Delirium Prevention: The State-of-the-Art & Implications to Improve Care in our State Jonny Macias, MD & Michael Malone, MD Aurora Health Care/ University of Wisconsin School of Medicine & Public Health May 19, 2014
Objectives Describe delirium Describe the Hospital Elder Life Program (HELP) as a model of care to prevent delirium. Explain how the HELP model can be integrated into the electronic medical record. Describe how the two models (Acute Care for Elders and HELP) can be integrated to improve care for vulnerable older patients. Define the HELP- Wisconsin project: a state-wide, collaborative for delirium prevention. 3
Aurora at a Glance State s largest health care provider State s largest private employer with 30,000 employees State s largest provider of Medicaid Serving 31 counties, 90 communities 15 hospitals, 155 clinics More than 1,650 employed physicians State s largest homecare provider Nearly 100 pharmacies $4.3 billion in annual revenue 16 employed geriatricians, 5 in the community. 7 geriatrics nurse practicioners. One electronic medical record. 2
Delirium: early descriptions Celsus, 1st Century: Sick people, sometimes in a febrile paroxysm, lose their judgment and talk incoherently when the violence of the fit is abated, the judgment presently returns From Edward Marcantonio lecture: Delirium: What is it, and what do we (not) know about it. Presented at Delirium in Older Adults: Finding Order in the Disorder, February 9-11, 2014, Bethesda, MD 4
Synonyms: on the wards Agitated Bonkers Combative Crazy Lethargic Out of it Out to lunch Poor historian Seeing things Sleepy Uncooperative Wild man From Edward Marcantonio lecture: Delirium: What is it, and what do we (not) know about it. Presented at Delirium in Older Adults: Finding Order in the Disorder, February 9-11, 2014, Bethesda, MD 5
Delirium is a syndrome of many names.. Standardizing language is the first step in its appropriate management. From Edward Marcantonio lecture: Delirium: What is it, and what do we (not) know about it. Presented at Delirium in Older Adults: Finding Order in the Disorder, February 9-11, 2014, Bethesda, MD 6
Delirium Rates Hospital Prevalence (on admission) 14-24% Incidence (in hospital) 6-56% Postoperative: 15-53% Intensive Care unit: 70-87% Nursing Home/Post Acute care: 20-60% Palliative Care: up to 80% Hospital Mortality: 22-76% One Year Mortality: 35-40%» Inouye SK,NEJM 2006;354:1157-65. Lancet 2013 online. 7 7
Delirium Consequences 10 fold increased risk of death in hospital Post-op complications Increased LOS Functional decline New NH placement Increased cost Distress for family patient and staff From Edward Marcantonio lecture: Delirium: What is it, and what do we (not) know about it. Presented at Delirium in Older Adults: Finding Order in the Disorder, February 9-11, 2014, Bethesda, MD 8
CAM Delirium Evaluation Patient Interview: Symptoms: confusion, perceptual disturbances Cognitive testing: orientation, attention Interviewer observations: Altered level of consciousness Psychomotor agitation, retardation Family/caregiver: time course, acuity CAM: puts it all together to make a diagnosis From Edward Marcantonio lecture: Delirium: What is it, and what do we (not) know about it. Presented at Delirium in Older Adults: Finding Order in the Disorder, February 9-11, 2014, Bethesda, MD 9
Delirium Diagnosis Delirium is a clinical diagnosis The Confusion Assessment Method (CAM) Sensitivity 94%-100% Specificity 90%-95% Hyperactive Delirium Restlessness / Agitation Hypoactive Delirium Slowed movement, unresponsive From Edward Marcantonio lecture: Delirium: What is it, and what do we (not) know about it. Presented at Delirium in Older Adults: Finding Order in the Disorder, February 9-11, 2014, Bethesda, MD 10
Confusion Assessment Method Feature 1 Acute onset and fluctuating course Feature 2 Inattention Feature 3 Disorganized thinking Feature 4 Altered consciousness Diagnosis of delirium requires features 1 and 2, and either 3 or 4 11
Testing Attention One of the most basic, but neglected areas of the mental status exam. Recommended methods: Digit span: 5 forwards, 4 backwards Days of week, months of year backwards Vigilance A task: HAVEAHEART From Edward Marcantonio lecture: Delirium: What is it, and what do we (not) know about it. Presented at Delirium in Older Adults: Finding Order in the Disorder, February 9-11, 2014, Bethesda, MD 12
Risk Factor Model of Delirium PREDISPOSING FACTORS/ VULNERABILITY High Vulnerability PRECIPITATING FACTORS/ INSULTS Noxious Insult Advanced age Dementia Functional impairment in ADLs Medical comorbidity History of alcohol abuse Male sex (maybe) Sensory impairment ( vision, hearing) Interaction Sleep deprivation. Infection. Acute illness. Iatrogenic event. High risk medication Low Vulnerability Trivial Insult 13
Delirium Evaluation Assume reversibility unless proven otherwise. Medications Infections Metabolic Disorders Cardiovascular Neurologic Miscellaneous Fecal impaction/urinary retention postoperative state sleep deprivation 14
Medications Associated with Delirium Tricyclic antidepressants.(amitriptyline) Anticholinergics (Cyclobenzaprine) Benzodiazepines. Corticosteroids (prednisone) H2 Receptor Antagonists. Opioids analgesics (Meperidine) Sedative hypnotics. Antipsychotics. 14
Delirium Assessment History baseline cognitive function-family/caregivers VS PE/Neurologic exam Target laboratory assessment based on clues from history and physical. Targeted Neuroimaging R/O CVA Electroencephalogram R/O Seizures Address acute medical illness Drug adjustments (opioids, sedatives, hypnotics, anticholinergics) 16
Delirium Management Nonpharmacologic measures are first line in the symptomatic treatment of delirium. frequent orientation presence of family at the bedside maintaining the sleep-wake cycle Minimizing nighttime interruptions. Ensuring patient is awake and situated in a bright room during daytime. 16
Delirium Management Non-pharmacologic interventions. Avoid physical restraints Assessment of drugs and reduce psychoactive drugs. Encourage mobility and self cares Let patient know their schedule and keep them involved in their care Communicate regularly with patients and their families. Ensure patients have glasses, hearing aids and dentures» Inouye SK,NEJM 2006;354:1157-65. Lancet 2013. 16
Delirium Management Pharmacologic interventions Reserve pharmacologic approaches for patients with severe agitation who risk interruption of essential medical treatment (eg, intubation) Self injury Have severe distressing psychotic symptoms (eg, hallucinations, delusions) NO EVIDENCE-LACK OF DATA to support this practice. Antipsychotics or sedating drugs can switch delirium from hyperactive to hypoactive, resulting in worse clinical outcomes Consider other approaches- non-pharmacologic 17 Aurora Health 15 Care, Inc.
Delirium Management Pharmacologic interventions For acute agitation and aggression that impairs care or safety. Haloperidol is the most often recommended and studied agent If QTc exceeds 500, do not administer any antipsychotic; all may prolong QTc Quetiapine is the drug of choice for patient with LBD, PD Benzodiazepines (alcohol or benzodiazepine withdrawal). 17 Aurora Health 15 Care, Inc.
Delirium is a Preventable Medical Condition Previous studies documented at least 30-40% of delirium is preventable. Hospital Elder Life program» Inouye 1999, 2000, Chen 2012 Proactive Geriatric Consultation» Marcantonio 2001 Exercise and rehabilitation interventions.» Caplan 2006, scweickert 2009 Sharon Inouye MD, MPH, HELP meeting March 2014, Pittsburg 15
HELP Program: 18 17
Hospital Elder Life Program (HELP) An evidence base medicine program developed by Sharon Inouye, MD. Designed to decrease delirium and functional decline in hospitalized older adults. This program is a prevention strategy. 19
HELP Evidenced based delirium prevention model. Statistically significant reduction in the onset of delirium. Research validated replication in multiple clinical settings. Cost-effective method for improving outcomes. 20
Goals of HELP Prevent unplanned readmissions. To maximize independence at discharge. To assist with the transitions from hospital to home. To maintain physical and cognitive. functioning throughout the hospitalization. 21
HELP - Hospital Elder Life Program @ St. Luke s Medical Center St Luke's is the largest acute care hospital in Wisconsin with 600+ beds and 27 nursing units. This model of care has been integrated into the Acute Care for Elders model. HELP uses skilled interdisciplinary staff and trained volunteers. HELP directs trained and supervised hospital volunteers to initiate specific prevention protocols to seniors identified by the ACE Tracker software program. 22
HELP - Hospital Elder Life Program @ St. Luke s Medical Center HELP Team Medical Director Geriatric Advanced Practice Nurse Elder Life Specialist Trained Volunteers 23
HELP Volunteer Interventions Daily Visitor Program Therapeutic Activities Early Mobilization Program Feeding Assistance Program Hearing and Vision Protocols 24
HELP Multicomponent intervention strategy targeted at six delirium risk factors Risk Factor Cognitive Impairment.. Sleep Deprivation.. Immobilization Vision Impairment.. Hearing Impairment Dehydration. Intervention Reality orientation Therapeutic activities Nonpharmacological sleep protocol Sleep enhancement protocol Early mobilization protocol Minimizing immobilizing equipment Vision aids Adaptive equipment Amplifying devices Adaptive equipment and techniques Early recognition and volume repletion Inouye SK, N Engl J Med 1999;340:669-76. 25
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HELP - Hospital Elder Life Program @ St. Luke s Medical Center Inclusion Criteria Age > 65 years. At least one risk factor for cognitive or functional decline. Cognitive impairment, mild-moderate. Any mobility or ADL impairment. Vision impairment. Hearing impairment. Dehydration Able to communicate verbally or in writing. 27
HELP - Hospital Elder Life Program @ St. Luke s Medical Center Exclusion Criteria Coma Mechanical ventilation Aphasia (expressive or receptive) Terminal condition with comfort care only Combative or dangerous behavior Severe psychotic disorder Severe dementia MMSE < 10 Airborne precautions or droplet precautions Neutropenic precautions Refusal by patient, family member 28
Could we integrate the HELP program into existing models of care and software systems? 29
ACE Tracker to Identify Older Patients who are at Risk for Delirium: Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 29
Delirium Markers: ACE Tracker Nursing assessment for delirium symptoms. Fluctuating cognition/ Change in mental status/ attention/ thought process/ level of consciousness Any physical restraint in the prior 48 hours. Any antipsychotic medication in the prior 48 hours: Haloperidol Risperidone Quetiapine Olanzapine 30
ACE Tracker as an tool to measure the rate of delirium marker : 31
Automated Prevalence of Delirium Rate among all Older Patients: 32
HELP Program Outcomes- Aurora St. Luke s Medical Center: What is the progress to date in implementing the HELP program? Between May 1, 2013 and February 28, 2014 the HELP program enrolled 528 older patients. Trained volunteers provided 1644 supervised visits to patients enrolled in the program. About 8 delirium prevention protocols deployed per patient. 33
HELP Program Outcomes- Aurora St. Luke s Medical Center: What percent of those who are eligible for the HELP program actually receive the care? We studied 97 older patients who were eligible for the HELP program on four nursing units from March 17, 2014 to March 21, 2014. 33 were enrolled in the program. 34 were not assessed. 30 were not eligible for HELP program. 13 already had delirium. 7 refused the HELP program. 5 too highly functioning. 5 end stage disease/ end of life care. 34
HELP Program Outcomes- Aurora St. Luke s Medical Center: Between January 1, 2014 and February 28, 2014, we compared HELP program patients (n= 152) from four HELP nursing units to HELP eligible patients on the same units, who were not enrolled (n= 501): HELP program delirium symptoms rate= 5/152 patients, 3.3%. Non- enrolled HELP eligible delirium symptom rate: 26/501 patients, 5.2%. Improved length of hospital stay. Number needed to treat to avoid one case of delirium: about 50. Length of Stay Usual care group = 6.44 days HELP treatment group = 5.49 days Quality improvement data from Aurora Health Care, 4-8- 2014. 35
Delirium quality measures for nine med- surgical nursing units at six Aurora hospitals from September 29 through October 28, 2013: Location: Patient days from 9-29-13 through 10-28-13: Days of Delirium per 100 patient days: Hospital A- unit 1 254 20.9 Hospital B- unit 1 399 12.5 Hospital C HELP program 265 10.1 Hospital C control group 319 9.7 Hospital D- unit 1 191 14.1 Hospital E- unit 1 536 14.4 Hospital E- unit 2 168 11.9 Hospital E- unit 3 196 2.6 Hospital F Neurology unit 134 24.6
Delirium Outcomes at the nursing unit: We used a daily ACE Tracker report to assess the rate of delirium marker for all older patients from September 29, 2013 to October 28, 2014. Delirium rate on HELP program at Acute Care for Elders unit at St Luke s: 10.1 delirium days per 100 patient days. Delirium rate on Acute Care for Elders unit at Aurora West Allis: 14.1 delirium days per 100 patient days. 38 36
Take Home Message: The HELP program can be successfully implemented in a large, tertiary care hospital. The electronic health record can be: programmed to automate the identification of older patients who are at risk of developing delirium. used to assist in the automated measurement of delirium in a large hospital. The identification of those at risk for delirium throughout a large health system may allow for broad implementation of delirium prevention- patient safety programs. 36
Can we integrate HELP into the Acute Care for Elders model of care? Acute Care for Elders: prevent functional decline and decrease the chance of new nursing home placement. Hospital Elder Life Program: prevent new onset of delirium and prevent functional decline. Integrating the two models of care: ACE Tracker. Advisory committees. Hospital and health system leadership. 37
Functional Decline During an Acute Illness: The Story of ACE, by Seth Landefeld in Acute Care for Elders- A model for interdisciplinary care, Malone, Capezuti, Palmer,eds. 2014. 38
The Acute Care for Elders Model: r Elders Model: The Story of ACE, by Seth Landefeld in Acute Care for Elders- A model for interdisciplinary care, Malone, Capezuti, Palmer,eds. 2014. Nursing assessment/ real-time checklists in the electronic health record 39
The Acute Care for Elders Model: r Elders Model: The Story of ACE, by Seth Landefeld in Acute Care for Elders- A model for interdisciplinary care, Malone, Capezuti, Palmer,eds. 2014. Nursing assessment/ real-time checklists in the electronic health record The Hospital Elder Life Program: Trained, supervised volunteers deploying targeted delirium prevention protocols. 40
Scaling up for the Health System and State: 807,164 older Medicare beneficiaries in Wisconsin. 193,470 hospital discharges of older Medicare patients in 2010. 966,210 total hospital days in 2010. 130 acute care/ 58 critical access hospitals in Wisconsin. Decrease the rate of new delirium from 15% to 10%: Across Aurora Health Care- avoid 1500 new cases of delirium per year. Across Wisconsin- avoid 10,000 new cases of delirium per year. Delirium $60,000 incremental costs per patient over subsequent 12 months. If HELP delirium prevention strategies were deployed: Across Aurora Health Care the potential savings: $90 million per year in health care costs. Across Wisconsin, the potential savings: $600 million per year in health care costs. Kaiser Family Foundation statehealthfacts.org KFF Compare Medicare Data 41
Ten Points in Scaling Up a Geriatrics Model of Care: 1. Carefully track outcomes. Baseline and comparison groups. 2. Define the business plan/ the economic impact of the model for the hospital. 3. Making sure stakeholders are clear about goals and the resources required. 4. Develop a timeline and a strategy for expansion. 5. Have appropriate staffing. 6. Integrate the model into the electronic health record. 7. Monitor and maintain fidelity of the model. 8. Provide a annual report to the hospital and health system. 9. Work with national leaders who can advise the project. 10. Include a patient on your advisory team- stay patient-centered. 42
A Vision to Spread HELP in Wisconsin: 1. Define state- wide stakeholders who have a interest in delirium prevention. 1. Wisconsin Hospital Association. 2. The Alzheimer's Association. 3. The Wisconsin Medical Society. 4. The Department of Health and Human Services. 5. Patient safety collaboratives. 2. Measure the rate of delirium among older patients in Wisconsin hospitals. 3. Use public health strategies to deploy delirium prevention strategies. 43