Strategies for Developing, Maintaining, and Spreading a Protocol to Decrease Delirium

Transcription

1 Strategies for Developing, Maintaining, and Spreading a Protocol to Decrease Delirium Maryjo Cleveland MD, CMD Sue Fosnight RPh, CGP, BCPS Joyce Restifo RN, MSN, Geriatric CNS

2 Summa Health System Akron City Hospital/ St Thomas Hospital/ Barberton Hospital Akron City/St. Thomas 544 beds 119 critical care beds Barberton Hospital 192 beds 22 critical care beds 2

3 Objectives By the end of this presentation the listener should be able to : 1. Explain the importance of minimizing delirium in the hospital setting 2. Discuss the value of developing an interdisciplinary delirium protocol 3. Identify strategies for adapting the protocol to a community hospital setting 4. Identify outcomes that delirium prevention can impact 3

4 Impact of Delirium Pictures Source: Microsoft Clipart Accessed Crit Care Clin 2015;31: ; J Bone and Bone Surgery 2015; 97:829-36; BMJ 2015;350:h2538 doi: /bmj.h2538; Amer J Geriatr Psychiatry 2013; 21: ; Crit Care Med ;41: ; Crit Care Med 2012; 40: ; Crit Care Care Med 2009; 35: ; Crit Care Med 2009; 37: ; Chest 2009; 135: 18-25; New Engl J Med 2006; 354: ; J Am Geriatr Soc 2003; 51: ; JAMA 2004; 291:

5 Prevention Protocols General patients Med-Surg patients Significantly decreased risk of delirium in most studies Number needed to treat = 4.6 to 19.6 patient to prevent one case of delirium Intensive Care Patients Significantly decrease ventilator days, length of ICU stay, and mortality documented Age Ageing Nov 25. pii: afu173. [Epub ahead of print]; Journal of Critical Care 2013: 28: ; Crit Care Med. 2013;41: ; Ann Intern Med. 2013;158: ; J Am Geriatr Soc 2005;53: 18-23; J Am Geriatr Soc 2001;49: ; N Engl J Med 1999; 340 (9)

6 JAMA Intern Med, Feb 2,2015 Meta-analysis of non-pharmacological, multicomponent interventions to decrease incident delirium In high quality studies Significant decrease in incident (new) delirium Decrease by 44% ( OR=0.56, 95% CI= ) Significant decrease in falls Decrease by 64% ( OR= 0.36, 95% CI= ) Length of Stay Reduction Decrease by average of 0.33 days, 95% CI = Post hospital institutionalization Decrease by 6% ( OR=0.94, 95% CI= ) JAMA Intern Med. doi: /jamainternmed

7 Weighing in on Delirium Risk Predisposing Risk Factors Age > 65 old/ older age Male Cognitive Impairment/ dementia/ Apolipoprotein E polymorphism Depression Visual Impairment Hearing Impairment High severity of Illness History of HTN Dehydration Malnutrition Treatment with multiple psychoactive medications Alcohol Abuse Prior Stroke or TIA Respiratory Disease Smoking Benzodiazepine use prior to ICU admission Precipitating Risk Factors Opioids Anticholinergics Corticosteroids Multiple medications Stopping a statin while in ICU? Alcohol/drug withdrawal Sedative/hypnotics Sleep deprivation Pain Stroke Infections/ Acute Infection Hypoxia Hypertension/hypotension Anemia/Anemia Dehydration Electrolyte abnormalities metabolic disturbance/hyperbilirubinemia/hypo albuminemia/ increased creatinine/ acidosis Malnutrition Surgery ICU stay Physical restraints Bladder catheter High vulnerability Low vulnerability Crit Care Med ;41: ; Ann Intern Med. 2012;156: ; Anesthesiology 2012; 116:788 96;Circulation 2009; 119: ; J Crit Care 2008; 23: ;Crit Care 2008 : 12: S3 (doi: /cc6149);arch Intern Med 2007; 167: ; J Am Geriatr Soc 2007; 55: ; JAMA 1996; 275: ; Morandi A, et. al. Crit Care Med 2014; 42: ;Schreiber ME, et. al. Crit Care Med 2014; 42: ;J Crit Care 2008; 23: ;Crit Care 2008 : 12: S3 (doi: /cc6149);arch Intern Med 2007; 167: ;Circulation 2009; 119: ; JAMA 1996; 275:

8 AN INTERPROFESSIONAL APPROACH TO DELERIUM 8

9 It Takes a Team Stake Holder s Meeting Nurses, internal medicine physician, surgeon, ER physician, geriatrician, geriatric psychiatry physician, quality improvement representatives, finance representatives, pharmacist, sleep specialist for insomnia order set Literature Review Order Set and Protocol Development Pharmacy and Therapeutics and Medical Executive Committee Approval Picture from Creative Commons : Accessed

10 Summa s Protocol Components Screen for Risk Six item screen on nursing admission If positive: Non-pharmacological prevention through nursing plan of care Order generation to pharmacy delirium risk Allows for computerized diseasedrug interaction notice to avoid medications causing or worsening delirium Screen for Delirium NuDESC or CAM-ICU in flowsheets Nursing order set in Med Surg if positive Order generation to pharmacy delirium Used in same way as delirium risk, more aggressive approach- placed monitoring list 10

11 Summa s Protocol Components Order Set Standard work-up for delirium Used for treatment if necessary if nursing order set already used Encourage correct use of medications when medications are needed No new benzodiazepines Correct dosing of antipsychotics when needed Link to insomnia order set Insomnia Order Set Encourages non-pharmacological therapies Encourages the avoidance of high risk medications in elderly Encourages use of melatonin agonist 11

12 Randomized Controlled Trials with Low Doses of Melatonin Agonists to Prevent Delirium in Older Patients Trial Delirium in Control Group Delirium in Melatonin Group Absolute Risk Difference Number needed to treat P value Al-Amma T, et.al. Int J Geriatr Psychiatry 2011; 26: % 12% 19% 5.3 patients p=0.014 Hatta K, et. el. JAMA Psychiatry 2014; 71: % 3% 29% 3.5 patients p=0.003 Dejonge A, et.al. CMAJ 2014; 186;E % 29.6% -4.1% p=

13 Maintaining the Momentum: The Delirium Quality Improvement Group Interdisciplinary Group Meet every other month Quality Improvement Education 13

14 Spreading the Word Barberton Hospital Summa Health System Community Hospital - Founded in 1915 Average daily census % older adults

15 Geriatric Services Introduced in 2012 SWOT Analysis SHS recognized nationally for advances in Geriatric medicine Minimal presence of Geriatric focused services Recognition and agreement by leadership Apprehension by some physician groups Acute Care for the Elderly (ACE) Unit Inpatient Geriatric Consult 15

16 ACE Unit Medical Surgical Unit 29 beds with ADC 25 60% of patients >65 80% are community dwellers 26% documented history of dementia 41% experience delirium during their stay 90% presented with functional decline 87% on 5 or more medications Summa Health Barberton Hospital, ACE Data,

17 Incidence of Dementia/Delirium on the ACE Unit older adult patients were included in ACE Rounds 171 patients had a documented history of dementia (21%) 114 patients with dementia experienced delirium as evidenced by a NuDESC score 2 67% of ACE patients with a known dementia experienced delirium during their hospital stay 73 (39%) patients who experienced delirium did not have a documented history of dementia

18 Acute Delirium Prevention Challenges Less efficient EMR Physician apprehension toward change Order set transition from paper to electronic Delirium Protocol Nursing Driven Model Pilot Study Screening Tools Guidelines for Plans of Care ACE interdisciplinary team

19 Monitoring Delirium SIS and NuDESC trends discussed during shift change report, Plan for Your Stay Rounds, ACE Rounds Risk for delirium (SIS 2) and incidence of delirium (NuDESC 2) warrant a written plan of care Physician alerted within 24 hours of a NuDESC 2) if the NuDESC score continues to trend upward the patient s delirium is worsening use SBARQ when talking with the physician Hyperactive delirium quickly captures our attention but, it is hypoactive delirium that often goes un-noticed by physicians and nurses Our goal is monitor for delirium routinely so as to avoid or keep s/s to a minimum

20 Guidelines for Plan of Care: Delirium Focus on Geriatric Syndromes Mobility/Functionality Orientation/ Therapeutic Activities Communication Sensory Therapy Elimination Hydration Nutrition Environment/Safety Pain Sleep 20

21 Orientation/ Therapeutic Activities Frequent orientation to time and place Encourage family visits to offer support and familiarity to patients Comforting items from home robe, lap blanket, photographs Large face clock with correct time Communication board up to date Cognitive stimulating activities word searches, cross word puzzles, picture puzzles, story books, painting: Therapeutic Activity Cart Provide family with Helping Your Loved One Avoid Confusion booklet 21

22 Document a Plan of Care (example) 22

23 Nursing Driven Acute Delirium Prevention Pilot Study ACE Unit Goal and measurement: To determine rates of delirium for community dwelling older adult patients on the ACE Unit at the start of and 1 year after implementation of a nursing-driven delirium prevention protocol 23

24 Akron City Hospital / St. Thomas Hospital Outcomes

25 Summa Data Summa Akron City- 28% drop in delirium house wide from 2013 to 2015 Summa ACH 29% decrease in lorazepam use within 2 years All Adult pt. DC ALOS Comparison All pts. >65 All pts. >65 MS units Summa ACH Jan-Sep Delirium Patients 4.1 LOS ( Days) Protocol 3.7 Mortality (% of patients) No Protocol 25

26 Nursing Order Set Compared to no order set: Use of nursing order set: 23 hours decreased LOS; 15.9% decrease in transfers to intensive care % 30% 25% 28.6% 100 No Order Set 20% No Order Set LOS (hours) Nursing Order Set Physician Med Surg Order Set 15% 10% 5% 0% 13.4% 12.7% % of pts with transfer to ICU Nursing Order Set Physician Med Surg Order Set

27 Conclusion Team approach is the best way to decrease delirium and effectively manage it Summa has multiple tools to help assist health care providers give best practice care in delirium prevention and management Communicate, Collaborate, Coordinate

28 SUPPLEMENTAL INFORMATION

29 Identifying Patients at Risk Six Item Screen and Summa Screening Question DELIRIUM RISK SCREEN / SIX-ITEM SCREEN (SIS) Plan Score of 2 is positive screen SUMMA SCREENING QUESTION Any problems with confusion at home or in previous hospitalization? No Yes

30 Identifying Delirium : Nu-DESC (Nursing Delirium Screening Scale) Behavior Disorientation: Verbal or behavior manifestation of not being oriented to time or place or misperceiving persons in the environment Inappropriate Behavior: To place and/or person (i.e..pulling at tubes and dressings, attempting to get out of bed when contraindicated Inappropriate communication: incoherent, noncommunicative, nonsensical or unintelligible speech Hallucinations : Seeing or hearing things that are not there, distortions of visual objects Psychomotor retardation: Delayed responsiveness, few or no spontaneous words /actions, Reaction is delayed or patient is nonresponsive 0=no symptoms Alert and oriented to person, place and time Calm, cooperative Appropriate None None Total score of 2 or greater : Notify physician, implement delirium IPC 1=present, but mild Disoriented. But easily oriented Restless, cooperative (i.e picking at tubes but follows commands Unclear thinking or rambling speech Paranoid, fear Delayed or slowed responsiveness Total= 2=present, pronounced Disoriented X2 or X3, not easily oriented Agitated, pulling at devices, climbing over siderails Incoherent, nonsensical or unintelligible speech Hallucinations, distortions of visual objects Excessive sleeping, somnolent, lethargic Score 30 Callahan, CM., Unverzagt, FW., Perkins, AJ., & Hundrie, HC. (2002). Medical care. Lippincot, Williams & Wilkins Inc.40(9);

31 Identifying Delirium : CAM- ICU (Confusion Assessment Method ICU) Acute Change or Fluctuating Mental Status: Is there an acute change in mental status or did patient s mental status fluctuate in the last 24 hours? No No Delirium Yes Inattention Squeeze my hand when I say the letter A. Read the following sequence of letters SAVE A H-A-A-R-T (Error if no squeeze for letter A or squeeze if no A). Use pictures if letters cannot be used. 0 to 2 errors No Delirium >2 errors 31

32 RASS Score Different than Zero: Yes Delirium No Disorganized thinking Will a stone float on water? Are there fish in the sea? Does one pound weigh more than two? Can you use a hammer to pound a nail? Hold up this many fingers ( demonstrate two fingers) Now do the same thing with the other hand (do not demonstrate), or state add one more finger (if unable to move other arm) >1 error Delirium 0 or 1 errors No Delirium 32

33 Delirium - Treatment Once diagnosis made, search for underlying cause Be aware of occult and atypical presentation of disease in elderly Review all medications Detect occult alcohol, benzodiazepine, or other medications causing withdrawal use via interview with patient and family Review vital signs including orthostatics & oxygen saturation, correct dehydration or hypoxia 33

34 Delirium Treatment Routine lab testing should be individualized and initially limited to CBC, CMP Further testing as suggested by H&P and initial labs Eliminate all possible precipitating factors Implement delirium prevention measures (if already not in place) Enlist family support (educate family on delirium), we provide a delirium fact sheet 34

35 Delirium Treatment Routine lab testing should be individualized and initially limited to CBC, CMP Further testing as suggested by H&P and initial labs Eliminate all possible precipitating factors Implement delirium prevention measures (if already not in place) Enlist family support (educate family on delirium), we provide a delirium fact sheet 35

36 Pharmacist Role in Delirium Prevention and Treatment 36

37 Alternatives to Anticholinergics For : Spasms Allergies Incontinence Parkinson s Disease Insomnia Depression Psychosis Pain Nausea Common Alternatives: Lowest effective dose for shortest effective time Loratadine, Saline Nasal Spray If acute allergic reaction: Lowest effective dose for shortest effective time Fesoterodine, Darifenacin, Solifenacin, Trospium Selegiline, Dopamine agonists, Levodopa/carbidopa Non-pharmacological methods, ramelteon, melatonin Venlafaxine, Duloxetine, Sertraline, Mirtazapine, Buproprion, Atypical antipsychotics Acetaminophen, appropriately doses Opioids, For Neuropathic pain:gabapentin, Pregabalin, Lidoderm Patch, Capsacian cream, Methadone? Ondansetron; Use lowest effective dose for shortest effective time 37

38 Pharmacist Follow-up for Positive Delirium Screen Verify that home medications are continued or are appropriately weaned to prevent withdrawal Common meds causing withdrawal Benzos try find out how much prn usage Barbiturates including Fioricet or Fiorinal Muscle relaxants meprobamate Gabapentin Verify that alcohol withdrawal orders are started if appropriate Limit anticholinergic use-avoid highly anticholinergic medications Check that infections are being treated optimally Insure electrolyte abnormalities are corrected Adequately treat pain Insure correct choice and dosing of opioids in opioid naïve patients 38

39 39 Med-Surg Delirium Order Set

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42 42 ICU Delirium Order Set

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48 48 Nursing Delirium Order Set

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