Original Study
Documentation and Management of Words Associated With Delirium Among Elderly Patients in Postacute Care: A Pilot Investigation

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Objective

To describe in a pilot investigation the frequency that keywords associated with delirium were documented by providers and to study the effect of reporting such observations on physician orders.

Design

Retrospective investigation.

Settings and Participants

Eighty elderly patients identified from 895 admitted to 2 postacute care (PAC) facilities.

Measurements

Keywords associated with delirium were confusion, disorientation, altered mental status, delirium, agitation, inappropriate behavior, mental status change, inattention, hallucination, and lethargy. The source of the words and actions taken were recorded.

Results

Keywords associated with delirium were identified in 80 (9%) of 883 patients who met inclusion criteria, with the term “confusion” most frequently noted (95%). Nurses and physicians recorded keywords in 79 (99%) and 55 (69%) patient charts. The actual term “delirium” was used in only 6 (7%) of 80 cases. In 55 (69%) cases when physicians were notified, treatments or evaluations were performed: pharmacological 55 (100%), nonpharmacological 11 (20%), assessments 38 (69%), transfer to the emergency department 19 (34%). Nurses did not alert physicians in 25 (31%) cases where keywords were found and thus no action was taken in these cases.

Conclusions

In this pilot investigation in the postacute setting, nurses and physicians documented words associated with delirium in 9% of the patient charts. When nurses notified physicians of patients with charted keywords suggesting delirium, physicians responded with orders for further assessments or pharmacological interventions. However, nurses did not refer patients with keywords in 1 of 3 cases and no actions were documented in the charts for these patients.

Section snippets

Methods

The design was a retrospective electronic and paper chart-based review study. Potential participants were patients admitted to 2 postacute facilities affiliated with Vanderbilt University Medical Center, Nashville, TN, from March 1, 2007, through March 31, 2008. An electronic search through the charts looking for 10 keywords associated with delirium, as previously validated in a chart-based review for delirium identification11 (ie, confusion, disorientation, altered mental status, delirium,

Results

A total of 92 (10%) patients of 895 charts reviewed were identified whose charts contained keywords suggestive of delirium. Twelve of these patients were excluded for severe dementia and hence prevalence of keywords associated with delirium for patients not severely demented was estimated to be 9% (80 patients). The characteristics of the population are described in Table 1. Among 80 patients included in the study 44% had a high school education. Almost half of the studied population (44%) had

Discussion

Health care providers (primarily nurses) described patient behaviors in the chart that are potentially associated with delirium in 9% of PAC patient charts who were not severely cognitively impaired but seldom used the term delirium. The term confusion was used in 95% of the cases to describe mental status when any word to describe mental status was used, whereas the term delirium was used in 7% of the cases when a descriptive word was provided in the chart. The patients in the “action-taken”

Acknowledgments

The authors acknowledge with gratitude Nona Cooper, Brenda Ray, Melinda Newell, and Jamie Spicer, GNP, for the great support in accessing the electronic and paper charts.

References (20)

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Dr. Ely has received research grants from the National Institute of Health. (AG027472-01A1) and VA-Meritgrant. The other authors report no financial disclosures.

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