Implementing System-Wide Delirium Prevention Strategies

Transcription

1 Implementing System-Wide Delirium Prevention Strategies Kellie L. Flood, MD Assistant Chief Medical Officer for Care Transitions & Geriatric Quality Officer, UAB Hospital Associate Professor UAB Division of Gerontology, Geriatrics, and Palliative Care

2 Disclosures No commercial conflicts of interest Co-investigator for NIH R21 grant to study delirium intervention post-discharge and NIH R03 grant to study impact of Delirium/Mobility care processes on outcomes and care transitions in GI surgical patients Teaching honorarium from University of Nebraska Medical Center and Aurora Health System, Wisconsin

3 Warm Greetings from UAB Hospital Where High Touch Meets High Tech Within 1,152-beds of complexity

4 Learning Objectives List strategies for creating a sense of urgency to drive change Describe rapid-cycle change methodology to hardwire evidence-based delirium prevention strategies into hospital workflows 4

5 Stomping Out Delirium is a Team Sport = Requires an Interprofessional Strategy

6 Rapid Cycle Change Methodology for System-Based Change Lasting solutions to complex problems in health care require breaking big goals into several smaller goals then Build on the Change Allows for repeated PDSA cycles for testing, revising, and celebrating wins along the way Act Plan Act Plan Act Study Plan Do Act Study Plan Do Act Study Plan Do Study Do Study Do

7 A Real Life Example of a Big Goal: Equipping an entire hospital to prevent/manage delirium as part of everyday workflow Inouye SK, Annals of Medicine, 2000; 32 (4): 257

8 Expect sand traps Entire hospital can prevent/manage delirium as routine care Once we know who is delirious, hardwire management processes Hardwire recognition of patients at risk for delirium and how to prevent it Determine how the system will screen for delirium Teach system what delirium is

9 When teaching about delirium: Must create a sense of urgency in the stakeholders needed to drive the change Start meetings/projects with a real case If this were your loved one. Bring in patients/families to tell the story/be interviewed Reflective journaling Music/videos as emotional movers Create a vision for the WOW factor

10 Creating Urgency Delirium is a MEDICAL EMERGENCY that causes suffering for all involved, kills people, costs a TON of money, and is potentially preventable

11 The Entire Interprofessional Team Can Concept Map Delirium

12 Engage Stakeholders From All Disciplines Including Those Closest to the Patients Ensure everyone is able to participate in the planning for the change Brainstorming techniques Asking instead of telling I think we should. Tell me about. Language is important Staff Those closest to the patient Recognize team members as experts in their work and specifically empower them to problem solve and lead the change in their microsystems Interprofessional team members process mapping current and future workflow together

13 Signs of Engagement, Empowerment, and a Sense of Urgency

14 Determining the Delirium Screen that Fits in Your System Develop Delirium curriculum and start delivering to interprofessional staff and targeted pilot units Pilot test evidencedbased Delirium Screen on 2 units Act Plan 100% 80% 60% 40% 20% 0% Post-Training Barriers in PDSA cycle tests of change can be your best friend Study Do Screen Not Completed Screen Completed

15 Sand Traps Can Allow You to End Up with a Process That Works and is Endorsed by the End Users Pilot test Delirium Screens 1 and 2 on units with RN surveys as an outcome measure Rec use on all units Completed in minutes Confident using Instructions clear Act Plan Had time to complete Overall Score Study Do Screen 1 Screen 2 1= Strongly Disagree, 2=Disagree, 3=Neutral, 4=Agree, 5= Strongly Agree

16 Building on the Change: We can now recognize delirium as delirium. What are we going to do about it? Pilot Test Delirium Prevention and Management Algorithm Act Study Plan Do

17 Sometimes Outside the Box is Literally a Box: Remember the Delirium Prevention Study If Patient Screens Positive for Delirium Symptoms:

18 Building on the Change: Incorporate Lessons Learned and Disseminate Develop process for restocking Delirium Prevention Toolkits Act Plan Study Do Delirium Prevention Totes on All 52 units and replenished through Hospital Central Supply: Unit Microsystems are Empowered and Equipped

19 Patients with a Screen Positive for Delirium Symptoms: 1 Ortho, 2 Trauma, 1 GI Surgery and 1 GI Medicine Unit 20% 18% * 15% * 10% 5% 10% 5% 7% 4% 8% Pre Post 0% All Patients Surgical Medical All Patients: Pre: 352 Screens in 211 pts; Post: 694 Screens in 508 pts *P<.05

20 Key Take Home Points People must feel an urgent need to change for change to happen and stick Those closest to the patient must be involved from the beginning The strategies must fit their workflow and you need them to promote the new workflows to their peers They must be equipped and empowered to drive and hardwire the change Delirium prevention strategies work better when physician order sets are already geriatric-friendly (free of Beers Meds) You will likely have to overstress the role of the team and tools in delirium prevention Celebrate the wins and the people creating the wins with each cycle and all along the way

21 QUESTIONS? UAB Hospital Kellie Flood,