Table 5 Final set of quality statements and PMs by category

Screening

 QS 01: All older adults (≥ 65 years of age) presenting to the ED will be identified as high-risk for delirium and assessed for other non-modifiable risk factors, including:

  • Cognitive impairment (past or present)/ dementia

  • Current fragility fracture (e.g., hip fracture), limb disfunction, or geriatric trauma

  • Severe illness with (or at risk for) deterioration

  • Nursing home residence

  • Hearing impairment

  • History of stroke

PM 01: Evidence of local structures, such as a prompt, checkbox, or automatic flag in the ED (electronic) health record to identify people at high-risk of developing delirium (including older age); (yes/no). (Structure)

PM 02: Proportion of older adults presenting to the ED documented as being at risk for delirium on arrival; (%). (Process)

PM 03: Proportion of older ED patients with documented assessment for other delirium risk factors upon initial assessment; (%). (Process)

 QS 02: Older adults presenting to the ED will be screened for delirium using the 4AT tool^c within 4 hours^b of arrival, and at least daily afterwards

PM 04: Evidence of the ready availability of the 4AT tool in the ED setting (e.g., tool embedded in ED health record); (yes/no) (Structure)

PM 05: Proportion of older adults presenting to the ED with a documented delirium screening using the 4AT within 4 hours^b of arrival; (%) (Process)

PM 06: Proportion of older ED patients with a documented 4AT screening at least once every per shift^a; (%) (Process)

Diagnosis

 QS 03: Older ED patients who have a positive screen for delirium will have an assessment and diagnosis by a trained healthcare professional (which can be the same person completing the screening) and have the diagnosis clearly documented in their health record (and written in a discharge summary^a when applicable)

PM 07: Proportion of older ED patients with a positive screen for delirium who have a formal diagnosis of delirium (or alternative diagnosis/reason for positive screen when applicable^a) clearly documented in their health record; (%). (Process)

PM 08: Proportion of older ED patients who are diagnosed with delirium and discharged from the ED that have the diagnosis written in a discharge summary^a; (%). (Process)

Risk Reduction

 QS 04: Older adults presenting to the ED will receive a range of tailored interventions to prevent delirium based on an assessment of clinical factors, including:

  • Orientation/reorientation

  • Providing pain management

  • Promoting sleep hygiene

  • Optimizing hydration and nutrition

  • Optimizing of oxygen saturation

  • Mobilizing as soon as possible

  • Addressing infection

  • Regulating bladder and bowel function while avoiding unnecessary catheterization

  • Providing visual/hearing aids as necessary (i.e., sensory optimization)

  • Prioritizing transfer to more appropriate care spaces^b

PM 09: Evidence of a readily available delirium protocol or care pathway for older ED patients to facilitate an assessment^a for clinical risk factors and tailor appropriate interventions to reduce the risk of delirium; (yes/no). (Structure)

PM 10: Proportion of older ED patients who are assessed for clinical risk factors or delirium; (%). (Process)

PM 11: Proportion of older ED patients who receive a range of tailored interventions (based on a clinical risk factor assessment) to reduce the risk of delirium; (%). (Process)

 QS 05: Older ED patients will have a medication review completed by an experienced healthcare professional

PM 12: Evidence a readily available tool to aid in the review and identification of medications that may increase the risk of delirium (e.g., BEERS criteria or STOPP/START criteria); (yes/no). (Structure)

PM 13: Proportion of older ED patients who have a medication review completed and documented by an experienced healthcare professional; (%). (Process)

Management

 QS 07: Older ED patients diagnosed^a with delirium will have a systematic assessment to identify and treat possible causes of delirium:

  • First, consider acute, life-threatening causes of delirium, including: low oxygen levels, low blood pressure, low glucose level, and drug/alcohol intoxication or withdrawal;

  • Second, identify other potential causes (e.g., medications, acute illness) noting multiple causes are common;

  • Third, optimize physiology and manage concurrent conditions

PM 15: Evidence of a readily available delirium care pathway in the ED to facilitate a systematic assessment; (yes/no). (Structure)

PM 16: Proportion of older ED patients diagnosed^a with delirium who have a systematic assessment to identify causes of delirium; (%). (Process)

 QS 08: Older ED patients with delirium will have a multicomponent management plan initiated while in the ED, including:

  • Cognitive engagement and reorientation

  • Promoting mobilization

  • Reviewing and adjusting medications

  • Promoting sleep hygiene

  • Providing visual and hearing aids (as necessary)

  • Regulating bladder and bowel function

  • Avoiding unnecessary stimuli (e.g., placing patient in care space with reduced noise)

  • Prioritizing transfer to more appropriate care spaces^b

PM 17: Evidence of a readily available delirium care pathway in the ED to facilitate a multicomponent management plan; (yes/no). (Structure)

PM 18: Proportion of older ED patients with delirium who have a multicomponent management plan initiated^a for the treatment of delirium; (%). (Process)

PM 19: Evidence of local structures available within the ED for older adults with delirium to be placed in a care space with decreased unnecessary stimuli; (yes/no). (Structure)

PM 20: Proportion of older ED patients with delirium who are placed in a care space with decreased unnecessary stimuli; (%). (Process)

 QS 09: Older ED patients with delirium who are distressed/agitated or are a risk to themselves or others are not given antipsychotic medication (e.g., haloperidol) unless de-escalation techniques^d are ineffective or inappropriate^e

PM 21: Proportion of older ED patients with delirium who have been given an antipsychotic medication (e.g., haloperidol) who were documented as being a risk to themselves or others and it is also documented that de-escalation techniques were ineffective or inappropriate; (%). (Process)

 QS 10: Older ED patients with delirium and their family members/caregivers will be given information that explains the condition that meets the needs (cultural, language, cognitive) of the person; and family members/caregivers will be encouraged to be present in the ED^a and involved in delirium care pre and post discharge^a, e.g., aiding in cognitive engagement and reorientation of the patient

PM 22: Evidence of a readily available communication tools (e.g., information pamphlets) in the ED to provide older adults with delirium and their family members/caregivers information that explains the condition; (yes/no). (Structure)

PM 23: Evidence of information available in English, French, and other languages suited to local demographics (e.g., Indigenous languages) using plain language (e.g., Grade 6 reading level); (yes/no). (Structure)

PM 24: Proportion of older ED patients with delirium and their families/carers^a who are given information explaining the condition; (%). (Process)