g2 - geriatric delirium quality improvement project
DESCRIPTION
This presentation was delivered in the Rapid Fire session E2 of Quality Forum 2014 by: Peter O'Connor Regional Department Head, Program Medical Director, Older Adult Fraser HealthTRANSCRIPT
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Geriatric Delirium
Quality Improvement Initiative Fraser Health Authority
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Dr. Jean Warneboldt Dr. Peter O’Connor Ms. Heidi Cumberworth
Dr. Irina Chorny Ms. Sharmen Lee
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Geriatric Delirium
Quality Improvement Initiative Fraser Health Authority
No Disclosures
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Delirium Physician Project
Context – Delirium interdisciplinary CPG available – physician participation? Issue – increase physician awareness and involvement in delirium management Intervention – shared work team, pre- and post-audits, leadership, delirium PPO (pre-printed orders) Measurements – chart audit based Challenges and Lessons learned
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Why Delirium?
occurs in 11-42% of hospitalized patients one-year mortality rate 35-40% associated with longer length of hospital stay and earlier admission to nursing homes estimated to cost $152 billion dollars annually in the USA
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How did it start?
Joint Quality Improvement Initiative between the Older Adult Program and Hospitalists to improve the care for older pts. with delirium in FHA
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Project Description formed multi-disciplinary committee reviewed literature and existing practice created Pre-Printed Order & Chart Audit Tool Pre-PPO Chart Audit implemented PPO and educated staff Post-PPO Chart Audit data review, feedback from stakeholders and
revision of PPO Sustainment Audit
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Findings n=114 randomly selected medical patients ERH and RCH with Hospitalist as MRP overall 32.5% delirium reaffirmed previously documented risk factors:
Delirium No Delirium
average age 81 76
dementia 46% 8%
previous delirium 14% 3.9%
sepsis 35% 13%
hypoxia 35% 27%
median # of moves in stay 3 2
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Benefits
please note that new restraint policy came into effect during this study.
Pre-PPO Post-PPO delirium identified by MD 95% 100% further investigations ordered 76% 100% meds changed 56% 82% delirium identified by allied health staff 15% 53% delirium identified in Kardex 50% 76% restraint use 15% 0%
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Pre-PPO Post-PPO
delirium prevalence 36% 29%
MD recognition of risk of delirium 10% 29%
average non-permanent Foley catheter use 2.3 days 0.67 days
Benefits
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Benefits
Decreased average Length Of Stay (days)
62% of delirium pts.. were Atypical (and therefore longer LOS) Average LOS for typical patients 22 vs. 18 days pre. Vs. post. PPO
Pre-PPO Post-PPO
Delirium 38 29
Sustainment Audit 6-8 months post PPO formal start date
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Hospital A: 357 total reviewed – 15.1% on PPO Hospital B: 382 total reviewed – 8.1% on PPO
Estimated Prevalence
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Limitations of study
Population size sampling pattern - randomly chosen cross-
section of medical in-pts. over-representation of longer stay, therefore atypical pts. (because represents medical pts. bed occupancy rather than admission rates)
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Why would you consider implementing this PPO?
Positive outcomes achieved decreased length of stay improved recognition of delirium by all staff streamlined investigation and treatment of delirium sets evidenced-based standard of care
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Why would you consider implementing this PPO?
Unexpected secondary gains improved MD and RN engagement and job satisfaction decreased catheter and restraint use increased medication adjustment
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Why would you change your practice?
This evidence-based tool discovers the underlying cause of delirium rapidly sets a standard of care initiates involvement of multi-disciplinary team improves RN documentation improves staff awareness of delirium streamlines management of delirium standardized approach to medication choice and
dosing to enhance patient safety
Challenges and Lessons Learned
Access to forms - Unit clerks Awareness of forms – nursing, physicians etc. Need to link to larger interdisciplinary focused effort – 48/6 initiative Need for champions Sustainment a challenge Effective approach to preventing delirium
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