Improving Delirium Management: Mapping Out One Unit s Journey. Geriatrics Institute June 27, 2013

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1 Improving Delirium Management: Mapping Out One Unit s Journey Geriatrics Institute June 27, 2013 Rebecca Ramsden, NP Mary Ann Hamelin, CNS Susanne Loay, RN

2 Objectives Background RNAO Best Practice Guideline Implementation

3 RNAO Best Practice Spotlight Organization (BPSO) MSH 2012/13 commitment - 4 BPGs Purpose: enhance the uptake of best practice guidelines (BPG s) across health care organizations enable excellence in practice and positive patient outcomes Acute Care for Elders Unit Delirium BPG

4 Delirium BPG MSH Delirium Program RNAO BPG implementation part of a larger organizational focus Safe patient/safe staff initiative Geriatric committee/ace staff skill development BPG spread across hospital Ultimate goal is to incidence and duration of delirium Detection Prevention Management

5 Implementation of Delirium BPG Documentation of baseline Cognition and function Detection Identify those at high risk Implement prevention strategies Prevention Implement Management strategies Hypo/hyper/mixed Management

6 Why is this important? Delirium is associated with -high mortality and morbidity rates -increased length of hospital stay -intensive nursing care -impact on health care costs

7 How Did We Implement RNAO BPG? Formed Interdisciplinary Delirium Champions Group (RNs, SW, OT, PT, CNS, NP and NUA)

8 Identified Current gaps Under detection of delirium Limitations to current kardex Under documentation of patient baseline information Inconsistency with use of CAM tool Delirium care plan failed to address specific care strategies

9 Prioritized Quality Initiatives Confusion Assessment Method (CAM) Education Baseline Form CAM positive algorithm CAM positive alert in Kardex Delirium Management Care Plans Delirium Risk Assessment Tool

10 Detection: Confusion Assessment Method (CAM) Education Identified current challenges with use of the tool Poor baseline information Fluctuating nature of delirium complicates detection Inconsistency between CAM score and other documentation about pt behaviour

11 Detection: Action Goal: Improve accuracy of CAM to help early identification of patients (>65 years old) at highest risk of delirium Knowledge is power! CAM Positive alert in Kardex

12 Detection: Baseline Collection Tool Current Issues: Data collection by multiple people and documented in multiple places Different interpretation of what baseline meant - Not collected routinely & importance undervalued No standardized tool Various people had different information Goal: Prevent functional and cognitive decline Facilitate early and safe discharge planning Recognize changes early

13 Detection: Action Developed and piloted an Interdisciplinary Patient Baseline Collection Form Access is on kardex Established what baseline meant Working group provided one-on-one coaching for all ACE staff Daily tracking of completion Daily discussion at Huddles

14 Prevention: Risk factors & prevention strategies for delirium reviewed in workshop Encourage implementing related care plans More work to be done on this portion of the delirium program

15 Delirium Management Current care plan Did not differentiate between hypoactive/hyperactive delirium Strategies were vague and not patient specific Lack of specific tools/supports for management of pts with delirium

16 Management: Action Redeveloped care plans to address hypoactive and hyperactive delirium Goals: Hypoactive delirium: provide stimulation & normalize routine Hyperactive delirium: address underlying triggers, ensure safety, and decrease overstimulation One on one coaching to explain/encourage use of tools

17 Management: Delirium Algorithm

18 Management of Acute Agitation of Delirium in the Elderly

19 Note: The information in this handout is intended as a guideline only. All patient care orders must be approved by the Most Responsible Physician / Medical or Surgical Team. Side Effects of Antipsychotics 1 All antipsychotics can lead to prolonged QT so baseline ECG and regular ECG monitoring is advised for extended use All antipsychotics, especially haloperidol and risperidone can contribute to EPS 2 All antipsychotics can contribute to increased risk of seizure, so lower doses and caution should be used in patients with seizure history Quetiapine is more sedating than haloperidol or risperidone 1. Antipsychotics include haloperidol, risperidone and quetiapine 2. EPS = extrapyramidal symptoms, which include tremor, dystonia, Parkinsonism Non-Pharmacologic Management of Delirium Language and sensory barriers can worsen behaviour: Ensure patients have glasses, hearing aids and appropriate interpretation Attend to unmet needs and common medical problems (toileting, food/drink, pain, shortness of breath, etc.) If patient becomes agitated with care - stop - ensure patient is safe and approach at a later time Promote Orientation: Orient the patient every shift to place and time, encourage family presence, provide window bed, avoid unnecessary room changes Promote sleep at night-time: When possible, group medication administration and procedure times to allow for uninterrupted sleep, provide warm blanket, and ensure dark and quiet environment with minimal interruptions. Last revised: April 16, 2013

20 Results >75% completion of Baseline Collection Tool All staff received delirium education CAM completion rates consistency higher Earlier recognition of delirium More discussion about delirium, baseline status and management strategies Improved interdisciplinary collaboration Increase knowledge on appropriate medications Changed unit culture

21 What still needs to be done? Develop and implement a Delirium Risk Assessment Tool Develop and add changes to electronic Kardex Allied to have access to on-line form to complete CAM Improve audit results Rollout to other GIM units and then hospital wide Ensure sustainability of the various QIs

22 Thank you!