The Journal of Thoracic and Cardiovascular Surgery
Adult: Perioperative ManagementDiagnostic accuracy of the “4 A's Test” delirium screening tool for the postoperative cardiac surgery ward
Graphical abstract
Diagnostic accuracy of nurse-administered 4AT to detect delirium on the postoperative cardiac surgery ward.
Section snippets
Study Design
This single-center, prospective, observational study was conducted at St Boniface Hospital, a tertiary care center located in Winnipeg, Manitoba. Patients aged more than 18 years, undergoing elective open surgery, and admitted to the postoperative cardiac surgery ward after ICU discharge were included in the study. The exclusion criteria were patients unable or unwilling to give consent and those in whom postoperative delirium could not be reliably assessed (eg, language barrier, hearing
Phase One
The primary outcome of interest was to determine the (1) diagnostic accuracy of researcher-administered 4AT compared with the reference standard in postoperative cardiac surgery patients. Additionally, we sought to determine (2) performance of nurse-administered CAM compared to the reference rater, (3) delirium severity (as measured by the Delirium Rating Scale-Revised 98 [DRS-R98]) compared with 4AT and CAM scores, and (4) secondary clinical outcomes as described earlier.
Phase Two
The primary outcome of
Patient characteristics
A total of 460 cardiac surgery patients (225 outpatients and 235 inpatients) were eligible for the study. Of those, 150 patients (115 outpatients and 24 inpatients) were consented and enrolled during the 5-month recruitment period. Ten of those patients dropped out of the study and were excluded from the data analysis. Three patients were unable to complete the study due to death or subsequent withdrawal from the study during the postoperative period. The patient demographics and operative
Discussion
This prospective cohort study is one of the first to validate the use of the 4AT as a delirium screening tool in a postoperative cardiac surgery patient outside of the ICU. This study had several strengths. This included a design in which the reference standard and screening tools were administered with each result blinded from the others. Patients with preexisting neurologic or psychiatric conditions were included, in contrast to some other studies.23,24,27 The 4AT assessments in phase 1 were
Conclusions
This study suggests that the 4AT performed once per day is a feasible and effective delirium screening tool as outlined in Figure 2. This study provides useful information with respect to real-world implementation of delirium screening outside the ICU on the postoperative ward, particularly with respect to the frequency and timing of use. Addressing nursing challenges and decreasing the frequency of 4AT use could improve adherence. Further studies should evaluate if use of the 4AT resulting in
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Cited by (4)
Commentary: The pervasive yet elusive problem of delirium after cardiac surgery
2023, Journal of Thoracic and Cardiovascular SurgeryCommentary: The 4AT score—reducing confusion about delirium diagnosis after cardiac surgery
2023, Journal of Thoracic and Cardiovascular SurgeryCommentary: 4A's for effort: Diagnosing delirium after cardiac surgery
2023, Journal of Thoracic and Cardiovascular Surgery
Funding: Department of Surgery GFT Grant, University of Manitoba; BSc Med Program, University of Manitoba.
- 1
Y.C. and S.M.R. contributed equally to this work.