HRET HIIN Falls Event

Transcription

1 HRET HIIN Falls Event Age Friendly Care: Detecting and Managing Silent Delirium to Prevent Falls March 7,

2 Welcome and Introductions Lauren Kaderabek Program Manager HRET 2

3 Upcoming Events HRET HIIN PFE Fellowship Making the Connection: PFE Strategies Part 1 March 8 11:00 a.m. 11:50 a.m. Click to Register HRET HIIN CDI Maybe It s Time We Tried Something New! March 9 11:00 a.m. 12:00 p.m. Click to Register Partnering for Progress in Quality and Safety: AONE and the HRET HIIN March 14 12:00 p.m. 12:45 p.m. Click to Register View all upcoming events 3

4 Join the Falls LISTSERV Join the Hospital-Wide (Falls) LISTSERV and enjoy benefits such as: Sharing of HRET HIIN resources Peer-to-Peer sharing of best practices and networking Learnings from subject matter experts Sharing of publically available resources Sign up today! 4

5 Agenda for Today 5

6 FALL RESULTS AND FRAMING Julia Heitzer, MS, Data Analyst HRET Jackie Conrad, RN, MBA, Improvement Advisor Cynosure Health 6

7 HIIN Baseline Falls Data Baseline Results - All Hospitals Reporting Measure Falls with injury (NQF 0202) Data Source Data submitted to HRET as of: 2/6/2017 # Hospitals Reporting / # Expected 1,213 / 1,600 Data Submission Rate 76% Baseline Rate 0.67 Year 1 Goal 7% reduction 0.63 Year 2 Goal 20% reduction

8 Age-friendly Hospitals and Fall Risk Reduction Fall Risk Reduction is Everyone s Business Allen R. Huang, MDCM, FRCPC, FACP, AGSF HRET-HIIN Webinar March 7,

9 Learning Objectives Understand the concept of an age-friendly hospital Understand the link between the use of certain medications and delirium and falls Be aware of hypoactive delirium Be able to list non-pharmacologic measures to help manage delirium 9

10 Hospital of the Future (now!) Smart Safe Healing Meets IHI Triple aim One you would want to work in One in which you would want your loved ones to be cared for One that is age-friendly 10

11 Age-friendly Hospital Concept A literature review of the hazards of hospitalization for older adults suggests that a change in the approach can be beneficial. Five guiding principles were suggested: 1. Favorable physical environment - Adapted to sensory & cognitively impaired people 2. Zero tolerance towards ageism at all levels in the organization - Knowledge, skills and attitudes of all staff are supportive 3. Integrated process to develop comprehensive services using the principles of the geriatric approach - e.g., delirium prevention, detection, management 11

12 Age-friendly Hospital Cont d 4. Assistance with appropriateness decision-making - Too much vs. too little. Patient-centered, measureable benefits 5. Fostering links between acute care and community - Care in the right place at the right time Huang, Larente, Morais. Can Geri J 2011, 14(4):

13 Delirium and Falls percent of fallers are delirious at the time of their fall A patient with delirium is 4.55 times more likely to fall (confidence interval: ) Meta-analysis of delirium interventions and falls have shown the chance of falling decreases by 62 percent (odds ratio 0.38, CI: ) Pendlebury et. al. BMJ Open 2015, Nov 16, 5(11):e Corsinovi et. al. Arch Gerontol Geriatr 2009, Jul-Aug 49(1): Hshieh et. al. JAMA Int Med 2015, Apr 175(4):

14 Medications, Delirium and Falls Medications have both therapeutic effects and sideeffects, which are sometimes harmful Medications which affect blood pressure and/or have CNS effects can be associated with increased fall risk (fall risk increasing drugs FRIDs) Medications with strong anti-cholinergic effects can lead to delirium 14

15 Examples of FRIDs Partial list of fall risk increasing drugs: Benzodiazepines **** Antidepressants *** Antipsychotics *** Antiepileptics Antihypertensives Glucose control meds including insulins Huang, Mallet. eds. Medication-related falls in older people. Causative factors and management strategies. Springer New York, New York. ISBN

16 Anticholinergic Effects Dry eyes, dry mouth, urinary retention, constipation, orthostatic hypotension, sedation, delirium, falls Examples Dimenhydrinate (Dramamine/Gravol) Diphenhydramine (Benadryl) Amitryptilline (Elavil) Tolterodine (Detrol) Cyclobenzaprine (Flexeril) 16

17 What About Delirium? Acute brain failure Confusion assessment method (CAM) assessment tool Quiet, hypoactive delirium, e.g. stupor, coma is as bad (or worse) than a patient who is physically and verbally agitated Analogy to trauma triage approach Simple Triage and Rapid Treatment (START protocol) Glascow Coma score (GCS) Quiet, less responsive patients need more urgent care Early detection and diagnosis of delirium can improve outcome 17

18 Trauma Triage, GCS 18 GCS less than 13 is NOT GOOD

19 Confusion Assessment Method 1. Acute onset and fluctuating course (1 point) Is there evidence of an acute change in mental status from the patient s baseline? Did the (abnormal) behaviour fluctuate during the day (tend to come and go, or increase and decrease in severity)? 2. Inattention (1 point) Did the patient have difficulty focusing attention (e.g. being easily distractible) or have difficulty keeping track of what was being said? 3a. Disorganized thinking (1 point) Was the patient s thinking disorganized or incoherent: such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? 3b. Altered level of consciousness (1 point) Patient s level of consciousness: alert [normal], vigilant [hyper-alert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [un-arousable]. Positive for any answer other than alert. Consider delirium if score is two or more. Sensitivity: 94 percent 100 percent; Specificity: 90 percent 95 percent Inoue SK. Ann Intern Med 1990; 113(12):

20 Action Items Screen for delirium (CAM tool) Periodic medication review (on admission, at least every week, at discharge) Medication appropriateness approach Right drug, right indication, right dose, right formulation, right administration (a shift away from polypharmacy ) Mobilize as soon as feasible and keep mobile Declutter the environment to decrease environmental hazards Engage the entire health care team 20

21 Whose Job Is It? Nurses Pharmacists Physicians Physiotherapists, occupational therapists Dieticians, ward clerks Volunteers Hospital managers Hospital leaders Health care system 21

22 Delirium Management Manage possible contributing medications Manage any contributing medical conditions (metabolic, infectious, ischemic, etc.) Assess for and manage PAIN Physical and chemical restraints are to be considered as a last resort, when staff or patient safety is at risk 22

23 Non-pharmacologic Interventions Glasses Hearing aids Adequate hydration Warm & dry Manage pain Anchor objects Human contact (family, sitters) 23

24 Conclusions Age-friendly hospitals can help maintain health and function of hospitalized older patients Falls are frequently multi-factorial Delirium is highly associated with falls Medications are a modifiable fall risk Delirium can be silent Managing falls and detecting and managing delirium is a team activity THANK YOU allenhuang@toh.ca 24

25 From Theory to Practice 25

26 Delirium Screening and Rounding Owensboro Health Delirium Team Owensboro, KY March, 2017 Salanda Bowman, MSN, RN Manager Skilled Nursing Bill Bryant, MD, FAAFP, CMD Chief Quality and Patient Safety Officer Terra Crabtree, BSN, RN Manager Cardiac Care Liz Emery, MSN, MBA, RN Nursing Director Debbie Enoch, MBA, MSN, RN Manager of Education Joy Everly, MSN, MPA, MSM Nursing Director 26

27 Our Story Owensboro Health Owensboro, Kentucky 477 Bed Regional Hospital 32 Bed ICU Level III Trauma Center Level III NICU Initial awareness & effort ~ 2005 Cultural barriers to change On-going awareness Second effort Delirium Screening by Primary Nurse each shift 2014 Med/Surg units Tool built in EMR Nursing staff: Delirium CE and Tool education & Healthstreams assignments 27

28 The Delirium Team Salanda Bowman, MSN, RN Manager Skilled Nursing Bill Bryant, MD, FAAFP, CMD Chief Quality and Patient Safety Officer Terra Crabtree, BSN, RN Manager Cardiac Care Liz Emery, MSN, MBA, RN Nursing Director Debbie Enoch, MBA, MSN, RN Manager of Education Joy Everly, MSN, MPA, MSM Nursing Director 28

29 Future We want to change the culture of care for the aging in our hospital, system, and community. Our Core Premise: Delirium: A symptom of how hospital care is failing older persons and a window (of opportunity) to improve quality of hospital care. -Sharon Inouye. American Journal of Medicine. May, (5):

30 Open Discussion 30

31 Bring it Home 31

32 Falls Resources Change Package New Falls Change Package coming soon!!! Falls resources available on the HRET HIIN website. 32

33 Falls Resources Hospital-Wide LISTSERV Join the LISTSERV Ask questions Share best practices, tools and resources Learn from subject matter experts Receive follow up from this event and notice of future events 33

34 Thank You! Find more information on our website: Questions or Comments: 34

35 Owensboro Supplemental Slides 35

36 bcam Snapshot 36

37 Now What? How to address delirium positive patients Reported at daily hospital safety huddle but no reliable intervention Educational sessions But culture stuck in the old mindset Most did not get it (Some still do not) 37

38 Genesis of Delirium Rounding Change concept: small test of change One nurse and physician rounded with primary nurse of a patient who screened positive Our initial very positive learning experience for everyone motivated us to continue rounding Small, but growing core group passionate about the importance of delirium 38

39 Aha! Moments Immediately Total lack of understanding of delirium What it is What to do about it What not to do about it bcam screening tool use What is an acute change (feature one) What is dementia, delirium, the difference Focus on orientation instead of attention (feature two) 39

40 Many Misconceptions Oversimplification Check urine They have a UTI and are confused They just had surgery and they are confused They are old and just confused They are sundowning And on and on and on 40

41 Evolution of Delirium Rounding Core group committed to round with primary nurse once for each positive patient Daily EMR report of positive patients of patients to round on goes out Team gathers at 0900 Initially minutes per patient We do not see the patient now 5-15 minutes depending on experience of primary nurse related to delirium rounding 41

42 Delirium Team Nurse lead, unit clinical pharmacist, physician, dietician, social worker Unit nurse manager attends Others also observe Nurse lead now assigned per week from core group Unit nurse manager being trained to do this Robust team collaboration, learning and coaching with primary nurse We do not interact with patient We all continue to learn new concepts 42

43 Rounding Process Brief history per primary nurse Review bcam scoring Many coaching opportunities for tool and delirium Medication review: home and current Tethers Non-pharmacologic interventions Recommendations/Considerations Nurse and/or pharmacist communicates to provider 43

44 Exhilarating Moments We all continue to learn new insights Each patient is different with unique challenges Observing a caregiver get it Primary Nurse able to lead us through rounds (Makes rounds quick & easy) Blinds are already open Patient is already up in a chair Foley and tethers already removed Medications already modified Etc. 44

45 Future We want to change the culture of care for the aging in our hospital, system, and community Our Core Premise: Delirium: A symptom of how hospital care is failing older persons and a window (of opportunity) to improve quality of hospital care. -Sharon Inouye. American Journal of Medicine. May, (5):