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