(inter professional prevention of delirium) Can Delirium be Prevented in the ED?

Transcription

1 (inter professional prevention of delirium) Can Delirium be Prevented in the ED? Jacques S. Lee MD, MSc, FRCPC

2 Learning Objectives At the end of the session, better understand: Why preventing delirium, in the ED, is important That delirium is acute brain failure Evidence supporting the effectiveness of delirium prevention Implementing delirium prevention in YOUR ED

3 What are my qualifications? 1) Knows how to read 2) Knows where the library is Where facts are few, experts are many. Donald R. Gannon

4 Executive Summary Can Delirium be Prevented in the ED? Yes

5 Why was New Years 2011 special? Hint: VE Day May 9 th, 1945 First Baby Boomer born Jan 1 st, =?

6 Why is Preventing ED Delirium Important?

7 Why is Preventing Delirium Important? Compression of Morbidity Need to keep the population healthier, longer Jared Timmerman, Masters Class Swimmer at 100 Sets new world records

8 All the News That You Knew Already The Obvious Times If It Ain t Obvious, It Ain t Here Doctors: Older people do better if we don t make them worse Full Storey Page 2 New York - According to Scientists Bob Loblaw, Bob Loblaw,& Bob Loblaw, by avoiding things known to make you worse, you can prevent becoming worse. This remarkable finding was recently published in the reputed to be reputable Medical Journal, NEJM (New Estonian Journal of Maladies). This stunning revelation was added to a litany of similar findings coming to light on a similar theme: running with scissors is indeed dangerous, drinking extremely hot coffee can cause intra-oral burns, and public-private partnerships have not saved money in any country they have been tried, because they to make a profit somehow. Furthermore, Bob Loblaw, Bob Loblaw, & Bob Loblaw added, by saying the same thing over and over again, eventually it becomes accepted as a proven fact. Furthermore, Bob Loblaw, Bob Loblaw,& Bob Loblaw added, by saying the same thing over and over again, eventually it becomes accepted as a proven fact. By saying the same thing over and over again, eventually it becomes accepted as a proven fact. By saying the same thing over and over again, eventually it becomes accepted as a proven fact. By saying the same thing over and over again, eventually it becomes accepted as a proven fact. According to Bob Loblaw, Bob Loblaw,& Bob Loblaw, by avoiding things known to make you worse, you can prevent becoming worse. This remarkable finding was recently published in the reputed to be reputable Medical Journal, NEJM (New Estonian Journal of Maladies). According to Bob Loblaw, Bob Loblaw,& Bob Loblaw, by avoiding things known to make you worse, you can prevent becoming worse. This remarkable finding was recently published in the reputed to be reputable Medical Journal, NEJM (New Estonian Journal of Maladies).

9 What is Delirium? = Acute Brain Failure

10 Why is ED Delirium Important? Delirium is COMMON - 1% in community % in ED - up to 60% at Discharge Delirium is LETHAL 1 year Mortality % Delirium is NOT ALWAYS REVERSIBLE (6-12 months to return to baseline) ED LOS > 12h= Delirium risk increased 2x!

11 Why Focus on Delirium in the ED? Little evidence that once delirium happens that you can shorten or reverse it Longer ED stays = More opportunity for delirium Many cases of ward or post-op delirium may have started in ED

12 Why Focus on Delirium in the ED? Because delirium is PREVENTABLE Inouye et al. Hospital Elder Life Program (HELP) 9

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14 Why Prevent Delirium in the ED? 852 patients 70 years of age or older Randomized to Tx. ward vs. usual care Delirium in Treatment Group: 9.9% Delirium in Control Group: 15% 50% Relative Reduction Streptokinase 1% 10% RR TPA 0.9%

15 Why Prevent Delirium in the ED? Duration Delirium Control: 161 Days Duration Intervention Group: 105 Days = 56 days ( >2 months) per patient!! (have we got your attention now?) Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM Jr. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med Mar 4;340(9):

16 Executive Summary Details Can Delirium be Prevented in the ED? It worked in other settings, so it should work in the ED

17 HELP Components Staff Education Hospital Elder Life Clinical Specialist ( FTE) Volunteer Coordinator Volunteers 25 to 40 Extensive Documentation requirement Now public domain, before $10k fee

18 HELP Program Practice Change: Target Low-Hanging Fruit 1) Immobility 2) Communication / Orientation 3) Restraints & Catheter use 4) Medications 5) Dehydration

19 IPPOD: What we did Developed Interactive workshops Sought feedback from staff on how to adapt HELP for use in ED Educated staff on why preventing delirium is important Created buy-in, allowed users input Focused on what WE control

20 Approach to Changing Practice Based on Kirkpatrick Pyramid: Impact learners Reaction / Attitude Transfer Knowledge Change Behaviour Improve patient outcomes!

21 IPPOD Components Staff Educational Resources - IPPOD Manual - IPPOD Videos - e-learning Module Mandatory part of orientation for new staff Increased Meals / Access to fluids VIP - Volunteer IPPOD Program Next Session: Nov 30th

22 Volunteer IPPOD Program: VIP VIP Components: Training Package Coordinating VIP volunteers assumed by existing acute-care coordinator Replaced Clinical Specialist with information system & interaction with the clinical team to identify patients Data tracking

23 Why Focus on MOBILITY? Mobility is an essential life-skill, but it can be easily compromised by even brief periods of immobilization It is estimated that every day of immobility results in a 5% loss of muscle mass

24 VIP Components VIP Delirium Prevention IPPOD Staff Training

25 Results: Staff Education Post Test mean Pre Test Mean P value Recognize Delirium < Assess Delirium < Identify Cause < Use Interventions < 0.001

26 Results: VIP Impact on Practice Oct - April, 2011 screened over 1416 ptnts. 760 Eligible for Volunteer IPPOD Program Volunteers provided water or just had a chat with over 95% of subjects 353 Patients ambulated with Volunteers (46%)

27 Results: Impact on Delirium IPPOD 1.0 IPPOD 2.0

28 Next Steps Participate in PSI Grant Application? (June 1 st!) Measure Baseline delirium rate at NYG Develop role-out model Customize educational package Introduce trained volunteers?

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30 References 1. Statistics Canada. Population projections for Canada, provinces and territories, Ottawa: Supply and Services Canada, 1990; Cat Evans, R. G., K. M. McGrail, et al. (2001). "Apocalypse no: Population aging and the future of health care systems." Can J Aging 20(Suppl. 1): Rueben, D., K. Herr, et al. (2006). Introduction. New York, The American Geriatrics Society. 4. Lipowski Z. Delirium (Acute confusional states). JAMA, 1987;258: Taylor D, Lewis S. Delirium. J Neurol Neurosurg Psych, 1993;56: Gaudreau JD, Gagnon P. Psychotogenic drugs and delirium pathogenesis: the central role of the thalamus. Med Hypotheses. 2005;64(3): Inouye SK, Viscoli CM, Horwitz RI, Hurst LD, Tinetti ME. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Int Med Sep 15;119(6): Inouye SK, Baker DI, Fugal P, Bradley EH; for the HELP Dissemination Project. J Am Geriatr Soc Oct;54(10): Dissemination of the hospital elder life program: implementation, adaptation, and successes. 9. Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM Jr. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med Mar 4;340(9):

31 References 10. Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC. Unrecognized delirium in ED geriatric patients. Am J Emerg Med Mar;13(2): Elie M, Rousseau F, Cole M, Primeau F, McCusker J, Bellavance F. Prevalence and detection of delirium in elderly emergency department patients. CMAJ, 2000;163: Hustey FM, Meldon SW, Smith MD, Lex CK. The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med. 2003;41(5): Kakuma R, du Fort GG, Arsenault L, Perrault A, Platt RW, Monette J, MorideY, Wolfson C. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc. 2003;51(4): Liptzin, B. and S. E. Levkoff (1992). "An empirical study of delirium subtypes." Br J Psychiatry 161: Singal BM, Hedges JR, Rousseau EW, Sanders AB, Berstein E, McNamara RM, Hogan TM. Geriatric patient emergency visits. Part I: Comparison of visits by geriatric and younger patients. Ann Emerg Med ;21(7): McConnel CE, Wilson RW. The demand for prehospital emergency services in an aging society. Soc Sci Med. Apr 1998;46(8): Grief CL. Patterns of ED use and perceptions of the elderly regarding their emergency care: a synthesis of recent research. J Emerg Nurs. Apr 2003;29(2):

32 Additional Reading Alagiakrishnan K, Wiens CA. An approach to drug induced delirium in the elderly.postgrad Med J Jul;80(945): Gaudreau JD, Gagnon P. Psychotogenic drugs and delirium pathogenesis: the central role of the thalamus. Med Hypotheses. 2005;64(3): Weber JB, Coverdale JH, Kunik ME. Delirium: current trends in prevention and treatment. Int Med J 2004;34: Cole MG, McCusker J, Bellavance F, Primeau FJ, Bailey RF, Bonnycastle MJ, Laplante J. Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. Cmaj 2002;167(7): McCusker J,Cole M, Abrhamowicz M, Han L, Poboda JE, Ramman-Haddad L. Environmental risk factors for delirium in Hospitalized older people. J Am Ger Soc, 2001;49: Duggleby W, Lander J. Cognitive status and postoperative pain: older adults. J Pain Symptom Manage 1994;9:19-27.

33 Additional Reading Tune LE. Anticholinergic effects of medication in elderly patients. J Clin Psychiatry 2001;62 Suppl 21:11-4. Folstein M, Bassett S, Romanoki A, et al. The epidemiology of delirium in the community: the Eastern Baltimore mental health survey. Int Psychogeriatrics, 1991;3:169. Naughton BJ, Moran MB, Kadah H, Heman-Ackah Y, Longano J. Delirium and other cognitive impairment in older adults in an emergency department. Ann Emerg Med Jun;25(6):751-5.

34 Additional Reading Kakuma R, du Fort GG, Arsenault L, Perrault A, Platt RW, Monette J, MorideY, Wolfson C. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc. 2003;51(4): Morrison RS, Magaziner J, Gilbert M, Koval KJ, McLaughlin MA, Orosz G, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003;58: Lynch EP, Lazor MA, Gellis JE, Orav J, Goldman L, Marcantonio ER. The impact of postoperative pain on the development of postoperative delirium. Anesth Analg 1998;86:781-5.

35 Preventing Delirium Compliance matters! Inouye, S. K., S. T. Bogardus, Jr., et al. (2003). "The role of adherence on the effectiveness of nonpharmacologic interventions: evidence from the delirium prevention trial." Arch Intern Med 163(8): Delirium Rate by Adherence Adherence Orientation Mobility Low (< 75%) 12/51 (24%) 19/135 (14%) Medium (75 90%) 9/68 (13%) 20/197 (10%) High (> 90%) 21/303 (7%) 3/90 (3%)

36 IPPOD Components: Standardized Order sets - NPO requires an order plus IV replacement fluids Patient & Family Brochure