nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 1

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1 Cognitive Behavior: Delirium The Impact of the Hospital Elder Life Program (HELP) on Patient, Operational, and Staff Outcomes Laura A. Shanks, MSN, MHA, RN-BC, ACNS-BC, NE-BC; Susan Heisey, MSW, LCSW, ASW-G April 15, 2015 Inova Mount Vernon Hospital Alexandria, VA 237-Bed Facility Acute Care Acute Inpatient Rehab Center Joint Replacement Inpatient Behavioral Health NICHE Designation December 2012 Hospital Elder Life Program (HELP) Helping to Maintain Cognitive, Physical, and Emotional Wellbeing in Hospitalized Older Patients Based on the Hospital Elder Life Program, 1999 Sharon K. Inouye, M.D., MPH 1

2 Copyright, Sharon K. Inouye, M.D., M.P.H. Delirium: Definition and Diagnosis Delirium is characterized by: Acute confusion, fluctuating mental status, inattention, disorganized thinking, altered level of consciousness Delirium is highly prevalent 14% - 56% of general hospital inpatients 13.2% % of surgical patients 11% - 87% of critically ill patients 30% - 40% of delirium cases are preventable Delirium is poorly diagnosed Missed in 32% to 67% of elderly hospitalized pts More than 25 terms in literature Balas, M. C., Rice, M., Chaperon, C., Smith, H., Disbot, M., & Fuchs, B. (2012). Management of delirium in critically ill older adults. Critical care nurse, 32(4), doi: Brooks, P. B. (2012). Post operative delirium in elderly patients. American journal of nursing, 112(9), Stall, N., & Wong, C. L. (2014). Five things to know about Hospital-acquired delirium in older adults. Canadian medical association journal, 186(1), E61. doi: /cmaj Complications of Hospitalization Hospitalization Precipitating Factors/ Medical Interventions Categories of Complications Rates Delirium 25-60% Functional decline 34-50% Adverse drug events 54% Operative complications 52% Diagnostic or therapeutic mishaps 31% Hospital infections 17% Physical injury/falls 15% Pressure sores 10% Pulmonary embolism 3% Complications Copyright, Sharon K. Inouye, M.D., M.P.H. 2

3 Hospital Elder Life Program Goals An innovative approach with the primary goals of: Maintaining physical and cognitive functioning throughout hospitalization Maximizing independence at discharge Assisting with the transition from hospital to home Preventing unplanned readmission Copyright, Sharon K. Inouye, M.D., M.P.H. KEY INTERVENTIONS OF THE PROGRAM Daily visitor program with structured cognitive orientation Therapeutic activities program Early mobilization Non-pharmacologic sleep control Hearing and vision protocol Feeding and fluid assistance Geriatric patient care education for unit nurses Copyright, Sharon K. Inouye, M.D., M.P.H. Hospital Elder Life Program Interventions Risk Factors Intervention Cognitive Impairment Vision/Hearing Impairment.. Immobilization... Psychoactive Medication Use Dehydration. Sleep Deprivation... Reality orientation Therapeutic Activities Program Vision/Hearing Aids Adaptive Equipment Early Mobilization Minimizing immobilizing equipment Non pharmacologic approaches to sleep/anxiety Restricted use of sleeping medications Early recognition Volume repletion Noise reduction strategies Sleep enhancement program 3

4 HOW ARE VOLUNTEERS UTILIZED? Volunteers attend 16 hours of classroom training, followed by precepted practice. They participate in periodic retraining and a formal quality assurance process. Volunteers are scheduled for 3-4 hour shifts, with 3 shifts/day or 21 per week. Each volunteer will work with 8-12 patients per shift, carrying out the interventions and documenting activities. Copyright, Sharon K. Inouye, M.D., M.P.H. JOANNE G. CRANTZ, MD GERIATRIC RESOURCE CENTER The Geriatric Resource Center is an innovative and interactive addition to the Inova Fairfax Hospital Health Sciences Library. The center provides valuable health care information to seniors and their caregivers and serves as a source for geriatric community resources Low-vision adaptive computer station Sight, Touch, Sound -Hands on assistive devices Community Education Programs Geriatric Resource Information Literature and Medicine Program Weekly Geriatric Consultation 4

5 Goals of The Impact of the Hospital Elder Life Program (HELP) on Patient, Operational, and Staff Outcomes 1. Determine if there is a difference in the incidence of delirium of patients age 70 and older who have and have not participated in HELP during their hospitalization. 2. Determine if there is a decrease in the number of sitter hours after implementation of HELP on the intervention nursing units. 3. Assess nursing staff perceptions of HELP. Inclusion Criteria Age 70 years and older At least one risk factor for cognitive or functional decline: Cognitive impairment-short Portable Mental Status Questionnaire (SPMSQ) tool with 2+ errors Any mobility or ADL impairment Dehydration-BUN/Cr ratio 18 Vision impairment >20/70 best corrected vision Hearing impairment <3 of 6 Whisper test Able to communicate verbally or in writing Copyright, Sharon K. Inouye, M.D., M.P.H. Exclusion Criteria Coma Mechanical ventilation Active delirium Aphasia (expressive and/or receptive) if communication ability severely impaired Terminal condition with comfort care only; death imminent Severe psychotic disorder Severe dementia Isolation Discharge firmly anticipated within 48 hours of admission Refusal by patient, family, or physician Non-English speaking patients Copyright, Sharon K. Inouye, M.D., M.P.H. 5

6 Study Design Study Type: A prospective, non-randomized, pre/post separate sample controlled study. Institutional Review Board approval was obtained prior to initiation of the study. Study Design: Subject Population: Patients: 70 years of age admitted to two intervention and control units (Pre n=28, Post n=77) Nursing Staff: Nurses and clinical technicians on the intervention and control units (Pre n=52, Post n=39) Study Procedure HELP program implemented on two intervention units with one control unit Pre- and Post-Intervention information was collected using the following methods HELP Program Survey to perceptions of the program (intervention units only) Confusion Assessment Method (CAM) instrument used twice daily to measure delirium Sitter hours to measure sitter hours used for patients > 70 years (Intervention and control units) Statistical Methodology Interval level pre-post measures of independent groups were evaluated using either an unpaired t-test or a Wilcoxon rank sum test, and categorical measures were evaluated using chi-square or Fisher s exact tests. Outcomes were reported as means with 95% CIs or as frequencies. Statistical significance was indicated by p<0.05 and all statistical analyses were performed using SAS software (v9.2, SAS Institute, Inc., Cary, NC). 6

7 Confusion Assessment Method (CAM) Concerns identified prior to start of study Documentation of CAM assessment in the Electronic Medical Record (EMR) Accuracy of CAM assessment Nurse knowledge regarding delirium identification CAM Documentation Changes Documentation changes made in EMR Standardization across system Automatic calculation to score CAM Mandatory completion of all fields within the CAM Implemented CAM and CAM-ICU CAM Assessment Accuracy CAM audits conducted CAM education provided System-wide education in Health Stream Unit based huddles and staff meetings One-on-one educational opportunities provided 7

8 Interventional Unit Staff Educational Modules Topics Hospital Elder Life Program (HELP) overview Age related changes in the older adult Delirium versus Dementia in the older adult Pain Management Sleep Fall prevention Interventional Unit Staff Educational Modules Methods PowerPoint slides with post tests Hard copy on units ed to all staff Handouts provided to staff One-to-one educational opportunities Try this series NICHE GRN modules Staff Meetings and Unit-based Huddle Discussions Posters on unit Patient and Family Education Unit-based posters HELP Brochure One-to-one conversations with patient and family members 8

9 Primary Outcome CAM results decreased from 7% delirium to 3% delirium (57% reduction) The findings were not statistically significant Trends indicated delirium reduction 8% 7% 6% 5% 4% 3% 2% 1% 0% Frequency of Positive CAM score (Pre & Post HELP) 7% Pre 3% Post 57% reduction Secondary Outcome: Sitter Hours Reduction in sitter total hours was 86.4 (51.7, 115.7), p< Total Sitter Hours - Intervention unit (Pre & Post Help) Pre Post hour reduction Secondary Outcome: Hospital Elder Life Program (HELP) nurse survey Statistical improvement in survey scores between preand post-intervention Staff provided positive feedback I hope the program will continue forever. RN Thank you for the program. It is going to be a great help for our elderly patients. Clinical Technician Nursing Survey Scores (Pre & Post Help) Pre Post 9

10 Study Limitations Convenience Sample Study conducted at one location Not matched pairs Lessons learned Ongoing training of nurses on accurate use of a delirium assessment tool Further study needed to assess nurses recognition of hypoactive delirium needed Ongoing nursing education needed Development of a delirium orderset Prevention Management Conclusions/Implications Improvement in patient outcomes Operational outcomes Increased staff awareness Increased HELP referrals and a greater understanding of the program. Expansion of the HELP throughout the hospital. Continuing nursing educational needs regarding delirium 10

11 Acknowledgements Marie T. Duffy, DNP, RN, FNP-BC, NEA-BC Mary Ann Friesen, PhD, RN, CPHQ; Kathy E. McNamara, MSN, RN-BC, NE-BC; Sara S. Phillippe DNP, MSHCA, BSN, RN, NE-BC; Michael J. Sheridan, ScD, FACE; Beverly Middle DNP, MSN, RN Ae-jin Jeannie Choi, BS Joseph Shuluk, NICHE Research Coordinator Confusion Assessment Method. 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113: Adapted with permission. 1999, Hospital Elder Life Program, LLC. References: Babine, R. L., Farrington, S., & Wierman, H. R. (2013). HELP prevent falls by preventing delirium. Nursing2013, Farrell, T. W., & Dosa, D. (2007). The Assessment and Management of Hypoactive Delirium. Medicine and Health Rhode Island, 90, 393. Hopkins, RO, Jackson, JC. Curr Opin Crit Care, 2006, 12: Hospital Life Elder Program. (2000). FAQs about the HELP program. Retrieved September 25, 2013, from The Hospital Life Elder Program: Inourye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Annals of Internal medicine, Inouye SK, AM J Med, 1994; 97: Inouye, S. K. (2004). A practical program for preventing delirium in hospitalized elderly patients. Cleveland Clinic journal of medicine, 71, Inouye, S. K., Bogardus, S. T., Baker, D. I., Leo-Summers, L., & Cooney, J. L. (2000). The Hospital Elder Life Program: A Model of Care to Prevent Cognitive and Functional Decline in Older Hospitalized Patients. Journal of American Geriatrics Society, References: Inouye, S. K., Viscoli, C. M., Horwitz, R. I., Hurst, L. D., & Tinetti, M. E. (1993). A Predictive Model for Delirium in Hospitalized Elderly Medical Patients Based on Admission Characteristics. American College of Physicians, McAiney, C., Patterson, C., Coker, E., & Pizzacalla, A. (2012). A Quality Assurance Study to Assess the One-Day Prevalence of Delirium in Elderly Hospitalized Patients. CANADIAN GERIATRICS JOURNAL, 2-7. NICHE GIAP. (2013, March 31). NICHE GIAP Result. Retrieved June 20, 2013, from NICHE GIAP Reports: US Hospitals: O'Keeffe, S. T., & Lavan, J. N. (1999). Clinical significance of delirium subtypes in older people. Age and Ageing, 28, Pandharipande P, et al; Curr Opin Crit Care, 2005, 11: Rausch, D. L., & Bjorklund, P. (2010). Decreasing the costs of constant observation. Journal Nursing Administration, Rosenbloom-Brunton, D. A., Henneman, E. A., & Inouye, S. K. (2010). Feasibility of Family Participation in a Delirium Prevention Program for Hospitalized Older Adults. Journal of Gerontological Nursing, Rubin, F. H., Neal, K., Fenlon, K., Hassan, S., & Inouye, S. H. (2011). Sustainability and Scalability of the Hospital Elder Life Program at a Community Hospital. Journal of the American Geriatrics Society,

12 References: Sandberg, O., Gustafson, Y., Brannstrom, B., & Bucht, G. (1999). Clinical profile of delirium in older patients. Journal of the American Geriatrics Society, 47, Sendelbach, S., & Finch-Guthrie, P. (2009). Evidence-Based Guideline Acute Confusion/Delirium: Identification, Assessment, Treatment, and Prevention. Journal of Gerontological Nursing, Spiva, L., Feiner, T., Jones, D., Hunter, D., Petefish, J., & VanBrackle, L. (2012). An evaluation of a sitter reduction program intervention. Journal of Nursing Care Quality, SteelFisher, G. K., Martin, L. A., Dowal, S. L., & Inouye, S. K. (2011). Sustaining Clinical programs During Difficult Economic Times: A Case Series from the Hospital Elder Life Program. Journal of the American Geriatric Society, U.S. Administration on Aging. (2004). A profile of older Americans. Washington, DC: Author. Zaubler, T. S., Murphy, K., Rizzuto, L., Santos, R., Skotzko, C., Giordano, J., et al. (2013). Quality Improvement and Cost Savings with Multicomponent Delirium Interventions: Replication of the Hospital Elder Life Program in a Community Hospital. Psychosomatics,