTk1PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 126, 129-131, 134 There are many possible reasons for the low sensitivity found in the present study. All research staff were trained in use of the CAM, but none was medically qualified. Prior studies have sometimes found that professional background does affect the sensitivity of the CAM. ADDIN EN.CITE <EndNote><Cite><Author>Inouye</Author><Year>2001</Year><RecNum>751</RecNum><DisplayText><style face="superscript">134</style></DisplayText><record><rec-number>751</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">751</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Inouye,S.K.</author><author> Foreman,M.D.</author><author> Mion,L.C.</author><author> Katz,K.H.</author><author> Cooney,L.M.</author></authors></contributors><titles><title>Nurses' recognition of delirium and its symptoms - Comparison of nurse and researcher ratings</title><secondary-title><style face="normal" font="System" size="100%">Archives of Internal Medicine</style></secondary-title></titles><pages>2467-2473</pages><volume>161</volume><keywords><keyword>ACUTE CONFUSIONAL STATES</keyword><keyword>AGE</keyword><keyword>cognitive</keyword><keyword>cognitive testing</keyword><keyword>CONFUSION</keyword><keyword>CONFUSION ASSESSMENT METHOD</keyword><keyword>delirium</keyword><keyword>DEMENTIA</keyword><keyword>DIAGNOSIS</keyword><keyword>DILEMMA</keyword><keyword>EDUCATION</keyword><keyword>ELDERLY MEDICAL PATIENTS</keyword><keyword>FEATURES</keyword><keyword>IMPAIRMENT</keyword><keyword>MINI-MENTAL STATE</keyword><keyword>NUMBER</keyword><keyword>OLDER</keyword><keyword>RATINGS</keyword><keyword>RATIO</keyword><keyword>RECOGNITION</keyword><keyword>RISK</keyword><keyword>RISK FACTOR</keyword><keyword>risk factors</keyword><keyword>RISK-FACTORS</keyword><keyword>SENSITIVITY</keyword><keyword>SPECIFICITIES</keyword><keyword>SPECIFICITY</keyword><keyword>SYMPTOM</keyword><keyword>SYMPTOMS</keyword><keyword>vision</keyword></keywords><dates><year>2001</year></dates><urls></urls></record></Cite></EndNote>134 Professional background might have a tendency to affect the degree of overall exposure to delirium and also the familiarity with the process of making a formal diagnosis in clinical practice, with a relative minority of non-medically qualified professionals having experience of this. The low sensitivity did not appear to be related to practice in a particular site, because the sensitivity was low in all three sites (though the overall number of cases of delirium diagnosed using the reference standard in one site (Sheffield) was low and thus it is difficult to draw a conclusion from these numbers alone). We found that virtually all of the positive 4AT scores that were aligned with the positive reference standard diagnosis were positive for Item 4 (acute onset or fluctuating course). This may partly be an artefact of the research process, because patients with a score of 4 on Item 1, and/or a combined score of 4 from Items 2 and 3, would be more likely to lack capacity to provide consent. Therefore, such patients would have had consent from a legal proxy, and that proxy would have likely have provided information informing Item 4. Patients with a positive 4AT score arising from Items 1, and/or 2 and 3, would likely not have been recruited into this study without involvement of a legal proxy. This situation differs from clinical practice, in that informant history is not present in a substantial minority of patients, especially in the very early stages of the assessment period. ADDIN EN.CITE <EndNote><Cite><Author>Hendry</Author><Year>2016</Year><RecNum>3552</RecNum><DisplayText><style face="superscript">56</style></DisplayText><record><rec-number>3552</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505376908">3552</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hendry, K.</author><author>Quinn, T. J.</author><author>Evans, J.</author><author>Scortichini, V.</author><author>Miller, H.</author><author>Burns, J.</author><author>Cunnington, A.</author><author>Stott, D. J.</author></authors></contributors><auth-address>Glasgow Royal Infirmary, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.Department of Medical Sciences and Community Health, University of Milan, Milan, Italy.Department of Medicine for the Elderly, Glasgow Royal Infirmary, Glasgow, UK.Greater Glasgow and Clyde NHS-Geriatrics, Glasgow, UK.</auth-address><titles><title>Evaluation of delirium screening tools in geriatric medical inpatients: a diagnostic test accuracy study</title><secondary-title>Age Ageing</secondary-title></titles><periodical><full-title>Age Ageing</full-title></periodical><pages>832-837</pages><volume>45</volume><number>6</number><keywords><keyword>acute care</keyword><keyword>cognitive impairment</keyword><keyword>delirium</keyword><keyword>dementia</keyword><keyword>geriatrics</keyword><keyword>older people</keyword></keywords><dates><year>2016</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1468-2834 (Electronic)0002-0729 (Linking)</isbn><accession-num>27503794</accession-num><urls><related-urls><url> The 4AT was designed to allow for a positive score based on bedside assessment alone, but in the present study the consenting process meant that that situation was unlikely to arise.The present study found a moderate correlation between total 4AT score and the DRS–R98. The 4AT scoring system was not designed to be linear; rather it was designed to have a threshold which can be crossed by three different means: a positive score on the binary level of alertness item (Item 1), or a combination of worse scores or untestability on Item 2 (abbreviated mental test – four) plus untestability on Item 3, or a positive score on the binary acute change or fluctuating course Item 4. Nevertheless, it is reasonable to assume that worse scores on Items 1-3 do reflect to some extent a more severe syndrome. Indeed, some scales measuring delirium severity such as the Memorial Delirium Assessment Scale ADDIN EN.CITE <EndNote><Cite><Author>Breitbart</Author><Year>1997</Year><RecNum>187</RecNum><DisplayText><style face="superscript">170</style></DisplayText><record><rec-number>187</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">187</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Breitbart,W.</author><author> Rosenfeld,B.</author><author> Roth,A.</author><author> Smith,M.J.</author><author> Cohen,K.</author><author> Passik,S.</author></authors></contributors><titles><title>The Memorial Delirium Assessment Scale</title><secondary-title><style face="normal" font="System" size="100%">Journal of Pain and Symptom Management</style></secondary-title></titles><periodical><full-title>Journal Of Pain And Symptom Management</full-title></periodical><pages>128-137</pages><volume>13</volume><number>3</number><keywords><keyword>ASSESSMENT SCALE</keyword><keyword>delirium</keyword><keyword>SCALE</keyword></keywords><dates><year>1997</year></dates><urls></urls></record></Cite></EndNote>170 and the Confusion Assessment Method – Severity (CAM-S) scale,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Jbm91eWU8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 171 assess the extent of the level of arousal change and degree of cognitive impairment. The present findings do not suggest that the 4AT can replace more formal assessments of delirium severity, but clinicians may find it useful to use information beyond the binary interpretation of delirium likely present or absent that the threshold score of 3/4 in the 4AT provides.Delirium is known to be associated with worse outcomes including length of stay, new institutionalisation, and mortality.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Jbm91eWU8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 8 In the present study, 4AT positive scores were associated with increased length of stay, and mortality at 12 weeks (though the latter note after adjustment for confounders). These findings provide some validation for the 4AT as an indicator of delirium. This study had a number of limitations which should be acknowledged. Recruitment proved challenging, with only 17% of those eligible consented. This likely meant that the recruited sample did not fully reflect the target population. The sample was mostly white, with very limited representation from other ethnic groups. We recruited under the target of 900, and numbers were further affected by the exclusion of some patients with indeterminate reference standard results, though the performance of 4AT and CAM was still estimated with acceptable precision. The prevalence of delirium in patients aged 70 or above at the early stages of hospital admission likely ranges from 10 to 20%.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaWRkaXFpPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48

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ADDIN EN.CITE.DATA 3, 172, 173 In the present study, according to the final reference standard ascertainment the prevalence of delirium was 12%. This prevalence is likely slightly lower than in the target population; however, the difference is small, and arguably does not substantially affect clinical generalisability. The study was performed in three different sites. Although this provides several advantages, it also means that there is the possibility of increased variability in how patients were recruited and the index assessments and reference standards were performed. In one site (Sheffield), the rates of delirium were low, likely reflecting the challenges associated with the target population that were predominantly in the Emergency Department in that site. It should also be acknowledged that given the fluctuating nature of delirium, the gap between assessments potentially reaching two hours means that assessments could have different findings. We used the CAM as a comparator, but shorter alternatives to the CAM, such as the 3D-CAM ADDIN EN.CITE <EndNote><Cite><Author>Marcantonio</Author><Year>2014</Year><RecNum>3429</RecNum><DisplayText><style face="superscript">159</style></DisplayText><record><rec-number>3429</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1455035504">3429</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Marcantonio, E. R.</author><author>Ngo, L. H.</author><author>O'Connor, M.</author><author>Jones, R. N.</author><author>Crane, P. K.</author><author>Metzger, E. D.</author><author>Inouye, S. K.</author></authors></contributors><titles><title>3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium: a cross-sectional diagnostic test study</title><secondary-title>Ann Intern Med</secondary-title><alt-title>Annals of internal medicine</alt-title></titles><periodical><full-title>Ann Intern Med</full-title><abbr-1>Annals of internal medicine</abbr-1></periodical><alt-periodical><full-title>Ann Intern Med</full-title><abbr-1>Annals of internal medicine</abbr-1></alt-periodical><pages>554-61</pages><volume>161</volume><number>8</number><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Algorithms</keyword><keyword>Confusion</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Delirium/*diagnosis</keyword><keyword>Female</keyword><keyword>Hospitalization</keyword><keyword>Humans</keyword><keyword>Interviews as Topic</keyword><keyword>Male</keyword><keyword>*Neuropsychological Tests</keyword><keyword>Reproducibility of Results</keyword><keyword>Sensitivity and Specificity</keyword></keywords><dates><year>2014</year><pub-dates><date>Oct 21</date></pub-dates></dates><isbn>1539-3704 (Electronic)0003-4819 (Linking)</isbn><accession-num>25329203</accession-num><urls><related-urls><url> (which takes a median of 3 minutes) have recently been developed and in some settings may be used in favour of the CAM. We also acknowledge that it is possible that researcher bias may have influenced how the different index assessments (4AT or CAM) were scored. The researchers were aware of the origin of the 4AT and this may have biased their responses. However, the CAM was administered according to standard recommendations, with multiple meetings reviewing any difficulties in test administration. The study was overseen by a Trial Steering Committee, which scrutinised the study protocol and conduct of the study. The dementia ascertainment was done through a combination of documenting existing formal dementia diagnosis (which is imperfect because around one third of dementia is not diagnosed) and use of the IQCODE. Unfortunately the number of IQCODE questionnaires completed was lower than expected.ConclusionsThis diagnostic accuracy study had the primary purpose of determining the performance of the 4AT against a reference standard assessment. The results are broadly consistent with the already published studies of the performance of the 4AT though the sensitivity was somewhat lower and the specificity was somewhat higher than in prior studies. No tool can provide perfect performance, especially in the case of delirium, a condition which has multiple domains of abnormality which vary in severity and which fluctuate. Tools such as the 4AT can provide a useful means of providing a consistent approach to screening, especially in busy environments where speed and practicality are important. However, scores in such tools should not be regarded as diagnostic and both individual practitioners and systems of care need to allow for this. No individual tool can be considered diagnostic. In all cases, whether the tool is designed for rapid assessment, or if the tool is more detailed, it necessary that the clinician judge the evidence against diagnostic criteria for delirium, and make a decision as to the diagnosis. The tools allow for standardisation of collection of key information used to inform the clinician diagnosis.In this study, the CAM had a substantially lower sensitivity than the 4AT, and a somewhat higher specificity. The present findings are consistent with some prior studies suggesting that performance of the CAM may be affected by the experience and background of the rater. Screening for cognitive impairment in general, which in the acute setting mostly comprises delirium and dementia, has traditionally been carried out by the use of cognitive tests alone such as the Abbreviated Mental Test – 10 or the Mini Mental State Examination. The 4AT was designed to function as a single instrument that had a primary function of detecting delirium, but also incorporated some general cognitive screening. The results of this study provide some support for the validity of the general cognitive screening items within the 4AT as specific rather than sensitive measures. The total score of the 4AT showed some relationship with more formal severity scoring, meaning that clinicians might consider those with higher scores as being showing more severe syndrome. In conclusion, the results support the use of the 4AT as a delirium screening instrument which detects delirium with reasonable accuracy, though as with every brief tool, scores need to be verified by clinical judgement by suitably trained practitioners, perhaps in combination with additional assessments.Health economicsIntroductionDelirium is associated with increased mortality, reduced quality of life and increased healthcare costs.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Jbm91eWU8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 4, 8, 59, 174-179 As a necessary pre-requisite to estimating the cost-effectiveness of a delirium screening tool such as the 4AT it is necessary to first characterise survival, cost and quality of life in patients with and without a diagnosis of delirium in a current UK population. The objectives of this economic evaluation within the 4AT study were to estimate the observed 12 week cumulative healthcare associated costs in these two groups of patients (delirium or no delirium) in the NHS in the three study sites. The costs were calculated by assigning unit costs to all NHS inpatient and outpatient activity, community care and additional services by all involved health-care professions. ADDIN EN.CITE <EndNote><Cite><RecNum>3627</RecNum><DisplayText><style face="superscript">180, 181</style></DisplayText><record><rec-number>3627</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1522067906">3627</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Information Services Division, </author></authors></contributors><titles><title>Scottish Health Service Costs</title></titles><pages>Information Services Division, NHS National Services Scotland</pages><number>1 September 2017</number><dates></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Curtis</Author><Year>2015.</Year><RecNum>3629</RecNum><record><rec-number>3629</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505662000">3629</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Curtis, L; Burns, A</author></authors></contributors><titles><title>Unit Costs of Health and Social Care.</title></titles><dates><year>2015.</year></dates><publisher>(PSSRU) Personal Social Services Research Unit.</publisher><urls></urls></record></Cite></EndNote>180, 181 The analysis was framed with a view to informing any subsequent health economic modelling. Originally it was planned that costs were calculated for groups identified as 4AT-delirium false positives, true positives, true negatives and false negatives. However, this was revised because in the main diagnostic accuracy study protocol the reference standard diagnostic process result was recorded in the casenotes (and thereby exerting an influence over practice) rather than the 4AT or the CAM. For the purposes of this study, the reference standard was assumed to be 100% correct. The CAM was selected as a comparison in the main diagnostic test accuracy study because at the time of the grant submission was the tool most commonly advocated for delirium screening in the UK NHS, and was likely the most-used tool at that time (albeit used in a minority of cases because of low use of any tool for delirium).When reading this chapter please note that the first section is a cost analysis using data collected within the study, and the second section is a cost-effectiveness analysis generated through a health economic model. MethodsResource use, costs and data collectionAll significant resource consumption, giving special scrutiny to that which was thought might differ in those diagnosed with delirium, was captured within the study, taking an NHS and personal social services perspective. The main cost drivers of costs associated with patient care were expected to mainly be the in-hospital time in the different wards. The time horizon of the base-case analysis for inclusion of costs was the 12-week period from randomisation.The measurement of healthcare resource used only data collected as part of the trial. Patients’ use of hospital services was obtained from the Health Economics Questionnaire as entered into a section of the Case Record Form (CRF), which had been completed via telephone call with the patient/carer and/or through scrutiny of the clinical notes 12 weeks after randomisation. The initial length of stay (length of stay for the initial hospital stay within the 12 weeks captured) was generated by using the day of randomisation and the discharge day directly from the clinical record. Research nurses conducted a telephone interview, if thought necessary if healthcare records were incomplete, with each of the patients or legal proxies 12 weeks after randomization. Thus, healthcare activity and resource use was captured by research nurses based on a combination of scrutiny of the clinical notes and the telephone interview.Methods for analysis and the handling of missing dataObserved mean (95% CIs) of costs are presented for all patients. An analysis of the costs occurring within the 12 weeks is presented. Preparation of the data, assigning costs and all further calculation was performed in Excel. In order to align with the population used for the main statistical analysis, cases with missing reference standard diagnostic information were omitted. Any other activity presumed to be missing was assumed equivalent to zero cost. Unit cost assignmentAll resource use was valued in monetary terms using appropriate standard UK unit costs assigned at the time of analysis. NHS Scotland Information Services Division (ISD) unit costs from 2015-16 were used for inpatient/day-case, outpatient, A&E and other elective or non-elective hospital based services in the 12 weeks after randomisation. ADDIN EN.CITE <EndNote><Cite><RecNum>3627</RecNum><DisplayText><style face="superscript">180</style></DisplayText><record><rec-number>3627</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1522067906">3627</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Information Services Division, </author></authors></contributors><titles><title>Scottish Health Service Costs</title></titles><pages>Information Services Division, NHS National Services Scotland</pages><number>1 September 2017</number><dates></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>180 NHS–PSSRU unit costs were used for community health services “Unit Costs of Health and Social Care 2016”. ADDIN EN.CITE <EndNote><Cite><RecNum>3627</RecNum><DisplayText><style face="superscript">180</style></DisplayText><record><rec-number>3627</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1522067906">3627</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Information Services Division, </author></authors></contributors><titles><title>Scottish Health Service Costs</title></titles><pages>Information Services Division, NHS National Services Scotland</pages><number>1 September 2017</number><dates></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>180Cost calculationUnit costs were assigned to inpatient stays specific to the admitting specialty. Where details of admitting specialty were missing patients were manually sorted into the corresponding ward according to their medical diagnosis. In a first step the inpatient, day case, outpatient or rehabilitation costs were calculated in order to sum up all hospital related costs. Subsequently the costs occurring from the use of different community services (District Nurse, GP, Health Visitors, Psychological Services, Social Workers, Home Carers, Chiropodists, Meals on Wheels, etc.) were calculated and added as a separate cost considered in addition to the secondary care costs in order to generate the total cost per patient. Costs were calculated separately for:Scottish costs: national tariff costs (inpatient) were based on the ward days and whether the case was elective or emergency. As far as possible all unit costs were taken from ISD and PSSRU. ADDIN EN.CITE <EndNote><Cite><RecNum>3627</RecNum><DisplayText><style face="superscript">180, 181</style></DisplayText><record><rec-number>3627</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1522067906">3627</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Information Services Division, </author></authors></contributors><titles><title>Scottish Health Service Costs</title></titles><pages>Information Services Division, NHS National Services Scotland</pages><number>1 September 2017</number><dates></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Curtis</Author><Year>2015.</Year><RecNum>3629</RecNum><record><rec-number>3629</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505662000">3629</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Curtis, L; Burns, A</author></authors></contributors><titles><title>Unit Costs of Health and Social Care.</title></titles><dates><year>2015.</year></dates><publisher>(PSSRU) Personal Social Services Research Unit.</publisher><urls></urls></record></Cite></EndNote>180, 181English costs: In the absence of costs per hospital day for the different wards, the average day cost for inpatient stay as well as day-cases was used. For the outpatient costs the NHS Reference Costs from 2015/16 were used. ADDIN EN.CITE <EndNote><Cite><Author>Department of Health</Author><RecNum>3708</RecNum><DisplayText><style face="superscript">182</style></DisplayText><record><rec-number>3708</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1528198105">3708</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Department of Health,</author></authors></contributors><titles><title>NHS reference costs 2015 to 2016</title></titles><number>1 September 2017</number><dates></dates><urls><related-urls><url> analysisIn a second cost analysis, undertaken as a sensitivity analysis, the costs based solely on the initial length of stay were calculated based on the PSSRU - Unit Costs of Health and Social Care 2016 for the initial stay, assuming a constant daily unit cost. Due to the unknown ward of the initial stay English and Scottish costs of the initial stay were calculated using PSSRU – Unit Costs of Health and Social Care 2016 multiplied by the length of stay. All healthcare activity was costed irrespective of whether it was delirium related or not.Scottish hospital costsThe Scottish costs taken from the CRFs, including every hospital stay and additional activity, which were incurred within 12 weeks after randomisation, were split into inpatient, day case and outpatient costs (see Table 13). The Scottish inpatient costs are costs per day in the different wards taken from ISD unit costs from 2015-16. ADDIN EN.CITE <EndNote><Cite><RecNum>3627</RecNum><DisplayText><style face="superscript">180</style></DisplayText><record><rec-number>3627</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1522067906">3627</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Information Services Division, </author></authors></contributors><titles><title>Scottish Health Service Costs</title></titles><pages>Information Services Division, NHS National Services Scotland</pages><number>1 September 2017</number><dates></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>180 In the details column of Table 13 are the assumptions made for assigning the patients to different wards. This was necessary because the dataset (from the CRFs) did not provide information on exact nature of the wards, and because many of the wards are known to be general. In the case where there were two different wards grouped into one – due to unclear descriptions of where the patients had been, additional assumptions are described. For example patients often described as “renal”, and this is split into Urology and Nephrology according to NHS costing standard definitions. In these cases the average costs of both ward types was calculated for inpatient per day, day cases and outpatient activities. In the frequent case of a missing allocation to a specific ward, the patients were allocated according to their medical diagnosis given. This is an approximation which reflects not necessarily the geographical ward and associated costs, but the nature of the care that the patient is receiving according to their diagnoses. Such care is often delivered in a general medical ward or a geriatric ward. The CRFs were filled by researchers on the study based on the follow-up phone call and through extraction of data from the electronic medical casenotes. Given this combination, some details of the derivation of the terms used are documented in the details/assumptions column. The costs for the initial hospital stay (unknown ward) were calculated separately, using the same calculation for Scotland and England. A fixed cost per day was set (PSSRU – Unit Costs of Health and Social Care 2016) and multiplied by the length of stay. Table SEQ Table \* ARABIC 13: Scottish hospital cost estimatesHospital Costs Scotland**Inpat/day (?)Daycase (?)Outpatient (?)source details/assumptionsA & E1594126**Summary of: ED, AE, Emergency Department , etc. Cardiology7181471140**Summary of: Cardiac problems, Pain in Chest, etc.Dermatology631907144**Summary of Dermatology, Derma, Skin, Skin disease etc.Ear Nose & Throat13431171110**Summary of all diagnoses in a related categoryGastroenterology538642218**Summary of Gastro, Gastroenterology, Pain in Stomach, Belly,… etc.General Medicine442744225**Additionally to General Medicine diagnoses, patients categorised as "Medical Unit" are included General Practice36132062**Additionally including DiabetesGeneral Surgery773866143**Summary of all unspecified surgeries and general surgeriesGeriatric Assessment333907176**Summary of: Geriatrics, Medicine of the Elderly, Elderly, Geriatric Medicine etc.Geriatric Long Stay267**Geriatric long stays (not including shorter ones) - weekly cost 1868 --> 267 per dayGynaecology1319933156**Summary of all gynaecology-related diagnosis Haematology955742324**Summary of all diagnosis related to the blood, referred to as blood issue etc.ICU2019**Summary of: intensive, care, intense care, ICU etc.Neurology11171031220**Summary of all Neurological issues combined with strokeOncology944944439**Summary of: Clinical and Medical Oncology (860/1028) (241/636), Onco, Oncology, etc.Ophthalmology15391291143**Mostly stated as suchOral Surgery16771057117**Including some dental issuesOrthopaedics9021429114**Summary of: Podiatry, Ortho, Vertebral Fractures, Obstetrics, Obstetric specialist and OrthopaedicsPlastic surgery15331049157**Including activity most closely matching this classificationRehabilitation Medicine500907260**Including activity most closely matching this classificationRenal716610167**Summary of: Urology and Nephrology (778/654) / (635/585) /(145/189) and renal Respiratory Medicine500751191**Summary of: breathing problems, COPD, inability to breath properly, etc.Rheumatology712724211**Mostly stated as suchThoracic 137882**Additionally including thoracic surgeriesVascular 5821130147**Summary of: vascular medicine and surgery**NHS - ISD unit costs from 2015-16 4English hospital costsThe English hospital costs (Table 14) were handled in a similar manner to the Scottish ones, split into inpatient, daycase and outpatient costs. However, one of the big differences is that the English inpatient costs defined as costs per stay and not per day, leading to very different values being displayed in the tables. The calculations incorporate from the initial stay, as well as including all stays from the CRFs are based on PSSRU Unit Costs of Health and Social Care 2016.Table SEQ Table \* ARABIC 14: English hospital cost estimatesHospital Costs England**Inpat/STAY?Daycase?Outpat ?source details/assumptionsA & E2926719146.68**Summary of: ED, AE, Emergency Department etc.Cardiology2926719155.235**Summary of: Cardiac problems, Pain in Chest, etc.Dermatology2926719101.63**Summary of Dermatology, Derma, Skin, etc.Ear Nose & Throat292671996.87**Summary of all diagnoses falling in a related categoryGastroenterology2926719136.57**Summary of Gastro, Gastroenterology, Pain in Stomach, Belly, etc.General Medicine2926719167.05**Additionally to General Medicine diagnoses, patients categorised as "Medical Unit" are included General Practice2926719158.525**Additionally including DiabetesGeneral Surgery2926719130.6**Summary of all unspecified surgeries and general surgeriesGeriatric Assessment2926719220.72**Summary of: Geriatrics, Medicine of the Elderly, Elderly, Geriatric Medicine, etc.Geriatric Long Stay2926**Geriatric long stays (not including shorter ones)Gynaecology2926719133.01**Summary of all gynaecology-related diagnosisHaematology2926719160.58**Summary of all diagnosis related to the blood, referred to as blood issues, etc.ICU2926719363.356**Summary of: intensive, care, intense care, ICU, etc.Neurology2926719175.6**Summary of all Neurological issues combined with strokeOncology2926719151.12**Summary of: Clinical and Medical Oncology, Onco, Oncology, CA, etc.Ophthalmology292671990.64**Mostly stated as suchOral Surgery2926719111.47**Including some dental issuesOrthopaedics2926719117.01**Summary of: Podiatry, Ortho, Vertebral Fractures, Obstetrics, Obstetric specialist and OrthopaedicsPlastic surgery2926719139.61**Summary of all diagnoses falling in one of these a related categoriesRehabilitation Medicine2926719125.2**Summary of all diagnoses falling in one of these a related categoriesRenal2926719127.985**Summary of: Urology and Nephrology and renalRespiratory Medicine2926719154.77**Summary of: breathing problems, COPD, inability to breath properly, etc.Rheumatology2926719142.74**Mostly stated as suchThoracic 2926719212.935**Additionally including thoracic surgeriesVascular 2926719153.1**Summary of: vascular medicine and surgery** PSSRU – Unit costs 2016 6Inpatient costs: NHS non-elective inpatient stays Day-patient costs: day cases HRG data, weighted average of all stays outpatient costs: NHS reference standard costs 2016 (national average)Costs of tests in hospitalThe cost of the different tests and imaging, which were included in the CRFs, are calculated separately using Scottish and English costs (Appendix 14). The Scottish costs used the NHS – ISD unit costs from 2015-16, and the English costs used the National Schedule of Reference Costs - Year 2015-16 (NHS trusts and NHS foundation trusts).Community health service costsIn order to calculate the full 12 week costs the community NHS service costs were included. All community service costs were priced (Appendix 15) according to the PSSRU - Unit Costs of Health and Social Care 2016. When assumptions had to be made in order to estimate the cost per hour, the assumptions are stated in the column as “additional”. When feasible, the hourly cost for specific professions were assumed to be the same, independent of whether the patient was seen in a clinic or at home. If there were different values stated in the PSSRU document the values were taken accordingly. As the CRFs were often filled in precisely (stating 5, 10, 15 minutes) for the hourly calculation the price of an “hour of direct contact/per hour of face-to-face contact” was chosen rather than an “hour worked”. Costs of additional activitiesIn order to decide whether to cost all additional activities the types and frequencies of additionally mentioned activities, such as “daily full package of care”, “Housework help” or “impact team” were captured (Appendix 16). We decided not to formally calculate costs for these services as such costs were very likely to be so small as to be insignificant. Additionally for some of those listed services the free-text description recorded in the CRFs was insufficiently precise to be able to make proper assumptions about the service referred to. ResultsAnalysis was undertaken considering two different costs: (1) Including all costs identified within the 12-week period as listed in the CRFs and, (2) Based on the costs of the index inpatient stay alone (sensitivity analysis). Cost analysis using original researcher delirium ascertainmentsCumulative costs are presented for the average per patient costs for all patients with the original categorization into delirium/no delirium as by the researchers. Due to the fact that all patients were assumed to be treated according to the reference standard (because this was the information that had to be included in the casenotes based on the protocol) it was not possible to assess different costs for true positive, true negatives, false positives and false negatives. This statement is not necessarily true for all patients as some of them switched from the category “Delirium” to “No Delirium” and vice versa after the final central reference standard ascertainment process, by which about 30 patients were labelled as “Indeterminate” patients. Therefore, the final costs are shown in two tables. Firstly the average cost of the patients as categorized by the researchers who did the initial assessment and secondly the final delirium ascertainment which was determined by analysis of the CRFs by the CI and 2 colleagues (see Chapter 5).Starting with the cumulative 12-week costs as categorized by the local researchers it can be seen that the cost of the initial inpatient stay (sensitivity analysis) is more than double for those patients with delirium as those who do not (Table 15). Taking into account the costs over the following 12-weeks from randomisation it can be seen that under NHS-ISD (Scottish) costs the costs of people with delirium is also more than one third higher than of those not suffering from delirium.4 The same trend, although with lower magnitude, can be observed if the calculation is based on PSSRU-Costs (overall UK costs).5Table SEQ Table \* ARABIC 15: Costs at 12 weeks for delirium versus no delirium by original researcher assessmentsCosts (12 weeks) as by sitesDelirium (?)95% CINo Delirium95% CIScottish costs initial stay2810[2734, 2886]1277[1267, 1287]Scotland costs 12 weeks (CRF)7559[7362, 7755]4215[4175, 4254]English costs initial stay2810[2734, 2886]1277[1267, 1287]England costs 12 weeks (CRF)5216[5107, 5326]4320[4295, 4346]*all costs are the mean cost per patient. The allocation to Delirium/no Delirium is based on the reference standard as categorized by the original researcher assessments (95% confidence interval)Cost analysis using final reference standard ascertainmentsThe costs as calculated after corrections of the final reference standard ascertainments are slightly different, although showing the same trend as the costs based on the reference standard diagnosis as categorized by the sites (Table 16). The new Indeterminate cost group (these patients for whom the diagnosis was considered uncertain based on the Reference Standard assessment) shows costs which are between the delirium and no delirium groups. This likely reflects the fact that patients in this group were a mix of those with delirium or without delirium. The values from the initial stay (sensitivity analysis) are again showing a greater difference between patients suffering from delirium and those who are not. Table SEQ Table \* ARABIC 16: Costs at 12 weeks for delirium versus no delirium by the final reference standard ascertainmentsCosts (12 weeks) as by CIDelirium95% CIno Delirium95% CIIndeterminate95% CIScottish costs initial stay2934[2862, 3006]1239[1229, 1249]1276[1210, 1341]Scottish costs 12 weeks (CRF)6889[6723, 7054]4230[4188, 4272]5177[4890, 5465]English costs initial stay2934[2862, 3006]1239[1229, 1249]1276[1210, 1341]English costs 12 weeks (CRF)4854[4754, 4953]4264[4239, 4290]4350[4169, 4531]*all costs are per patient. The allocation to Delirium/no Delirium/Intermediate is based on the final reference standard ascertainmentsHealth Economic Model – Cost Effectiveness AnalysisThe aim of the 4AT cost-effectiveness analysis is to compare the cost effectiveness of the 4AT with that of CAM. In order to calculate cost-effectiveness it was necessary to build on the within trial analysis as it could only include the costs according to the reference standard diagnosis. To be able to compare 4AT and CAM in terms of cost-effectiveness, the estimated costs for true positive, true negative, false positive and false negative cases have to be known as well as estimated quality of life associated with these categories. It should be noted that initial plans to undertake a meta-analysis of diagnostic test accuracy parameters was abandoned upon completion of the literature survey in the field. It became apparent that quantitative estimation was not going to be feasible given the lack of previously published relevant studies. The approach outlined here relied instead on the formal elicitation of expert opinion.To calculate the cost effectiveness of 4AT and CAM, a health economic model was developed. Model StructureIn the basic structure, the model was a decision tree being parameterised with the reference standard delirium and non-delirium probabilities, divided into branches dictated by the sensitivity and the specificity of 4AT and CAM (Figure 4).Figure SEQ Figure \* ARABIC 4: Decision TreeIn a next step, the model was parameterised with the costs and Quality Adjusted Life Years (QALYs) in order to calculate the Incremental Cost Effectiveness Ratio (ICER). The utilization and interpretation of the ICER outcomes is described hereinafter. The ICER was calculated by dividing the difference in mean cost between the comparators by the difference in mean QALYs between those two groups:ICER=Ci-CcEi-Ec=C/Ewhere Ci and Ei are the expected cost and effectiveness of the new intervention or the new diagnostic test (4AT), Cc and Ec are the expected cost and effectiveness of the comparator strategy, which is mostly the treatment or diagnostic test in place - in this case CAM. Therefore, ΔC was showing the incremental costs and ΔE was representing the incremental effectiveness of 4AT and CAM. If a new intervention is more effective and less costly, or if a new intervention is less effective and more costly, the decision whether to introduce the new intervention are straightforward. That is, being clearly in favour of introducing it in the first case and against in the second scenario. For these cases, the ICER calculation is playing a subordinate role. The ICER is important if we expect a trade-off between additional effect for additional cost and less effect for less cost. If a new intervention is more costly and more effective than the standard intervention than the ICER is describing how much the intervention costs for an additional unit of benefit, in this study for a QALY. If it is cheap to gain an additional unit of benefit, it is still likely that the intervention will be introduced. For all cases the intervention is less costly and less effective the value of the ICER is representing how much money would be saved by renouncing a QALY. In this case it is the opposite way round, saying if a small loss in benefits saves a considerate amount of resources it may be worth it. In a practical setting, this decision can be made based on the decision maker’s willingness to pay (WTP), which varies between countries and interventions. In the UK, NICE adopts a willingness-to-pay threshold value of ?20,000 per QALY. That means if a new intervention has an ICER value below ?20,000 per additional QALY or being worth more than ?20,000 saved per QALY lost, then an intervention is likely to be considered a cost-effective use of NHS resources. Values outside these ranges are conventionally not considered to be cost effective. Model ParametersThe costs for true positive and true negative patients as well as the values for the sensitivity and specificity of the different tests were taken from the within trial analysis. The data for the costs can be found in the cost tables above. All other values were gathered through a new survey of experts conducted for this study. This step was necessary as a systematic review of the literature in order to identify parameters did not provide sufficient information. These included mortality estimates, quality of life estimates and costs associated with delirium, particularly with respect to false negative diagnoses and false positive diagnoses. Nevertheless, the literature search provided information that was used to construct an expert interview and subsequent survey. Expert SurveyA survey (Appendix 17) was developed through consultation with the clinical advisors and Chief Investigator of the 4AT study. The survey had the purposes of eliciting parameter estimates with regards mortality estimates, quality of life estimates and costs associated with delirium, particularly with respect to false negative diagnoses and false positive diagnoses. The draft survey was then scrutinized for internal validity by members of the study team and rewritten. Subsequently an online survey using the Bristol Online survey tool (BOS) was set up and launched and sent out through two mechanisms: (i) a mailing list of recognised clinical experts and, (ii) via social media targeting health professionals. From the 53 expert answers, 46 were included in the final analysis. The other 7 were excluded as the responses were mostly incomplete.Values informing the parametersThe values from the expert survey as well as from the within trial analysis inform the parameters which subsequently flow into the model. The values and the sources of the different parameters can be found in Appendix 18. ReportingBase case results are reported using the Scottish cost estimates and the ‘best estimates’ from the expert elicitation. Alternative cost estimates were used in a sensitivity analysis, as were high and low estimates of parameters obtained from expert elicitation. Methods for the sensitivity analysisThree sets of sensitivity analyses were conducted to test the robustness of results to alternative assumptions and understand the uncertainty present in the estimates. Firstly, scenario analysis (an alternative to the base case analysis with different assumptions or sets of parameter values) was conducted using English costs estimates instead of Scottish estimates. In addition, for both Scottish and English estimates respectively, other parameter estimates were taken at the ‘highest estimates’ or ‘lowest estimates’ (from the expert elicitation) respectively. Secondly, one-way sensitivity analysis was conducted in which the values of individual model parameters were varied over a range of +/- 25% of the base case values. The differences in costs, and the differences in QALYs, between alternatives under each one-way sensitivity analysis are reported using tornado plots. Finally, a probabilistic sensitivity analysis (PSA) was conducted to investigate uncertainty in the cost-effectiveness estimates due to sampling uncertainty of the parameter estimates. The PSA includes a gamma distribution for costs and beta distributions for probability and utility values and 1000 iterations. The results of the PSA are reported using a scatterplot on the cost-effectiveness plane and a cost-effectiveness acceptability curve (CEAC).Results from the Health Economic ModelAll of the results suffer the common problem seen with the economic evaluation of diagnostic tests in that the incremental costs and QALYs are very small and cluster close to zero (Appendix 19). This makes the results of the cost-effectiveness analysis difficult to interpret, with wildly fluctuating ICERs. In general, the CAM produced slightly higher healthcare costs compared with the 4AT with only very small differences in QALYs. The results of the base case analysis show that the difference in costs between 4AT and CAM is ?90.35, indicating that 4AT resulted in lower total healthcare costs over 12 weeks. The difference in QALYs was -0.00053 indicating slightly worse health outcomes using 4AT compared to CAM over 12 weeks. The ICER of ?170,533 means that for each QALY lost ?170,533 would be gained in resources. Using conventional thresholds 4AT would be considered cost-effective relative to CAM. In the scenario analysis with English costs at the best estimate of parameters from expert elicitation the difference in costs was ?-61.52. The difference in QALYs remains the same as in the base case, yielding an ICER of ?116,133. As in the base case, this would be considered cost-effective at conventional thresholds.Scenario analysis using the lowest and highest estimates from the expert elicitation exercise produced different results. At the lowest estimates the ICER was ?24,289 which is in a range that may be considered cost effective depending on other factors. At the highest estimates 4AT dominates CAM, being more effective and less expensive. One-way sensitivity AnalysisThe results of the one-way sensitivity analysis indicate that in relation to differences between 4AT and CAM in total cost the model was most sensitive to the costs of FN classified cases, specificity of both 4AT and CAM and the costs of TN classified cases. The model was less sensitive to the sensitivity of 4AT and CAM, the true proportions of positive and negative cases and other cost estimates.In relation to differences between 4AT and CAM in QALY outcomes the model was most sensitive to 4AT and CAM specificity and the QALY estimates for each of the four diagnostic classifications. The model was less sensitive to the sensitivity of 4AT and CAM and the true proportions of positive and negative cases. See Appendices 20 and 21.Probabilistic Sensitivity AnalysisThe results of the PSA indicate that there is considerable uncertainty in the estimated cost-effectiveness of 4AT compared to CAM. In the figure (Appendix 22), many points are spread across all four quadrants of the plane indicating that is non-negligible probability each alternative may be more or less costly and/or more or less effective. The CEAC (Appendix 23) displays the probability that 4AT would be considered a cost-effective alternative to CAM at various thresholds of willingness-to-pay for additional QALYs. The results indicate that the probability of cost-effectiveness is not greatly influenced by the threshold. This is because increasing the threshold makes scenarios in which 4AT is more expensive but more effective more acceptable however it makes scenarios in which 4AT is less effective but less expensive less acceptable. Scenarios in which one test dominates (more effective and less expensive) the other are unaffected by the threshold value.DiscussionOur economic analysis had the main purpose of showing the differences in estimated costs between patients with and without delirium. We also used a modelling approach to estimate as well as the cost-effectiveness of the 4AT, within a methodological framework of diagnostic test evaluation.Discussion of the Cost-AnalysisOur main finding from the cost analysis was that delirium is associated with higher costs, taking into account 12-week costs as well as already on the initial hospital stay. This is true if calculated with English costs as well as for Scottish costs, the latter shows showing a bigger effect when calculated based on the Scottish costing system. This could be due to the fact that for English costs the average cost per stay was taken into account whereas the Scottish calculation was a more detailed one, based on the single days estimated to be spent in the different specialties or receiving care for specific conditions. Prior studies have also shown that a diagnosis of delirium confers a higher healthcare cost than is observed in patients without delirium for example as shown by Leslie and colleagues in 2008, who looked at the one year financial costs of care related to delirium PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZXNsaWU8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 21. The costs of delirium arise from multiple possible sources including increased risk of falls, other medical complications such as pressure sores, increased staff time, new institutionalisation, and increased length of stay ADDIN EN.CITE <EndNote><Cite><Year>2010</Year><RecNum>1950</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>1950</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">1950</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>NICE,</author></authors></contributors><titles><title>Delirium: diagnosis, prevention and management.</title></titles><number>1 Dec 2017</number><dates><year>2010</year></dates><urls><related-urls><url>.uk/CG103</url></related-urls></urls></record></Cite></EndNote>4. There may also be substantial indirect costs, for example the effects on relatives and staff in addition to patients. ADDIN EN.CITE <EndNote><Cite><Author>Partridge</Author><Year>2012</Year><RecNum>2764</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>2764</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">2764</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Partridge, J. S.</author><author>Martin, F. C.</author><author>Harari, D.</author><author>Dhesi, J. K.</author></authors></contributors><auth-address>Division of Health and Social Care Research, Kings College London, London, UK; Department of Ageing and Health, 9th Floor, North Wing, St Thomas' Hospital, London, UK. judith.partridge@gstt.nhs.uk.</auth-address><titles><title>The delirium experience: what is the effect on patients, relatives and staff and what can be done to modify this?</title><secondary-title>Int J Geriatr Psychiatry</secondary-title></titles><periodical><full-title>Int J Geriatr Psychiatry</full-title></periodical><edition>2012/11/01</edition><dates><year>2012</year><pub-dates><date>Oct 30</date></pub-dates></dates><isbn>1099-1166 (Electronic)0885-6230 (Linking)</isbn><accession-num>23112139</accession-num><urls><related-urls><url> Additionally, delirium is associated with a higher risk of long-term cognitive impairment.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYWNMdWxsaWNoPC9BdXRob3I+PFllYXI+MjAwOTwvWWVh

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ADDIN EN.CITE.DATA 183, 184 Prevention of delirium has been shown to be cost-effective. ADDIN EN.CITE <EndNote><Cite><Author>Leslie</Author><Year>2011</Year><RecNum>3634</RecNum><DisplayText><style face="superscript">4, 185</style></DisplayText><record><rec-number>3634</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505669070">3634</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Leslie, D. L.</author><author>Inouye, S. K.</author></authors></contributors><auth-address>Department of Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA. douglas.leslie@psu.edu</auth-address><titles><title>The importance of delirium: economic and societal costs</title><secondary-title>J Am Geriatr Soc</secondary-title></titles><periodical><full-title>J Am Geriatr Soc</full-title></periodical><pages>S241-3</pages><volume>59 Suppl 2</volume><keywords><keyword>Aged</keyword><keyword>Cost of Illness</keyword><keyword>Costs and Cost Analysis</keyword><keyword>Delirium/*economics</keyword><keyword>Humans</keyword></keywords><dates><year>2011</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1532-5415 (Electronic)0002-8614 (Linking)</isbn><accession-num>22091567</accession-num><urls><related-urls><url> app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="0">1950</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>NICE,</author></authors></contributors><titles><title>Delirium: diagnosis, prevention and management.</title></titles><number>1 Dec 2017</number><dates><year>2010</year></dates><urls><related-urls><url>.uk/CG103</url></related-urls></urls></record></Cite></EndNote>4, 185 However, the treatment of delirium is under-researched such that there remains a lack of unequivocal trial evidence that treatment of delirium is effective. Likewise, it is unknown if prompt detection of delirium leading to earlier treatment is cost saving.Due to the fact that all patients were treated according the reference standard diagnosis it was not possible to split the cost analysis further than separating costs for people with delirium and those without. Therefore, it was also not possible to define actual costs for 4AT and CAM as well as split those into true positives, true negatives, false positives and false negatives. Another limitation of this study was that the local researcher reference standard diagnosis did not fully agree with the final reference standard diagnosis, but the original reference standard was the one that was recorded in the clinical case notes. A further additional issue to consider is that the reference standard process likely had a tendency to produce earlier and more accurate diagnosis than as normal in standard care. In fact, due to the under detection of delirium observed in many studies, PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db2xsaW5zPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48

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ADDIN EN.CITE.DATA 7 the study process possibly led to increased rates of delirium diagnosis in the recruited population. Discussion of the Cost-Effectiveness AnalysisIn order to calculate the cost effectiveness of 4AT and CAM and to address some of the limitations from the cost analysis a health economics model was conducted. From the cost analysis it could have been hypothesised that the cost for false positives are likely to be lower than false negatives and that the latter are considerably higher than the costs for true positives. This assumption was confirmed by taking into account expert opinion in our model, with results showing the cost for false positive cases to be ?4653.00, whereas the cost for a false negative cases is ?8955.70. The additional costs resulting from a missed diagnosis of delirium (cost FN- cost TP) were estimated at ?2066.70 in the base case analysis. In terms of QALYs, there is very little difference between 4AT and CAM. The ICER of over ?170 000 is stating that for each QALY lost there could be saved ?170 000 which could be spend elsewhere. Equivalently, it would not be cost effective to switch from 4AT to using CAM because the cost per additional QALY gained would be more than ?170 000 which is clearly above the NICE value of ?20 000 per QALY gained. ADDIN EN.CITE <EndNote><Cite><Author>NICE;</Author><RecNum>3665</RecNum><DisplayText><style face="superscript">186</style></DisplayText><record><rec-number>3665</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1513150245">3665</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>NICE;</author></authors></contributors><titles><title>The guidelines manual: 7 Assessing cost effectiveness</title></titles><number>13 Dec 2017</number><dates></dates><urls></urls></record></Cite></EndNote>186 This study had several limitations from an economic point of view starting with relatively limited numbers such that there was insufficient power to analyse economic outcomes. Additionally there were s no data about the quality of life available within the trial, therefore most parameters rely on expert opinion. These expert parameters can on the other hand be seen as strength of the study as they included estimates of a diverse sample of experts including specialists from Geriatrics, Critical Care, General Medicine, General surgery, Psychiatry, Cardiology, A&E and Palliative care. This cost-effectiveness analysis demonstrates the potential of 4AT as a screening test for delirium detection. It also highlights the need for a better understanding of the clinical pathway of delirium as a considerable part of this analysis had to rely on expert opinion. Improved detection of delirium may have the potential to produce large cost-savings within the health care system but substantial research will be required to realise this potential. As is common in the economic evaluation of diagnostic testing strategies, the clustering of incremental costs and incremental QALYs either side of zero leads to an unstable ICER that fluctuates wildly with small changes in the underlying model assumptions. Also there is clear potential for screening tools like the 4AT to be cost-effective, large incremental changes resulting in a clearly cost-effective strategy may rely on a more consistently demonstrated impact on the clinical pathway. Linkage of a 4AT result to a clearly defined treatment protocol that contains a clearly demonstrated effect on longer term clinical and cost outcomes may be a necessary pre-requisite to very high value care. General discussionThis project had two phases, with the first phase aimed at evaluating acceptability and usefulness of the 4AT delirium assessment tool in the context of current UK practice, and the second phase concerned with a diagnostic accuracy study and an evaluation of UK healthcare costs associated with delirium care including the estimated costs of making versus missing the diagnosis. With respect to the 4AT, the main results were respondents to the survey mostly considered to be a usable and effective tool in its existing form, with the diagnostic accuracy study finding that it had reasonable sensitivity and high specificity. These findings support the use of the 4AT in clinical use in settings where rapid assessment by staff who may not have specialist training is required.Survey A had the objective of providing a recent and comprehensive understanding of practice, knowledge, and attitudes in the UK around delirium assessment in doctors, nurses, physiotherapists, and occupational therapists. With more than 2000 respondents, the survey is to our knowledge the largest in the world on delirium to date. There were several interesting findings. The overwhelming majority gave the clear opinion that it is important to make a formal diagnosis of delirium including explicitly distinguishing it from dementia. Moreover, nearly all respondents stated that they thought that delirium treatment is effective in improving care. On this basis, it might be expected that tools and systems of care would be in place to support both delivering detection and treatment. However, respondents indicated that though most of their units had some form of delirium guidelines, they were mostly not followed, with much delirium thus under detected and treated. Another important finding from that survey is that practitioners and colleagues in their organisations use a wide variety of terms to describe delirium, mostly not using the term delirium itself. This finding has implications for education and training. Further support for the need for education training is that many respondents lacked confidence in their ability to detect delirium. Of note, doctors varied considerably in their opinions as to whether acute onset drowsiness leading to patients not be able to produce speech (but not comatose) was compatible the diagnosis of delirium. This is significant in the light of expert opinion and DSM-5 ADDIN EN.CITE <EndNote><Cite><Author>American Psychiatric Association</Author><Year>2013</Year><RecNum>3544</RecNum><DisplayText><style face="superscript">2</style></DisplayText><record><rec-number>3544</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1505369966">3544</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>American Psychiatric Association,</author></authors></contributors><titles><title>Diagnostic and Statistical Manual of Mental Disorders</title></titles><edition>5th</edition><dates><year>2013</year></dates><pub-location>Washington, DC.</pub-location><urls></urls></record></Cite></EndNote>2 which hold that such patients would in general fulfil diagnostic criteria for delirium. ADDIN EN.CITE <EndNote><Cite><Author>European Delirium</Author><Year>2014</Year><RecNum>3309</RecNum><DisplayText><style face="superscript">187</style></DisplayText><record><rec-number>3309</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1446483353">3309</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>European Delirium, Association</author><author>American Delirium, Society</author></authors></contributors><auth-address>MRC Unit for Lifelong Health and Ageing, University College London, 33 Bedford Place, London WC1B 5JU, UK. daniel.davis@ucl.ac.uk.</auth-address><titles><title>The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer</title><secondary-title>BMC Med</secondary-title><alt-title>BMC medicine</alt-title></titles><periodical><full-title>BMC Med</full-title><abbr-1>BMC medicine</abbr-1></periodical><alt-periodical><full-title>BMC Med</full-title><abbr-1>BMC medicine</abbr-1></alt-periodical><pages>141</pages><volume>12</volume><keywords><keyword>Delirium/*diagnosis</keyword><keyword>Diagnostic and Statistical Manual of Mental Disorders</keyword><keyword>Humans</keyword><keyword>Sleep Arousal Disorders/*diagnosis</keyword></keywords><dates><year>2014</year></dates><isbn>1741-7015 (Electronic)1741-7015 (Linking)</isbn><accession-num>25300023</accession-num><urls><related-urls><url> Survey A also provided interesting results with respect to perceived roles of different staff. In particular, the majority of nurses did not believe that they have a responsibility to produce a diagnosis of delirium, rather placing most of the emphasis on responsibility for screening for delirium. This finding has implications for the design of systems in nurses which might do much of the assessment for delirium, and were a diagnosis made by nurse could result in more prompt initial treatment. Future studies could build on the questions used in Survey A in the assessment of knowledge and attitudes around delirium assessment.The second of the two surveys was smaller, with 100 participants. The survey was valuable in that it asked practitioners with experience in the use of the 4AT to comment on its usability and other aspects. Generally speaking, opinions on the tool were favourable, with no consistent major issues identified. Some of the opinions expressed related to broader challenges in delirium assessment, such as the frequent lack of availability of an informant to provide a history regarding any change in mental status. However, the survey did suggest that the provision of training in the 4AT would be valuable. The implication of this is that members of the study team will produce additional training documentation and training video which will be added to the main 4AT website ().Alongside Survey B we also gathered information on use of the 4AT in clinical settings and its presence in policy documents and web-based resources for clinicians. Judging by the available evidence, the use of the 4AT in clinical practice has grown rapidly since its release in 2011. It is now present in multiple national and international policy documents. We are also aware through email contacts and publications that it is the standard tool used for delirium assessment in multiple organisations across the UK. Use of the 4AT is now a mandatory part of the best practice tariff for the care of acute fracture patients in the UK (this will influence the care of 50,000 patients per year). With respect to use in acute medical settings, two case studies from London and Sunderland provided examples; as well as demonstrating multiple uses of the 4AT in routine clinical work, feedback from these sites has largely been positive with respect to the practicality and clinical value of the tool. Nevertheless, aligned with some of the findings from Survey B, some training issues with respect to delirium in general but also the 4AT were evident, suggesting that the availability of training specific to the 4AT (as well as broader training efforts) would be beneficial. Additionally, the 4AT has been used as part of broader quality improvement work on delirium detection and care across nine hospitals in Scotland led by Healthcare Improvement Scotland (Scottish Government). This has directly led to an estimated many thousands of uses of the 4AT not just in these nine sites but in many others across Scotland with residual ongoing clinical use.The qualitative studies yielded valuable insights into the barriers to implementation of delirium assessment. The observational studies highlighted the complexity and pace of working in acute care settings, as well as the range of levels of experience of staff. These findings, whilst not new, must be borne in mind prominently in any initiative to improve delirium detection. Thus, solutions involving substantial time or certain conditions such as having sufficient staff specially trained in the use of particular with this requirement. One of the key novel findings was the issue of prioritisation. That is, staff, having limited time, prioritise various elements of the multiple numbers of assessments (nutrition, skin assessments, et cetera) that they are expected to do according to their perceived importance. For some staff, the actions following a positive delirium assessment are not clear, and moreover the results of such assessments may not feature in interdisciplinary discussions. Delirium assessments may thus sometimes be de-prioritised and ultimately not conducted. Related to this issue is the apparent variability in knowledge of delirium. The findings from the present study, as well as several previous surveys, ADDIN EN.CITE <EndNote><Cite><Author>Jenkin</Author><Year>2016</Year><RecNum>3447</RecNum><DisplayText><style face="superscript">35</style></DisplayText><record><rec-number>3447</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1504334205">3447</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jenkin, R. P.</author><author>Al-Attar, A.</author><author>Richardson, S.</author><author>Myint, P. K.</author><author>MacLullich, A. M.</author><author>Davis, D. H.</author></authors></contributors><auth-address>Department for the Care of Older People, Whittington Hospital, London, UK.Department of Medicine for the Elderly, St Mary's Hospital, London W2 1NY, UK.Institute of Neuroscience, Newcastle University, Newcastle Upon Tyne, UK.School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland AB25 2ZD, UK.Geriatric Medicine, University of Edinburgh, Edinburgh EH16 4SA, UK.MRC Unit for Lifelong Health and Ageing, University College London, London, UK.</auth-address><titles><title>Increasing delirium skills at the front door: results from a repeated survey on delirium knowledge and attitudes</title><secondary-title>Age Ageing</secondary-title></titles><periodical><full-title>Age Ageing</full-title></periodical><pages>517-22</pages><volume>45</volume><number>4</number><keywords><keyword>delirium</keyword><keyword>education</keyword><keyword>older people</keyword><keyword>questionnaire</keyword><keyword>survey</keyword></keywords><dates><year>2016</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1468-2834 (Electronic)0002-0729 (Linking)</isbn><accession-num>27118700</accession-num><urls><related-urls><url> suggest that fundamental lack of knowledge of delirium is a critical factor in preventing effective implementation of delirium assessment. This knowledge is not only important in informing correct use of assessment tools and in providing excellent management of delirium, but also encouraging engagement with delirium assessment. The implications are that any initiative to introduce delirium screening needs to be accompanied by training in delirium. Overall, qualitative studies urge a whole systems approach, in which not only are staff trained in the basics of delirium and informed about the use of assessment tools, but that the organisation and its culture support delirium assessment and treatment, and that there is a clear action plan following delirium diagnosis. In the main diagnostic accuracy study, the 4AT was found to have a sensitivity of 76% and a specificity of 95%. Taken in the context of the existing other diagnostic accuracy studies, which on the whole have shown higher sensitivity and lower specificity, the 4AT can be considered as a useful tool for delirium assessment in acute care. These conclusions are supported by the other part of this project, notably Survey B, and the widespread adoption of the 4AT by multiple external organisations and healthcare professionals. The much lower sensitivity of the CAM was surprising, given that in most prior studies the sensitivity was higher; however, present findings are not unique with some other studies also showing low sensitivity. Our study findings suggest that the 4AT is more sensitive than the CAM; this is of interest because the 4AT and CAM were conducted in the same settings and patient cohorts. Interestingly, in recognition of the fact that the CAM takes too long for routine clinical use, since the present study was commenced alternative and shorter forms of the CAM have been developed with the explicit aim of shortening its duration. These include the 3D-CAM and the Brief CAM.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXJjYW50b25pbzwvQXV0aG9yPjxZZWFyPjIwMTQ8L1ll

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ADDIN EN.CITE.DATA 159, 173 Additionally, some other short tools have been tested, for example a two-question set (involving months of the year backwards and asking patients what the day of the week is) followed by a longer delirium assessment if one or more of these is wrong. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GaWNrPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA 189 The choice of tool in a given context will depend on the time available, the desired performance characteristics, training available, and so on.We have been able to corroborate previous work that suggests that delirium adds substantially to healthcare costs. An accurate estimate of these excess costs in a UK context will be a valuable resource for future research and service planning. The formal assessment of cost-effectiveness in the context of this study was difficult for several reasons. Because patient management took place on the basis of a reference standard diagnosis, we were not able to measure costs and other outcomes as they would be if care had been based on the 4AT score. Our modelling approach relied on a comparison of diagnostic properties – a fundamental requirement of this approach is information on the costs and outcomes associated with false negative and false positive diagnoses. As data on these was not available from our study, and due to the sparsity of the published literature, we were forced to rely on expert opinion with all of its inherent flaws. Despite the limitations, the economic analysis was able to demonstrate the potential of the 4AT as a cost-effective screening tool. In order to determine how it should best be used to maximise cost-effectiveness further research is required. This should specifically focus on resolving some on the uncertainties around costs, mortality and quality of life experienced by patients who are managed subsequent to 4AT screening. Given the challenges of performing a formal phase III RCT in this context, it might be that observational studies of practice and outcomes in real-world settings could do much to provide the basis of a better informed economic model.Research implications1. The fundamental lack of knowledge of delirium across the healthcare system and across disciplines constitutes a critical barrier to better delirium assessment and care. Research on the presence of delirium in undergraduate and postgraduate training of health professionals as well as its presence in mandatory continuing professional development programmes should be studied. Some studies have begun to address this,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GaXNoZXI8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 37, 38 However, given the complexity of the educational challenge, working towards a range of validated education approaches for professionals in different disciplines would be valuable.3. There is consensus that delirium is an important and common problem, and that delirium assessment and care, as well as efforts to reduce the risk of delirium, are essential in providing excellent care. Yet the results of Survey A, as well as other studies and audits, demonstrate that healthcare organisations show a variable approach to delirium care. Although education of individual professionals is critical in improving delirium care, it is also essential that organisations have a coherent approach to delirium. Research on what policies on delirium care exist among healthcare organisations in the UK and beyond would inform planning and policy making.4. The present study on the diagnostic accuracy of the 4AT provides encouraging results, and several other studies on the 4AT as detailed in Chapter 1 also provide support. Additional studies in different settings such as in palliative care, care homes, and in surgical populations would be of value.5. The findings from health economics analysis are lined with prior studies showing that delirium is associated with substantial increase costs. Further work detailing the costs of delirium, and in particular the costs of this delirium based on real-world analysis rather than expert opinion (as was used in the present study) would help inform policymakers as to the value of providing effective systems for delirium care.6. The 4AT is an initial assessment tool and does not provide a diagnosis. The diagnosis might be based largely on the 4AT findings in conjunction with clinical judgement, or the clinician might seek additional information before coming to a conclusion. The processes by which the use of a tool like the 4AT leads to a diagnosis needs to be better studied, in particular whether additional information and formal assessment against DSM criteria are used, or if the diagnosis largely relies on the 4AT.Clinical implicationsThe studies this project suggest that the 4AT as a useful and practical method of detecting delirium in acute hospital care. The 4AT is intended to be used as part of the assessment at first encounter with a high-risk patient, and also where delirium is suspected. It is not intended to be used in daily monitoring for new onset delirium. Therefore whilst the 4AT has a place in the range of validated tools for delirium, practitioners might consider using alternative tools for day to day monitoring of delirium. The results of the surveys and qualitative studies strongly suggest that there are significant training needs for clinical staff, which policymakers might consider addressing alongside introduction of the 4AT and other tools. Moreover, the findings suggest a lack of clarify in understanding of the roles of different members of the multidisciplinary team in detecting delirium. These findings suggest that making consistent delirium detection a reality requires not only tools and skilled and knowledgeable staff, but also institutional support and the development of systems of care for delirium which can be applied following a diagnosis are also necessary. There is a clear need for a more consistent approach to the treatment of delirium once it has been identified. One such approach is the TIME (Think, Investigate, Manage, Engage and Explore) Bundle produced by Healthcare Improvement Scotland, ADDIN EN.CITE <EndNote><Cite><Author>Bond</Author><Year>2015</Year><RecNum>3704</RecNum><DisplayText><style face="superscript">190</style></DisplayText><record><rec-number>3704</rec-number><foreign-keys><key app="EN" db-id="p9rar2z21wv2tjeswdux0rz0efdwdxp2awt5" timestamp="1522071382">3704</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bond, P.</author><author>Goudie, K.</author></authors></contributors><auth-address>Healthcare Improvement Scotland, Glasgow.</auth-address><titles><title>Identifying and managing patients with delirium in acute care settings</title><secondary-title>Nurs Older People</secondary-title></titles><periodical><full-title>Nurs Older People</full-title></periodical><pages>28-32</pages><volume>27</volume><number>9</number><keywords><keyword>Delirium/*diagnosis</keyword><keyword>Humans</keyword><keyword>Scotland</keyword><keyword>acute care</keyword><keyword>delirium</keyword><keyword>medical emergency</keyword><keyword>older people</keyword><keyword>patient care bundles</keyword><keyword>toolkit</keyword></keywords><dates><year>2015</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1472-0795 (Print)1472-0795 (Linking)</isbn><accession-num>26511424</accession-num><urls><related-urls><url> which covers the first two hours after diagnosis. Another more comprehensive approach derived from expert consensus is the Comprehensive Delirium Management Pathway produced by the Scottish Delirium Association (scottishdeliriumassociation).AcknowledgementsThis study was supported by the National Institute for Health Research Health and Technology Assessment (HTA) programme. Alasdair MacLullich and Susan Shenkin are members of the University of Edinburgh Centre for Cognitive Ageing and Cognitive Epidemiology, part of the cross council Lifelong Health and Wellbeing Initiative (grant No MR/K026992/1).The authors would like to thank all the patients and carers who give up their time to take part in the study. We would also like to thank all the NHS staff who supported the study in the three sites. The authors acknowledge the help of the Trial Steering Committee. The committee was chaired by Prof Miles Witham, and other members were Prof Phyo Myint, Dr Julia Boyd, Dr Linda Wolff, Ms Barbara Lamb, Dr Daniel Davis, Ms Ann Stewart, Ms Jo-Anne Robertson, Ms Fiona Redmond, Prof Christopher Weir, and Prof Alasdair MacLullich. We thank all the administrative staff in the three study sites for their support. We thank Dr Valentia Assi for contributing to the statistical analyses. We acknowledge the help of the Edinburgh Clinical Trials Unit, including Mr Allan Walker (database programmer) and Dr Lorraine Smith. We thank Miranda Odam, Mia Paderanga, and Louise Ross from the Emergency Medicine Research Group of Edinburgh (EMERGE). We thank the research nurses and other research staff in the Clinical Research Facilities who took part in the recruitment and testing. Contributions of authorsAlasdair MacLullich (Prof of Geriatric Medicine), Chief Investigator and co-site lead for Edinburgh, conceived and planned the study and acted as study lead. Led writing of the report and all aspects of study design, conduct and analysis. Designed and led the training of research staff.Susan Shenkin (Senior Lecturer in Geriatric Medicine), co-site lead for Edinburgh, provided expertise in geriatric medicine, and contributed to protocol design and statistical analysis, supervision of staff, and drafted sections of the report.Steve Goodacre (Prof of Emergency Medicine) was site lead for Sheffield, provided expertise in emergency medicine, and contributed to protocol design, staff training and supervision, and writing the report.Mary Godfrey (Reader in Health and Social Care) provided expertise in qualitative research, and contributed to the design, conduct, and analysis of the qualitative studies, staff training and supervision, and drafted sections of the report.Janet Hanley (Reader in Nursing Studies) provided expertise in qualitative research, and contributed to the design, conduct, and analysis of the qualitative studies, staff training and supervision, and drafted sections of the report.Antaine Stíobhairt (Research Associate in Psychology) contributed to the design and analysis of the qualitative studies, recruited and interviewed patients for these studies, and drafted sections of the report.Elizabeth Lavender (Qualitative Researcher) contributed to the design and analysis of the qualitative studies, recruited and interviewed patients for these studies, and drafted sections of the report.Julia Boyd (Project Manager) provided expertise in study management, and contributed to protocol design and staff training and supervision, and was project manager.Jacqueline Stephen (Statistician) was a trial statistician and contributed to the development of the statistical analysis plan, undertook the statistical analyses and drafted sections of the report.Christopher Weir (Statistician) was the trial statistician, and co-designed the protocol and led the design of the statistical analysis plan, and oversaw the statistical analyses, and contributed to the writing of the report.Allan MacRaild (Research Nurse) contributed to study design, participated in patient recruitment and testing, and participated in staff training.Jill Steven (Research Nurse) contributed to study design, participated in patient recruitment and testing, and participated in staff training.Polly Black (Research Nurse) contributed to study design, participated in patient recruitment and testing, and participated in staff training.Katharina Diernberger (Health Economist) provided expertise in health economics, and co-designed the health economics analysis, carried out the analysis of the health economics data, and drafted sections of the report.Peter Hall (Health Economist) provided expertise in health economics, and co-designed the health economics analysis, supervised the analysis of the health economics data, and drafted sections of the report.Zo? Tieges (Research Psychologist), provided expertise in psychology, and contributed to design of the reference standard assessment, and data analysis.Christopher Fox (Prof of Old Age Psychiatry), provided expertise in dementia, and contributed to protocol design and writing of the report.Atul Anand (Clinical Research Fellow in Geriatric Medicine) contributed to protocol design and writing of the report. John Young (Prof of Elderly Care Medicine), Bradford site lead, and contributed to protocol design and writing of the report.Najma Siddiqi (Consultant Psychiatrist), provided expertise in psychiatry and contributed to protocol design and writing of the report.Alasdair Gray (Prof of Emergency Medicine), provided expertise in emergency medicine, was co-site lead for Edinburgh, and contributed to staff training and supervision, and writing of the report.Data Sharing StatementAll data requests should be submitted to the corresponding author for consideration. 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Diagnostic and Statistical Manual of Mental Disorders. 3rd, revised edn. Washington DC: American Psychiatric Association; 1987.150.Jorm AF. A Short-Form of the Informant Questionnaire on Cognitive Decline in the Elderly (Iqcode) - Development and Cross-Validation. Psychological Medicine 1994;24:145-53.151.Jackson TA, MacLullich AM, Gladman JR, Lord JM, Sheehan B. Diagnostic test accuracy of informant-based tools to diagnose dementia in older hospital patients with delirium: a prospective cohort study. Age Ageing 2016;45:505-11. M, Wyller TB, Engedal K, Juliebo V. Delirium is an important predictor of incident dementia among elderly hip fracture patients. Dement Geriatr Cogn Disord 2011;31:63-70. BE, Hall RJ, Seljeflot I, Frihagen F, MacLullich AM, Raeder J, et al. Associations Between Delirium and Preoperative Cerebrospinal Fluid C-Reactive Protein, Interleukin-6, and Interleukin-6 Receptor in Individuals with Acute Hip Fracture. J Am Geriatr Soc 2016;64:1456-63. A, Han JH, Meagher D, Vasilevskis E, Cerejeira J, Hasemann W, et al. Detecting Delirium Superimposed on Dementia: Evaluation of the Diagnostic Performance of the Richmond Agitation and Sedation Scale. J Am Med Dir Assoc 2016;17:828-33. AF. The Informant Questionnaire on cognitive decline in the elderly (IQCODE): a review. Int Psychogeriatr 2004;16:275-93.156.Hart RP, Levenson JL, Sessler CN, Best AM, Schwartz SM, Rutherford LE. Validation of a cognitive test for delirium in medical ICU patients. Psychosomatics 1996;37:533-46.157.Tieges Z, Stiobhairt A, Scott K, Suchorab K, Weir A, Parks S, et al. Development of a smartphone application for the objective detection of attentional deficits in delirium. Int Psychogeriatr 2015;27:1251-62. CH, Hughes DA. Methods for the collection of resource use data within clinical trials: a systematic review of studies funded by the UK Health Technology Assessment program. Value Health 2010;13:867-72. (11)71817-4 [pii]159.Marcantonio ER, Ngo LH, O'Connor M, Jones RN, Crane PK, Metzger ED, et al. 3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium: a cross-sectional diagnostic test study. Ann Intern Med 2014;161:554-61. KJ, Nelliot A, Inouye SK, Ely EW, Bienvenu OJ, Lee HB, et al. Delirium diagnosis methodology used in research: a survey-based study. Am J Geriatr Psychiatry 2014;22:1513-21. KJ. Delirium classification by the Diagnostic and Statistical Manual - a moving target. Int Psychogeriatr 2015;27:881-2. E, Franco JG, Trzepacz PT, Gaviria AM, Meagher DJ, Palma J, et al. Delirium diagnosis defined by cluster analysis of symptoms versus diagnosis by DSM and ICD criteria: diagnostic accuracy study. BMC Psychiatry 2016;16:167. E, Franco JG, Trzepacz PT, Gaviria AM, Vinuelas E, Palma J, et al. Performance of the Delirium Rating Scale-Revised-98 Against Different Delirium Diagnostic Criteria in a Population With a High Prevalence of Dementia. Psychosomatics 2015;56:530-41. JV, Pitkala KH, Strandberg TE, Tilvis RS. Impact of different diagnostic criteria on prognosis of delirium: a prospective study. Dement Geriatr Cogn Disord 2004;18:240-4. M, Wynaden D, McGowan S, Speed G. Assessing cognition in elderly patients presenting to the emergency department. Int Emerg Nurs 2008;16:73-9. (08)00010-4 [pii]10.1016/j.ienj.2008.01.005166.Schofield I, Stott DJ, Tolson D, McFadyen A, Monaghan J, Nelson D. Screening for cognitive impairment in older people attending accident and emergency using the 4-item Abbreviated Mental Test. Eur J Emerg Med 2010;17:340-2. T, Keat S, Tate M, Bown A, Hart A, Ghosh R. Assessing the performance of the four question abbreviated mental test in the acute geriatric setting. Acute Med 2013;12:13-7.168.Dyer AH, Briggs R, Nabeel S, O'Neill D, Kennelly SP. The Abbreviated Mental Test 4 for cognitive screening of older adults presenting to the Emergency Department. Eur J Emerg Med 2016; 10.1097/MEJ.0000000000000394. SK, Zhang Y, Han L, Leo-Summers L, Jones R, Marcantonio E. Recoverable cognitive dysfunction at hospital admission in older persons during acute illness. Journal of General Internal Medicine 2006;21:1276-81.170.Breitbart W, Rosenfeld B, Roth A, Smith MJ, Cohen K, Passik S. The Memorial Delirium Assessment Scale. Journal of Pain and Symptom Management 1997;13:128-37.171.Inouye SK, Kosar CM, Tommet D, Schmitt EM, Puelle MR, Saczynski JS, et al. The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med 2014;160:526-33. JH, Wilson A, Ely EW. Delirium in the older emergency department patient: a quiet epidemic. Emerg Med Clin North Am 2010;28:611-31. (10)00034-9 [pii]10.1016/j.emc.2010.03.005173.Han JH, Wilson A, Vasilevskis EE, Shintani A, Schnelle JF, Dittus RS, et al. Diagnosing Delirium in Older Emergency Department Patients: Validity and Reliability of the Delirium Triage Screen and the Brief Confusion Assessment Method. Annals of Emergency Medicine 2013; S0196-0644(13)00436-8 [pii]10.1016/j.annemergmed.2013.05.003. (13)00436-8 [pii]10.1016/j.annemergmed.2013.05.003174.Holmes J, House A. Psychiatric illness predicts poor outcome after surgery for hip fracture: a prospective cohort study. Psychological Medicine 2000;30:921-9.175.Thomason JW, Shintani A, Peterson JF, Pun BT, Jackson JC, Ely EW. Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients. Crit Care 2005;9:R375-81. I, Vincent S, Germain C, Salles N, Jenn J, Rasoamanarivo E, et al. Delirium symptoms and low dietary intake in older inpatients are independent predictors of institutionalization: A 1-year prospective population-based study. Journals of Gerontology Series A-Biological Sciences and Medical Sciences 2004;59:350-4.177.Zywiel MG, Hurley RT, Perruccio AV, Hancock-Howard RL, Coyte PC, Rampersaud YR. Health economic implications of perioperative delirium in older patients after surgery for a fragility hip fracture. J Bone Joint Surg Am 2015;97:829-36. CHt, Laflam A, Max L, Lymar D, Neufeld KJ, Tian J, et al. The Impact of Delirium After Cardiac Surgical Procedures on Postoperative Resource Use. Ann Thorac Surg 2016;101:1663-9. TS, Murphy K, Rizzuto L, Santos R, Skotzko C, Giordano J, et al. Quality improvement and cost savings with multicomponent delirium interventions: replication of the Hospital Elder Life Program in a community hospital. Psychosomatics 2013;54:219-26. Services Division. Scottish Health Service Costs. URL: (Accessed 1 September 2017).181.Curtis LB, A. Unit Costs of Health and Social Care.: (PSSRU) Personal Social Services Research Unit.; 2015.182.Department of Health. NHS reference costs 2015 to 2016. URL: (Accessed 1 September 2017).183.Langan C, Sarode DP, Russ TC, Shenkin SD, Carson A, Maclullich AM. Psychiatric symptomatology after delirium: a systematic review. Psychogeriatrics 2017; 10.1111/psyg.12240. D, Hardy R, Howell D, Mythen M. Identifying clinical and acute psychological risk factors for PTSD after critical care: a systematic review. Minerva Anestesiol 2013;79:944-63.185.Leslie DL, Inouye SK. The importance of delirium: economic and societal costs. J Am Geriatr Soc 2011;59 Suppl 2:S241-3. ;. The guidelines manual: 7 Assessing cost effectiveness. 13 Dec 2017).187.European Delirium A, American Delirium S. The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer. BMC Med 2014;12:141. DM, Inouye SK, Guess J, Ngo LH, Jones RN, Saczynski JS, et al. Preliminary development of an ultrabrief two-item bedside test for delirium. J Hosp Med 2015;10:645-50. A, Bastiaens J, Bourgeois JA, Neuhaus J, Josephson SA, Chinn J, et al. Validation of a Nurse-Based Delirium-Screening Tool for Hospitalized Patients. Psychosomatics 2017; 10.1016/j.psym.2017.05.005. P, Goudie K. Identifying and managing patients with delirium in acute care settings. Nurs Older People 2015;27:28-32. AppendicesAppendix 1. Survey ASurvey ADelirium - National Survey of UK Healthcare PractitionersSurvey Legend* = Mandatory question= One response only= Multiple responses acceptedR = Responses randomised Need to finish off which ones were * and R and R(excluding bottom option)Survey Legend* = Mandatory question= One response only= Multiple responses acceptedR = Responses randomised Need to finish off which ones were * and R and R(excluding bottom option)We greatly appreciate your interest!Who are the intended respondents?This survey is intended for UK-based doctors, nurses, physiotherapists and occupational therapists that come into contact with adult patients with delirium (or 'acute confusional state') as part of their routine work.Please do not fill in this survey if you are not a UK health practitioner.Why this survey?There is some variation among healthcare practitioners regarding how delirium is detected and assessed. As part of our efforts to improve delirium detection and assessment, we are interested in finding out more about these variations.What is delirium?Broadly speaking, delirium is an acute deterioration in cognition or other mental functions caused by an acute medical problem, drug side-effects or other acute causes. What does the survey cover?Attitudes and knowledge around delirium detection and assessment.Who is funding this survey?The UK National Institute for Health Research, Health Technology Assessment programme. Link to NIHR webpage on the study.Which institutions are involved?Team members are employed by the NHS (Edinburgh, Sheffield, Bradford, Leeds), the University of Edinburgh, the University of Sheffield, the University of Leeds and the University of East Anglia. Are my responses anonymous?The survey is completely anonymised. No personal identifiable information will be collected as part of the survey. No computer location information will be collected. There are some broad questions on your professional background, the type of setting you work in, and the country in which you work. The results of this survey will be published and some completely anonymised responses may be quoted in these publications. How long will the survey take?10-15 minutes. If you are interested in helping with the survey, please read the first question below and if appropriate, click 'I agree':Do you agree to participate in this survey and consent to the potential use of your anonymised responses as described above? *I agreeI do not agreeAsterisks (*) are shown beside questions that require an answer to allow the survey to proceed.For those working in community-based palliative care, please refer to your work settings where the survey uses the term 'unit'.Please click Next to begin.===== page break =====Which clinical setting(s) do you currently work in? (primarily, but tick more than one option if your time is divided) Emergency departmentAcute assessment / medical assessment unitIntensive careMedicine of the elderlyOrthopaedicsRehabilitation wardOncologyStrokeHospice / Palliative careInternal medicine specialist ward (e.g. cardiology, respiratory, gastroenterology, nephrology, endocrinology, neurology)Old age mental health wardLiaison mental healthSurgical ward (not including orthopaedics)Other (please specify)===== page break =====What nation do you work in? *REnglandNorthern IrelandScotlandWalesOther (please specify)===== page break =====How many years have you been working (approximate full-time equivalent) since obtaining your primary professional qualification? ===== page break =====Which field is your primary professional qualification in? *RMedicineNursingOccupational therapyPhysiotherapyOther (please specify)===== page break ========== Begin filter: For respondents who chose ‘Medicine’ in the previous question =====Which stage of your career are you at? *RFY1 – 2ST1 – 2ST3+ConsultantSpecialist doctorAssociate specialistGPOther (please specify)===== page break =====Which of the following specialties are you trained in (i.e. to CCT/CCST level) or undergoing training in? General PracticeSurgical specialtyIntensive CarePalliative MedicineEmergency MedicineGeneral (Internal) MedicineGeriatric MedicineGeneral Adult PsychiatryAnaestheticsOld Age PsychiatryAcute MedicineLiaison PsychiatryOther (please specify)===== page break =====The following four questions concern various aspects of delirium assessment. Please answer according to your own views. These questions are not intended to test knowledge but rather to understand more about existing variations in clinical opinion.===== page break =====In your opinion, in order to allow bedside assessment for delirium, does a patient need to have a sufficiently high level of consciousness to produce verbal responses?YesNoDon’t know===== page break =====If a patient presents with recent onset drowsiness and is not producing verbal responses, but is responding intermittently to one-stage commands, in practice which of the following terms would you most likely use to describe this state?ComaObtundationDeliriumStuporEncephalopathyOther (please specify)===== page break =====A patient has recent-onset drowsiness and is not producing verbal responses, but is responding intermittently to one-stage commands. In your opinion, how likely is it that the patient has delirium?Very unlikely 0 – 20%Unlikely 21 – 40%Neither likely nor unlikely 41 – 60%Likely 61 – 80%Very Likely 81 – 100%===== page break =====Please answer the following questions using the 5-point scale provided.Never / rarely (0 – 20%)Sometimes (21 – 40%)About half of the time (41 – 60%)Frequently (61 – 80%)Almost always / always (81 – 100%)In patients with cognitive impairment, how often do you seek a history of mental status changes from collateral sources (e.g. family, GP, etc.)?When you have detected delirium, how often do you record this using the term "delirium" in the case notes?===== page break ========== End filter: For respondents who chose ‘Medicine’ in earlier question =====In your opinion, of all the cases of delirium in your unit, what percentage of patients have their delirium diagnosed and documented?0 – 20%21 – 40%41 – 60%61 – 80%81 – 100%(I don’t know)===== page break =====Please indicate the extent to which you think the following potential causes contribute to under-detection of delirium in your unit.Very smallSmallModerateLargeVery large(Don’t know)Lack of consensus on which screening tools/criteria are usedDetection is considered the duty of certain healthcare practitioners onlyLack of staff knowledge of deliriumTime constraintsDelirium detection not part of routine assessmentDifficulty in discriminating delirium from dementiaLack of staff confidence in assessmentPlease list anything else you that you think contributes to under-detection of delirium in your unit, and the extent to which you think they contribute.===== page break =====Please indicate how often the following terms are used in your unit to describe patients with acute deterioration in cognition or other mental functions caused by an acute medical problem, drug side-effects or other acute causes.Never / rarely (0 – 20%)Sometimes (21 – 40%)About half of the time (41 – 60%)Frequently (61 – 80%)Almost always / always (81 – 100%)Septic encephalopathyDeliriumConfusionAcute confusional state / Acute confusionPlease list any other terms and how often they are used in your unit to describe the clinical syndrome described above.===== page break =====Are there guidelines in place for any of the following in your unit?NoYesDelirium detectionDelirium management===== page break =====In your opinion, how often are these guidelines followed?Never / rarely (0 – 20%)Sometimes (21 – 40%)About half of the time (41 – 60%)Frequently (61 – 80%)Almost always / always (81 – 100%)Don’t knowN/ADelirium detectionDelirium managementAdd comments here.===== page break =====Are there routine audits of any of the following in your unit?NoYesDelirium detectionDelirium management===== page break =====Do you think there has been an increase in awareness of delirium among colleagues in your specialty in the last three years?YesNoDon’t knowN/A (if qualified less than three years)===== page break =====Do you think there has been an increase in how often delirium is mentioned in the following domains, in the last three years?NoYesDon’t knowClinical JournalsTwitterFacebookClinically-related websitesProfessional conferencesTraining eventsGeneral media coverage (e.g. BBC, newspapers)Training curriculumAny comments or additional domains?===== page break =====What is your level of confidence in your own ability to detect delirium? *(Can’t decide)Very lowLowModerateHighVery High===== page break =====Have you ever used a tool to detect delirium? (i.e. a specific assessment tool or cognitive test)NoYes===== page break =====Please rank the following tools/criteria in order of how often you have used them to detect delirium in your clinical practice.Drag-and-drop the options below into the appropriate order, where 1 = most often.Please mark the items that you have never used as 'N/A' using the option on the right; this could apply to all the items listedConfusion Assessment Method (CAM)N/ADelirium Observation Scale (DOS)N/AConfusion Assessment Method – Intensive Care Unit (CAM-ICU)N/ANursing Delirium Scale (NU-DESC)N/ADelirium Rating Scale (DRS/DRS-R-98)N/A4ATN/AOther 1 (please give details below)N/AOther 2 (please give details below)N/AMany more delirium assessment tools exist. Please add any other tools that you have used.===== page break =====When you are assessing a patient for possible delirium, how often do you use bedside cognitive testing?Never / rarely (0 – 20%)Sometimes (21 – 40%)About half of the time (41 – 60%)Frequently (61 – 80%)Almost always / always (81 – 100%)===== page break =====When you use a cognitive test as part of assessment for possible delirium, which test(s) do you use?Drag-and-drop the options below into the appropriate order, where 1 = most often.Please mark the items that you have never used as 'N/A' using the option on the right; this could apply to all the items listedAbbreviated Mental Test – 10 itemN/AAbbreviated Mental Test – 4 itemN/AMonths of the year backwardsN/ADays of the week backwardsN/ACounting from 20 down to 1N/ASerial 7sN/ADigit spanN/AOrientation to time, place, personN/AVigilance test (e.g. SAVEAHEART)N/AMini-Mental State ExaminationN/AMontreal Cognitive Assessment (MoCA)N/AOther 1 (please give details below)N/AOther 2(please give details below)N/APlease add any other cognitive tests that you have used.===== page break =====Please briefly describe your approach if/when you do not use a delirium assessment tool or cognitive test to detect delirium.===== page break =====Please indicate your level of agreement with the following statements.Strongly disagreeDisagreeNeither disagree nor disagreeAgreeStrongly agreeMaking a formal diagnosis of delirium is important to provide good delirium careDelirium treatment improves patient outcomesDistinguishing between delirium and dementia is important in providing good care===== page break =====In your opinion, which of the following tasks should each healthcare practitioner consider their duty in regards to delirium detection?Flagging potential casesScreening high risk patientsMaking a formal diagnosisDoctorsNursesPhysiotherapistsOccupational Therapists===== page break =====Please use this space to comment on any of the issues raised in this survey or additional issues surrounding the detection and assessment of delirium that have not been addressed.===== page break =====We may wish to contact some participants to ask them to expand on some of their answers. If you're happy to share another few minutes of your time please enter your name and email address below. (optional)By providing contact details your results will no longer be anonymous; however this information will only be used to contact you and will not be used for any other purpose.If you do not wish to provide contact details please press next.NameEmail address===== page break =====Your responses have been submittedThank you - your time and effort is very much appreciated!This survey is part of a larger study which aims to develop and validate the 4AT - a new triage tool for delirium - developed at the University of Edinburgh.We would be very grateful if you could help us reach more UK health practitioners.Please consider:? Forwarding the email you received to relevant medical, nursing, physiotherapy and occupational therapy staff in your department, Trust/Health board and contacts list. (e.g. Emergency department, ICU, AAU/MAU, Elderly Care, Trauma & Orthopaedics , Oncology, Stroke services, Palliative care/hospices).? Displaying an A4 poster highlighting the survey in your staff area (simply email astiobha@staffmail.ed.ac.uk for a copy)Clicking 'Done' will bring you to where you will find more information about the 4AT. Appendix 2. Survey B Survey Legend* = Mandatory question= One response only= Multiple responses acceptedR = Responses randomised RL = Responses randomised except for bottom optionWHAT ABOUT BOTTOM OPTION?Finish off which ones were * and RSurvey Legend* = Mandatory question= One response only= Multiple responses acceptedR = Responses randomised RL = Responses randomised except for bottom optionWHAT ABOUT BOTTOM OPTION?Finish off which ones were * and RThe 4AT Delirium Assessment Tool: An International Survey of its Use in Clinical PracticeWe greatly appreciate your interest!Who are the intended respondents?This survey is intended for healthcare practitioners worldwide that use the 4AT to screen patients for delirium (or 'acute confusional state').Please do not fill in this survey if you have never used the 4AT.We recently carried out a general survey relating to delirium detection and assessment in the UK. Practitioners who completed that survey are also invited to complete this one. We are very grateful for the support we have received so far.Why this survey?As part of our efforts to improve delirium detection and assessment, we plan to carry out a large-scale validation study of the 4AT, but first we would like to find out more about how it is currently used clinically and how it may be improved.What does the survey cover?Current practice surrounding the use of delirium screening tools, particularly the 4AT, and your opinions of the 4AT itself.Who is funding this survey?The UK National Institute for Health Research, Health Technology Assessment programme. Click here to see the NIHR webpage on the study.Which institutions are involved?Team members are employed by the NHS (Edinburgh, Sheffield, Bradford, Leeds), the University of Edinburgh, the University of Sheffield, the University of Leeds and the University of East Anglia.Are my responses anonymous?The survey is completely anonymised. No personal identifiable information will be collected as part of the survey. No computer location information will be collected. There are some broad questions on your professional background and the type of setting you work in.The results of this survey will be submitted as part of a report and published in academic journals. Some completely anonymised responses may be quoted in these publications.How long will the survey take?About 10 minutes.We highly recommend having a copy of the 4AT in front of you while completing this survey. Please click here to view or download a copy from Do you agree to participate in this survey and consent to the potential use of your anonymised responses as described above?I agreeI do not agreeAsterisks (*) are shown beside questions that require an answer to allow the survey to proceed.Please click Next to begin.===== page break =====Which clinical setting(s) do you currently work in? (primarily, but tick more than one option if your time is divided) * RLEmergency departmentAcute assessment / medical assessment unitIntensive careMedicine of the elderlyOrthopaedicsRehabilitation wardOncologyStrokeHospice / Palliative careInternal medicine specialist ward (e.g. cardiology, respiratory, gastroenterology, nephrology, endocrinology, neurology)Old age mental health wardLiaison mental healthSurgical ward (not including orthopaedics)Other (please specify)===== page break =====Which nation do you work in? * RLEnglandNorthern IrelandScotlandWalesOther (please specify)===== page break =====How many years have you been working (approximate full-time equivalent) since obtaining your primary professional qualification? *===== page break =====Which field is your primary professional qualification in? * RMedicineNursingOccupational therapyPhysiotherapyOther (please specify)===== page break =====Which stage of your career are you at? * RLFY1 – 2ST1 – 2ST3+ConsultantSpecialist doctorAssociate specialistOther (please specify)===== page break =====Which of the following specialties are you trained in (i.e. to CCT/CCST level) or undergoing training in? * RGeriatric MedicineAcute MedicineEmergency MedicineAnaestheticsIntensive CarePalliative MedicineOld Age PsychiatryLiaison PsychiatryGeneral Adult PsychiatryGeneral PracticeSurgical specialtyGeneral (Internal) MedicineOther (please specify)===== page break =====What is your level of confidence in your own ability to detect delirium? *(Can’t decide)Very lowLowModerateHighVery High===== page break =====Please answer the following questions using the 5-point scale providedNever / rarely (0 – 20%)Sometimes (21 – 40%)About half of the time (41 – 60%)Frequently (61 – 80%)Almost always / always (81 – 100%)How often do you assess patients for delirium?When assessing for delirium, how often do you use a scale or other tool?===== page break =====Please rank the following tools/criteria in order of how often you have used them to detect delirium in your clinical practice.Drag-and-drop the options below into the appropriate order, where 1 = most often.Please mark the items that you have never used as 'N/A' using the option on the right; this could apply to all the items listed4ATN/AConfusion Assessment Method (CAM)N/AConfusion Assessment Method – Intensive Care Unit (CAM-ICU)N/ANursing Delirium Scale (NU-DESC)N/ADelirium Rating Scale (DRS/DRS-R-98)N/ADelirium Observation Scale (DOS)N/AOther 1 (please give details below)N/AOther 2 (please give details below)N/AMany more delirium assessment tools exist. Please add any other tools that you have used.===== page break =====Approximately how long has it been since you first used the 4AT?<1 month1 – 6 months7 – 12 months>1 yearPlease add any comments here.===== page break =====How often do you use the 4AT in patients at risk of delirium?Never / rarely (0 – 20%)Sometimes (21 – 40%)About half of the time (41 – 60%)Frequently (61 – 80%)Almost always / always (81 – 100%)===== page break =====When using a tool to screen for delirium, what factors influence your decision to use the 4AT instead of another tool?When using a tool to screen for delirium, what factors influence your decision to use another tool instead of the 4AT?===== page break =====Is the 4AT used as part of routine assessment by you or others in your unit?NoYesPlease add any comments here.===== page break =====Approximately what proportion of patients in your unit undergo the 4AT?(Don’t know)0 – 20%21 – 40%41 – 60%61 – 80%)81 – 100%===== page break =====Do you think that use of the 4AT as part of routine assessment is feasible in your unit?NoYesPlease explain why you think so.===== page break =====To what extent are the following necessary in order for healthcare practitioners to use the 4AT effectively?(Don't know)None / very littleSomeA moderate amountQuite a bitAn extensive amountKnowledge of deliriumTraining in the use of the 4AT===== page break =====Please indicate the extent to which you think the following potential barriers prevent the 4AT from being used more regularly in your unit. Very smallSmallModerateLargeVery largeTime constraintsExisting use of / familiarity with an alternative toolLack of staff confidence in using the toolLack of perceived need to use a delirium screening toolLack of staff knowledge of deliriumAre there any other factors which prevent the 4AT from being used more regularly? Please state why and the extent to which they contribute.===== page break =====Please mark the responses below that best reflect your typical experience in using the 4AT with the following groups.If you have never used the 4AT on a particular group of patients choose 'N/A'. RVery easy EasyNeither easy nor difficultDifficultVery DifficultN/ADrowsy patients who can not produce verbal responsesPatients with dementia who are alert and able to conversePatients who are agitated and distressed===== page break =====Approximately how long does it typically take you to complete all three of the bedside components of the 4AT (items 1 - 3: 'Level of alertness', 'Months backwards' and 'AMT4')?<1 minute1 – 2 minutes3+ minutesPlease add any comments here===== page break =====Approximately how long does it typically take you to do item 4 ('Acute change or fluctuating course')?Time [drop down menu with option for “<1 minute” to “10+ minutes”]From:__________To:__________Please add any comments here===== page break =====Would you suggest any changes to item 1 ('Alertness')?YesNoIf so please describe which changes, and why.===== page break =====Would you suggest any changes to item 2 ('AMT4')?YesNoIf so please describe which changes, and why.===== page break =====Would you suggest any changes to item 3 ('Attention')?YesNoIf so please describe which changes, and why.===== page break =====Would you suggest any changes to item 4 ('Acute change or fluctuating course')?YesNoIf so please describe which changes, and why.===== page break =====Would you suggest any changes to the scoring system?YesNoIf so please describe which changes, and why. (Is there an alternative system you could suggest that would work better?)===== page break =====Would you suggest any changes to the current guidance notes?YesNoIf so please describe which changes, and why.===== page break =====What is your general opinion of the 4AT?===== page break =====Broadly speaking, how has the 4AT been received by your colleagues?(Don’t know) Very PoorlyPoorlyNeutralWellVery wellMedicalNursingOther (if applicable, specify below)Why do you think this is so?===== page break =====Please use this space to comment on any of the issues raised in this survey or any concerns that have arisen through use of the 4AT.===== page break =====We may wish to contact some participants to ask them to expand on some of their answers. If you're happy to share another few minutes of your time please enter your name and email address below. (optional)By providing contact details your results will no longer be anonymous; however this information will only be available to members of the research team and will only be used to contact you in connection with this survey and will not be used for any other purpose.If you do not wish to provide contact details please press next.NameEmail address===== page break =====Your responses have been submittedThank you - your time and effort is very much appreciated!We would be very grateful if you could help us reach more 4AT users.Please consider:? Forwarding the email you received to 4AT users in your department, Trust/Health board and contacts list, particularly junior doctors and nurses.? Displaying an A4 poster highlighting the survey in your staff area (simply email astiobha@staffmail.ed.ac.uk for a copy)Clicking 'Done' will bring you to where you will find more information about the 4AT. Appendix 3. Survey B: respondent characteristicsMedicine (tertiles of years of experience)NursingOccupational TherapyPhysiotherapyTotalLowerMidUpperOverallFrequency (% of sample)171235643231100Years qualified (Mdn(IQR))1.50 (1 – 2.5)9.50 (8 – 11.50)16 (12 – 20)12 (4.75 – 16.26)18 (10 – 30)5 (3 – 7.5)7 (NA)12 (6 – 19.25)SettingAcute inpatient medical10112849222174Emergency department434113--12Intensive care unit1--11--3Rehabilitation unit1-56---6Surgical ward413841013Psychiatry-1353109Other*1-342--6Table SEQ Table \* ARABIC 17: Survey B: respondent characteristicsAll estimates relate to frequency of respondents except where stated otherwise. Cells for settings are not equal to the total sample size as respondents could choose multiple settings. Acute inpatient medical = acute Assessment/ medical assessment unit, medicine of the elderly, orthopaedics, oncology, stroke, internal medicine specialist ward (e.g. cardiology, respiratory, gastroenterology, nephrology, endocrinology, neurology); Surgical ward (exl. ortho.) = Surgical ward not including orthopaedics.* Acute medicine (n = 2), community psychiatry (n = 2), general practice (n = 1), immediate care (n = 1) Appendix 4. Survey B: assessment tools used and the frequency of use among respondentsTable SEQ Table \* ARABIC 18: Survey B: assessment tools used and the frequency of use among respondentsHas been used by% (n)Frequency of useMdn rank (IQR)4AT100 (90/90)1 (1 – 1)Confusion Assessment Method (CAM)67.78 (61/90)2 (2 – 3)Delirium Observation Scale (DOS)33.33 (30/60)3.5 (3 – 4)CAM-ICU32.22 (29/90)3 (2 – 3)Delirium Rating Scale (DRS/DRS-R-98)27.78 (25/90)5 (4 – 5)Nursing Delirium Scale (NU-DESC)20.00 (18/90)6 (6 – 7)Respondent specified toolsSingle Question in Delirium (SQUID)(2)Memorial Delirium Assessment Scale (MDAS)(1)In-house tool(1)All estimates as shown in % (proportion) of the total responses for each tool. Rank of 1 = used most often. Ranking for delirium screening tools ranged from 1 – 8. ‘Respondent specified tools’ refer to tools that were not listed in the survey as response options but were specified by participants in an open-text field which followed the question. Accurate percentages and ranks could not be generated for these tools. Appendix 5. User opinions of the 4AT from Survey BQ14 When respondents were asked which factors influence their decision to use the 4AT instead of another tool, several respondents reported and that it is the recommended tool of use in their unit/trust (n = 25), and that it is easy (n = 23) and brief to use (n = 20). Respondents also reported the presence of the tool in paperwork (n = 11), familiarity (n = 5), the ease with which the items can be remembered (n = 5), the fact that it is free to use (n = 2), used by others in their unit (n = 2), based on useful clinical markers of delirium (n = 2) and because little training is required for staff (n = 2). A number of respondents referred directly to the strengths of the 4AT over alternative tools, stating that it “takes factors other than patient questions into account”; is “more clear for learners than CAM”; has the “ability to quantify attentional deficit, ability to include the drowsy/untestable”; “helps to differentiate Delirium and Dementia”; and tool users have “Instant access online to jog memory of components”.Q15 Factors that influence the decision of respondents to use another tool instead of the 4AT include the need for a more detailed assessment (n = 11), recommended use of another tool (n = 8), familiarity with another tool (n = 7), limited time (n = 3) and the tests that have already been carried out (n = 2). Respondents also stated to they sometimes specifically want the results of the CAM or will continue to use the same tool used to establish a baseline. Importantly, these comments largely refer to systemic and cultural factors rather than the tool itself. Additional noteworthy comments include: “speed of use of AMT4”; “Lack of corroborative history”; and “4AT does not discriminate well in patients with pre-existing dementia”. Such comments suggest that these respondents have limited understanding of delirium diagnosis and its importance, indicating that appreciation of the 4AT might rely on a basic knowledge of delirium among those who use it.Q19 PT1 When respondents were asked to what extent knowledge of delirium is necessary in order for healthcare practitioners to use the 4AT effectively, 7.14% (6/84) said ‘none/very little’, 58.33% (49/84) said ‘some’ or ‘a moderate amount’, and 34.52% (29/84) said ‘quite a bit’ or ‘an extensive amount’. PT2 When respondents were asked to what extent training in the use of the 4AT is necessary in order for healthcare practitioners to use the tool effectively, 16.67% (14/84) stated ‘none/very little’, 59.52% (50/84) stated ‘some’ or ‘a moderate amount’, and 23.81% (20/84) stated ‘quite a bit’ or ‘an extensive amount’. Although the 4AT was designed to require minimal knowledge of delirium and training, these results demonstrate that many 4AT users believe that at least moderate levels of both are necessary for effectively use of the tool.Q18 When respondents were asked if they thought that use of the 4AT as part of routine assessment was feasible in their unit, a majority of 95.29% (81/85) said ‘yes’, with many referring to the ease (39.47%, 15/38) and speed if use (28.95%, 11/38). One comment again draws attention to the fact that routine use relies on broader systemic factors:“It worked and improved detection when done as part of an improvement project. However there has been some difficulty embedding it in routine practice involving change of paperwork etc”(ST3+, MAU/MoE)Among the 4.71% (4/85) of respondents who stated ‘no’, only one explained why they thought this was the case and said that they “already use a validated tool”. This highlights the need to explicitly state the advantages of the 4AT over alternative tools in order to encourage change to clinical practice.Q20 Q21 Respondents believed that the largest barrier preventing the 4AT from being used more regularly in their unit was a ‘lack of perceived need to use a delirium screening tool’, with 43.37% (36/83) considering it to have a ‘large’ or ‘very large’ effect. This was followed by ‘lack of staff confidence in using the tool’ (27.71%, 23/83), ‘time constraints’ (26.51%, 22/83), ‘lack of staff knowledge of delirium (24.10%, 20/83) and finally by ‘existing use of / familiarity with an alternative tool (14.46, 12/83; see table 3). These findings again suggest that delirium education is necessary for appreciation and use of the 4AT. Additional noteworthy barriers highlighted by respondents include:“Not being aware the tool is available and not having a short teaching session to explain delirium and how the tool can help highlight if a patient has changed from their baseline” (Nurse (3 yrs), Ortho.)“Lack of confidence in what to do when you've made the diagnosis!”(Consultant, MoE)“once completed no action seems to be taken” (Nurse (12 yrs), MoE)“Location of 4AT in the admission pack, who is to fill it in is not clear in certain units”(FY1 – 2, MAU/Rehab./GP)“The component items are easy to remember but the scoring is difficult to remember and so raters need to have the scoring sheet with them”(Lecturer, MoE/Stroke)“Clinical assessment for delirium predominates. This is likely because it is common in our unit and nurses and medical staff look out for it”(Consultant, MoE)“change in practice takes re-enforcement”(Nurse (32 yrs) Internal med. Specialist/ Surgical ward)Q32 When respondents were asked how the 4AT had been received by their medical colleagues only 4.92% (3/61) said ‘very poorly’ or ‘poorly’, 49.18% (30/61) said ‘neutral’ and 45.90% (28/61) said ‘well’ or ‘very well’. Response rates were very low when asked how the 4AT had been received by nursing staff, however all respondents who answered this item (9) said ‘neutral (4), ‘well’ (4) or ‘very well’ (1). When asked to explain why they thought this was so, one respondent stated “concerns over validation”. The remaining noteworthy comments were we summed up by one particular respondent who stated: “1) Yet another process to complete! 2) Lack of interest/awareness by non-geriatrician. 3) Is it unnecessary duplication? Ultimately if all patients >75yrs have AMTs on admission we would then proceed to MMSE, MOCA +/or ACE III as require”.(ST3+, MAU/MoE)Q31 Q32 When respondents were asked for their general opinion of the 4AT, 84.29% (59/70) had positive views, 14.29% (10/70) had neutral or mixed views and one 1.43% (1/70) had a negative view. While those with positive views generally liked it because it was quick, easy and suitable for different inpatient environments, those who gave mixed opinions provided particularly valuable insights: “Easy to use. Not convinced as a reliable screen but better than AMTS” (Consultant, ED/ MAU/MoE/Rehab./Internal Med. Specialist/Surgical ward)“Good, most probably easier for non-expert to use than the CAM. Unclear how it helps more experienced staff”.(ST3+, MAU/MoE)“Good quick bedside screen BUT some non-specialist staff do not fill in correctly, esp acute/fluct course box”(Consultant, MoE)“I don't use it as clinical assessment is more reliable. I can see its use in AMU and non-MOE specialties where staff are less familiar with delirium - however it needs to lead into a care bundle to assist with management/prevention”.(Consultant, MoE)“I like the 4AT find it easy to use, and easy for others non specialist with moderate training. I would like to use the 4AT Trust wide for delirium but Nice Guidance appears to suggest CAM as best practice validated tool”.(Nurse (18yrs), MAU)“It's fine - but if you make it any more complex, you risk it being ignored or worse, completed as a 'best guess' by clinicians who are already too busy to care”.(GP, ED)“It's pretty good. I think the major challenge is clinical staff (beyond the already converted) being aware of both the tool and the general idea of delirium as a diagnosable, treatable and important condition”.(Consultant, MAU/MoE)“Pragmatic, quick tool. Performs best if staff doing it have some knowledge of delirium. Also needs to be tied to some kind of action plan if the score is positive”.Consultant, MoE/Ortho.)“simple tool that can be used to assist in detection of delirium but should be used with clinical judgement as well”.(Nurse (20 yrs) MoE)Q33 Few respondents made use of an open-comments field in which they were asked to comment on any of the issues raised in this survey or any concerns that have arisen through use of the 4AT, however a number of those that did made noteworthy comments: “The 4AT needs more publicity if it is to be implemented routinely. In a surgical setting, target junior doctors as senior clinicians have little time/interest in diagnosing delirium”. (FY1 – 2, Surgical) “I think it is important to keep an open mind and encourage diversity in the use of tools available for delirium assessment. I have serious concerns regarding how the 4AT is being promoted and enforced in Scotland”.(Nursing (30 yrs), MoE)“Staff forget that the 4AT is a screening instrument and should apply their clinical judgement with regards to diagnosis of delirium”.(Consultant, Liaison MH) Appendix 6. Interviewees by hospital and department in qualitative studyTable SEQ Table \* ARABIC 19: Interviewees by hospital and department in qualitative study4AT ‘Virgin’ SitesAvonfield &Cranford4AT‘Experienced’ SiteDenburyParticipants By Hospital SettingNNED63MAU/EAU46Ward9 (2 surgical; 7 older people wards)15(11 from older people wards, 2orthopaedic trauma, 1 cardio and 1 stroke) Appendix 7. Interviewees by profession and seniority in qualitative studyTable SEQ Table \* ARABIC 20: Interviewees by profession and seniority in qualitative study4AT ‘Virgin’ SitesAvonfield &Cranford4AT ‘Experienced’ SiteDenburyParticipants by Profession and seniorityNNConsultant/senior doctor47Junior doctor63Senior/specialist nurse34PhysiotherapistFrailty unit1-Occupational therapistWard1Staff nurse49Health support worker (HSW)1- Appendix 8: Topic guide for qualitative staff interviews. Identifying delirium: knowledge, screening practices and barriers to identifying delirium in acute hospitalsObjectivesThe study objectives were to:Examine screening practices for delirium at specific points in the patient journey into and through hospital; Explore staff knowledge of delirium and the value attached to identifying delirium including the strategies called forth to manage it at different points in the patient journey;Determine organisational, environmental and system level barriers that impact use of screening tools to identify patients with possible delirium across the patient journey;Consider staff use of screening tools generally and the 4AT specifically, the contexts in which it is used, speed and ease of use and value attached to use. Introduction Introduce study; confidentiality; timing; recording and consent.Role Job titleWork unitExperience Summary of role Location on Care Pathway/Patient JourneyPatient journey into the ED/MAU etc to the ward (focus will depend on the location of the informant)Patients coming into the ED (or…specific to each point in the patient journey)Process for triage and diagnostics in respect of patients coming in via different routes (e.g. ambulance, independently mobile)What happens and length of time at each point in the processDecision-making on destination in respect of older people – does dementia/confusion enter into decision-makingProblems/consequences – of organisational constraints and co-morbidities Routine information gathering: Explore what kind of information is collected and recorded routinely about older patients at each point in the journey, including what is asked of patients/relatives at each stage of the patient journey (A&E; MAU; Ward). [Collect relevant documentation]. Probe:What routine information is collected and recorded at each stage in the patient journey (at A&E; at MAU; and at Ward level)? How and by whom?What information is communicated to which staff at each stage How is it communicated Adequacy of information as perceived by staff at different points in the journeyProblems with collecting/recording/ communicating information across the patient journey? What is routinely collected/usually or often missing? And cognitive impairment? Delirium? How and why?Identifying cognitive impairment and delirium (at each point in the patient pathway)Can you talk me through the process for identifying people with a cognitive impairment? And delirium? – use the following as probesAre older patients typically screened for cognitive impairment? (Screening tools employed and by whom)Are older patients typically screened for delirium? All? Some? Specific triggers? (observation of behavioural cues; use of systematic tools? (what and by whom)What are the contexts in which individual older patients are screened for cognitive impairment generally and for delirium specifically (all, some?)How and who makes the decision as to which patients should be screened for deliriumWhat cues trigger assessment of delirium and how does it occur? Who does it?How is information collected and from whom about the patient’s cognitive state prior to current episodeKnowledge of Delirium Is ‘delirium’ a term that you would use? What term would you use? What does this mean to you? ProbeOwn understanding of delirium? What does this [whatever term is used] mean to youUnderstanding of delirium [whatever term is used]among team membersAcquisition of knowledge about deliriumPerceived value attached to delirium screening (staff member/team/hospital)Does it/should it affect the treatment/management plan? How and in what respects does it do so? Training received about delirium (What training? Covered in professional training? Professional development? Hospital mandatory training?)Use of 4AT Reflecting back now on your use of the 4AT in your work setting, can we go through what happened? ProbeContext in which it was used; how decided which patient to use it withEase/difficulty of useWhat contributed to ease/difficulty of use from your experienceDid you have to think about what the responses meant/were they self=evidentWhat level of knowledge is required to use it effectivelyHow would you rate it in comparison with other screening tools What would need to happen to encourage you/your team to use it routinelyConversely what might inhibit you/your team in using it routinelyHow might use of the tool change practice on managing deliriumPerceived costs versus benefits(time/resources)What would need to happen to change the balance of benefits and costsOrganisational, environmental and system barriers to screening for cognitive impairment and deliriumCould you take me through a recent admission of a patient who appeared to be ‘confused’? ProbeWhat was it that alerted you to the ‘confusion’?Is this how a patient with ‘confusion’ typically presents? What is typical? What happened next? Typical or not?Perceived dilemma/difficulty of distinguishing between dementia and acute confusion? What would you look out for in making such a distinction? What makes it feasible/practicable to assess this in your work setting? Value attached to identifying delirium in this context? Is the distinction between dementia and delirium useful in making a decision about what to do? Did it make a difference to the assessment/managing the person’s care in this case? How do you usually go about identifying delirium in [this setting]? And does it make a difference to what action follows for the patient? What are the barriers within this environment to screening and assessing for delirium? (organisational, environmental, knowledge) Anything else?Thank you for your time Appendix 9. Comments and examples of suggested changes to the 4AT. These comments are drawn from from the qualitative study interviews.We employed the ‘think aloud’ method to elicit comments from study participants about the 4AT. Presented with a copy of the tool, each participant went through it, offering their reflections on its use in their particular setting. Title, presentation and layout Is that the same as the AMT? Its confusing and then there’s the AMT4 referred to as well. Junior doctor, ED.It looks pretty user friendly and that it t won’t take long to do which is key; otherwise people just won’t do it. Senior nurse, surgical ward.The guidance notes in this form aren’t helpful. They don't explain things clearly. But if I’m busy with a patient or doing clerking I wouldn't read them anyway. Guidance notes aren’t enough; it needs a teaching session to to explain why it should be done and not only how to complete the form. Senior doctor, MAUWhich patients should be targeted?It wouldn't be feasible to use this on everyone coming into the ED. I don't like the idea of using an age cut-off either. Should it be patients at risk of ddelirium? Consultant, ED Specific items AlertnessI’m not trying to be overly pedantic but altered level of alertness in normal waking hours, yes it could well be delirium; but altered alertness for someone coming in to A&E in the middle of the night having fallen…we need to be e careful about over-interpretation. Junior doctor, Care of older people ward. Just by knowing the patient, you would know if someone were more drowsy; you’d notice it naturally. Staff nurse, Care of older people ward.AttentionDate of birth might not always be the best one. There are cultural issues. Elderly Asian men and women may not have a formal record of their date of birth. Isnt there a similar sor of question to use instead? Senior nurse, Care of older people ward. Acute change or fluctuating courseThat's not difficult when you know their baseline – these are the essential ones. Easy when you know the patient. Junior doctor, Surgical wardThat would be really difficult if you’ve got someone whois confused in front of you and there is no-one who knows the person with them. It might take time to find out. Its not the question as such; its being able to find the answer. If you don't have that information to hand how would you score it. What would you do? That's the critical question for delirium Junior doctor, EDWe do drum it into staff that they are allowed to ring GPs and they are allowed to ring relatives and the care homes to find out what the patient is normally like, and get old notes. So there’s lots of different ways you can try and find out if this is a patient’s normal state or whether this is a significant change. Consultant, EDScoringHow do you score patients who have clearly improved but have had an acute onset/fluctuating course over the previous two weeks? Would you use the 4AT to review change? Would that be right? There’s no guidance? Senior nurse, Care of older people wardAppendix 10: STARD flow diagrams of recruitment at each site Appendix 10A: Edinburgh10013394353900Figure SEQ Figure \* ARABIC 5: STARD diagram of flow of participants through the Edinburgh site Appendix 10B: Sheffield8347211223100Figure SEQ Figure \* ARABIC 6: STARD diagram of flow of participants through the Sheffield site75501538163500 Appendix 10C: Bradford Figure SEQ Figure \* ARABIC 7: STARD diagram of flow of participants through the Edinburgh site Appendix 11. Receiver Operator Characteristic Curve for 4AT diagnostic accuracy4AT scores range from 0-12. The cut-point of 3/4 is used in the scoring scheme to denote likely delirium. The 4AT scores are considered against the reference standard delirium assessment.left169507The area under the receiver-operator characteristic curve is 0.90 (95% CI 0.84-0.96).Figure SEQ Figure \* ARABIC 8: Receiver Operator Characteristic Curve for 4AT diagnostic accuracyAppendix 12. Diagnostic Test Accuracy of 4AT versus CAM for diagnosis of delirium Table SEQ Table \* ARABIC 21: Diagnostic Test Accuracy of 4AT versus CAM for diagnosis of DeliriumSensitivitySpecificityPPVNPVDiagnostic ORYouden's Index4AT (>3)75.51% (61.13%,86.66%)94.46% (91.48%,96.63%)66.07% (52.19%,78.19%)96.43% (93.84%,98.14%)52.57 (23.65,116.85)0.70CAM - Delirium40.48% (25.63%,56.72%)99.71% (98.38%,99.99%)94.44% (72.71%,99.86%)93.17% (90.08%,95.53%)231.71 (29.63,1811.89)0.40Fishers Exact Test p-value0.0012<.00010.02970.0629Odds Ratio4.53 (1.85,11.11)0.05 (0.01,0.38)0.11 (0.01,0.93)1.98 (0.98,4.01)Difference in Proportions35.03% (14.66%,53.17%)-5.25% (-12.70%,2.23%)-28.37% (-53.44%,-1.72%)3.26% (-4.14%,10.64%)Numbers?are?estimate?(95%?CI).?Difference?in?proportions?is?for?4AT-CAMAbbreviations:?CI,?confidence?interval;?PPV,?positive?predictive?value;?NPV,?negative?predictive?value;OR,?odds?ratio.Youden's?Index?is?equal?to?sensitivity+specificity-1,?a?value?of?zero?indicates?no?value,?and?a?value?of?1indicates?a?perfect?test. Appendix 13. Diagnostic test accuracy of individual items of 4AT for diagnosis of delirium Table SEQ Table \* ARABIC 22: Diagnostic test accuracy of individual items of 4AT for diagnosis of deliriumSensitivitySpecificityPPVNPVYouden's IndexAlertness (4 versus 0)30.61% (18.25%,45.42%)99.13% (97.47%,99.82%)83.33% (58.58%,96.42%)90.91% (87.53%,93.62%)0.30Acute Change (4 versus 0)75.51% (61.13%,86.66%)95.61% (92.87%,97.52%)71.15% (56.92%,82.87%)96.46% (93.90%,98.16%)0.71AMT4 (1 or 2 versus 0)63.27% (48.29%,76.58%)82.80% (78.38%,86.64%)34.44% (24.74%,45.20%)94.04% (90.74%,96.43%)0.46AMT4 (2 versus 1 or 0)40.82% (27.00%,55.79%)96.21% (93.61%,97.97%)60.61% (42.14%,77.09%)91.92% (88.60%,94.52%)0.37Attention (1 or 2 versus 0)71.43% (56.74%,83.42%)79.01% (74.31%,83.20%)32.71% (23.95%,42.45%)95.09% (91.90%,97.29%)0.50Attention (2 versus 1 or 0)30.61% (18.25%,45.42%)99.13% (97.47%,99.82%)83.33% (58.58%,96.42%)90.91% (87.53%,93.62%)0.30Numbers?are?estimate?(95%?CI).Abbreviations:?CI,?confidence?interval;?PPV,?positive?predictive?value;?NPV,?negative?predictive?value;Youden's?Index?is?equal?to?sensitivity+specificity-1,?a?value?of?zero?indicates?no?value,?and?a?value?of?1indicates?a?perfect?test.Delirium is defined by the reference standard assessment.174625162954800 Appendix 14. Scatterplot of DRS-R98 scores and 4AT scoreFigure SEQ Figure \* ARABIC 9: Scatterplot of DRS-R98 scores and 4AT scores Appendix 15. Kaplan Meier Plot for 4AT and length of stayleft214851Figure SEQ Figure \* ARABIC 10: Kaplan Meier Plot for 4AT and length of stay Appendix 16. Costs of tests – health economics analysisTable SEQ Table \* ARABIC 23: Costs of tests – health economics analysisTest Scotland (?)England (?)source Scotlandsource EnglandCT90129*NHS - ISD unit costs from 2015-16 **National Schedule of Reference Costs - Year 2015-16 - NHS trusts and NHS foundation trustsECG140106*NHS - ISD unit costs from 2015-16 **National Schedule of Reference Costs - Year 2015-16 - NHS trusts and NHS foundation trustsMRI210196*NHS - ISD unit costs from 2015-16 **National Schedule of Reference Costs - Year 2015-16 - NHS trusts and NHS foundation trustsPhysio- therapy4448*NHS - ISD unit costs from 2015-16 **National Schedule of Reference Costs - Year 2015-16 - NHS trusts and NHS foundation trustsUltra- sound5672*NHS - ISD unit costs from 2015-16 **National Schedule of Reference Costs - Year 2015-16 - NHS trusts and NHS foundation trustsxray5530****NHS - ISD unit costs from 2015-16 **National Schedule of Reference Costs - Year 2015-16 - NHS trusts and NHS foundation trusts* ** *** Assumption based on National tariff information workbook 2014/15 – Non mandatory costs Appendix 17. Community health service costs Table SEQ Table \* ARABIC 24: Community health service costsSocial service costs per hourCcostsSource AdditionalCareAttendantHome30PSSRU -unit costs 2016**CareManagerHome40PSSRU -unit costs 2016**CareSupportWorkerHome30PSSRU -unit costs 2016**ChiropodistHome32PSSRU -unit costs 2016**Community based Health Care Staff qualification band 4 or 5CommPsychiatristClinic138PSSRU -unit costs 2016**CommPsychiatristHome135PSSRU -unit costs 2016**Consultant CommPsychMentalHealthHome44PSSRU -unit costs 2016**DietitianClinic63PSSRU -unit costs 2016**Clinic and home assumed to be the same priceDietitianHome63PSSRU -unit costs 2016**Clinic and home assumed to be the same priceDistrictNurseClinic86PSSRU -unit costs 2016**Band 5 in hospital per hour patient contactDistrictNurseHome61PSSRU -unit costs 2016**Hourly costs of patient contact GPClinic104PSSRU -unit costs 2016**GPHome216PSSRU -unit costs 2016**HealthVisitorHome30PSSRU -unit costs 2016**Assumption - based on the cost for similar professionsHomeCareWorkerHome24PSSRU -unit costs 2016**Per hour face to faceMealsOnWheelsHome3*** from AESOPS Per meal - no hourly priceOccHealthHome44PSSRU -unit costs 2016**PhysiotherapistClinic64PSSRU -unit costs 2016**Clinic and home assumed to be the same pricePhysiotherapistHome64PSSRU -unit costs 2016**Clinic and home assumed to be the same pricePracticeNurseClinic86PSSRU -unit costs 2016**Band 5 in hospital per hour patient contactPracticeNurseHome61PSSRU -unit costs 2016**Consultant fPsychologistClinic64PSSRU -unit costs 2016**SocialWorkerHome79PSSRU -unit costs 2016**** PSSRU -unit costs 2016 6*** AESOPS - NHS health technology assessment (2013) Volume 17/25 7 Appendix 18. Costs of additional activitiesTable SEQ Table \* ARABIC 25: Costs of additional activitiesAdditional activities mentioned MinutesHours/visitsCleaner20850375.0Phlebotomist1602.7Speech and Language Therapist601.0Daily full package of care240040.0Hospital @ Home37 visitsPodiatrist3005.0Chest, Heart & Stroke Liaison Nurse4207.0Housework Help432072.0IMPACT TEAM4507.5Breathing Nurse901.5Tissue Viability & Leg Ulcer Service601.0BDCT continence service3 visitsDiabetes hub2 visitsVirtual Ward - community support services9870164.5Community gateway services- neighbourhood therapy901.5Cardiac rehab nurse1502.5Optician2 visitsDentist1 visitGP telephone appointment1502.5Cardiac Rehab team751.3Audiology, hearing aid300.5Step-down, frail elderly7 visitsSteady Steps2404.0Pulmonary Rehab team109018.2Intermediate care team1 visitStroke Nurse8 visitsacupuncture1803.0Carer for daily meds84014.0Home care worker72012.0POA Edinburgh North Care Service1 visitcommunity support nurse601.0Continence services250.4Nurse practitioner1352.3Diabetes Nurse Specialist901.5Stoma Nurse1803.0Heart Failure Nurse601.0Community matron92015.3Respiratory team200.3community support team- falls assessment400.7COPD Clinic1202.0 Appendix 19. Health economics survey 4AT Health Economics Model Questionnaire67056017018000Page 1: IntroductionWe are running a study to model the implications of routine screening for delirium in patients admitted to hospital under acute medical or geriatric specialties. A screening tool may lead to false positives (FP) – patients who are incorrectly labelled as having delirium in whom unnecessary investigation or treatment may be initiated. It may also lead to false negatives (FN) – patients who are labelled as not having delirium when in fact they do, which may lead to false reassurance and delayed or missed diagnosis. Mislabelling patients with or without delirium may have consequences for mortality, healthcare costs and patient quality of life.In the absence of comprehensive data, we are also seeking the opinion of people experienced in delirium care to help inform some estimates in delirium detection and treatment. We will be asking for your spontaneous guess about how delirium detection and care effect duration and intensity. There is no need to consult books or other literature. Even if you are uncertain or find these questions difficult to answer, please just give your best guess.The study is being led by Katharina Diernberger (Edinburgh Clinical Trials Unit, University of Edinburgh) and Dr Peter Hall (Edinburgh Clinical Trials Unit - University of Edinburgh, Cancer Research UK Edinburgh Centre - MRC Institute of Genetics & Molecular Medicine) in collaboration with Prof Alasdair MacLullich (Edinburgh Delirium Research Group - University of Edinburgh)All responses are anonymised. Please send any queries to: a.maclullich@ed.ac.uk or katharina.diernberger@ed.ac.ukPage 2: Mortality rates (1)Please consider the average 12-week mortality rates in all patients aged between 80 and 85 who are admitted to acute medical or geriatric hospital wards. Please consider absolute numbers not relative risks. Please assume an estimated 12-week mortality of 14 out of 100 for patients suffering from (all cases/detected or not) delirium and 10 out of 100 for patients without.Best guesslowest guesshighest guessOut of 100 people who are incorrectly labelled with a diagnosis of delirium (FP), how many will die within 12 weeks as a direct consequence of that incorrect label?Out of 100 delirium sufferers in whom delirium is missed (FN), how many will die within 12 weeks as a direct consequence of that missed or delayed diagnosis?Do you have any additional comments?65151016637000Page 3: Mortality rates (2)Please be aware that in this question the values which should be assumed are different to the last question. Please consider the average 12-week mortality rates in all patients aged between 80 and 85 who are admitted to acute medical or geriatric hospital wards. Please consider absolute numbers not relative risks. Please assume an estimated 12-week mortality of 18 out of 100 for patients suffering from (all cases/detected or not) delirium and 8 out of 100 for patients without.Best guesslowest guesshighest guessOut of 100 people who are incorrectly labelled with a diagnosis of delirium (FP), how many will die within 12 weeks as a direct consequence of that incorrect label?Out of 100 delirium sufferers in whom delirium is missed (FN), how many will die within 12 weeks as a direct consequence of that missed or delayed diagnosis?Do you have any additional comments?65151016637000Page 4: CostsPlease consider a cohort of patients aged between 80 and 85 who are admitted to acute medical or geriatric hospital wards.Best guesslowest guesshighest guessAssume the average hospital cost of a person suffering from delirium and being treated appropriately (TP) is 100%. What would you estimate as the total cost in % if the delirium is missed?Now assume the average hospital cost of a person who is not suffering from delirium (TN) is 100%. What would you estimate as the total cost in % if the person is incorrectly investigated or treated for delirium?Do you have any additional comments?65151016637000Page 5: Routine CareNow assume all patients are treated according to a reference standard (perfectly accurate) diagnosis, which is assumed to promptly identify 100% of all patients suffering from delirium.Best guesslowest guesshighest guessIn routine standard care, out of 100 patients with a reference standard diagnosis of delirium, how many would be missed completely in your type of ward? Please state the number out of 100.In routine care, for patients who are getting a diagnosis but being delayed, how long on average would you estimate for the diagnosis to be delayed? Please write your answer in days and/or hours.Do you have any additional comments?6515101663700065151039941500Please choose the main type of healthcare setting you are working in.A&ECardiologyCritical CareDiagnostic imagingENTGastroenterologyGeneral surgeryGeriatricsGynaecologyHaematologyNephrologyNeurologyOncologyOrthopaedicsRheumatologyUrologyotherOtherIf you selected Other, please specify:65151016637000Page 6: Quality of Life (from a health economic perspective)The last part of the survey concerns the impact of delirium on quality of life. Please answer spontaneously based on your experience where on the provided scale patients' quality of life can be placed. A Quality of Life (QoL) score can represent various defined health states usually between 0 and 1 where 0 indicates death and 1 full physical and mental health. Average quality of life is observed to decrease with age whereby the average QoL of 80 to 85 year olds is estimated to be 0.7. In order to make the placement easier a scale is provided (link below) showing different health states/medical conditions with the referring utility weights taken from the literature.Please be aware that the scale is a mix of acute and chronical conditions. It is not meant to be comprehensive but rather to give some orientation.Please open the following link in a new tab (right click - open link in a new tab) as it might be helpful for answering the remaining questions: the following questions, please consider 3 time periods:Period 1: During an episode of delirium with or without an accurate diagnosis Period 2: Hospital stay following resolution of delirium (or removal of incorrect label) Period 3: Following hospital discharge (assuming resolution of delirium)In order to answer the “% of care”, please consider the overall care staff time, number-, difficulty-, duration- of intervention, care intensity.For all people who are not suffering from delirium and are labelled/treated correctly (TN)the % of care is assumed to be 100% during the hospital stay. The quality of life is assumed to be0.7 during the hospital stay and within the following12 weeks.People who are suffering from delirium and are labelled/treated correctly (TP) - Be aware that "Best guess duration" and "% of care" just can be filled in for Period_1 and Period_2. - The quality of life estimates (QoL) are supposed to be filled in for Period_1 and Period_3 only.Best guess duration (days)% of careBest guess QoL (0-1)lowest QoL estimatehighest QoL estimatePeriod_1Period_2Period_3People who are suffering from delirium with a missed diagnosis (FN) - Be aware that "Best guess duration" and "% of care" just can be filled in for Period_1 and Period_2. - The quality of life estimates (QoL) are supposed to be filled in for Period_1 and Period_3 only.Best guess duration (days)% of careBest guess QoL (0-1)lowest QoL estimatehighest QoL estimatePeriod_1Period_2Period_3People with an incorrect diagnosis of delirium (FP) - Be aware that "Best guess duration" and "% of care" just can be filled in for Period_1 and Period_2. - The quality of life estimates (QoL) are supposed to be filled in for Period_2 (as patients are not actually suffering from delirium, but any other condition) and Period_3 only.Best guess duration (days)% of careBest guess QoL (0-1)lowest QoL estimatehighest QoL estimatePeriod_1Period_2Period_3Page 7: Thank you for completing our questionnaire!Your answers have been successfully submitted.Thank you for taking time to fill out the survey today, we really appreciate your time and effort.67056017843500 Appendix 20. Model ParametersTable SEQ Table \* ARABIC 26: Model ParametersParameterValueSourceParameters used to derive decision tree node parametersProportion with delirium by reference standard (%)0.1341Within trial analysis - based on values from Chapter 5 *Proportion without delirium by reference standard (%)0.8659Within trial analysis - based on values from Chapter 5 *4AT test sensitivity (%)0.7551Within trial analysis - based on values from Chapter 5 *4AT test specificity (%)0.9456Within trial analysis - based on values from Chapter 5 *CAM test sensitivity (%)0.4048Within trial analysis - based on values from Chapter 5 *CAM test specificity (%)0.9971Within trial analysis - based on values from Chapter 5 *Decision tree node Parameters4AT: Probability of being TP0.10Within trial analysis - based on values from Chapter 5 *4AT: Probability of being FP0.05Within trial analysis - based on values from Chapter 5 *4AT: Probability of being TN 0.82Within trial analysis - based on values from Chapter 5 *4AT: Probability of being FN 0.03Within trial analysis - based on values from Chapter 5 *CAM: Probability of being TP0.05Within trial analysis - based on values from Chapter 5 *CAM: Probability of being FP0.00Within trial analysis - based on values from Chapter 5 *CAM: Probability of being TN0.86Within trial analysis - based on values from Chapter 5 *CAM: Probability of being FN0.08Within trial analysis - based on values from Chapter 5 *12 week Cost TP6889.00Within trial analysis - based on values from Chapter 5 *12 week Cost FP4653.00Based on 12 week Scottish costs and expert elicitation12 week Cost TN4230.00Within trial analysis - 12 week cost as above (Scotland)12 week Cost FN8955.70Based on 12 week Scottish costs and expert elicitationQALY TP0.09derived from multiple responses in the Expert ElicitationQALY FP0.13derived from multiple responses in the Expert ElicitationQALY TN0.15derived from multiple responses in the Expert ElicitationQALY FN0.09derived from multiple responses in the Expert Elicitation*Sensitivity, Specificity of the tests and proportion of delirium and non-delirium patients based on the reference standard Appendix 21. Results from the Health Economic ModelTable SEQ Table \* ARABIC 27: Differences in Costs and Effectiveness and ICERsCost 4ATCost CAMQALY 4ATQALY CAM in Costs in QALYsICERBase caseScottish Costs - 12 weeks - best estimates (Costs and QALYs)468047700.140500.14103-90.35-0.00053170553Scenario Analysislowest cost and QALY estimates 461446590.133740.13557-44.49-0.0018324289highest cost and QALY estimates476548820.145850.14459-117.350.00127-92744English Costs - 12 weeks - best estimates (Costs and QALYs)441644780.140500.14103-61.52-0.00053116133lowest cost and QALY estimates 436443990.133740.13557-34.94-0.0018319070highest cost and QALY estimates448845570.145850.14459-69.100.00127-54609First Stay (English/Scottish) - best estimates (Costs and QALYs)150615540.140500.14103-47.96-0.0005390522lowest cost and QALY estimates 148115070.133740.13557-25.92-0.0018314147highest cost and QALY estimates153716020.145850.14459-64.470.00127-50952QALY – Quality Adjusted Life YearICER – Incremental Cost Effectiveness Ratio in Costs – Difference in Costs in QALYs – Difference in Quality Adjusted Life Years Appendix 22. Tornado plot: difference in costs right790161Figure SEQ Figure \* ARABIC 11: Tornado plot: difference in costs Appendix 23. Tornado plot: difference in effectiveness-127607130838Figure SEQ Figure \* ARABIC 12: Tornado plot: difference in effectiveness Appendix 24: Cost-effectiveness planecenter541765Figure SEQ Figure \* ARABIC 13: Cost-effectiveness plane Appendix 25. Cost-effectiveness-acceptability curve (CEAC)right227632Figure SEQ Figure \* ARABIC 14: Cost-effectiveness-acceptability curve (CEAC) ................
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