10/2/2014. Disclosure. Is Playing NICE Enough? AMP 2014 Annual Meeting. Learning Objectives

Transcription

1 Is Playing NICE Enough? Implementing a Delirium Identification and Prevention Protocol Throughout a Hospital System October 11, 2014 Thomas W. Heinrich, MD, FAPM Professor of Psychiatry and Family Medicine Medical College of Wisconsin Medical College of Wisconsin Froedtert Hospital AMP 2014 Annual Meeting Disclosure Thomas Heinrich, MD With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship between the parties listed above (and/or spouse/partner) and any for-profit company in the past 24 months which could be considered a conflict of interest. Please be warned I will mention an off-labeled use of antipsychotics! Learning Objectives Upon completion of this session, participants will be able to: 1. Identify key aspects of delirium prevention and management as detailed in the NICE Guideline 2. State important metrics to monitor to document efficacy of the a delirium prevention, identification, and treatment protocol across systems 3. Report on mechanisms utilized to bring the multi-institution and multidisciplinary clinical project to fruition 1

2 NICE Clinical Guideline Delirium: Diagnosis, Prevention, and Management Key Concepts Delirium Prevention The guideline was developed by using standard NICE methodology The multidisciplinary guideline development group included health care professionals from secondary care (internists, psychiatrists, and specialist nurses), a care home manager, and patient representatives. Guideline addressed the efficacy and safety of pharmacologic along with single- and multicomponent nonpharmacologic interventions for delirium prevention. 2

3 Target population The guideline is directed at persons aged 18 years or older who are in a hospital or long-term residential care setting. It does not cover persons receiving end-oflife care or persons who are intoxicated or withdrawing from drugs or alcohol. Recommendations Ensure that persons at risk for delirium are cared for by a team of health care professionals who are familiar with the person at risk. On the basis of the initial guideline development process and their experience, the guideline development group formulated recommendations Risk factor assessment Screen for delirium Interventions to prevent delirium Recommendations Give a tailored, multicomponent intervention package Initiated within 24 hours of hospitalization Assess persons at risk for clinical factors contributing to delirium Provide a multicomponent intervention tailored to the person s individual needs and care setting The tailored, multicomponent intervention package should be delivered by a multidisciplinary team trained and competent in delirium prevention. 3

4 The MCW Approach Target population The guideline is directed at persons aged 18 years or older who are in a hospital or long-term residential care setting. Three Froedtert Hospitals One AMC and two community hospitals No long-term residential settings Excluded patients in the ED and OB It does not cover persons receiving end-of-life care or persons who are intoxicated or withdrawing from drugs or alcohol. Included end-of-life care and AODA The Hospitals The Northwest Corridor The Hospitals Froedtert Hospital Beds: 500 Net Patient Revenue (FY13): $1,008M Discharges: 26,186 Outpatient Visits: 713,487 Medical Staff: 818 Residents: 315 4

5 The Hospitals Community Memorial Hospital Beds: 237 Net Patient Revenue (FY13): $178.2M Discharges: 8,741 Outpatient Visits: 95,989 Medical Staff: 256 Residents: 0 The Hospitals St. Joseph s Hospital West Bend Beds: 70 Net Patient Revenue (FY13): $92.9M Discharges: 3,479 Outpatient Visits: 77,024 Medical Staff: 81 Residents: 0 Delirium Project: Overview Patient Admitted to Hospital Risk Factor Assessment 5

6 Risk factor assessment Risk factors Age 65 or older Cognitive impairment and/or dementia Current hip fracture Severe illness * (a clinical condition that is deteriorating) * Intensive Care Unit Patient Delirium Project: Overview Patient Admitted to Hospital Risk Factor Assessment Positive Negative Institute Prevention Protocol CAM Screening Reassess The MCW Approach Delirium screening Instruments General medical and surgical floors CAM Intensive care units CAM-ICU Frequency Upon admission Qshift A positive CAM following a 48h negative trend (i.e. 6 consecutive negative shift CAMs) would represent a new change in condition and a notification of the clinician 6

7 Delirium Project: Overview Patient Admitted to Hospital Risk Factor Assessment Positive Negative Institute Prevention Protocol CAM Screening Reassess Issues to direct interventions to prevent delirium Cognitive impairment Dehydration or constipation Hypoxia Immobility or limited mobility Infection Multiple medications Pain Poor nutrition Sensory impairment Sleep disturbance Prevention Interventions Cognitive impairment or disorientation Provide appropriate lighting and clear signage. A clock (consider providing a 24-hour clock in critical care) and a calendar should also be easily visible to the person at risk Reorientate the person by explaining where they are, who they are, and what your role is Introduce cognitively stimulating activities for example, reminiscence Facilitate regular visits from family and friends Hypoxia Assess for hypoxia and optimize oxygen saturation if necessary 7

8 Prevention Interventions Immobility or limited mobility Encourage the person to: Mobilize soon after surgery Walk Encourage all people, including those unable to walk, to carry out active range-of-motion exercises Multiple medications Carry out a medication review for people taking multiple drugs, taking into account both the type and number of medications Infection Look for and treat infection Avoid unnecessary catheterization Implement infection control procedures Prevention Interventions Sleep disturbance Avoid nursing or medical procedures during sleeping hours, if possible. Reduce noise to a minimum during sleep periods. Good sleep hygiene should be advised in people with any sleep disturbance and includes: Avoidance of stimulants (for example, coffee, tea, caffeine) in the evening Establishment of a regular pattern of sleep Comfortable bedding and temperature Restriction of daytime siestas A review of all medication and avoidance of any drugs that may affect sleep or alertness Delirium Project: Overview Patient Admitted to Hospital Risk Factor Assessment Positive Negative Institute Prevention Protocol CAM Screening Reassess Positive Negative Institute Prevention Protocol & Institute Prevention Protocol & Reassess Every Shift 8

9 Initial management Delirium prevention protocols Continued assessments Clinician notification Order set development Froedtert Hospital Division Delirium Prevention Project Identification Treatment Prevention I Prevention II Froedtert Hospital Division Delirium Prevention Project Identification Identification of patients at risk CAM screening Delirium diagnosis Documentation 9

10 Froedtert Hospital Division Delirium Prevention Project Identification Treatment Identify and manage the underlying cause(s) Initiate appropriate antipsychotic for behavioral Communication of diagnosis to entire treatment team Effective communication, reassurance, and reorientation Identify and address family distress Education Avoid restraint Document delirium resolution Froedtert Hospital Division Delirium Prevention Project Identification Treatment Prevention I Cognitive impairment, disorientation, or both Multiple medications Sleep disturbance Mobility Nutrition Sensory impairment Froedtert Hospital Division Delirium Prevention Project Identification Treatment Prevention I Prevention II Infection Dehydration, constipation,or both Pain Hypoxia Antipsychotic perioperative prophylaxis * 10

11 Getting Sponsorship: Making a case for Improvement Can you improve quality metrics that are tied to reimbursement? Mortality Readmissions Hospital acquired conditions (infections, DVT) Can you decrease cost of care? Length of stay Drug, lab, radiology utilization Teams outperform individuals Task is complex Creativity is needed The path forward is unclear High commitment is needed Task is cross-functional/cross-sectional Cooperation is essential to implementation Create an effective improvement team that has frontline knowledge, is diverse, has clear goals, is sponsored, has leadership, has resources and is committed. The Team Dummer, Susan, RN, Change Management Benson, Mary, RN, SJH Community Division Director of Nursing Denson, Steven, MD, Geriatrics Emanuel, Chris, Process Improvement Fisher, Travis, MD, Psychiatry Fridlington, Linda, RN, CNS Heidenreich, Amy, RN, Nurse Educator Heinrich, Thomas, MD, Psychiatry Hoefs, Susan, RN, Nurse Educator Klockow, Karen, RN, Nurse Manager Koester, Katie, PT, Rehab Services Acute Kozeniecki, Michelle, RD, Dietician McAndrew, Natalie, RN, CNS Nanchal, Rahul, MD, Critical Care Roznowski-Olson, Julie, RN, Geriatrics Siclovan, Danielle, RN, Director of Neuroscience Nursing Smith, Jeri, RN, CNS Holly Pollex, Informatics 11

12 The Team Process Improvement Experts Community Hospital Nursing AMC Nursing Community Hospital Psychiatry AMC Family Medicine - Psychiatry AMC Geriatrics Rehabilitation Critical Care Dietary Informatics Leadership Communicate the vision Clarity, repeatedly and without ambiguity Supply tools Training, time, budget Coordinate across members in a team, and across teams Remove barriers Celebrate success and inspire Measurement Purpose of measurement is improvement Get data from information systems as well as from daily routine work Use quantitative as well as qualitative data Develop a dashboard 12

13 General Principles Outcome and Process metrics Dashboard must detect meaningful deviation Easy to interpret Balance is critical Balanced data A lot of data A lot of data = distraction Useful data > Perfect data > No data > Bad data Dashboard Statistical Process Control Special Cause variation Common Cause variation Common Cause variation Special Cause variation TIME 13

14 Detecting Meaningful Variation Rules for interpreting: what is a meaningful deviation A single point outside control limits 7 consecutive points on the same side of average Summary For quality improvement to be successful: Get Sponsorship by objectively aligning to organizational goals Create an effective improvement Team Provide Leadership Use rigorous quality improvement Methodology Measure what you do, know when you have improved. CAM Validity 14

15 Bibliography NICE clinical guidelines CG103 Delirium: Diagnosis, prevention and management Young J, Murthy L, Westby M, et al. Diagnosis, prevention, and management of delirium: summary of NICE guidance. BMJ. 2010;341:c3704 O'Mahony R, Murthy L, Akunne A, et al. Synopsis of the National Institute for Health and Clinical Excellence guideline for prevention of delirium. Ann Intern Med. 2011;154(11): Thanks! Comments and/or questions are welcomed 15