By Dorothy Brooks
It is challenging in many EDs to timely place patients into appropriate inpatient beds. New research provides incentive to expedite this process, particularly regarding patients older than age 65 years.1
A team of emergency physicians gathered data showing that among older patients, there is an association between time spent in the ED and the development of delirium, a condition marked by the sudden changes in mental status (e.g., confused thinking or rapid mood changes).
In a retrospective study, 5,886 patients presented to the ED at UC Davis Medical Center in Sacramento, CA. These patients were admitted to family or internal medicine services. A total of 1,408 participants developed delirium during their hospital encounters during the study (Jan. 1, 2018, to Dec. 31, 2019). Researchers found that for every hour spent in the ED, the risk of developing delirium increased by roughly 2%.
The authors excluded patients with critical illnesses who were admitted to an ICU as well as those who were admitted for surgical services, focusing on patients who were admitted to a general medical floor. Katren Tyler, MD, vice chair for geriatric emergency medicine and wellness at UC Davis Medical Center and the senior author of the study, says there are two likely reasons why these patients develop delirium. “They were more exposed to the conditions in the ED, which contribute to the development of delirium ... and they failed to get [a prompt] patient bed on an inpatient floor that generally does a much better job of respecting people’s sleep-wake cycles.”
Meanwhile, Tyler and colleagues did not find any association between developing delirium and two other factors: non-clinical patient moves within the ED and time spent in the hallways. However, these investigators noted that the authors of at least one other recent study did find an association between time spent in hallways and the developing delirium.2
Nonetheless, as a result of their findings, the authors advised ED leaders to prioritize the placement of older patients who are admitted from the ED. Further, it is important to develop a good understanding of the factors that can cause delirium, and how to recognize the condition so that it can be managed appropriately.
Tyler says delirium is a short-term process that results in brain dysfunction, but it can produce lasting consequences. “Once somebody gets delirium, they’re much less likely to be able to return home. They’re much more likely to need some kind of residential care facility, like a skilled nursing facility, after their hospital stay,” Tyler explains. “At a minimum, [delirium] usually adds on the order of two days to [a patient’s] hospital admission.”
Tyler says time spent in the ED can upset a patient’s normal circadian cycle; they are accustomed to sleeping in the evenings when it is dark and waking up in the mornings with the sun.
“We also know that for patients who are at high risk for delirium, which would include patients with a history of cognitive impairment — especially dementia — having things around them that help to orient them to where they are can be super important,” Tyler explains.
For example, a window in the department that looks out into the outside world is important because it helps orient patients to their location and to the time of day. “Anyone who has spent any time in the ED will quickly understand that we do a very poor job of providing any of those features,” Tyler laments. “There is mostly not natural lighting, and people are not generally allowed to sleep during their normal sleep-wake cycles.”
Further, Tyler observes the rooms in a typical ED tend to be clinical “in the extreme,” and they lack any familiar objects to help orient people. “The ability for people to come and visit for extended periods of time is quite limited,” Tyler adds.
Tyler notes she and her colleagues often will ask a relative or a caregiver of patients who have presented with cognitive impairments if they can stay with the patients. This can help prevent these patients from tipping over into delirium. “The [visitor] restrictions we experienced during COVID were substantial, and they probably contributed to difficulties in managing delirium for many older patients, both in the ED and as inpatients,” Tyler offers.
For example, Tyler notes patient rooms on inpatient floors often include windows, and the inpatient nurses tend to help patients stand and walk around more often. “Our recommendation would be that for patients older than 65, in general we should try to minimize the time that they spend in the ED if they are being admitted to the hospital,” Tyler says.
Emergency providers also should try to limit using restraints on patients at risk for delirium. “Even though [restraints] might get temporary control of a situation where the patient is very agitated, we know that restraints actually contribute to the development of delirium,” Tyler explains.
Another option is providing sedatives to an agitated patient, but these drugs come with similar risks. “A sedative is like kicking the can down the road. It doesn’t solve the delirium at all, and mostly contributes to worsening delirium,” Tyler says. “Getting patients to an environment that has access to natural lighting and is a little less disruptive, noisy, and agitation-provoking than the ED can actually help manage the symptoms.”
Tyler observes emergency clinicians are becoming better at recognizing delirium, but this remains challenging in such a fast-paced environment. “For patients who have what we call hyperactive delirium, where the patients are more agitated, it’s usually much more straightforward to recognize that a patient [may have delirium] because they are not acting like themselves. They’re saying things that are odd, or in some cases ... they may be even violent,” Tyler says.
However, patients with hypoactive delirium, which accounts for most cases, show much subtler signs. “It just looks like the patient is sleeping,” Tyler says. “For example, when you walk into a hospital room, most people will wake up, especially if the lights get turned on. It is very unusual for someone to sleep through that.”
Consequently, if a clinician enters a patient room, and the patient does not wake up or respond, that is suggestive of hypoactive delirium. However, Tyler notes that in many different settings, healthcare workers generally are not adept at specifically recognizing hypoactive delirium unless the condition is targeted in a screening process.
With all the challenges and resources that go along with recognizing and managing delirium, it makes good sense to focus more on preventing the condition in older patients who present to the ED. “If you can get somebody upstairs a little more quickly, and it then saves you two or three days on the end of their admission, that is really important,” Tyler stresses. “Hospitals are really looking for ways to improve their throughput ... by focusing on the early part [of a patient’s hospital encounter], we can actually improve things at the other end.”
REFERENCES
1. Elder NM, Mumma BE, Maeda MY, et al. Emergency department length of stay is associated with delirium in older adults. West J Emerg Med 2023;24:532-537.
2. van Loveren K, Singla A, Sinvani L, et al. Increased emergency department hallway length of stay is associated with development of delirium. West J Emerg Med 2021;22:726-735.
A team of emergency physicians gathered data showing that among older patients, there is an association between time spent in the ED and the development of delirium. Researchers found that for every hour spent in the ED, the risk of developing delirium increased by roughly 2%.
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