G2 - Geriatric Delirium Quality Improvement Project
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Transcript of G2 - Geriatric Delirium Quality Improvement Project
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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
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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
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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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