MN/OH Delirium Collaborative Place picture here November 16, 2017
Housekeeping Introductions: MHA- Naira Polonsky OHA- Rosalie Weakland OHA- Jim Guliano In December 2015, the Minnesota and Ohio HENS began an intentional and active partnership to address delirium. This collaboration has been highly beneficial in the identification, development and dissemination of delirium tools and resources, as well as provide a greater learning opportunity for both states. Minnesota and Ohio have chosen to continue the collaboration as part of the HIIN work. Bi-Monthly webinars: Various topics will be reviewed by subject matter experts. Each webinar will consist of a Virtual Learning Session, followed by time for participants to ask questions, share challenges and connect with hospitals that may have found solutions and success. Please invite the appropriate individuals within your organization to participate in this collaborative, send their contact information to MHA or OHA.
Speaker Introduction Aminata Cham, RN, MSN, APRN, ACNS-BC Ms. Cham has been a nurse since 2004 and a clinical nurse specialist since 2012. She leads delirium work throughout her healthcare system and is a member of the American Delirium Society and American Geriatrics Society. Additionally, she is a long-time member of the MHA Delirium Committee and has most recently been involved in a major delirium awareness education project. She does not have any conflicts of interest to disclose.
Leveraging Data And The EMR In Delirium Prevention Aminata Cham RN, MS, APRN, ACNS-BC NOVEMBER 16 TH 2017
OBJECTIVES Define delirium. Examine the impact of delirium on patient outcomes. Identify tools used for detecting monitoring delirium.
HEALTHEAST Located in St Paul and surrounding areas. Includes four hospitals and fourteen Clinics. Joined Fairview on June 1 st 2017.
Delirium An acute disorder of attention and cognition Common, serious, costly, under recognized and often fatal. Current approach to diagnosis and treatment of delirium remains a clinical diagnosis.
Significance In the United States, >2.6 million adults 65 years and older each year develop delirium. Total costs range from $16,303 to $64,421 per patient. Accounts for >$164 billion in annual healthcare expenditure. Included on the pt. safety agenda. Targeted as an indicator of healthcare quality for seniors. Hold significant societal implications.
Adverse Outcomes Associated With Delirium Most common adverse health events for older adults. Independently associated with an increased risk of death. Potential risk factor for complications: falls, increase LOS, pressure ulcers, and functional decline.
Delirium Superimposed On Dementia Older adults with dementia are at greatest risk for delirium. 89% experience delirium when hospitalized and between 24% and 76% die within one year of the index episode.
Delirium (DSM-5) Diagnostic Criteria Disturbance in attention and awareness. Change in cognition that is not better accounted for by a preexisting, established, or evolving dementia. The disturbance develops over a short period. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause.
Forms Of Delirium HYPERACTIVE HYPOACTIVE MIXED The hypoactive form is more common among older adults Often unrecognized Associated with higher rates of complications and mortality Delirium was found in ~90% of patients in the last days of life in a 2013 systematic review. Hypoactive delirium was the most prevalent delirium subtype in the palliative care population (68% 86% of cases).
Diagnosis Underrecognized and easily overlooked. Only 12 to 35% of delirium cases are recognized. Current reference standard diagnostic criteria are: DSM-5 ICD-10 Over 24 delirium instruments have been used in published studies. CAM-most widely used instrument. Currently, there are at least 11 diagnostic codes for delirium in ICD-9 and 23 codes in ICD-10. Only 3% of delirium cases are coded in medical records.
Significance Of Accurate Coding Medicare has a list of disease states that will increase hospital payments based on whether the primary DRG diagnosis also carries a complicating or comorbid condition (CC) or major complicating or comorbid condition (MCC) that determines the MS-DRG. Delirium is a (CC) and Encephalopathy is a (MCC)
Difference In Payment
OUR JOURNEY System delirium committee Multidisciplinary Monthly meetings
Unit Delirium Champions Four hours a month dedicated to delirium work. 90 minutes monthly meetings. Connect with unit staff one-on-one. Chart audits and staff follow-up.
Our Process DEAR risk assessment: pre-operative for all patients 65 years and older CAM assessment: All patients 65 years and older every shift and/or with change in mental status CAM-ICU: Patients 65 years and older in the critical care unit
Confusion Assessment Method in our EHR
What Makes the CAM Positive The Diagnosis of Delirium using CAM instrument requires an acute onset, fluctuating course, the presence of inattention, and either disorganized thinking or an altered level of consciousness.
Best Practice Alert with + CAM
Delirium Banners Activated with a positive DEAR and CAM assessments
Prevention and Treatment Estimated 30%-40% of cases of delirium are preventable Primary prevention with multicomponent nonpharmacological approaches has consistently demonstrated to be the most effective strategy Strategies include: Early mobilization Adequate hydration Sleep enhancement Orientation to time and place Therapeutic activities Hearing and vision optimization Proactive geriatric approach is another successful approach
Reduction Of Constant Observation Hours For Patients With Delirium Our organization expends $2.8 million yearly on constant observation cost 40% of our patients in constant observation have delirium
A Quality Improvement Project We conducted a quality improvement project to decrease the cost of constant observation (CO) hours for patients with delirium. Project was piloted on two units: orthopedics and oncology Pilot units averaged a combined 145 hours of CO per week prior to project implementation. Three months post implementation, the number of CO hours decreased to 94 hours per week - a 35% DECREASE Total organizational savings Oct/2016-August 2017 was $301,202.
Pharmacologic Approaches At present there is no convincing, reproducible evidence that any of these treatments are clearly effective. Current clinical trials focused primarily on antipsychotics Treatments may reduce agitation and behavioral symptoms associated with delirium No evidence that these treatments are effective in improving outcomes from delirium
Reduction Of High Risk Medication Use
Patient And Family Delirium Brochure Added to all pt. admission folders
CONCLUSION Given that delirium is highly multifactorial and linked to many other common geriatric syndromes, addressing delirium provides a highly practical and effective strategy to improve outcomes, decrease costs, and raise the quality of healthcare system-wide
REFERENCES Inouye, S. K., Leo-Summers, L., Zhang, Y., Bogardus, S. T., Leslie, D. L. and Agostini, J. V. (2005), A Chart-Based Method for Identification of Delirium: Validation Compared with Interviewer Ratings Using the Confusion Assessment Method. Journal of the American Geriatrics Society, 53: 312 318. Kosar, C. M., Thomas, K. S., Inouye, S. K. and Mor, V. (2017), Delirium During Postacute Nursing Home Admission and Risk for Adverse Outcomes. J Am Geriatr Soc, 65: 1470 1475. Pendlebury, S. T., Lovett, N. G., Smith, S. C., Wharton, R., & Rothwell, P. M. (2017). Delirium risk stratification in consecutive unselected admissions to acute medicine: validation of a susceptibility score based on factors identified externally in pooled data for use at entry to the acute care pathway. Age and Ageing, 46(2), 226 231. Abraha, I., Trotta, F., Rimland, J. M., Cruz-Jentoft, A., Lozano-Montoya, I., Soiza, R. L., &... Cherubini, A. (2015). Efficacy of Non-Pharmacological Interventions to Prevent and Treat Delirium in Older Patients: A Systematic Overview. The SENATOR project ONTOP Series. Plos One, 10(6), e0123090. doi:10.1371/journal.pone.0123090 Davis, D. J., Muniz Terrera, G., Keage, H., Rahkonen, T., Oinas, M., Matthews, F. E., &... Brayne, C. (2012). Delirium is a strong risk factor for dementia in the oldest-old: a population-based cohort study. Brain: A Journal of Neurology, 135(Pt 9), 2809-2816. doi:10.1093/brain/aws190 Dharmarajan, K., Swami, S., Gou, R., Jones, R., Inouye, S. (2017). Pathway from delirium to death: Potential in-hospital mediators of excess mortality. Journal of American Geriatrics Society, 65 (5), 1026-1033 Inouye, S. K., Westendorp, R. J., & Saczynski, J. S. (2014). Delirium in elderly people. Lancet, 383 North American Edition (9920), 911-922. doi:10.1016/s0140-6736(13)60688-1 Joseph, F. (1992). Delirium in older adults. Journal of American Geriatrics Society, 40(8), 829-838. Kolanowski, A. (2016). Delirium in people living with dementia: A call for global solutions. Journal of Aging and Mental Health, 0(0), 1-3. Leslie, D. L., Marcantonio, E. R., Zhang, Y., Leo-Summers, L., & Inouye, S. K. (2008). One-year health care costs associated with delirium in the elderly population. Archives of Internal Medicine, 168(1), 27-32. doi:10.1001/archinternmed.2007.4 McCusker, J., Cole, M.; Abrahamowicz, M., Primeau, F., Belzile, E. (2006). Delirium predicts 12-month mortality. Archives of Internal Medicine, 162(4), 457-463. Rudolph, J. L., Inouye, S. K., Jones, R. N., Yang, F. M., Fong, T. G., Levkoff, S. E., & Marcantonio, E. R. (2010). Delirium: an independent predictor of functional decline after cardiac surgery. Journal of The American Geriatrics Society, 58(4), 643-649. doi:10.1111/j.1532-5415.2010.02762.x
Schedule Next Webinar: January 25, 2018 2018 Schedule*: o March 22, 2018 o May 24, 2018 o July 26, 2018 o September 27, 2018 *All calls are scheduled from 11:00-12:00 (CT)
Thank You Next call is January 25, 2018 Please invite the appropriate individuals within your organization to participate in this collaborative, send their contact information to MHA or OHA Please fill out survey and send to MHA or OHA to receive certificate of participation