William Osler Health System Implementation of a Standardized approach to Delirium Assessment, Prevention & Management Cohort 1: Stephanie Jarvis, CNS, Seniors Health System Kuldeep Chahal, ELS, Hospital Elder Life Program Tammy Datars, Clinical Service Manager, Seniors Health System Aaron Yuen, Manager, Volunteers & Community Resources Rachelle DeLeon, Clinical Service Manager, Medicine March 2 nd, 2017
AIM STATEMENT Year 1 Pilot and Implementation Phase Provide staff education on delirium detection in the ED (Etobicoke General Hospital) Implementation of Confusion Assessment Method (CAM) in the ED (Etobicoke General Hospital). Target 85% compliance for age 65+. Year 2 Spread and Sustainability Phase Implementation of Standardized Process for Delirium Detection, prevention and management on a medical unit (ACE Collaborative, Canadian Foundation for Healthcare Improvement)
YEAR 1 - RESULTS % CAM completed 100 Percentage of Patients (65+) in Emergency Department with CAM Completed 80 60 Target [VALUE]% 40 20 0 March May June July Aug Sept Oct Nov *Exclusion Applied *Fast-track and ambulatory care were excluded as they are expected to have short LOS
YEAR 2 CHANGES (SPREAD TO ACE/ MEDICINE) Front-line Delirium Champions Engagement Education Surveys and focus groups Delirium Competency Checklist developed by staff Active Patient/Family Advisor Staff incentives Lunch N learns, Quizzes, Prizes CAM training for all staff Delirium Management Lunch N Learn: Case study GPA Training for staff and HELP Volunteers (ongoing) Tools Senior-friendly GIM Admission Order Set (Corporate) Delirium Management Order set (approved, rolling out) About-ME board on ACE Family Involvement Poster (pending) Sleep Hygiene Booklet (pending) Behaviour Mapping Tool (approval process) Senior-Friendly Activity Tool Kit & Montessori Approach to dementia care Hospital Elder Life Program
DELIRIUM PROCESS FLOWCHART CAM Positive? Yes No Continue to Monitor CAM q Shift/PRN Notify MRP/Team Initiate Delirium Order Set Initiate Delirium Prevention/Management Interventions HELP Program Family Involvement ABOUT Me Poster Environment Senior Friendly Activities Sensory Support Pain Management Function/Mobility Medication Review Bowels/Bladder Assess Oxygenation Monitor for Infection Hydration/Nutrition Sleep Hygiene Behaviour Mapping GPA techniques
YEAR 2 - MEASURES Rate of Baseline Delirium Screening on ACE/Medicine Objective: By May 2017, we will maintain a rate of baseline delirium screening of > 90% Rate of Hospital-Acquired Delirium on ACE/Medicine Objective: By May 2017, we will see an increase in delirium detection using the CAM, indicated by the following: An increase in the rate of hospital acquired delirium (using the CAM) *Note*: We expect to see an increase in hospital acquired delirium as detection with the CAM improves overtime before we see an overall decrease
YEAR 2 - MEASURES Staff Confidence in Delirium Detection and Management Objective: By May 2017, over 80% of staff will report being pretty confident or very confident Patient/Family Satisfaction Objective: By May 2017, 80% of patients will indicate yes to receiving education on prevention strategies and activities to prevent/manage delirium (Patient Experience Survey) Objective: Themes (qualitative data) from our patient interviews will indicate satisfaction with Senior-friendly activity kits
YEAR 2 - RESULTS 99% 97% 95% 93% 91% Rate of CAM Screening (Blue) and Incidence (Green) 25% 20% 15% 10% 89% 87% 85% Rate of CAM Screening Target CAM Screening Rate Delirium Incidence Rate Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 5% 0%
YEAR 2 - RESULTS Pre-implementation Data on ACE/Medicine Pilot Unit (1) Staff Confidence in Delirium Assessment: Only 52% of surveyed staff reported being pretty confident or very confident in identifying delirium (2) Staff Confidence in Delirium Management: Only 73% of surveyed staff reported being pretty confident or very confident in managing delirium Post- implementation Data collection in May 2017
YEAR 2 - CHALLENGES Barriers Changes in Leadership New manager, director, chief, project lead, team members, strategic direction Workload Code Gridlock 6 continuous weeks, outbreaks, competing priorities (Accreditation and opening of new facility) Strategies/Facilitators Stakeholder Engagement Need strong leadership Re-define Vision Review Resource Availability Revise and Revamp project charter Leverage other initiatives to streamline efforts and gain momentum Staff Engagement and Incentives Participation - Delirium Champion Initiative, Late Career Nurses
NEXT STEPS Implementation of a Pilot Delirium Management Order Set on 1 unit (ACE/Medicine) Implementation of Behaviour Mapping tool to assist with management of Behavioural and Psychological Symptoms of Dementia (BPSD) Finalize Corporate Delirium Policy based on findings from pilot project Plan for roll-out of delirium education/order set/tools across all medicine units Plan for roll-out of Gentle Persuasive Approaches (GPA) in Dementia across all medicine units
LESSONS LEARNED Staff, Patient & Family Engagement is critical to success! Actively involving staff, patients and family (entire interprofessional team) in as many stages of the change initiative increases the perceived value of the project Physician involvement is critical Patient-family advisor is very helpful Let the team take ownership of the project Train and Utilize Front-line Champions this will support sustainability Frequent PDSA cycles to test the change is helpful!
TIPS FOR OTHER TEAMS Check out the Highly Adoptable Quality Improvement Model : http://www.highlyadoptableqi.com/
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