Background: Delirium is a common and costly occurrence in hospitalized patients, particularly elderly patients. Diagnosing delirium can be challenging, particularly given the fluctuating nature of presentation and subtle hypoactive motor subtypes. The Brief Confusion Assessment Method (bCAM) is a delirium screening tool that has been validated for use in the med-surg clinical area. As part of a quality improvement project to improve delirium detection and management, our hospital initiated twice-daily nursing administered bCAM delirium screening on the first non-ICU unit in January 2017. Additional units were systematically added over the next 18 months now reaching all adults patients admitted to our large academic hospital.
Methods: We conducted a retrospective cohort study of patients admitted to an academic medical center from January 2017 to August 2018. Encounter-level data, including results of bCAM, demographic information, ICD-10 coding of delirium or related illness, discharge disposition and length of stay were extracted from the electronic medical information database maintained by the hospital. The study includes all patients 18 years and older admitted to a unit that had initiated the delirium screening program. A positive bCAM at any point during the hospitalization was considered a positive finding, regardless of ICD-10 coding. Additional comparison between ICD-10 delirium diagnosis in the medical record before and after initiation was also analyzed.
Results: There were 21,606 patients admitted to units where screening was being used. 2,833 (13.1%) patients had at least one positive bCAM screen during their admission. The mean age of bCAM positive patients was 63.4 years, compared to 52.8 years in the bCAM negative group. Prior to initiation of the screening protocol, 3.03% of patients had an ICD-10 delirium diagnosis in their medical record, compared to the 7.7% seen afterwards.
Conclusions: Nearly 1 in 7 of all adults admitted to our hospital had a positive delirium screen during their admission. The incidence of 13% is in line with what is reported in the literature for non-ICU delirium, however the sample size used in this study is much larger than other non-ICU studies. Although the bCAM is only a screening tool, the discrepancy between the incidence a positive bCAM screen and ICD-10 code diagnosis suggests continued room for improvement in diagnosing and managing delirium. After hospital wide use of systematic delirium screening, the ICD-10 diagnosis increased from 3 to over 7% of patients. The use of hospital wide screening is likely helpful tool in increasing documentation and awareness of this dangerous syndrome, particularly considering its diverse phenotype. Early detection and management of delirium is an important step in improving outcomes and providing a higher quality of care to all patients, particularly the elderly.