Delirium Management Program - IHIapp.ihi.org/.../Document-7153/AB17_Delirium_Storyboard.pdf ·...
Transcript of Delirium Management Program - IHIapp.ihi.org/.../Document-7153/AB17_Delirium_Storyboard.pdf ·...
Delirium Management Program
In September 2010, Kaiser Permanente San Rafael Medical Center
(KP-SRF) initiated a pilot project aimed at providing the best care
for hospitalized patients at high risk of developing delirium during
their acute illness and hospital stay. Recognizing the need in the
San Rafael residence area–-which has a large aging population
–-KP-SRF’s Dementia Taskforce began a program in which a
multi-disciplinary team used evidence-based practices for the
management and ultimately the prevention of delirium.
The initial pilot of the Delirium Management Program included 470
unique patients who received consultation from September 2010
– July 2012, a period of 23 months. Patients receiving service from
the delirium team were primarily in medical surgical units.
Identifying, addressing and managing delirium (which often
includes combative or agitated behavior) is critical to providing
excellent care. Through more effective use of relevant protocols,
order sets, and medications, as well as comprehensive staff
education, the patient care experience at KP-SRF was improved.
The program attained a 23 percent reduction in average length of
stay for patients with a diagnosis of delirium, which translates to
an estimated $2.4 million annual savings.
BACKGROUNDWhile “delirium” is often confused with “dementia,” it can be
distinguished as a state of acute confusion characterized by
inattention, an abnormal level of consciousness, disorganized
THINKING��AND�A��UCTUATING�course. Risk factors for delirium
include underlying cognitive
impairment, dementia,
advanced age, acute infection,
and exposure to medications.
Older patients, particularly
those who have dementia, are
most susceptible to delirium.
For those with acute delirium
and no prior diagnosis of
dementia, there is an increased
chance of acquiring a dementia
diagnosis within the following
year. Delirium is considered a stress test for the brain. Most
staggering is that 40 percent of all patients 65 years or older who
develop delirium will die within one year.
The goal of the program
was to implement
a process for timely
identifi cation and
treatment of hospitalized
patients with delirium.
Treating Delirium in Elderly Hospitalized Patients
APPROACHThe KP-SRF Delirium Management Program is a comprehensive
program with multiple complementary components. The pilot
began with structured rounding Monday through Friday by a
Psychiatrist and a Clinical Nurse Specialist and later expanded to
include psychiatric consultation on weekends.
The program then continued to develop through implementation
of the following:
z Dedicated dementia social work role, instrumental in
providing support and education to delirium patients
and their families
z 3IMPLIÚ�ED�+AISER�0ERMANENTE�(EALTH#ONNECT��gDRAG�and drop” referral mechanism
z Confusion Assessment Method tool (CAM-ICU©)
EMBEDDED�IN�+0�(EALTH#ONNECT�TO�ASSESS�DELIRIUM
z New templated note to ensure that standard elements
were documented, including risk factors, baseline
cognitive status, and review of current and past
medications that might contribute to delirium
z Recommended interventions summarized in
a delirium management protocol
z Staff education for all hospital-based RNs and patient
care technicians
z Medication dosing guide distributed to hospitalists
and Emergency Department staff to promote selection
of appropriate, safe medicines
AWARD FOR QUALITY WINNER2013 JAMES A. VOHS
OBJECTIVESThe overarching goal of the Delirium Management Program was
to implement a multidisciplinary, systematic process for timely
IDENTI�CATION�AND�TREATMENT�OF�HOSPITALIZED�PATIENTS�WITH�DELIRIUM��The program had the following objectives:
1. Achieve staff and patient safety through effective
management of delirium
2. Raise awareness of delirium and educate all care providers
OF�THE�BENEÚ�TS�AND�NECESSITY�OF�A�TEAM�APPROACH�TO�THIS�disease process
3. Assist hospitalists in working up the possible etiology of
delirium while at the same time providing appropriate
medical management of this challenging disease process
Delirium Management Program
TheQuality Leader
EvidenceBasedCare
Specialized Teamfor Delirium Rounds
Multi-disciplinary Approach
Hospital Environment
Education and Training for Hospital RNs & Patient Care Technicians (PCTs)
Medication Management
Leverage KP HealthConnect®
GOAL DRIVERS FOCUS AREAS
SEPTEMBERQ�Delirium Management Team Established
Q�Monday - Friday Delirium Rounds Start
JANUARYQ�Dedicated Dementia Social Worker
APRILQ�Addition of Falls and Pneumonia Prevention Recommendations
OCTOBERQ�Psychiatry Rounding on Weekends
Q�Pharmacy Creates List of Medications That Contribute to Delirium
APRILQ�Grand Rounds Delirium and Dementia
SEPTEMBERQ��Dot Phase Created in KP HealthConnect for Order Set Reminder
and Adding Diagnosis to Problem List
NOVEMBERQ�Delirium/Dementia Education for RNs & PCTs Begins
Q�Guidelines for Medication Management Introduced
Q�Resource Binders Distributed to All Medical Surgery Units
MAYQ�Delirium / Dementia Website Added to KP-SRF Website
NOVEMBERQ�Volunteers Trained to Visit At-Risk Patients
Delirium Management Program Project Timeline
2010
2011
2012
MEASURED RESULTSThree indicators of quality of care were measured for the
target population:
z Average length of stay (ALOS)
z Restraint days as a percent of all patient days
z Falls as a percent of all hospital admissions
Average length of stay in the target population decreased from
8.5 to 6.5 days, comparing the baseline to the period after
program implementation. This improvement was for an annualized
volume of 480 discharges in the target population.
Trended data for restraints and falls was very limited and
inconclusive. A regional mandate to decrease sitter usage in 2011
is thought to have caused an increase in restraint use, creating bias
in the data.
!��NANCIAL�ANALYSIS�WAS�CONDUCTED�FOR�THE�PROJECT��COMPARING�THE�INCREMENTAL�STAF�NG�AND�TRAINING�COSTS�TO�AGGREGATE�SAVINGS�in average length of stay for the target population. Assuming an
improvement of 2.0 days in ALOS for 480 discharges annually,
and a variable cost per hospital day of $2,700, the Delirium
Management Program is estimated to have avoided $2.6 million
IN�COSTS�PER�YEAR��4HIS�IS�OFFSET�BY�THE�INCREMENTAL�STAF�NG�COST�OF�a 0.5 FTE Clinical Nurse Specialist, plus training costs of $40,000,
for a net savings of $2.4 million annually from the efforts of this
program.
TRANSFER POTENTIALKP San Rafael Medical Center’s Delirium Management Program
is a low-cost model to implement and has high transfer potential.
It primarily consists of a retooling of psychiatry resources and the
collaboration of a clinical nurse specialist who provides program
coordination, clinical support, staff education and training. A key
aspect is empowering existing staff to manage this complicated
disease process consistently and more effectively
Recognizing the impact that their delirium work could have for
patients and families at other Kaiser Permanente medical centers,
the Delirium Management Team has widely shared their program
and multi-disciplinary team experience through presentations and
site visits at other KP regions. They were included in the National
Nursing Leadership Council (NNLC) Delirium Pilot Collaborative
and Kickoff, and the NNLC has begun piloting delirium
management work, in particular as it relates to falls prevention, at
�VE�PILOT�SITES�ACROSS�THREE�REGIONS��
KP-SRF Delirium Management Team co-developed and has greatly
contributed to the Care Management Institute’s Delirium Wiki
site, which is used as a venue to share best practices among the
regions.
KAISER PERMANENTE SAN RAFAEL MEDICAL CENTERNORTHERN CALIFORNIA REGION
SINGLE SITE/SERVICE AREA CATEGORY
SAN RAFAEL MEDICAL CENTER SAN RAFAEL MEDICAL CENTER
2013
VOHSSINGLE SITEAWARD WINNER
JA
ME
SA
. VO H S p A W A R D
FO
RQ
UA
LIT
Y
KP-SRF Average Length of Stay — Patients with Delirium