Pilot study of a two-step delirium detection protocol administered by certified nursing assistants, physicians, and registered nurses

The feasibility and acceptability of a twostep screening protocol for delirium identifi cation was pilot tested. Step 1, a screening tool, comprises two items: "Please tell me the day of the week," and "Please tell me the months of the year backwards starting with December." If either/both items are incorrect, Step 2, a 3-minute diagnostic assessment, follows. Trained researchers enrolled 24 hospitalized older adults and identifi ed 22% to be delirious after a reference standard assessment. Thereafter, physicians and RNs completed the two-step protocol, whereas certifi ed nursing assistants (CNAs) completed the screener only, on the same patients. All three clinical assessments were successfully completed in 100% of enrolled participants and within the target 2-hour time window in 91%. The screener and two-step protocol achieved high sensitivities and specifi cities in RNs, CNAs, and physicians. Qualitative information on barriers to and facilitators of implementation was also collected. Nurses and other clinicians can feasibly implement this ultra- brief screener and two-step protocol, which holds promise to improve delirium identifi cation. [Journal of Gerontological Nursing, 44(5), 18-24.].