Towards delirium prevention: The
outcomes of clinical research
Isabel Higgins
Professor of Older Person Nursing
School of ...
Aim
Premise:
• Older people high risk
• Delirium detection/ prevention
essential during transitions
To share outcomes of c...
Epidemiology of delirium
• 40-53% long term care
• 10-15% on admission to hospital
– 30% with hip fracture
– 21% community...
The steps towards delirium
prevention
• Establishing the main concerns for
managers and clinicians
• A pilot PAR study
• E...
In the beginning: Establishing the
concerns of clinicians
Kick-starting older person research program by
Professor Tina Ko...
The problem of Delirium
• High prevalence & incidence
• Often misidentified, misdiagnosed, mistreated
• Associated with ad...
Causes
• General illness, infection: pneumonia,
UTI
• CNS disorders: stroke, haematoma
• Cardiac & respiratory failure
• M...
Delirium
• is a disturbance of consciousness
and a change in cognition that
develops over a short period of time
• tendenc...
• Participatory Action Research using Koch &
Kralik’s (2006) story telling approach
• Eleven member team with 8 clinicians...
Application of PAR
• Weekly meetings - Ward based, dedicated
time & commitment
• Looking - Shared stories, experiences,
kn...
Findings & outcomes
• Constraints to practice identified
– Delayed transfer from ED – 4.5 to 25hrs, ED concerns
– Ward rou...
Chart audit
Cognitive assessment in pre and post-pilot study
17
23
1
29
34
6
0
5
10
15
20
25
30
35
40
Cognitive
assessment...
Staff survey - 2008
How often do staff refer to the Delirium Alert Protocol
(DAP) to assess patients
2
5
8
4
0
2
4
6
8
10
...
Staff survey
KnowledgeofsubtypesdeliriumpreandpostDAP
10
5
7
13
12
13
0
2
4
6
8
10
12
14
Hyperactive Hypoactive Mixed
Deli...
The delirium word
So when they say, “oh they’re a bit
confused”, I’d say, “so we’re talking
delirium here? Or are we talki...
Ongoing challenges
It’s a challenge to the ward to continue to
put it forward… every new person who
comes or someone who d...
The ED studies – 2010 to 2012/3
Phase 1: 2010
Focus groups
Aims:
• To explore management of acutely
unwell patients in residential aged
care facilities (R...
Focus Groups
• 4 Residential aged care facilities
• Self care beds, low and high care
beds
• Focus group at each facility
...
Facilitators
• RACF staff prefer to care for
residents at home
• Transfer
Challenges
• Staffing
• Medications
• GPs
• Allied health, diagnostics, equipment for
RACF staff, environment
• Transfer
•...
Solutions
• Chronic care plans and CNC support
• Improved acute care skills in RACF eg
changing catheters and tracheostomy...
Solutions
• Simple contact point for advice on
acutely unwell residents
• Standardised transfer documents
and procedures t...
Phase 2: 2011
Pilot study MOC
• MOC
–Aged Care Emergency (ACE) CNC
–Older Person Technical Assistant (OPTA) in ED
Aims of MOC
• Facilitate access to appropriate care
within and external to the ED
• Ensure that there is an increased
rate...
ACE
• Provision of
• telephone liaison
• direction and support service for the staff
of RACFs via an Aged Care Emergency
(...
OPTA
Systematic screening and supportive
care, including delirium prevention and
management, provided by Older
Person Tech...
Data collection
Multiple methods
–Literature review
–Document analysis
–Interviews & FGs
–Survey of older people & carers
...
Findings
•ACE
•OPTA
•Overall
Conclusion
• Prevention of delirium - focus of change
• Reflections
collaborative processes
engaging stakeholders
MOC
comm...
Acknowledgements
• Funding: SNM TUN, DOHA
• Senior Management of the JHH, HNELHD, New South
Wales.
• Researchers:
– Jenny ...
Further reading
Day, J., Higgins, I., Koch, T. (2008) Delirium and older people.
In: Nay R, Garatt S. (Eds.) Interdiscipli...
References
Inouye, S., Bogardus, S. T. J., Baker, D. I., Leo-Summers, L., & Jr., C. L. 2000. The
Hospital Elder Life Progr...
Isabel Higgins, University of Newcastle & Centre for Practice, Opportunity and Development (CPOD), Hunter New England Loca...
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Isabel Higgins, University of Newcastle & Centre for Practice, Opportunity and Development (CPOD), Hunter New England Local Health District - Towards delirium prevention: The outcomes of clinical research

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Isabel Higgins, Professor of Nursing, Older Person
Care, School of Nursing and Midwifery, University
of Newcastle; Clinical Chair, Centre for Practice
Opportunity and Development (CPOD), Hunter New
England Local Health District delivered the presentation at the Transition Care: Improving Outcomes for Older People Conference 2013.

The Transition Care: Improving Outcomes for Older People Conference explores a combination of residential and community transition care programs. It also features industry professionals' experiences in transitional aged care, including the challenges and successes of their work.

For more information about the event, please visit: http://www.communitycareconferences.com.au/transitioncareconference13

Published in: Healthcare, Health & Medicine
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Isabel Higgins, University of Newcastle & Centre for Practice, Opportunity and Development (CPOD), Hunter New England Local Health District - Towards delirium prevention: The outcomes of clinical research

  1. 1. Towards delirium prevention: The outcomes of clinical research Isabel Higgins Professor of Older Person Nursing School of Nursing and Midwifery, Faculty of Health Collaborating Centre for Older Person Care (CCOPC): Research Centre for Gender Health and Ageing Clinical Chair University of Newcastle Centre for Practice Opportunity & Development (CPOD) Nursing & Midwifery Network Lead Hunter Medical Research Institute Hunter New England Health
  2. 2. Aim Premise: • Older people high risk • Delirium detection/ prevention essential during transitions To share outcomes of collaborative research activities undertaken over the past 6 years
  3. 3. Epidemiology of delirium • 40-53% long term care • 10-15% on admission to hospital – 30% with hip fracture – 21% community • Up to 40% in hospital – 60% post op – 20% general ward www.health.gov.au/internet/main/publishing.nsf/Content/9E46460CFDAFBA03CA25732B004C4331/ $File/Background%20information.pdf
  4. 4. The steps towards delirium prevention • Establishing the main concerns for managers and clinicians • A pilot PAR study • ED studies1, 2 & 3 • Towards sustainability
  5. 5. In the beginning: Establishing the concerns of clinicians Kick-starting older person research program by Professor Tina Koch ‘What are the concerns claims and issues surrounding older person care?’ 60 key stakeholders in the Hunter New England (NSW) Health area were interviewed Top research priority Older people and delirium
  6. 6. The problem of Delirium • High prevalence & incidence • Often misidentified, misdiagnosed, mistreated • Associated with adverse events in hospital – increased LOS, – use of restraint, – falls, – pressure areas – results in discharge to residential care or death • Preventable • Poor uptake of EB guidelines Inouye et al, 2000, 2001, 2005, 2006
  7. 7. Causes • General illness, infection: pneumonia, UTI • CNS disorders: stroke, haematoma • Cardiac & respiratory failure • Medications • Disorders of metabolism; renal failure, dehydration
  8. 8. Delirium • is a disturbance of consciousness and a change in cognition that develops over a short period of time • tendency to fluctuate during the course of the day (Inouye, 2006)
  9. 9. • Participatory Action Research using Koch & Kralik’s (2006) story telling approach • Eleven member team with 8 clinicians & high speed typist • Unconditional commitment from senior management • Oversight committee • Research Ethics Committee approval • 32 bed acute care medical ward in large tertiary referral hospital in NSW PAR pilot study - 2007
  10. 10. Application of PAR • Weekly meetings - Ward based, dedicated time & commitment • Looking - Shared stories, experiences, knowledge understanding, literature, guidelines as evidence • Thinking - Reflection on looking, what is going on here? • Acting - Minutes captured movement toward action, three data sets generated
  11. 11. Findings & outcomes • Constraints to practice identified – Delayed transfer from ED – 4.5 to 25hrs, ED concerns – Ward routines, role of relatives – Missed diagnosis, absence of assessment skills – Pressure to reduce LOS • Changed practice – Delirium room innovation – Reduced restraint use – Delirium Alert Protocol • Measured incidence of delirium & cases missed – 1pt (2.7% n=48) with delirium diagnosis – 8 (22% n=48) pts suspected
  12. 12. Chart audit Cognitive assessment in pre and post-pilot study 17 23 1 29 34 6 0 5 10 15 20 25 30 35 40 Cognitive assessment (ED) Cognitive state recorded MMSE Cognitive Assessment Numberofpatients(n=37) Pre-pilot Post-pilot
  13. 13. Staff survey - 2008 How often do staff refer to the Delirium Alert Protocol (DAP) to assess patients 2 5 8 4 0 2 4 6 8 10 Seldom Sometimes Often Always Frequency Numberofstaff
  14. 14. Staff survey KnowledgeofsubtypesdeliriumpreandpostDAP 10 5 7 13 12 13 0 2 4 6 8 10 12 14 Hyperactive Hypoactive Mixed DeliriumSubtypes Numberofstaff BeforeDAP(n=26) Post DAP(n=22)
  15. 15. The delirium word So when they say, “oh they’re a bit confused”, I’d say, “so we’re talking delirium here? Or are we talking dementia? What are we talking here?” And it’s usually, they’d say,” oh, it probably is delirium, or it is delirium, because they’re uroseptic or whatever.” Li et al., 2009, 2010
  16. 16. Ongoing challenges It’s a challenge to the ward to continue to put it forward… every new person who comes or someone who doesn’t work here regularly [needs to be reminded of the prevention of delirium and the DAP] So you’re kind of leading them [with reference to the resident medical officer] a little bit along that way. Because our doctors rotate every two months it is a bit of a challenge. Li et al., 2009, 2010
  17. 17. The ED studies – 2010 to 2012/3
  18. 18. Phase 1: 2010 Focus groups Aims: • To explore management of acutely unwell patients in residential aged care facilities (RACF) • To explore challenges and facilitators of transfer of acutely unwell patients from RACF to ED
  19. 19. Focus Groups • 4 Residential aged care facilities • Self care beds, low and high care beds • Focus group at each facility • Focus group with GPs nominated by RACF
  20. 20. Facilitators • RACF staff prefer to care for residents at home • Transfer
  21. 21. Challenges • Staffing • Medications • GPs • Allied health, diagnostics, equipment for RACF staff, environment • Transfer • ED • On return
  22. 22. Solutions • Chronic care plans and CNC support • Improved acute care skills in RACF eg changing catheters and tracheostomy care • Guidelines and procedures for common problems • Understanding what community services are available
  23. 23. Solutions • Simple contact point for advice on acutely unwell residents • Standardised transfer documents and procedures to and from ED • Simplified ambulance process • Access to emergency medication and starter packs
  24. 24. Phase 2: 2011 Pilot study MOC • MOC –Aged Care Emergency (ACE) CNC –Older Person Technical Assistant (OPTA) in ED
  25. 25. Aims of MOC • Facilitate access to appropriate care within and external to the ED • Ensure that there is an increased rate of screening of older people in the ED in order to minimise risk of adverse events, in particular, delirium, pressure areas and falls. • Enhance the satisfaction of older people and their carers with the ED experience.
  26. 26. ACE • Provision of • telephone liaison • direction and support service for the staff of RACFs via an Aged Care Emergency (ACE) CNC • Evidence based response protocols/ algorithms for staff of RACF
  27. 27. OPTA Systematic screening and supportive care, including delirium prevention and management, provided by Older Person Technical Assistants (OPTA)
  28. 28. Data collection Multiple methods –Literature review –Document analysis –Interviews & FGs –Survey of older people & carers –Chart audit –Outcomes data –Cost of MOC
  29. 29. Findings •ACE •OPTA •Overall
  30. 30. Conclusion • Prevention of delirium - focus of change • Reflections collaborative processes engaging stakeholders MOC communication
  31. 31. Acknowledgements • Funding: SNM TUN, DOHA • Senior Management of the JHH, HNELHD, New South Wales. • Researchers: – Jenny Day, Tina Koch, Iris Li, Michelle Giles, Fran Dumont – Leanne Bashford RN, Greg Schwager RN, Rhonda Spain RN, Helen Ryan Physio, Melissa Oakman RN, Joanne Firth RN, Mathew Lockyer EN, Debbie Harper, NUM, J3, John Hunter Hospital – Carolyn Hullick, Jane Conway, Jacqueline Hewitt, Deborah Armitage, Ian O’Dea, John Attia, Amy Stokoe – Participants: GPs, RACF staff, ED staff, residents, carers
  32. 32. Further reading Day, J., Higgins, I., Koch, T. (2008) Delirium and older people. In: Nay R, Garatt S. (Eds.) Interdisciplinary Care of Older People: Issue and Innovations. Elsevier Australia, Sydney. (in press). Day, J. Higgins, I, Koch, T. (2009). The process of practice redesign in delirium care for hospitalised older people: A participatory action research study. International Journal of Nursing Studies. 46, 12-21 Day, J., Higgins, I., Koch, T. (2008) Delirium and older people: What are the constraints to best practice delirium care. International Journal of Older People Nursing, 3, 170-177. Li, P., Bashford, L., Schwager, G., Spain, R. Ryan, H. Oakman, M., Firth, J., Lockyer, M., Harper, D., Higgins, I. (2010) Clinician’s experience of participating in an action research study. Journal of Contemporary Nursing. 35(1), pp 147-156. Day Jennifer Lynn, Higgins Isabel Johanna, Keatinge Diana Rosemary,'Orientation strategies during delirium: Are they helpful?', Journal of Clinical Nursing, 20 3285-3294 (2011)
  33. 33. References Inouye, S., Bogardus, S. T. J., Baker, D. I., Leo-Summers, L., & Jr., C. L. 2000. The Hospital Elder Life Program: A model of care to prevent cognitive and functional decline in older hospitalised patients. Journal of the American Geriatrics Society, Vol 48(Number 12). Inouye, S., Foreman, M., Mion, L., Katz, K., & Cooney, L. J. 2001. Nurse's recognition of delirium and its symptoms. Archives of Internal Medicine, 161(Nov 12), 2467-2473. Inouye, S. 2004. A practical program for preventing delirium in hospitalized elderly patients. Cleve Clinical Journal Medicine, 71(11), 890-896. Inouye, S., Leo-Summers, L., Zhang, Y., Bogardus, S. J., Leslie, D., & Agostini, J. 2005. A chart-based method for identification of delirium: Validation compared with interviewer ratings using the confusion assessment method. Journal of American Geriatric Society., 53(2), 312-318. Inouye, S. K. 2006. Delirium in older persons. New England Journal of Medicine, 354(11), 1157-1165. Koch, T. & Kralik, D (2006). Participatory action research in health care. Blackwell publishing, Carlton, Victoria. Li, P., Bashford, L., Schwager, G., Spain, R. Ryan, H. Oakman, M., Firth, J., Lockyer, M., Harper, D., Higgins, I. (in press accepted May 2010) Clinician’s experience of participating in an action research study. Journal of Contemporary Nursing. Meagher, D. 2006 Delirium: optimising management. BMJ. 322(7279): 144–149.

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