Inpatient Delirium Management: A Quality Improvement Project for Hospitalized Veterans

Transcription

1 Inpatient Delirium Management: A Quality Improvement Project for Hospitalized Veterans IIndiana Nursing Summit November 5, 2018 Veteran Health Indiana

2 At the conclusion of this presentation, participants will be able to: Identify impact of delirium on hospitalized patients. Discuss screening for delirium Identify treatment modalities for acute care. Discuss impact of delirium management.

3 There is no consistent process for proactively identifying and addressing delirium in the Medical-Surgical areas. Increased calls (Rapid Response and Code Orange) r/t delirium on Med-Surg units (7N & 7S) Providers met to discuss interventions and medical management Delirium Team convened

4 Led by Evidence-Based Practice (EBP) APNs Anna Bober Earlie Hale Alex Radovanovich Candace Whittler-Ducre Jo Lee Coleman Jason McClara Heather Nixon Celine Alba-Patino Rebecca Parks Sara Clay Shelly Keiser Tamra Pierce Dr. Cathy Schubert Dr. Eric Boss Dr. Maria Poor

5 Gather and review baseline data Discuss delirium screening options for use in medical surgical patients Review components of Delirium Management in ICU areas Discuss need for aids (restraint alternatives, delirium kit, etc.) Discuss implementation of trial on key units: 2 medical units were chosen

6 Restraints Falls psychotropic medication use consults code orange incidents

7 Type of restraint: vest, mitts, soft wrist, enclosure bed Number of Patients in Restraints (FY16Q2-FY17Q2) 7N=54 7S= FY16Q2 FY16Q3 FY16Q4 FY17Q1 FY17Q2 7N 7S (Jan 2016-March 2017)

8 DAYS Average Number of Days in Restraints (FY16Q2-FY17Q2) Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 7 A North 7 A South

9 Fall Rate Fall Rate North Fall Rate Oct-15Nov-15Dec-15 Jan-16 Feb-16Mar-16Apr-16May-16Jun-16 Jul-16 Aug-16Sep-16Oct-16Nov-16Dec-16 Jan-17 Feb-17Mar-17 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Inpatient Monthly Fall Rate South Fall Rate Oct-15Nov-15Dec-15 Jan-16 Feb-16Mar-16Apr-16May-16Jun-16 Jul-16 Aug-16Sep-16 Oct-16Nov-16Dec-16 Jan-17 Feb-17Mar-17 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Inpatient Monthly Fall Rate

10 Antipsychotic Use among Restrained Patients Majority of patients were treated appropriately Providers had ordered PRN medication but very few doses were ever administered (despite the fact that most of the doses were charted as effective when given) Medications were potentially underutilized in some patients that were severely agitated. *Haldol IV Push not approved for use on medical surgical units at the time

11 Inpatient Geriatric Consults 2016 Month Hospital 7 North 7 South January February March April May June July August September October November December Total

12 FY16: 25 Delirium-related incidents 19 out of 25 incidents involved physical and verbally disruptive behavior Area 7 North 10 7 South 10 8 North 2 8 South 1 ED 1 Other 1 # of Incidents

13 Gaps Lack of protocol Inconsistent medical management by Providers Inconsistent follow-up Inconsistent nursing care interventions Communication

14 Action Development of a protocol to standardize the process (screening and order set) Vet trial plan to Nursing Documentation, Acute Care, Nurse Executive and Clinical Practice Committees Provider, Pharmacy and Nursing Staff education about the trial Trial the process on 7N & 7S Request report that shows patients with positive screen Purpose/Outcome Standardize identification of patients with delirium and management of symptoms Approval and additional feedback from all disciplines Consistent information provided to promote successful trial Test and identify additional improvements on the protocol before full implementation Efficient way to track patients for just in time review during trial

15 Literature review Delirium Screening and Order Set Query to other VA hospitals and local area hospitals Review of MICU Delirium Protocol Development of Medical-Surgical Delirium Protocol Mirror MICU except Haldol PO or IM instead of IV Obtaining permission from the author to use Short CAM (Confusion Assessment Method) screening tool Development of the Short CAM into a CPRS template note (Delirium Screening Note)

16 Face-to-face training (2 weeks) CPRS documentation of nursing screening and assessment Order set Nurses were slotted into 30-minute scheduled blocks with nurse manager input Pre and post-test administered 6-item questionnaire Assess knowledge of common signs & symptoms of delirium, risk factors, interventions, and nurse comfort level related to assessing patients for delirium

17 Delirium Protocol Trial Education Delirium Protocol trial on 7N & 7S is from April 11-May 11, Background: Increased calls (code oranges, rapid response calls) related to patients experiencing delirium on medical surgical units. Goal: Early identification of delirium and implementation of interventions. An ounce of prevention is worth a pound of cure. Protocol includes Order Set, screening for delirium, and appropriate interventions Order Set: Built in CPRS very similar to MICU order set pathway: Same medications, different route. Differences: 1) Order for Inpatient Geriatric Consult for (Age 65 or Older) link included on menu, 2) Different routes (PO or IM). IV Haldol for MICU/SICU only 3) note to contact pharmacy for medication review 2 PO OR IM Haloperidol 1 3

18 RN will screen patient on admission and every shift and as needed when there is a change in mental status using the Delirium screening Note. Provider will be notified of a positive screen so that the Delirium Order Set can be initiated. Nursing staff will implement appropriate interventions to manage symptoms.

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20 Delirium Screening: Types: ICUs use ICU CAM in Essentris while Med-Surg use the Short CAM in CPRS Who completes and when: by RN on admission and every shift and as needed when there is a change in pt. mental status. Location of note: Essentris, Nursing Admission, Nursing 24 Hour Flow Sheet & stand alone note. Includes documentation of patient behaviors

21 Care Plan Documentation In CPRS, use the care plan titled, Cognitive Function Altered for any disease or condition with altered cognitive function (e.g. delirium, dementia, TBI, electrolyte imbalance, etc.)

22 Definition of Delirium Types of Delirium Possible Causes of Delirium Negative Impact of Delirium Importance of Recognizing Delirium Managing Behavioral and Psychological Symptoms and Communication Techniques

23 Focus on: Awareness of risk factors for delirium (alcohol withdrawal, pain, post-procedure, delirium superimposed on dementia, etc.) Considering restraint alternatives prior to restraints Least restrictive restraint Encouraging consults (Geriatric, Pharmacy review of medications, etc.) Importance of reassessment

24 Questionnaires completed from 7/24/17-8/3/17 Multiple Choice and Tor F questions: Pre-test average score (N=46) was 72% Post-test average score (N=46) was 82%

25 I am comfortable assessing my patients for delirium. Response PRE-TEST POST-TEST Strongly Disagree 4 4 Disagree 2 1 Neutral 21 4 Agree Strongly Agree 5 13 Total 46 46

26 Monitor completion of delirium screening Daily review of reminder report Feedback to individual staff and manager (absence of screening, incorrect screening, etc.) Monitor patients in restraints and with sitters Be a resource for all staff and to reinforce education Collect data

27 # of Patients in Restraints Total # of Days in Restraints Ave. # of Days in Restraints # of Patients on 4- Way Restraints 7 North 7 South April May April May Geriatric Consults Falls Code Orange

28 Summary of Patients with Positive Screen More patients became positive during stay Protocol ordered more for patients on 7 North Focused chart audit revealed that there were no negative outcomes for patients not on protocol 1 patient received CIWA Protocol meds and no delirium protocol meds 100% 80% 60% 40% 20% Positive Screens (7N & 7S) n=16 0% Positive on Admission Positive During Stay Protocol ordered Protocol Meds 7North 7South

29 Medication Use During Trial Medications ordered for all patients who screened positive except 1 patient. Quetiapine and Trazadone ordered most often. Haldol 1 time only doses noted. 1 patient did not receive scheduled medications. Pt. escalated and code orange called. Restraints for short period of time

30 Barriers that were addressed: Providers (Moonlighters) not aware of the protocol, some reluctant to order protocol Protocol not ordered with positive screen Pts. Transferred with ICU Delirium Protocol delay in order reconciliation Delay in re-screening patients with a change in patient condition Inconsistent completion of the screening.

31 Positive Outcomes Nurses empowered to advocate for patients Increased effective communication with providers Increased use in restraint alternatives and fall prevention interventions. Delirium care education elevated the practice level of the nurses

32 # OF PATIENTS Number of Patients in Restraints (FY17Q3-FY18Q2) N=27 7S= FY17Q3 FY17Q4 FY18Q1 FY18Q2 7N S

33 DAYS Ave. Number of Days (FY17Q3-FY18Q2) Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 7 A North 7 A South

34 Fall Rate Fall Rate North Fall Rate May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Inpatient Monthly Fall Rate South Fall Rate May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Inpatient Monthly Fall Rate

35 Inpatient Geriatric Consults 2017 Month Hospital 7 North 7 South January February March April May June July August September October November December Total

36 Code Oranges FY17 Total Code Oranges 22 Delirium-related incidents 10 out of 22 incidents involved physical and verbally disruptive behavior (compared to 19 out of 25 pre-trial) Area 7 North 11 7 South 10 # of Incidents

37 Haldol IV Push in Non-ICU areas Discussion: Black Box warning: 9/2007 FDA advisory was published and updated 08/14/2013 Risk of QT prolongation and Torsades de Pointes (TdP) especially when given IV Due to the risks, ECG monitoring is recommended if haloperidol is given IV Statement on vial, IM Use Only

38 Query Question Results VA (Pharmacy) If Haldol IV was given at their facility 43 responses 38 yes (require telemetry) 5 no Indianapolis (Nursing) If Haldol IV given on medical surgical units 5 Hospital Systems Can administer Haldol on medical surgical units based on specific patient need

39 Approval for Haldol IV Push to be given on Medical-Surgical units. Combine ICU and Med-Surgical units protocols into one Recommendations for Provider to order EKG prior to Haldol use Delirium Nursing Interventions automatic on all patients

40 Go-Live August 14 th, 2017 Order sets (Med-Surg & ICU) combined into one Face-to-Face training for RN staff on 8North, 8South, and 4 West (two-week training schedule) Pharmacy and Provider Education Nursing Documentation changes to ensure restraint alternative and/or mobility can be documented by RN, LPN, HT, and CNA.

41 Action Development of TMS modules for orientation (RN & unlicensed nursing staff [LPN, HT, NA]) Development of MCM Face-to-Face Training for unlicensed nursing staff Delirium toolkit Monitoring & data analysis Status Completed Completed pending Pending Ongoing

42 Toolkit planning-difficult endeavor Patient scenarios were powerful tool as they included actual patients Pre and post test administration challenges CIWA Protocol and Delirium Protocol-which one to use

43 Reduced Restraint Use Significant decrease of 4-point restraint use Falls trended down Reduction of code oranges related to delirium/dementia Increased awareness of geriatric consult availability Standardized medication management of patients with delirium Improved comfort level and ability of nurses to screen for delirium and provide care

44 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Goldstein, N. & Morrison, R. (2013). Evidence-based practice of palliative medicine. Elsevier Saunders: Philadelphia Inouye S. K. (2006). Delirium in older persons. New England Journal of Medicine, 354:1157e1165. Veterans Health Administration. (2014). Interdisciplinary Delirium Resource Team Manual VISN 10. Cleveland, OH: Geriatric Research Education and Clinical Center. McConnell, S. & Karel, M. (2016). Improving management of behavioral and psychological symptoms of dementia in acute care. Nursing Administration Quarterly, 40 (3), Solberg, M., Plummer, C., May K. & Mion, L. (2013). A quality improvement program to increase nurses detection of delirium on an acute medical unit. Geriatric Nursing, 34,

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