Geriatric Delirium
Quality Improvement Initiative
Fraser Health Authority

Dr. Jean Warneboldt
Dr. Peter O’Connor
Ms. Heid...
Geriatric Delirium
Quality Improvement Initiative
Fraser Health Authority

No Disclosures

2
Delirium Physician Project
 Context – Delirium interdisciplinary CPG
available – physician participation?
 Issue – incre...
Why Delirium?
 occurs in 11-42% of hospitalized patients
 one-year mortality rate 35-40%
 associated with longer length...
How did it start?

 Joint Quality Improvement Initiative
between the Older Adult Program and
Hospitalists to improve the ...
Project Description
 formed multi-disciplinary committee
 reviewed literature and existing practice
 created Pre-Printe...
7
Findings
 n=114 randomly selected medical patients
 ERH and RCH with Hospitalist as MRP
 overall 32.5% delirium
 reaff...
Benefits
Pre-PPO
delirium identified by MD

95%

100%

further investigations ordered

76%

100%

meds changed

56%

82%

...
Benefits
Pre-PPO Post-PPO
delirium prevalence

36%

29%

MD recognition of risk of delirium

10%

29%

average non-permane...
Benefits
 Decreased average Length Of Stay (days)
Pre-PPO
Delirium

Post-PPO

38

29

62% of delirium pts.. were Atypical...
Sustainment Audit
6-8 months post PPO formal start date
Hospital A: 357 total reviewed – 15.1% on PPO
Hospital B: 382 tota...
Limitations of study
 Population size
 sampling pattern - randomly chosen crosssection of medical in-pts.
 over-represe...
Why would you consider implementing
this PPO?
 Positive outcomes achieved
 decreased length of stay
 improved recogniti...
Why would you consider implementing
this PPO?
 Unexpected secondary gains
 improved MD and RN engagement and job
satisfa...
Why would you change your practice?
 This evidence-based tool discovers the
underlying cause of delirium rapidly
 sets a...
Challenges and Lessons Learned
 Access to forms - Unit clerks
 Awareness of forms – nursing, physicians etc.
 Need to l...
Contacts

 Dr. Peter O’Connor
peter.oconnor@fraserhealth.ca

18
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G2 - Geriatric Delirium Quality Improvement Project

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This presentation was delivered in the Rapid Fire session E2 of Quality Forum 2014 by:

Peter O'Connor
Regional Department Head, Program Medical Director, Older Adult
Fraser Health

Published in: Health & Medicine
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G2 - Geriatric Delirium Quality Improvement Project

  1. 1. Geriatric Delirium Quality Improvement Initiative Fraser Health Authority Dr. Jean Warneboldt Dr. Peter O’Connor Ms. Heidi Cumberworth Dr. Irina Chorny Ms. Sharmen Lee 1
  2. 2. Geriatric Delirium Quality Improvement Initiative Fraser Health Authority No Disclosures 2
  3. 3. 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 (preprinted orders)  Measurements – chart audit based  Challenges and Lessons learned 3
  4. 4. 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 4
  5. 5. 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 5
  6. 6. 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 6
  7. 7. 7
  8. 8. 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 8
  9. 9. Benefits Pre-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  Post-PPO 15% 0% please note that new restraint policy came into effect during this study. 9
  10. 10. Benefits Pre-PPO Post-PPO delirium prevalence 36% 29% MD recognition of risk of delirium 10% 29% average non-permanent Foley catheter use 2.3 0.67 days days 10
  11. 11. Benefits  Decreased average Length Of Stay (days) Pre-PPO Delirium Post-PPO 38 29 62% of delirium pts.. were Atypical (and therefore longer LOS) Average LOS for typical patients 22 vs. 18 days pre. Vs. post. PPO 11
  12. 12. Sustainment Audit 6-8 months post PPO formal start date Hospital A: 357 total reviewed – 15.1% on PPO Hospital B: 382 total reviewed – 8.1% on PPO Estimated Prevalence 12
  13. 13. Limitations of study  Population size  sampling pattern - randomly chosen crosssection of medical in-pts.  over-representation of longer stay, therefore atypical pts. (because represents medical pts. bed occupancy rather than admission rates) 13
  14. 14. 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 14
  15. 15. 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 15
  16. 16. 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 16
  17. 17. 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 17
  18. 18. Contacts  Dr. Peter O’Connor peter.oconnor@fraserhealth.ca 18

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