Observe

Determine

Analyze

Synthesize

Apply/ Evaluate

Disseminate

Background Confusion Assessment Method

With early detection, protocols can be implemented to prevent and treat delirium, slow the progression of decline with dementia, and treat depression. Without systematic assessment, health care providers report greater frustration and job stress in caring for these individuals and the cost of providing care is much greater. Because of our large population of patients age 65 and older that are admitted each year, a large hospital system in the southwestern United States, identified the need for an assessment tool to detect patients at risk for delirium.

Comparison of Age Groups in Hospital System

The purpose of this practice innovation was to select and implement an evidence-based approach for identification and management of patients at high-risk for delirium, including an educational program to improve clinical and financial outcomes across the health system. Through implementation of the Confusion Assessment Method (CAM) instrument, nurses are able to assess delirium using a standardized tool. This benefits all members of the healthcare team by providing consistent information on which to base care.

In hospitalized elderly patients, does the use of the Confusion Assessment Method (CAM) improve detection and care planning for patients with delirium compared to current nursing assessment techniques?

After educating staff and assessing how the CAM was being used it was apparent that further intervention and additional education were needed. After just a short trial it was evident that many cases of delirium were not being identified necessitating further insight into how use of this evidence-based tool could be used more consistently. Further staff inservices, PowerPoint presentations and mentoring have increased the use of this evidence-based instrument. Next steps include data analysis to determine the actual number of delirium cases identified using ICD-9 codes and by consistent use of the CAM. With earlier recognition and management of delirium, a decrease in sitter usage, hospital length of stay, and fall rates is expected. Ultimately, improvement in patient and family satisfaction, quality of care, and financial outcomes are the goals.

Confusion Assessment Method for the ICU (Oct 2010). Retrieved from http://www.mc.vanderbilt.edu/icudelirium/docs/CAM_ICU_training.pdf

Francis, J. (2013). Prevention and treatment of delirium and confusional states. Retrieved from www.update.com.

Guenther, U. & Radtke, F. (2011). Delirium in the postanesthesia period. Current Opinion in Anesthesiology, 24(6), 670-75.

Honess, C., Gallant, P., & Keane, K. (2009). The clinical scholar model: Evidence-based practice at the bedside. Nursing Clinics of North America, 44(1), 117-130.

NICHE (2012). Delirium. Retrieved from http://www.nicheprogram.org.

Nurses Improving Care for Healthsystem Elders. Retrieved from http://elearningcenter.nicheprogram.org

Robinson, S., Vollmer, C., Jirka, H., Rich, C., Midiri, C., & Bisby, D. (2008). Aging and delirium: Too much or too little pain medication? Pain Management Nursing, 9(2), 66-72.

Strout, T., Lancaster, K., & Schultz, A. (2009). Development and implementation of an inductive model for evidence-based practice: A grassroots approach for building evidence-based practice capacity in staff nurses. Nursing Clinics of North America, 44, 93-102.

Beverly Copoulos, MSN, RN, CCRN at bbcopoulos@shc.org

Beth Sposito, MSN, RN-BC, ONC at esposito@shc.org

Purpose

References

PICO Question

Are You Confused about Delirium?

Beverly Copoulos, MSN, RN, CCRN; Beth Sposito, MSN, RN-BC, ONC; Mary Comeau, MSN, CMSRN; and Melanie Brewer, DNSc, RN, FNP-BC Scottsdale Healthcare — Scottsdale, Arizona

Contact

Framework Discussion and Future Direction

Implementation

Through HealthStream, the e-learning method used by the health system to provide education to staff, the Geriatric Institutional Assessment Profile was assigned to all nurses and Patient Care Technicians in May of 2012. The purpose was to assess health care workers’ knowledge, attitudes, and perceptions regarding care of geriatric patients, and to assess the perceived adequacy of the institution’s environment to serve the geriatric patient needs.

An education packet was developed by the NICHE Education Committee and made available to health system and unit-based educators and nursing supervisors to educate staff

Skills fairs and presentations were provided at staff meetings by educators, supervisors, and nurse practitioners

The CAM went live in the Horizon Expert Documentation charting system in the fall of 2012

Delirium assessment charting has hover capability showing interventions that can be used to provide care

NICHE website was created on SHC’s intranet with additional delirium tools and guidelines

NICHE newsletters for staff education

‘Try This’ handouts were available on the intranet including topics such as: • SPICES • Communication • CAM instrument and algorithm • Delirium or Dementia

“Forget me not” reference card for badge

Educational handouts for families that define delirium, its causes, signs, how they can help to manage it, and tips for how to cope

Clinical Scholar Model©

Feature 1 Acute Onset of Changes or

Fluctuations in the Course of Mental Status

Feature 2 Inattention

Feature 3 Disorganized Thinking

Feature 4 Altered Level of Consciousness

Delirium

AND

AND EITHER

OR

The diagnosis of delirium requires the presence of acute onset of changes or fluctuations in the course of mental status AND inattention, AND EITHER disorganized thinking OR an altered level of consciousness.

Increased staff knowledge regarding delirium assessment and management, and the CAM using a post test to evaluate staff understanding

Increased use of the CAM during patient assessments

Increased detection of delirium through CAM use

Use of tools for nursing care plan development

Increased nurse-physician communication regarding patient status

Outcomes and Evaluation

3594 4154 4985

12733

0

5000

10000

15000

Jul-Sep 2012 Oct-Dec 2012 Jan-Mar 2013 Total

Num

ber

of P

atie

nts

Utilization of the CAM

Delirium, a pathological condition of cognitive impairment, has significant consequences for elders, their families, and the health care system. According to the Hartford Institute for Geriatric Nursing, recognition of high-risk patients and implementation of evidence-based protocols can detect early signs of delirium and improve outcomes.

Delirium S Sleep Disorders P Problems with Eating or Feeding I Incontinence C Confusion E Evidence of Falls S Skin Breakdown

Use this tool to assess your elderly patients to prevent and detect the most common complications.

http://consultgerirn.org/uploads/File/trythis/try_this_1.pdf

N urses I mproving C are for H ealthsystem E lders