delirium and dementia care - ic4n.org · 11.5.18 2 gather and review baseline data discuss delirium...
TRANSCRIPT
11.5.18
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Inpatient Delirium Management:A Quality Improvement Project
for Hospitalized Veterans
November 5, 2018
IIndiana Nursing Summit
Veteran Health Indiana
At the conclusion of this presentation, participants will be able to:
‣ Identify impact of delirium on hospitalized patients.
‣ Discuss screening for delirium
‣ Identify treatment modalities for acute care.
‣ Discuss impact of delirium management.
Increased calls
(Rapid Response
and Code Orange)
r/t delirium on
Med-Surg units
(7N & 7S)
Providers met to
discuss
interventions and
medical
management
Delirium Team
convened
There is no consistent process for proactively identifying and addressing delirium in the Medical-Surgical areas.
Led by Evidence-Based Practice (EBP) APNs
Anna Bober Rebecca Parks
Earlie Hale Sara Clay
Alex Radovanovich Shelly Keiser
Candace Whittler-Ducre Tamra Pierce
Jo Lee Coleman Dr. Cathy Schubert
Jason McClara Dr. Eric Boss
Heather Nixon Dr. Maria Poor
Celine Alba-Patino
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Gather and review baseline data
Discuss delirium screening options for use in medical surgical patients
Review components of Delirium Management in ICU areas
Discuss need for aids (restraint alternatives, delirium kit, etc.)
Discuss implementation of trial on key units: 2 medical units were chosen
Restraints
Falls
psychotropic medication use
consults
code orange incidents
0
2
4
6
8
10
12
14
16
FY16Q2 FY16Q3 FY16Q4 FY17Q1 FY17Q2
Number of Patients in Restraints
(FY16Q2-FY17Q2)
7N 7S
7N=547S=48
(Jan 2016-March 2017)
Type of restraint: vest, mitts, soft wrist, enclosure bed
0
2
4
6
8
10
12
14
16
18
Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
DA
YS
Average Number of Days in Restraints
(FY16Q2-FY17Q2)
7 A North 7 A South
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0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
Oct-15Nov-15Dec-15 Jan-16 Feb-16Mar-16Apr-16May-16Jun-16 Jul-16 Aug-16Sep-16Oct-16Nov-16Dec-16 Jan-17 Feb-17Mar-17
Fall
Rat
e
Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Inpatient Monthly Fall Rate 14.74 6.74 0.00 4.23 9.50 10.44 10.46 0.00 0.00 1.88 7.63 3.77 0.00 6.80 4.20 7.95 4.30 0.00
7 North Fall Rate
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
Oct-15Nov-15Dec-15 Jan-16 Feb-16Mar-16Apr-16May-16Jun-16 Jul-16 Aug-16Sep-16 Oct-16Nov-16Dec-16 Jan-17 Feb-17Mar-17
Fall
Rat
e
Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Inpatient Monthly Fall Rate 2.06 8.55 5.27 1.90 2.12 5.36 1.92 8.65 3.70 6.78 5.01 1.83 5.50 1.90 6.10 14.21 7.80 0.00
7 South Fall Rate
‣ Antipsychotic Use among Restrained Patients
Majority of patients were treated appropriately
Providers had ordered PRN medication but very few doses were ever administered (despite the fact that most of the doses were charted as “effective” when given)
Medications were potentially underutilized in some patients that were severely agitated.
*Haldol IV Push not approved for use on medical surgical units at the time
Month Hospital 7 North 7 SouthJanuary 19 8 12
February 24 8 7
March 19 6 10
April 26 7 6
May 28 10 9
June 16 7 5
July 26 8 6
August 25 12 6
September 20 5 6
October 13 5 4
November 16 8 7
December 33 12 8
Total 265 96 86
Inpatient Geriatric Consults 2016 FY16: 25 Delirium-related incidents
19 out of 25 incidents involved physical and verbally disruptive behavior
Area # of Incidents
7 North 10
7 South 10
8 North 2
8 South 1
ED 1
Other 1
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Lack of protocol
Inconsistent
follow-up
Communication
Inconsistent
nursing care
interventions
Inconsistent
medical
management by
Providers
Gaps Action Purpose/Outcome
Development of a protocol to standardize the process (screening and order set)
Standardize identification of patients with delirium and management of symptoms
Vet trial plan to Nursing Documentation, Acute Care, Nurse Executive and Clinical Practice Committees
Approval and additional feedback from all disciplines
Provider, Pharmacy and Nursing Staff education about the trial
Consistent information provided to promote successful trial
Trial the process on 7N & 7S Test and identify additional improvements on the protocol before full implementation
Request report that shows patients with positive screen
Efficient way to track patients for “just in time” review during trial
Delirium Screening and Order Set
• Literature review
• Query to other VA hospitals and local area hospitals
• Review of MICU Delirium Protocol
• Development of Medical-Surgical Delirium Protocol
Mirror MICU except Haldol PO or IM instead of IV
• Obtaining permission from the author to use Short CAM
(Confusion Assessment Method) screening tool
• Development of the Short CAM into a CPRS template note
(Delirium Screening Note)
Face-to-face training (2 weeks) CPRS documentation of nursing screening and assessment
Order set
Nurses were slotted into 30-minute scheduled blocks with nurse manager input
Pre and post-test administered 6-item questionnaire
Assess knowledge of common signs & symptoms of delirium, risk factors, interventions, and nurse comfort level related to assessing patients for delirium
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Delirium Protocol Trial Education
Delirium Protocol trial on 7N & 7S is from April 11-May 11, 2017.
Background: Increased calls (code oranges, rapid response calls) related to patients experiencing delirium on medical surgical units.
Goal: Early identification of delirium and implementation of interventions. “An ounce of prevention is worth a pound of cure.”
Protocol includes Order Set, screening for delirium, and appropriate interventions
Order Set:
Built in CPRS – very similar to MICU order set pathway: Same medications, different route.
Differences: 1) Order for Inpatient Geriatric Consult for (Age 65 or Older) link included on menu, 2) Different routes (PO or IM). IV Haldol for
MICU/SICU only 3) note to contact pharmacy for medication review
Screening: Nurses will use the Short CAM to screen patients for delirium
RN will screen patient on admission and every shift and as needed when there is a change in pt. mental status using the Delirium Screening Note
Provider will be notified of 1st positive screen so that the Delirium Order Set can be ordered. Changes in status will be reported to provider.
Nursing staff will implement appropriate interventions to manage symptoms
1
2
PO OR IM
Haloperidol
3
RN will screen patient on admission and every shift and as needed when there is a change in mental status using the Delirium screening Note.
Provider will be notified of a positive screen so that the Delirium Order Set can be initiated.
Nursing staff will implement appropriate interventions to manage symptoms.
Delirium Screening: Types: ICUs use ICU CAM in Essentris while Med-Surg use the Short CAM in CPRS Who completes and when: by RN on admission and every shift and as needed when there is a change in
pt. mental status. Location of note: Essentris, Nursing Admission, Nursing 24 Hour Flow Sheet & stand alone note. Includes documentation of patient behaviors
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In CPRS, use the care plan titled, Cognitive Function Altered for any disease or condition with
altered cognitive function (e.g. delirium, dementia, TBI, electrolyte imbalance, etc.)
Care Plan Documentation
Definition of Delirium
Types of Delirium
Possible Causes of Delirium
Negative Impact of Delirium
Importance of Recognizing Delirium
Managing Behavioral and Psychological Symptoms and Communication Techniques
‣ Focus on:
Awareness of risk factors for delirium (alcohol withdrawal, pain, post-procedure, delirium superimposed on dementia, etc.)
Considering restraint alternatives prior to restraints
Least restrictive restraint
Encouraging consults (Geriatric, Pharmacy review of medications, etc.)
Importance of reassessment
Questionnaires completed from
7/24/17 -8/3/17
Multiple Choice and Tor F questions:◦ Pre-test average score (N=46) was 72%
◦ Post-test average score (N=46) was 82%
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“I am comfortable assessing my patients for delirium.”
Response PRE-TEST POST-TEST
Strongly Disagree
4 4
Disagree 2 1
Neutral 21 4
Agree 14 24
Strongly Agree 5 13
Total 46 46
•Monitor completion of delirium screening
Daily review of reminder report
Feedback to individual staff and manager
(absence of screening, incorrect screening,
etc.)
•Monitor patients in restraints and with sitters
•Be a resource for all staff and to reinforce
education
•Collect data
7 North 7 South
April May April May
# of Patients in Restraints
4 5 1 4
Total # of Days in Restraints
6 10 3 11
Ave. # of Days in Restraints
1.5 2 3 2.75
# of Patients on 4-Way Restraints
0 0 0 0
Geriatric Consults 4 11 4 13
Falls 1 3 0 3
Code Orange 4 0 0 1
0%
20%
40%
60%
80%
100%
Positive on Admission Positive During Stay Protocol ordered Protocol Meds
Positive Screens (7N & 7S)n=16
7North 7South
• More patients became positive during stay• Protocol ordered more for patients on 7 North• Focused chart audit revealed that there were no negative outcomes
for patients not on protocol • 1 patient received CIWA Protocol meds and no delirium protocol
meds
Summary of Patients with Positive Screen
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‣ Medication Use During Trial
Medications ordered for all patients who screened positive
except 1 patient.
Quetiapine and Trazadone ordered most often.
Haldol 1 time only doses noted.
1 patient did not receive scheduled medications. Pt. escalated
and code orange called. Restraints for short period of time
‣ Barriers that were addressed: Providers (Moonlighters) not aware of the protocol, some
reluctant to order protocol
Protocol not ordered with positive screen
Pts. Transferred with ICU Delirium Protocol – delay in order
reconciliation
Delay in re-screening patients with a change in patient condition
Inconsistent completion of the screening.
‣ Positive Outcomes Nurses empowered to advocate for patients
Increased effective communication with providers
Increased use in restraint alternatives and fall prevention interventions.
Delirium care education elevated the practice level of the nurses
FY17Q3 FY17Q4 FY18Q1 FY18Q2
7N 14 4 5 4
7S 9 5 6 6
0
2
4
6
8
10
12
14
16
# O
F P
AT
IEN
TS
Number of Patients in Restraints (FY17Q3-FY18Q2)
7N=277S=26
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0
1
2
3
4
5
6
7
8
9
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18
DA
YS
Ave. Number of Days
(FY17Q3-FY18Q2)
7 A North 7 A South
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Fall
Rat
e
May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Inpatient Monthly Fall Rate 6.10 13.30 3.80 13.70 4.00 0.00 8.40 3.50 3.30 3.80 7.00
7 North Fall Rate
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Fall
Rat
e
May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Inpatient Monthly Fall Rate 5.20 5.30 3.70 3.60 3.80 3.60 6.30 3.70 6.40 5.40 1.80
7 South Fall Rate
Month Hospital 7 North 7 SouthJanuary 30 7 13
February 15 4 8
March 26 10 9
April 18 4 4
May 39 11 13
June 30 8 12
July 25 5 11
August 16 2 4
September 22 6 10
October 13 7 3
November 15 5 8
December 22 8 7
Total 271 77 102
Inpatient Geriatric Consults 2017 Code Oranges FY17
Total Code Oranges 22 Delirium-related incidents
10 out of 22 incidents involved physical and verbally disruptive behavior (compared to 19 out of 25 pre-trial)
Area # of Incidents
7 North 11
7 South 10
11.5.18
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Haldol IV Push in Non-ICU areas
‣ Discussion:
Black Box warning: 9/2007 FDA advisory was published and updated 08/14/2013
Risk of QT prolongation and Torsades de Pointes (TdP) especially when given IV
Due to the risks, ECG monitoring is recommended if haloperidol is given IV
Statement on vial, “IM Use Only”
Query Question Results
VA (Pharmacy) If Haldol IV was given at their facility
43 responses 38 yes (require
telemetry) 5 no
Indianapolis(Nursing)
If Haldol IV given on medical surgical units
5 Hospital Systems Can administer
Haldol on medical surgical units based on specific patient need
Approval for Haldol IV Push to be given on Medical-Surgical units.
Combine ICU and Med-Surgical units protocols into one
Recommendations for Provider to order EKG prior to Haldol use
Delirium Nursing Interventions automatic on all patients
‣ Go-Live August 14th, 2017
‣ Order sets (Med-Surg & ICU) combined into one
‣ Face-to-Face training for RN staff on 8North, 8South, and 4 West (two-week training schedule)
‣ Pharmacy and Provider Education
‣ Nursing Documentation changes to ensure restraint alternative and/or mobility can be documented by RN, LPN, HT, and CNA.
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Action Status
Development of TMS modules for orientation (RN & unlicensed nursing staff [LPN, HT, NA])
Completed
Development of MCM Completed
Face-to-Face Training for unlicensed nursing staff
pending
Delirium toolkit Pending
Monitoring & data analysis Ongoing
‣Toolkit planning-difficult endeavor
‣Patient scenarios were powerful tool as theyincluded actual patients
‣ Pre and post test administration challenges
‣CIWA Protocol and Delirium Protocol-which one touse
Reduced Restraint Use
Significant decrease of 4-point restraint use
Falls trended down
Reduction of code oranges related to delirium/dementia
Increased awareness of geriatric consult availability
Standardized medication management of patients with delirium
Improved comfort level and ability of nurses to screen for delirium and provide care
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Arlington, VA: American Psychiatric Publishing.
Goldstein, N. & Morrison, R. (2013). Evidence-based practice of palliative medicine. Elsevier Saunders: Philadelphia
Inouye S. K. (2006). Delirium in older persons. New England Journal of Medicine, 354:1157e1165.
Veterans Health Administration. (2014). Interdisciplinary Delirium Resource Team Manual VISN 10. Cleveland, OH:
Geriatric Research Education and Clinical Center.
McConnell, S. & Karel, M. (2016). Improving management of behavioral and psychological symptoms of dementia in
acute care. Nursing Administration Quarterly, 40 (3), 244-254.
Solberg, M., Plummer, C., May K. & Mion, L. (2013). A quality improvement program to increase nurses’ detection of
delirium on an acute medical unit. Geriatric Nursing, 34, 75-79.