Delirium: developing and implementing a multi-component intervention

Transcription

1 Delirium: developing and implementing a multi-component intervention Dr. Duncan Forsyth Consultant Geriatrician Addenbrooke s Hospital Cambridge University Hospitals NHS Foundation Trust Cambridge, England

2 Engaging with management Psychiatric illness in older people in general hospitals: Is common Affects outcomes Is often unrecognised Is often inappropriately treated

3 Length of stay Mortality Costs

4 Our core business

5 Age Limited or not modifiable Patient Disease Define at risk individuals Cardio-vascular disease Gender Cerebral pathology Living alone Respiratory disease Smoking Alcohol No clock Bed moves Isolation Precipitating illness Sensory deprivation Define interventions / preventative strategy ITU Poor nutrition / dehydration Tubes & catheters Drugs More modifiable Restraints Environment Ilness

6 What have we done? Nurse education and support Support of LOAP Junior doctor awareness of cognitive problems Carer involvement Dementia friendly staff and environment Day room to be functional for confused patients Colour coded ward bays Dementia friendly signage Coloured toilet seats Better seating Watering hole Artwork

7 Formalised Training Alongside the environmental changes training was provided. A specialist dementia nurse was appointed. The specialist mental health nurses designed a teaching package which ensures that staff are aware of strategies to use when working with people living with dementia that are admitted to an acute ward and are able to utilise the environment and the resources to improve the patients experience. Training was delivered over 8 sessions each of 20 minutes and each session was repeated as necessary so that all ward staff might attend. Session 1 Dementia. Session 2 Person Centred Care. Session 3 Behaviour as communication. Session 4 Behaviour as communication. Session 5 Meaningful activities. Session 6 Depression. Session 7 Delirium. Session 8 Dementia/Delirium.

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9 Dementia Friendly Environment After Before

10 Before After

11 Before After

12 Before After

13 Before After

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16 Environmental risk factors Moving room No clock No glasses local audit data Others not conclusive

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19 Orientation Hydration Nutrition Constipation Infection Pain Polypharmacy Improve mobility Reduce sensory impairment Avoid sleep deprivation Reduce bed moves Maintain consistency of staff Preventing delirium NB: Multicomponent intervention trials provide low quality evidence for reducing: Incidence of delirium LOS Gustafson 1991 Wanich 1992 Landefeld 1995 Inouye 1999 Harari 1997 Marcantonio 2001 Bogardus 2003 Lundstrom 2005 Wong 2005» Inouye 1999, Marcantonio 1999 and 2001

20 Delirium prevention Inouye et al. NEJM patients aged > 70 admitted to general medical wards. One patient from intervention unit matched with two patients from usual care units Intervention consisted of standardized protocols for cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration Intervention group Less delirium - 9.9% vs 15% of usual care group fewer days of delirium and fewer episodes of delirium No difference in LOS

21 Cornerstones Early recognition Missed in < 2/3 Treatment of delirium Elimination or correction of underlying causal factors Multifactorial causation Multicomponent interventions Symptomatic and supportive care

22 Causes of delirium (precipitants) D rugs E ndocrine M etabolic E nvironmental N eoplasm T rauma I nfection A poplexy (stroke) D rugs: CNS active drugs particularly anticholinergics, polypharmacy, withdrawal (antidepressants, alcohol and benzodiazepines) I nfection & Intracranial pneumonia, urinary tract, skin Stroke, subdural, epilepsy M etabolic glucose, calcium, ammonia, hypoxia, low cardiac perfusion E lectrolytes sodium, dehydration All may be associated with immobility remember restraining

23 Treatment of delirium Moderate quality evidence that attention to: Orientation Hydration / nutrition Medication management Early mobilisation Reduce Length of delirium LOS But NOT Institutionalisation rates» Pitkala 2006 and 2008

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25 Orientation Hydration Nutrition Constipation Infection Pain Polypharmacy Improve mobility Preventing / manging delirium Reduce sensory impairment Avoid sleep deprivation Reduce bed moves Maintain consistency of staff NB: Multicomponent intervention trials provide low quality evidence for reducing: Incidence of delirium LOS Gustafson 1991 Wanich 1992 Landefeld 1995 Inouye 1999 Harari 1997 Marcantonio 2001 Bogardus 2003 Lundstrom 2005 Wong 2005» Inouye 1999, Marcantonio 1999 and 2001

26 Hyperactive Agitation, plucking at bedclothes Deranged sleep pattern (day-night reversal) Persecutory delusions and visual hallucinations Wandering Aggression, labile mood, euphoria Hypoactive Apathy, poor motivation, poor engagement, no trouble Diagnostic confusion Most common and misdiagnosed Highest mortality Prone to pressure sores, malnutrition, dehydration, VTE Mixed Tailor intervention to delirium type

27 For incident delirium Also observe: For resolution of prevalent delirium

28 Bay nursing the issues Staff feeling stressed and under pressure Staff feeling unsafe in practice Unsafe for patients Too many specialling requests, leading to staff covering the shifts who were not dementia/delirium trained Budget overspend Addenbrooke s Hospital Rosie Hospital

29 Bay nursing: improves staff well being and saves money Oct 2013 Nov 2013 Dec 2013 Jan 2014 Feb 2014 Cost over 6 months: Ward 1 Ward 2 Ward 3 Ward 4 Ward % 3.09% 4.46% 5.05% 5.81% 17, % 4.94% 3.08% 2.90% 3.94% 14, % 5.71% 7.77% 7.27% 10.08% 22, % 2.80% 1.83% 0.53% 1.39% 7, % 1.59% 2.97% 4.02% 4.18% 14, 711,51

30 Knock on benefits: falls have reduced significantly One fall during bay nursing hours ( ), as a result of reduced staffing Reduced length of stay More appropriate care due to increased likelihood of patients being allocated to most suitable beds in most suitable locations Reduced risk of HAI Reduced risk of mortality Impact of bay nursing on falls Addenbrooke s Hospital Rosie Hospital

31 Reduction in specialling Addenbrooke s Hospital Rosie Hospital

32 Introduction of delirium ward reduced specialling 06/09/09-23/8/ additional shifts to be covered for the purpose of specialing. 06/09/10 27/8/ additional shifts to be covered for the purpose of specialing A cost pressure saving of approximately 44,000 based on the assumption that each shift is 7.5 hours.

33 Bay nursing has enabled us to improve care, ensuring we give person centred care at high standards. We are now able to provide extra activities, such as: Patients eating together at a dining table Board games, hair and nails being done Communication between nurses, patients and relatives is a lot more effective Additional benefits Addenbrooke s Hospital Rosie Hospital

34 Patient and relative feedback Bay Nursing gives staff the chance to get to know us, its more sociable. Extracted from patient experience questionnaire My mum is well looked after she is eating so well and gaining weight something we have struggled with as a family for months. Cherie (Daughter of a patient) You hear so much bad press about dementia care, they need to come to G6 and see there is amazing care going on, my mum is safe and well looked after. Jean (Daughter of a patient) I do not need to use my buzzer as staff are always there to help me. Extracted from patient experience questionnaire Addenbrooke s Hospital Rosie Hospital

35 Future plans Occupational therapy to undertake kitchen style assessments on the ward rather than having to wait to book a slot in for a kitchen assessment on level 2 Physiotherapists to gain experience in music and dance therapy to be able to apply this on the ward for patients Addenbrooke s Hospital Rosie Hospital

36 Music project

37 NICE Quality Standards 2014: audited by Jill Christy (Medical Student)

38 NICE Quality Standards 2014: audited by Jill Christy (Medical Student) 1. Our Dementia Case Finding Tool (60% fully completed) and Frailty CQUIN (96% completed) were useful in capturing recent changes in behaviour 2. Using proxy measures of food / fluid / bowel charts; pain scoring, observation charts, medication review and behaviour charts seemed to identify whether multicomponent intervention packages are implemented (96-100% documentation) However: Medication review documentation poor (70% documentation).

39 NICE Quality Standards 2014: audited by Jill Christy (Medical Student) 3. Low levels of antipsychotic prescription (11%) and compliant (100%) with Trust guidelines - comparable to a previous audit in % of discharge summaries mentioned altered cognition (only half of these used the term delirium or delirious). Most reliable reporting was for those presenting with (prevalent) delirium. 5. We have patient and carer information leaflets BUT it was unclear whether they were given out.

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41 Morbidity (falls, HAI. VTE, pressure sores, malnutrition, ADEs) Mortality LOS Institutionalisation rates (LOS) quality patient care costs of unnecessary Ix (e.g. CT head scans) costs of specialling complaints Helps us meet National Dementia Strategy incidents of aggression towards staff Can we establish the benefits?

42 Good dementia and delirium management simultaneously improves care and costs. Good care costs less. Dr Keith McNeil, Addenbrooke s CEO Addenbrooke s Hospital Rosie Hospital

43 THANK YOU FOR YOUR ATTENTION

44 Cognitive screening algorithm Is there cognitive impairment? MMSE, CLOX1 Duration of cognitive impairment? CAM, IQCODE Delirium Delirium and chronic impairment (?dementia) Chronic impairment (?dementia) Ix and Rx Assess for severity, consider depression, etc.?referral