Project Timeframe: October, 2011 – ongoing
Problem: Delirium is an acute medical disorder that results in disturbances of attention and cognition. It is marked by a rapid onset of a reduced ability to focus or to sustain or shift attention, and a change in cognition or the development of a perceptual disturbance, often including visual hallucinations. Almost 30 percent of older medical patients experience delirium at some time during hospitalization. The risk of older surgical patients developing this condition assessed to range from 10 to greater than 50 percent. It is estimated that delirium occurs at a rate of between 70 to 87 percent in patients admitted to the intensive care unit.
Delirium is a medical emergency and the most effective treatment strategy for it is prevention. However, if the condition occurs it is essential that casual factors be identified and supportive care and clinical interventions be provided to mitigate any lasting neurological squeal
BMH Medical staff identified the need for an evidence based protocol for:
- assessing patients on admission for the risk of delirium
- simple nursing interventions to prevent the development of delirium
- defined treatment protocols for treatment of delirium in those patients developing it
Goal: To determine if the patient is experiencing a delirium at the time of admission and identifying those patients that may have a dementia placing at increased risk for the development of the condition. Decrease incidence of delirium by 10%.
Interventions: In October, 2011, we put together a multidisciplinary Task Force including the Chief Medical Officer, several Hospitalists, the VP of Patient Care Services, a Psychiatric Social Worker, Special Care Unit Manager, and Care Managers to research evidence based assessment and treatment tools and to develop a series of protocols.
Currently all Hospitalist admitted patients 65 years and older receive a standardized assessment of their mental status completed at the time of their admission (SPMSQ) to assess for delirium and determine baseline cognitive functioning a functional assessment interview completed by Care Management staff. Data from those assessments is being gathered and analyzed.
The team has developed simple nursing interventions for preventing delirium. These interventions include:
- Non-pharmacological sleep hygiene strategies: such as quiet, non-interrupted sleep at night
- Early mobilization: PT assessment / exercise; having the patient be frequently out of bed
- Frequent Orientation/Cognitive Stimulation: Reorientation by staff, family, sitters; visible clocks and calendars; frequent verbal engagement
- Maintain sensory acuity: Secure hearing aid batteries and glasses for patients as needed; ensuring ears are free from wax build up that might cause hearing loss
Training for Nursing staff in neurological assessment and the formal utilization of these interventions will begin this Fall Once training is completed we will continue to track data to assess the effectiveness of our interventions, and to refine both assessment and treatment protocols.
Measures: We are currently gathering data on he number of patients meeting screening criteria, the number actually screened and those assessed as being at risk for delirium. We are also gathering data on those with delirium on admission and those developing delirium during their hospital stay. Due to a relatively low number of patients within each category we will continue to gather data for several more months before completing a comprehensive analysis.
Michele Rowland, RN, LICSW
Executive Director, Quality, Utilization and Care Management
Brattleboro Memorial Hospital
17 Belmont Avenue, Brattleboro, VT 05301