Delirium Prevention On a Medical Unit. By Melissa Knopper, BSN, RN, MS Porter Adventist Hospital November 2, 2018

Transcription

1 Delirium Prevention On a Medical Unit By Melissa Knopper, BSN, RN, MS Porter Adventist Hospital November 2, 2018

2 Background Delirium not well-studied on non-icu units. PICO: Can a medical unit decrease its overall delirium diagnosis rate by screening at-risk patients (age 65+) and using targeted nursing interventions to prevent its onset?

3 Definition Delirium is a sudden change in mental status associated with physical illness and related medications. A delirious patient may experience bouts of confusion, lethargy, agitation, or hallucinations alternating with periods of lucidity. (Center for Advancing Health) Patients can have hyperactive symptoms, such as hitting, pulling at lines, yelling. Or, hypoactive symptoms, such as increased confusion and acting more lethargic. Understanding their baseline mood and cognition is key.

4 Case study/video

5 Take-Home Message Increase awareness of non-icu delirium Spread delirium-prevention system to other units and hospitals.

6 Purpose of Pilot Project Prevent delirium Alleviate suffering and improve care Protect staff

7 Methods Literature search led to screening tool, Confusion Assessment Method (CAM) Tool use Staff education: video, individual instruction, info boards Tied to bedside rounding Created new pharmacy consult procedure

8 Key Risk Factors Age 65+ Dementia Sensory impairment Recent surgery/anesthesia High-risk medications; drug reactions Kidney impairment

9 Interventions If RN detects risk factors, screens with CAM tool Q shift. CNAs ambulate, feed/hydrate, put on glasses, reorient. Sleep/wake routines are key. RN discusses risk factors with MD during bedside rounds.

10 Defined Roles If RN gets positive CAM score, calls MD. MD searches for etiology, eliminates benzodiazepines and narcotics. If drug-related etiology, MD triggers pharmacy consult. Identified appropriate meds for sleep, pain and agitation.

11 Data: Pre/post-intervention Overall delirium diagnosis (DX) Falls/Restraints Length of stay (LOS) and 30-day re-admission Discharge to skilled nursing facility (SNF) vs. home Mortality

12 Results: 44% Decrease in Delirium DX #Patients 12 n=16 8 n=9 4 0 Delirium DX Baseline Post-data

13 Quality Improvement on Three Levels: 6 20% 5 50% # Patients 4 n=5 3 50% n=4 n=4 1 0 n=2 n=1 n=2 Restraints Readmit DC to SNF Baseline Post-data

14 Hypothesis testing Screening tool did decrease overall rate of delirium. Prevention did not affect falls, LOS, cost. Reasons?

15 Limitations Did we pick the best risk factors? Small sample size/duration; 3-month pilot Delirium diagnosis code challenges

16 Conclusions Prevention does work; we improved quality of care. Gathered valuable data: snapshot of typical delirium patient on a medical unit. Staff reports fewer behaviors, increased family satisfaction.

17 Next Steps Sharing education materials (already spread to: ER, med/surg, oncology and cardiac units) Possible approval of Centura-wide delirium clinical guideline. More family education, support from volunteers. Verify findings with a larger sample size from more than one hospital.

18 Helpful Links American Geriatric Society (Beers List): American Delirium Society: Hospital Elder Life Program (HELP): NICHE (Nurses Improving Care for Healthsystem Elders): ANA Delirium program: CAM tool handout: ELP%20Program%20CAM%20Flowsheet.pdf Educational Video. Delirium: A Patient s View :

19 Acknowledgements Thank you to: Vanessa Gardner, RN; Jocelyn Robinson, RN; Thuy Nyguen; Dmitri Cohen; Payam Khalighi, MD; and Connie Bassam, RN, CNS. My team, 5 East RNs and CNAs who made this project a success. Kryssy Enriquez, RN; Leigh Milhorn, RN; and the Porter Hospital NICHE Committee. Sue Ann Glusenkamp, RN; Jean Beckel, DNP, RN, MPH, CNML My family, Rose and Steve Knopper.

20 graphic Questions?

21 References Colwell, Janet. Quick screening tools may help hospitalists identify more patients at risk. ACP Hospitalist (2016). Retrieved from: Delirium Resource Web Page. UCSF. Delirious: Study Finds Simple, Humane Fixes for Aged, Disoriented Patients. Hospital Elder Life Program, Yale University School of Medicine (2015). Retrieved from: Hanlon, Joseph T., et al. Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug Disease Interactions in the Elderly Quality Measures (2015). Journal of the American Geriatrics Society (JAGS). Inouye, S.K., et al. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine Mar 4;340(9), pp Kiely, Dan, et al. Persistent Delirium Predicts Mortality (2009). Journal of the American Geriatrics Society Jan (57) 1: pp Patient Safety Network. In Conversation with Sharon K Inouye (2012). Retrieved from:

22 About the Presenter Melissa Knopper, RN, BSN, MS, has worked at Porter Adventist Hospital on the Medical Unit since she graduated from Regis University in She serves on the hospital s NICHE Committee, a magnet-status program for geriatric nursing. Melissa is a second-career nurse with 15 years of previous experience as a news reporter and science writer. She earned a master s degree from Columbia University in New York in 1991, and has written two books. Melissa covered medical conferences for Reuters and also wrote for the Robert Wood Johnson Foundation, CBS HealthWatch and the Chicago Tribune, among other publications. Contact: MelissaKnopper@Centura.org