nicheprogram.org 16th Annual NICHE Conference Forging New Paths and Partnerships 1

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1 Improving Patient Outcomes in Geriatric Post-Operative Orthopedic Patients: Translating Research into Practice Tripping into The CAM Presented by: Diana LaBumbard, RN, MSN, ACNP/GNP-BC, CWOCN Denise Williams, RN-C Why worry about delirium in post-operative orthopedic patients? Delirium is found on general or specialty medical and surgical units. The highest incidence seen in post-operative patients undergoing cardiac or orthopedic surgery. Delirium during hospitalization is associated with increased morbidity and mortality, nursing home placement, and readmission, as well as costly prolonged hospitalizations. There is also evidence that delirium during hospitalization can prognosticate death for up to 12 months. 2 Pavilion Orthopedic Specialty Unit 1

2 Try This: Best Practices in Nursing Care to Older Adults Issue Number 13, Revised 2007 The Confusion Assessment Method (CAM) 2

3 THE CAM Included in the Detroit Medical Center s electronic medical record (EMR) is the short version of the CAM. The CAM was integrated t into the EMR because evidence supports that it is a standardized tool for non-psychiatrically trained clinicians to identify delirium quickly and accurately. The short CAM uses 4 features that were found to have the greatest reliability to distinguish delirium from other types of cognitive dysfunction. CAM: the clinician assesses for the presence or absence of delirium. Four features assessed: 1. Mental status altered from baseline (acute onset or fluctuating) 2. Inattention (lack of attention) 3. Disorganized thinking (A failure to be able to "think straight." Thoughts may come and go rapidly. The person may not be able to concentrate on one thought for very long and may be easily distracted, unable to focus attention. ) 4. Altered level of consciousness The diagnosis of delirium by CAM requires the presence of 1 and 2 and either 3 or 4. Pre-test Administration Staff RN s were given a 6 item pre-test to assess their knowledge of delirium assessment prior to self-learning l module administration. 20 pre-tests were returned 3

4 All of the items below put patients at risk for delirium except: older age, dementia, infection, severe illness. (1) older age with multiple co-morbidities, dehydration, and psychotropic medication use. older age, alcoholism, vision impairment, and fractures. (2) older age, dementia, and use of beta blockers. (15) (1): NO RESPONSE How often do you use the Confusion Assessment Method [CAM] to screen your patients for delirium? Never (11) Sometimes (2) Only on patients over the age of 65. (5) Always for every patient. (1) How often should patients be assessed using the CAM? Just once upon admission. Every shift. (16) On admission and then every 4 hours. On admission, after any procedures, and then every 4 hours. (3) Delirium Assessment Pre-Test STAFF RN RESPONSES Delirium occurs in 25-60% of older hospitalized patients, and is associated with increase risk of nursing home placement, costs, length of stay, mortality rates, functional decline of the individual, and increase use of chemical and physical restraints. True (19) False The CAM is a standardized di d method to enable clinicians to identify delirium quickly and accurately and is located in the electronic medical record [EMR] in the following assessments: The Adult Admission assessment on the neurological system assessment.(3) The Adult Admission assessment and Ongoing Assessment under the Geriatric Assessment it is the C [confusion] in SPICES.(9) It is not located in EMR. (1) The Adult Admission and Ongoing Assessments under Geriatric assessment. (4) (2): NO RESPONSE Training to administer and score the CAM is necessary to obtain valid results? True (18) False (1) Training to administer and score the CAM is necessary to obtain valid results. 24 RN s on the Post-operative orthopedic unit were instructed to read Issue Number 13 and then view the video available on: A PowerPoint presentation was available with step by step instructions RN s were given post-test after completing the module. So What? After the educational module the staff nurses knew where The CAM was located in the EMR and they understood that; The CAM is a standardized method that enables clinicians to identify delirium quickly and accurately. 4

5 Post-Test Results 20 tests returned Question #5 previously answered correctly by only (9) RN s on the pre-test was answered correctly by (19) on post-test. Increase in clinician knowledge from 47% to 95%. Take Away from our TRIP Because our hospitalized patient population is aging there is an escalation in the prevalence of delirium. Postoperative orthopedic patients are at an exponentially increased risk for delirium. The CAM (short version) is a reliable and valid tool that enables trained clinicians to identify delirium quickly and accurately and once identified warrants prompt intervention. Tripping toward a practice change. 5

6 Positive CAM the RN must intervene The Professional Nurse Council Present the outcomes at monthly meeting and utilize shared governance to decide on plan to educate and integrate use of The CAM in all patient care areas. Work with interdisciplinary team (e.g. NICHE Steering Council, Interdisciplinary Rounds, Unit Practice Councils to develop Delirium Protocols. PAT developing research study to utilize The Telephone Interview for Cognitive Status (TICS) for preoperative patients. Patient at Risk? Side Effects Elderly CNS Disorder Medication General Anesthesia Psychiatric Disorder Uncontrolled Pain Acute Metabolic Disorder Dementia/Delirium Lack of Muscle Control Sensory Impairment Psychosocial Stressors Use of Mattress Overlay Sleep Disturbance Confusion/Disorientation Patient Size (very large or very small) Hypoxia Behavior History Fecal Impaction Restlessness Increased fall risk score Urinary Retention, Incontinence, Frequency Desire for independence Yes Post partum Initiate Prevention Strategies Orient to surroundings/routine Visual supervision Yes Refocus attention Avoid loud noise confusion Actual/Potential Harmful Behaviors? Provide reassurance Remove sources of agitation Evaluate medications Limit setting Address fluid, nutrition, oxygen needs Define Actual/Potential Harmful Behaviors Attend to pain, relief/comfort measures (use least restrictive interventions whenever possible) Patient/family education General Interventions Involve family in staying with patient; bring in objects, music and other diversional activities Approach calmly Provide night light Orient patient, verbal reminders Address by preferred name Assign consistent caregivers Provide quiet or family provided music Develop scheduled care routine Consider selective anti-anxiety medication Provide uninterrupted sleep Schedule toileting attendance at all times Monitor for Changes No Continue Prevention Strategies Wandering Climbing Reorient Reorient Place in room Place in room near near station station Engage in Check frequently activity Offer toileting every 2 Schedule hours ambulation Physical identification Check frequently of patient at risk Physical identification of patient at risk Yes Continue Current Strategies Pulling at Tubes/ Restlessness Dressings Identify and remove Assess for potential d/c irritations of tubes Place in room near Check frequently station Secure tape Offer toileting every 2 Consider occlusive hours dressing, Kling Provide comfort items wrap/stockinette, Provide reassurance abdominal binder, mesh Schedule ambulation panties Physical identification of patient at risk Interventions successful? Aggression Avoid confrontation Approach calmly Allow ventilation Schedule ambulation Provide quite environment Provide quiet music Consider selective psychotropics No Homicide/ Suicide/ Elopement Confined, quiet environment Sitter Calm approach Caring atmosphere Avoid Consult Physician/LIP Consider confrontation use of restraint (least restrictive device) Vest/Posey Enclosure bed Soft limb Lock belt Hard leather Reverse safety belt Mitts 6