Article, Geriatrics

Evaluation of the Ottawa 3DY as a screening tool for cognitive impairment in older emergency department patients

a b s t r a c t

Objective: This study sought to evaluate the implementation of the Ottawa 3DY Tool, a simple screening instru- ment for cognitive impairment, by front-line ED clinicians.

Methods: We conducted a prospective cohort study in an academic ED. Patients >=75 years underwent cognitive screening with the Ottawa 3DY by front-line nurses and physicians. Descriptive statistics were used to describe level of implementation and acceptability of the tool. Sensitivity and specificity was calculated using an Mini- mental state Exam b25 as the cut-off for cognitive impairment. A weighted kappa was calculated to establish inter-rater agreement.

Results: Cognitive screening was completed in 260/332 eligible patients (78.3%), who were 60% female and had a mean age of 83.7 years. Facilitators to screening: perceived importance and ownership of screening and feasibil- ity of Ottawa 3DY. Barriers to screening were: over confidence in clinical judgement and perceived lack of patient benefit. Ottawa 3DY had a sensitivity of 84.6% (64.3-95.0) and specificity of 54.2% (39.3-68.4) when completed by nurses. When completed by emergency physicians, sensitivity was 78.9% (53.9-93.0) and specificity was 70.0% (45.7-87.2). Inter-rater agreement kappa score was 0.67.

Discussion: This study demonstrated that incorporating the Ottawa 3DY tool into the routine evaluation of older ED patients by front-line ED clinicians is both feasible and effective. With its demonstrated good inter-rater reli- ability and moderate level of sensitivity and specificity when compared with the much longer MMSE, the routine adoption of this tool may help lead to improved recognition of cognitive impairment and ultimately patient and system outcomes.

(C) 2019

  1. Introduction

Cognitive impairment, both dementia and delirium, is common yet often vastly under-recognized in older patients presenting to the Emer- gency Department (ED) [1-13]. These conditions are often associated with gathering unreliable histories, achieving poor medication compli- ance, and increased rates of hospitalization, length of stay, functional decline, higher rates of institutionalization, and increased mortality [13-19]. Although, multiple guidelines recommend the use of validated Screening tools to identify older ED patients presenting with altered mental status [20-25], and structural and process quality indicators have been developed to provide a framework for Improved care in the

* Corresponding author at: Department of Emergency Medicine, University of Ottawa, The Ottawa Hospital – Civic Campus, Ottawa, ON K1Y 4E9, Canada.

E-mail address: [email protected] (D. Eagles).

evaluation of cognitive impairment in the ED [26,27] most existing tools are lengthy and require forms and writing instruments to com- plete them. This may be one major reason why emergency physicians do not detect cognitive impairment up to 70% of the time [6,10]. Fur- thermore, studies have shown that emergency physicians formally as- sess cognitive status in b25% of their patients [28-30]. This is likely due in part to the absence of an ED-validated and feasible screening tool for cognitive impairment; especially one that is easy to remember and score and does not require any extra instruments to administer [31]. Screening for cognitive impairment in older ED patients is essential to identify patients at risk for adverse outcomes.

The Ottawa 3DY is a screening tool developed to detect an altered mental status that consists of 4 questions: What is the Day? What is the Date? Spell the word “worlD” backwards; and What is the Year? If any of the questions are answered incorrectly, the patient is likely to have cognitive impairment. Its initial derivation and validation, using

https://doi.org/10.1016/j.ajem.2019.12.036

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data collected as part of the Canadian Longitudinal Study of Health and Aging, demonstrated an achieved sensitivity of 82% and specificity of 55% [32]. It has been subsequently and prospectively validated in older ED populations. A recent diagnostic meta-analysis of dementia screening instruments in emergency medicine reported: 1) a pooled sensitivity of 0.92 (0.84 to 0.96); 2) a pooled specificity of 0.63 (0.58

to 0.68); 3) a pooled positive likelihood ratio of 2.26 (1.45 to 3.52);

and 4) a pooled negative likelihood ratio of 0.17 (0.05 to 0.66) [33]. In these studies, the Ottawa 3DY was performed by highly trained evalua- tors, such as either research assistants or Geriatric EMergency manage- ment nurses. To date, there have been no real-world studies that have examined its actual performance when implemented in the field by ED front line health care providers.

The overall goal of this study was to see if use of this tool could im- prove screening for cognitive impairment in patients 75 years or older presenting to an academic ED. More specifically, we sought to evaluate the implementation of the Ottawa 3DY in older ED patients and assess:

1) the overall screening compliance achieved by front-line nurses and physicians; 2) barriers and facilitators to its use as a screening tool;

  1. the inter-rater reliability between nurse and physician scores; and
  2. its classification performance compared with the use of the more well-established Mini-Mental State Exam (MMSE) screening instrument.
  3. Methods
    1. Design and setting

We conducted a prospective cohort study at an academic tertiary care hospital ED between June and August 2013. The hospital Research Ethics Board granted approval to conduct the study without the need to obtain the explicit written consent of individual patients.

Selection of participants

All patients 75 years or older who presented to the ED Monday to Friday between 0800 and 1600 h were eligible to be included in the study. Patients were excluded, however, if they: had a known history of cognitive impairment or were obviously cognitively impaired; were non-English or French speaking patients; had auditory, verbal or Visual impairments severe enough to affect cognitive testing; were critically ill; resided in a long-term care home or were transferred from other hospitals.

Interventions

  1. Training

The research assistant (DO) received two weeks of training with Ge- riatric Emergency Management nurses. The training consisted of didac- tic teaching, observed interactions and supervised patient assessments. The ED physicians and nurses received an initial email explaining the ra- tionale and goals of the study as well as a copy of the screening tool. During the rollout, the principal investigator and/or research assistant held short teaching sessions during the nurses’ nutrition breaks to re- view the Ottawa 3DY tool. Further teaching for physicians was provided during a Grand Rounds session presented by the principal investigator (DE). The research assistant was available in the ED throughout the course of the study to answer any questions that arose.

Implementation

The ED registration clerk put two Ottawa 3DY screening forms on the charts of all patients who were 75 years or older presenting during study hours. The front-line nurse and physician independently com- pleted their forms and placed them in a sealed envelope after assessing the patient. The research assistant collected the forms. If the patient on any form had a documented score of b4, the research assistant then assessed the patient by taking a structured history and completed the

Mini-Mental State Evaluation (MMSE) tool and the Confusion Assess- ment Method (CAM) tool to screen for delirium [34]. The research assis- tant also independently assessed 10% of the patients that had a score of four on the Ottawa 3DY tool by their clinicians to monitor if it was being completed correctly.

Survey

A post-implementation survey of nurses and physicians was con- ducted. The survey was adapted from the Ottawa Acceptability of Clin- ical Decision Rules Instrument [35]. Feedback from the front-line nurses and physicians regarding their use of the Ottawa 3DY tool was also incorporated. Respondents were asked to rate their level of agree- ment with each statement on a seven point Likert scale, which ranged from strongly disagree to strongly agree. The survey was designed on Survey Monkey Inc., a web-based survey development company and administered using a modified Dillman technique [36,37].

Data collection and statistical analysis

All patient data were collected onto a case record form. This included information on patient demographics, enrolment status, cognitive eval- uation scores (Ottawa 3DY, MMSE, ISAR, CAM), ED disposition and 30- day outcomes (return to ED, mortality). Survey data was collected by the Survey Monkey Inc. website and then exported in MS Excel spread- sheets for analysis. Data was analyzed using SPSS (IBM SPSS Statistics for Windows, Version 22.0 Armonk, NY: IBM Corp). Simple descriptive statistics were used to assess level of implementation, and barriers and facilitators of screening for altered mental status. Cohen’s Kappa was utilized to evaluate inter-rater reliability between ED physician and nurse scores. Sensitivity and specificity with 95% confidence inter- vals were calculated using the MMSE with cut-off of <=24 as the criterion standard for a definitive diagnosis of cognitive impairment [38].

  1. Results

Fig. 1 shows the patient flow diagram. During the two-month enrol- ment period, there were 539 potential patients identified; 160 were ex- cluded while 47 did not have study forms placed on their charts, leaving a total 332 eligible patients to be studied. Table 1 shows the descriptive characteristics of the 260 patients who had their cognitive status assessed. These enrolled patients had a mean age of 83.7 years and 60% were female. Characteristics between enrolled and missed patients were similar.

Compliance

ED nurses screened 213/332 (64.2%) of the eligible patients, while ED physicians screened 172/332 (51.8%) of the eligible patients. Overall 260/332 (78.3%) of the eligible patients had their cognitive status eval- uated with the Ottawa 3DY tool by at least one clinician (Fig. 1).

Identified barriers and facilitators to cognitive screening and use of the Ottawa 3DY tool

The overall achieved response rate for Ottawa 3DY Acceptability Sur- vey was 79.0% based on 39/54 ED nurses and 40/46 ED physicians com- pleting the survey (Appendix 1 shows respondent demographics). Fig. 2 illustrates the proportion of ED physicians and nurses who moderately or strongly agreed to statements regarding screening for cognitive im- pairment in older ED patients and their experiences in using of the Ot- tawa 3DY tool.

ED nurses

Most ED nurses (84%) rated screening for cognitive impairment as an important part of the assessment of an older ED patient; 87% re- ported that it was their responsibility to screen; the feasibility of the

Table 1

Older emergency department patient demographics.

Patient characteristics

Excluded patients

Missed

Enrolled patients

N = 160

N = 72

N = 260

Female gender: N (%)

101 (63)

42 (58)

156 (60)

Mean age: (SD)

85.6 (6.0)

83.1 (5.6)

83.7 (5.9)

Current living situation: N (%)

Unknown

29 (18)

22 (31)

44 (17)

Live alone

30 (19)

23 (32)

79 (30)

Live in own home with family

47 (29)

16 (22)

91 (35)

Live in retirement residence

36 (23)

11 (15)

46 (18)

Live in nursing home

18 (11)

0 (0)

0 (0)

Highest level of education: N (%) Unknown

133 (83)

65 (90)

134 (52)

Primary school

8 (5)

0 (0)

27 (10)

Secondary school

12 (8)

4 (6)

47 (18)

Post-secondary school

7 (4)

3 (4)

52 (20)

marital status: N (%)

Unknown

42 (26)

31 (43)

55 (21)

Married

34 (21)

18 (25)

83 (32)

Divorced/separated/widowed

80 (50)

22 (31)

111 (43)

Never married/single

4 (3)

1 (1)

11 (4)

Past medical history: N (%)

Unknown

2 (1)

3 (4)

12 (5)

Diabetes

41 (26)

14 (19)

42 (16)

Hypertension

102 (64)

38 (53)

152 (58)

Dyslipidemia

42 (26)

17 (24)

70 (27)

Atrial fibrillation/flutter

42 (26)

14 (19)

63 (24)

Stroke/TIA

24 (15)

7 (10)

45 (17)

Coronary artery disease

26 (16)

15 (21)

46 (18)

Myocardial infarction

15 (9)

4 (6)

35 (13)

Fig. 1. Study flow diagram for older ED patients.

Congestive heart failure

19 (12)

11 (15)

39 (15)

COPD

19 (12)

17 (24)

24 (9)

Location in ED: N (%)

scale was strongly endorsed with 97% agreeing that the Ottawa 3DYtool is easy to learn and use and 94% reporting that it is easy to remember; only 55% strongly agreed that patients would benefit from screening with 28% reporting that their clinical judgement was equal or better than the Ottawa 3DY.

ED physicians

Most ED physicians (83%) felt that screening for cognitive impair- ment is an important part of the assessment of an older ED patient and that it was their responsibility as an emergency physician to screen; 98%, 95% and 88% of physician respondents judged the Ottawa 3DYtool to be easy to learn, to use, and to remember, respectively; 50% of physi- cians felt the would be useful in their practice and only 31% of physi- cians felt patients would benefit from its use.

Inter-rater reliability of nurse and physician Ottawa 3DY tool scores

Inter-rater agreement was assessed on 112 pairs of observations. Table 2a shows the inter-rater reliability of the ED nurse and physician Ottawa 3DY tool score. Table 2b shows the inter-rater reliability of nurse and physician scores that differentiate between impaired (b4) and normal (=4). When discriminating between impaired vs normal cognitive status, agreement was high at 83.9%. Cohen’s Kappa for both specific scores and dichotomized scores (abnormal b4 and normal = 4) were calculated. They were similar with linear weighted Kappa of

0.67 (95% CI 0.55 to 0.79) and un-weighted Kappa of 0.65 (95% CI 0.51 to 0.80) indicating a substantial level of agreement between nurse and physician scores.

Classification performance of the Ottawa 3DY tool compared with MMSE tool

The MMSE was completed on 98 patients. The score for attention was based on either spelling the word ‘WORLD’ backwards or performing serial 7’s (counting backward from one hundred by sevens). Sensitivities and specificities were calculated and are illustrated in Tables 3a and 3b. The Ottawa 3DY tool performed better when

Unknown

0 (0)

0 (0)

1 (b1)

Resus/emergent

42 (29)

13 (22)

63 (24)

Observation

79 (55)

35 (40)

99 (38)

Urgent care

23 (16)

34 (39)

97 (37)

ED disposition: N (%)

Discharged home

89 (56)

57 (79)

191 (74)

return ED visits in 30 days: N (%)

30 (19)

24 (33)

46 (18)

Mortality: N(%)

7 (4)

1 (1)

7 (3)

completed by nurses, with a sensitivity of 81.5-84.6% and a specificity of 54.2-57.1%. In comparison, the sensitivity and specificity of the Ot- tawa 3DY tool when completed by physicians was 70.0-78.9% and 34.8-39.4%, respectively. For both, the sensitivity was greater when compared with the test of attention where the patient is required to spell the word, world, backwards. The overall level of agreement be- tween the Ottawa 3DY tool scores and the MMSE tool was fair, ranging from 51.2% with physicians to 64.9% with nurses.

  1. Discussion

Implementation of the Ottawa 3DY tool resulted in a high rate of cognitive evaluation completion by front-line ED nurses and physicians of older patients presenting to a large tertiary academic ED. The Ottawa 3DY, a simple 4 question screening tool developed to help detect altered mental status, demonstrated its moderate sensitivity and specificity when compared with the well-established but longer MMSE tool and good inter-rater reliability amongst treating ED physician and nurse cli- nicians. Its feasibility was strongly endorsed by both front-line ED nurses and physicians. The barriers that were identified to screening for cognitive impairment in ED settings included an overestimation of clinicians’ self-reported ability to identify cognitive impairment without a standardized tool and a perceived lack of patient benefit around screening.

Following the implementation of the Ottawa 3DY tool into the rou- tine clinical practice of our ED, we were able to demonstrate an achieved screening rate of 78.3%, an increase of nearly 300% compared with what clinicians self-report as their usual screening rates in the literature [28,29]. While evaluating the classification performance of the Ottawa

Fig. 2. Proportion of physician and nurse agreement (moderately and strongly agree) to barriers and facilitators of the Ottawa 3DY as a screening tool for altered mental status in older emergency department patients.

3DY tool compared with the more lengthy MMSE tool, demonstrated that the Ottawa 3DY tool yielded a lower sensitivity and specificity than in the prior validations [39,40], this was not unexpected in an im- plementation study, where the tool was included as part of the routine bedside clinical evaluation and was performed by multiple users with more limited training than research assistants.

Teodorczuk et al. reporting on their expert consensus work sur- rounding delirium recognition noted that a “lack of immediate recognisable benefit to bringing about delirium recognition was felt to be a major factor to hamper change” [41]. This is consistent with our study, which found that only 31% of ED physicians and 55% of ED nurses moderately or strongly agreed that patients would benefit from use of the Ottawa 3DY tool to evaluate their cognitive status. Furthermore 40% of physicians and 50% of nurses in ED slightly, moderately or

Table 2a

Linear weighted kappa agreement between nurse and physician Ottawa 3DY (O3DY) scores.

Nurse O3DY score Physician O3DY score

0 1 2 3 4 Total

0 3 1 0 0 0 4

1

2

1

0

3

0

1

3

0

3

1

2

6

8

Abnormal

Normal

Total

3

0

2

3

11

5

21

Abnormal

31

8

39

4

0

0

0

10

63

73

Normal

10

63

73

Total

4

6

7

24

71

112

Total

41

71

112

strongly agreed that their clinical judgement was as good or better for detecting altered mental status.

Nevertheless, the literature is quite clear that physicians are very poor at identifying cognitive impairment, missing it up to 80% of the time [6,9,10]. Indeed, the overconfidence of clinician’s in their self-reported ability to recognize cognitive impairment without a validated tool is concerning and likely contributes to low detection rates of altered mental status. This study’s survey has again underscored how knowledge gaps around screening for impaired cognition can be barriers to utilization of screening tools for cognitive changes in older ED patients. Without a val- idated screening tool, these patients remain at risk of suffering adverse patient and system outcomes from having potentially acute Mental status changes such as delirium and dementia in general going unnoticed.

Study strengths and limitations

This study is noteworthy for several reasons. To our knowledge, this is the first study to evaluate the implementation of a cognitive screening

Table 2b

Binary kappa agreement between nurse and physician Ottawa 3DY (O3DY) scores. Nurse O3DY score Physician O3DY score

Agreement between nurse and physician score (95%CI): 0.74 (0.65-0.82). Kappa with linear weighting (95% CI): 0.67 (0.55-0.79).

Agreement between nurse and physician score (95% CI): 0.84 (0.76-0.90). Kappa (95% CI): 0.65 (0.51-0.80).

Table 3a Sensitivity and specificity of Ottawa 3DY score completed by the bedside nurse compared with mini-mental state exam (MMSE) in older emergency department patients.

O3DY b 4

MMSE b 25

World reversal

Yes

No

Total

Yes

22

22

44

No

4

26

30

Total

26

48

74

Agreement O3DY score and MMSE = 64.9% Sensitivity (95% CI): 84.6% (64.3-95.0)

Specificity (95% CI): 54.2% (39.3-68.4)

O3DY b 4

MMSE b 25

Serial 7’s

Yes

No

Total

Yes

22

15

37

No

5

20

25

Total

27

35

62

Agreement O3DY score and MMSE = 67.7%. Sensitivity (95% CI): 81.5% (61.3-93.0).

Specificity (95% CI): 57.1% (39.5-73.2).

tool into routine ED clinical practice. Previous studies on cognitive screening have focussed on the test characteristics of the tool being studied. As such, a research assistant most often performed these eval- uations and thus it’s difficult to know how these studies’ findings will translate when actually implemented by front-line clinicians. The main strength of this study is that the screening was conducted by the actual front-line ED nurse and physician as part of their usual care of older patients. In addition, this is one of the first studies to identify bar- riers and facilitators to cognitive screening in older ED patients in general and around the use of the Ottawa 3DY specifically. This informa- tion can be used to develop more targeted and successful interventions in future implementations.

This study is not without its limitations. We used a convenience sample of older patients to study the use of our tool. The lack of 24 hour sampling can be a source of bias but was unavoidable in our study due to availability of the research assistant. We expect any bias as- sociated with the implementation to be minimal as the same providers (nurses and physicians) work both day and night shifts, and as such their practice patterns are likely to be similar regardless of the time. Fur- thermore, it has been widely established that older patients seek care in EDs during usual business hours. Our study excluded 207 of a possible 539 eligible patients. The proportion of excluded patients, however, is

Table 3b

Sensitivity and specificity of Ottawa 3DY score completed by the emergency physician compared with mini-mental state exam (MMSE) in older emergency department patients.

O3DY b 4

MMSE b 25

World reversal

Yes

No

Total

Yes

15

20

35

No

4

13

17

Total

19

33

52

Agreement O3DY score and MMSE = 53.8% Sensitivity (95% CI): 78.9% (53.9-93.0)

Specificity (95% CI): 39.4% (23.4-57.8)

O3DY b 4

MMSE b 25

Serial 7’s

Yes

No

Total

Yes

14

15

29

No

6

8

14

Total

20

23

43

Agreement O3DY score and MMSE = 51.2%. Sensitivity (95% CI): 70.0% (45.7-87.2).

Specificity (95% CI): 34.8% (17.2-57.1).

not unusual for this type of study. Indeed, nearly half were excluded due to them having a known history of dementia. Including patients with a known diagnosis would be inappropriate, as it would falsely elevate the sensitivity of the test. We used the MMSE as our criterion standard for our sensitivity analyses. The MMSE has several well- documented weaknesses, including education, language and cultural biases [42-45]. In spite of this, it remains the most widely used criterion standard for cognitive studies in the ED setting. Having a research assis- tant in the ED collecting forms and evaluating a subset of the patients may have further falsely elevated our achieved screening rates, as it could have served as a cue to complete the cognitive evaluation how- ever, it was our study’s the only way to help us determine our tool’s inter-rater reliability and classification performance.

Study implications

This study focused on the process of implementation and further ex- plored factors that influence cognitive screening in older ED patients. It identified some barriers to cognitive screening, however, further work is needed to explore this issue in greater depth. The more we under- stand barriers to behavioural change, the better our ability will be to de- velop effective targeted implementation strategies. While this study, demonstrated a robust level of uptake over a Short period of time, more work is needed not only to replicate this finding but also to study the sustainability of achieving continued cognitive screening at levels that can significantly improve patient and system outcomes.

A positive score on the Ottawa 3DY is indicative of cognitive impair- ment, which may be due to dementia, delirium or depression. Delirium is a medical emergency and therefore all ED patients who scores less than four on the Ottawa 3DY needs further evaluation to rule out delir- ium. The Confusion Assessment Method is the most commonly used tool for delirium [46]. If delirium is ruled out, the next step is dependent on the clinical situation and resources available. This could include re- ferring in the ED to a Geriatric Emergency Management team, referring to the primary care giver for further evaluation, or referring to special- ized geriatric services in the community.

Currently, very little research is available on the clinical impact of cognitive screening in the ED environment. Some studies, have found that the identification of cognitive impairment has not resulted in any clinical care alteration for patients [47-49]. As a result, much work re- mains to be done to describe how a positive cognitive screen could im- pact clinical care in the ED and beyond. Will a positive screen increase likelihood of gaining collateral history in impaired patients that lead to better outcomes; will it lead to earlier consults in the ED for evaluation by Geriatric Emergency Management specialist clinicians with more ap- propriate care and discharge planning occurring earlier on in the course of their ED stay; will it highlight cognitive changes that would benefit from a more comprehensive cognitive evaluation in the community or inpatient setting? What is the impact of routine screening on admission, length of stay and return ED visits? And finally, no studies that we know of have evaluated patient/family or caregiver acceptability of cognitive screening in the ED setting.

Conclusion

This is the first implementation study of a screening tool for cogni- tive impairment in older patients presenting to the ED. With little train- ing and cost, frontline ED nurses and physicians integrated the Ottawa 3DY tool – a sensitive, validated, four question instrument – into their clinical practice leading to a high rate of cognitive screening. The Ottawa 3DY tool was further demonstrated to achieve moderate sensitivity and specificity when compared with the MMSE tool and good overall inter- rater reliability amongst physicians and nurses. ED clinicians reported a high level of acceptability of the tool, strongly endorsing its feasibility. This study has demonstrated that incorporating the Ottawa 3DY tool into the routine evaluation of older patients is feasible and can be widely

adopted by frontline nurses and physicians in the ED. Use of this tool may lead to improved recognition of cognitive impairment and ulti- mately achieve better patient and system outcomes in this older patient population.

Author contribution

The author contributions were as follows: Debra Eagles conceived the idea, coordinated the study, and wrote the manuscript. Damanjot Otal was responsible for study coordination, data collection, and manu- script revisions. Laura Wilding assisted with data collection and manu- script revisions. Samir Sinha contributed to concept development and manuscript revision. Ian Stiell provided assistance with concept devel- opment, study design, analysis and manuscript revisions. Venkatesh Thiruganasambandamoorthy provided assistance with manuscript revi- sions. George Wells provided assistance with study design, statistical analysis and manuscript revisions. Debra Eagles had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Sources of funding

None.

Declaration of competing interest

None to declare.

Appendix 1

Ottawa 3DY survey respondent demographics, N = 79.

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  3. Barron EA, Holmes J. Delirium within the Emergency care setting, occurrence and detection: a systematic review. Emerg Med J 2013;30(4):263-8.
  4. Elie M, Rousseau F, Cole M, Primeau F, McCusker J, Bellavance F. Prevalence and de- tection of delirium in elderly emergency department patients. Can Med Assoc J 2000;163(8):977-81.
  5. Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department pa- tients: recognition, risk factors, and psychomotor subtypes. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2009; 16(3):193-200.
  6. Han JH, Wilson A, Vasilevskis EE, et al. Diagnosing delirium in older emergency de- partment patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med 2013;62(5):457-65.
  7. Han JH, Shintani A, Eden S, et al. Delirium in the emergency department: an indepen- dent predictor of death within 6 months. Ann Emerg Med 2010;56(3):244-52 [e241].
  8. Han JH, Eden S, Shintani A, et al. Delirium in older emergency department patients is an independent predictor of hospital length of stay. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2011;18(5):451-7.
  9. Wofford JL, Loehr LR, Schwartz E. Acute cognitive impairment in elderly ED patients: etiologies and outcomes. Am J Emerg Med 1996;14(7):649-53.
  10. Callahan CM, Hendrie HC, Tierney WM. Documentation and evaluation of cognitive impairment in elderly primary care patients. Ann Intern Med 1995;122(6):422-9.
  11. Grober E, Sanders A, Hall CB, Ehrlich AR, Lipton RB. Very mild dementia and medical comorbidity independently predict Health care use in the elderly. J Prim Care Com- munity Health 2012;3(1):23-8.
  12. Vida S, Galbaud du Fort G, Kakuma R, Arsenault L, Platt RW, Wolfson CM. An 18- month prospective cohort study of functional outcome of delirium in elderly pa- tients: activities of daily living. International psychogeriatrics / IPA 2006;18(4): 681-700.
  13. Eeles EM, Hubbard RE, White SV, O’Mahony MS, Savva GM, Bayer AJ. Hospital use, institutionalisation and mortality associated with delirium. Age Ageing 2010;39 (4):470-5.
  14. Kakuma R, du Fort GG, Arsenault L, et al. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc 2003;51(4):443-50.
  15. Carpenter CR, Bromley M, Caterino JM, et al. Optimal older adult emergency care: in- troducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine. Ann Emerg Med

Gender, n (%)

Overall (N = 79)

Nurse

(N = 39)

Physician (N = 40)

2014;63(5):e1-3.

  1. Geriatric emergency department guidelines, Ann Emerg Med 2014;63(5):e7-25.
  2. Cooke M, Burns A, Oliver D. The silver book: quality care for older people with ur- gent and emergency care needs United Kingdom ; 2012.

Male 30 (38) 9 (23) 21 (53)

Female

Age, n (%)

49 (62)

30 (77)

19 (48)

25-34

24 (30)

14 (36)

10 (25)

35-44

30 (38)

13 (33)

17 (43)

45-54

19 (24)

9 (23)

10 (25)

55-64

6 (8)

3 (8)

3 (8)

65 to 74

0 (0)

0 (0)

0 (0)

Physician professional designation, n (%)

CCFP-EM

n/a

26 (65)

FRCPC

Employment status, n (%) Full-time

70 (89)

30 (77)

14 (35)

40 (100)

Part-time

Years worked in the ED, n (%)

9 (11)

9 (23)

0(0)

0-5 years

22 (28)

11 (29)

11 (28)

6-10 years

22 (28)

12 (32)

10 (25)

11-15 years

18 (23)

8 (21)

10 (25)

16-20 years

9 (12)

3 (8)

6 (15)

N20 years

7 (9)

4 (11)

3 (8)

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