Decreasing Delirium Resolution Times for the Elderly: An Interprofessional Approach

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1 Decreasing Delirium Resolution Times for the Elderly: An Interprofessional Approach Featuring: Felice Rogers Evans BSN RN BC Ty Breiter MSN RN CNL Tampa General Hospital NICHE exemplar hospital Three time Magnet designated hospital US News and World report recognized in 6 specialties Delirium Delirium is a disturbance in the level of awareness with impaired attention & disorganized thinking. American Psychiatric Association (APA)

2 Epidemiology 11 to 42% of older adults develop delirium during hospitalization (Siddiqi et at, 2006) 46% of post-operative patients Increase in LOS & associated costs Occurs 4-5 times more often in those with dementia Patients with hospital-acquired delirium, may continue with symptomatology post discharge Epidemiology Continued Increased post-operative complications New nursing home placements Functional decline Increased mortality Distress for the patient, family members, and hospital staff Some patients have vivid recollections of delirium Epidemiology Continued In-hospital delirium may go undetected in the absence of a validated screening tool Nurses play a key role in both the prevention & early recognition of this potentially devastating condition in the older hospitalized patient ( Milisen et at. 2005) 2

3 Signs & Symptoms of Delirium Rapid onset over hours or days Memory impairment Inattention-reduced ability to focus, sustain or shift attention Disorganized thinking Disorientation Delusions and/or hallucinations Misperceptions of stimuli Three Types of Delirium Hyperactive Hypoactive Mixed Restlessness Irritability Rapid speech Increased psychomotor activity Tendency towards hallucinations Combativeness Wandering Impatience Euphoria Apathy Lethargy Decreased alertness Slowed speech Somnolent Slowed movements Staring Quiet patient whom the diagnosis is often missed Shifts between the hypoactive and hyperactive states (fluctuates) Accounts for 52% of episodes Opportunities Noted Prior to Implementation No current process for delirium identification in place for non- ICU units Decreased awareness of delirium and its impact Unresolved delirium which prolonged LOS Ordering of diagnostic tests for structural work-up despite lack of focal deficits Restraint use 3

4 Interprofessional Approach ACE Unit Manager ACE Unit-Based Educator Unit-Based Pharmacist Psych Nurse Team Clinician Psych Nurse Team Clinical Nurse Leader Nursing Clinical Quality Specialist Support from CNO, CMO Selection of the Screening Tool Intensive Care Delirium Screening Checklist (ICDSC) was utilized in the critical care areas for delirium detection. ICDSC has a 99% sensitivity for the diagnosis of delirium. Geriatric Resource Nurse opinion was sought prior to determining which tool to utilize for the ACE unit. In the literature (Neufeld et al.), the sensitivity for detecting delirium with the ICDSC was lowered when used in a medicalsurgical setting however it was superior to the Confusion Assessment Method (CAM) Delirium Screening Checklist (ICDSC) 4

5 Training Education went out to nursing staff in January 2015 on how to differentiate between Delirium/Depression/Dementia Educated on how to wrench in the Intensive Care Delirium Screening Checklist (ICDSC) onto the flowsheet Screening, scoring, & consults Placed flyers within the nursing station Piloted on ACE unit in February, 2015 Interventions and Consults Based on Screening Results For any acute changes in mentation the RN was to wrench in the Delirium screening checklist. If the score was > 4, the patient was considered positive for delirium: RN Interventions Pharmacy consult Psych nurse consult 5

6 Delirium Screening Pharmacist Interventions Pharmacist reviews all patients with a positive score for delirium Review medication list for medications that may contribute to delirium Ensure non-pharmacologic methods for delirium prevention are being utilized Speak with provider about options for treatment of delirium 6

7 Delirium Screening Psych Nurse Interventions Psychiatric Resource Nurse consulted for scores of > 4 on the Delirium Screening Checklist. Assist the Primary Team in differentiating between delirium, dementia, and/or depression. Review case for possible etiologies including metabolic and electrolyte derangements, infectious processes, hypoxemia, hypo/hyperglycemia, thyroid dysfunction, CVA, MI, etc. Leave a consult note with recommendations, as well as discuss the case with the primary RN Assist nurse for episodes of combativeness (abrupt and fluctuating mood is somewhat expected with this diagnosis) Utilize verbal de-escalation skills such as identifying and validating the root cause of their concern, remain calm, maintain composure, practice empathy & be supportive, be cognizant of your body posture, voice inflection and any mannerisms which can be misperceived RN Interventions Frequent reorientation (clocks, calendars) Invite family to stay with patient in order to reduce suspiciousness and paranoia. Familiar objects (pictures) Optimize sleep and wake cycles lights off at night and on during the day Psychotropics for acute agitation (Haldol) only Quite & low stimulus environment Ensure patient has visual & hearing assistive devices Pain management prn Promote early mobilization Maintain consistent caregivers Minimize relocation Prevent injury Avoid restraints DON T GET DELIRIOUS, TAKE SLEEP SERIOUS!!! 7

8 Evaluation Average age is 83 years 9 females & 3 males Admitting diagnosis are varied, but 3 had AMS on admit Mean day to develop delirium from admit is 6.0 days Average initial delirium score is 6.78 Average LOS: days Mortality: 0%; All patients survived to discharge Evaluation Continued Days to documented delirium resolution: 1.84 days. (One patient was discharged with unresolved delirium.) This is under a published range from 4.2 to 7.4 days. Our initial success can be attributed to the multidisciplinary team approach we have taken. Summary Through the utilization of a proven screening tool and enactment of a best practice model, elderly patients on an ACE unit had earlier resolution of the symptoms of delirium. This was made possible through a collaborative interprofessional approach which focused on improved identification of delirium and post screening activation of consults to implement various multidisciplinary interventions. 8

9 Future Directions Delirium assessments to be done on the ACE unit every shift All patients seen by the Psych Nurse Team will be evaluated for delirium Additional consults to other disciplines such as occupational therapy Tampa General Hospital NICHE exemplar hospital Three time Magnet designated hospital US News and World report recognized in 6 specilties Questions? 9