By Michele Rowland
On June 19 the Brattleboro Reformer published an Associated Press article citing recent research showing that patients who experience a delirium during a hospital stay have an increased risk of mortality. At the very least, delirium prolongs the hospital stay, resulting in increased healthcare costs. It also increases the likelihood of functional decline and loss of independence. Patients experiencing a delirium while in the hospital also have a higher likelihood of nursing home placement within a year.
Aware of these risks, BMH has recently instituted a new initiative to identify patients who may be at risk for delirium, and take simple, low-cost, non-invasive measures to prevent them from occurring. This initiative is part of our participation in the federal program seeking to achieve a 40% reduction in preventable harm and to decrease hospital readmissions by 20%.
A delirium is primarily a disruption of attention. It involves a reduction in the ability to focus and to maintain or shift attention. Delirium can also include a change in the ability to think clearly, and may involve visual or hearing disturbances. The greatest risk factor for identifying the disorder is a pre-existing diagnosis of dementia such as Alzheimer’s disease or other neurological impairment. Delirium is different from dementia in that delirium has a brisk onset—usually within hours or a few days—and a patient’s level of awareness can fluctuate during the day. Most importantly, delirium is often tied to an identifiable cause, which can include a reaction to a certain medication or withdrawal from alcohol. While experiencing a delirium the patient may become very agitated. This can lead to complications in providing care, including the risk of harm to the patient or attending nurses and physicians.
Under our new initiative we now screen all newly admitted patients to assess their risk for developing delirium. This screening tool involves a series of simple questions which allow us to detect if the patient has any impairment in their ability to think or recall simple facts. We then follow up with the family to get a more complete picture of a patient’s state of mind by finding out their level of independence on daily basis – if they still drive safely or maintain their own checkbook accurately, for example.
Based on all the information we collect, we then can incorporate some simple interventions nurses can take to minimize the risk that a delirium will occur. Since delirium is a disruption of attention, these interventions are simple ways to help the patient refocus and maintain attention throughout their hospital stay. These interventions are grouped into three categories.
- Sensory acuity. Patients typically arrive at a hospital in a condition of crisis. They may have fallen or have trouble breathing, and arrive at the hospital without glasses, hearing aids or other items they may need. Contacting family members and asking them to bring these items to the patient can be critical to maintaining their ability to focus attention.
- Orientation. Between hospital staff and family members, a patient may have 20 people visit them on any given day. The nurse is the one constant face they may see over an eight hour shift. So we make sure the nurses orient a patient regularly, telling him or her several times a day what’s going to happen over the course of their stay, which reduces confusion and agitation.
- Ambulation. Getting a patient up and walking around for short periods is beneficial for his or her physical and mental state, and restores a sense of ability and independence.
These small interventions, which carry no costs, have been shown to reduce the risk of delirium even in patients with advanced Alzheimer’s disease. While at BMH we don’t have a high incidence of delirium, the more we work toward implementing these small prevention techniques, the more we will increase a patient’s quality of life when they go back out into the community. That result alone makes them very important to us.
Michele Rowland, RN, LICSW is the Executive Director of Quality, Utilization and Care Management at Brattleboro Memorial Hospital.