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Publication Date
4-29-2020
Disciplines
Internal Medicine
Abstract
INTRODUCTION: This quality improvement project involved hiring, training, and managing 3 Delirium Mobility Aids to implement a non-pharmacologic delirium prevention bundle package, including early mobility, on hospitalized patients age >65.
Background: Delirium affects 20-30% of older hospitalized patients [1]. Patients with delirium have double the mortality rate [3], which increases with delirium duration [4]. Delirium worsens long term cognitive functioning [9,10,11,12]. Hospital costs increase by $2,500 per patient, totaling $6,900,000,000 in Medicare expenditures [7]. A single delirium episode increases total yearly costs by ~$64,421 [2]. Research suggests the best treatment is non-pharmacologic multicomponent interventions [6], and those with most benefit include early mobility, reorientation, cognitive/sensory stimulation, and hydration [5].
Methods: A delirium prevention protocol was created addressing four main pillars. • Hydration: water placed within patient reach. • Sensory input: • window blinds opened by 9:00 am • hearing-aids and eye-glasses retrieved and utilized. • Soothing music via delirium TV channel for non-communicative patients. • Reorientation: oriented to person/place/time 3 times daily. • Mobility: 20-min walk (mobilization event) 3 times daily Work and time constraints prohibited existing health professionals (CNA, RN, MD, PT, OT) from implementing the protocol. Thus a new job position (Delirium Mobility Aid) was created to implement this protocol for all patients age >65 admitted to Medical A(28-bed medical unit). This was proposed to Providence St. Vincent Medical Foundation who awarded a $170,000 institutional grant for 12 months. The project residents reviewed applications, interviewed, and hired 3 CNA's to fill the position 12 hr/day, 7 days/week. Physical and Occupational Therapy trained the aids for 3 weeks in delirium management and mobilization techniques. Data was collected in Epic flowsheetsand chart notes. Confusion-Assessment-Method (CAM) is a established delirium scoring system utilized on Medical A. Data from intervention year (2019) was compared to baseline data collected 2 years prior (2017, 2018) on the same hospital unit.
Results: Preliminary data collected at month 9 of 12: • No statistically significant change in total delirium burden. However there is a trend toward decreased delirium in prolonged hospitalization (measured after day 4). For these patients with LOS > 6 days, there was a 4% reduction in late-stay delirium compared to 2018 and 10% from 2017. • 7.5-13% more patients were completely delirium free after day 4 • Length of Stay (LOS): no significant change (5.5 days) • Patients admitted from home experienced a 4% increase in discharge to home (rather than care-facility) approaching near significance (p-value 0.06). • There was a trend toward reduction in hospital falls: 2017-33. 2018-29. 2019 (present)-19, projected to reach 25 by year’s end. • Press-Ganey patient satisfaction scores remained stable.
Conclusion: Non-pharmacologic multicomponent prevention protocols, which include mobilization, implemented by specialized CNA’s, are a potentially viable treatment of delirium in elderly patients with prolonged hospitalization. This may increase rate of discharge to home, without worsening falls, LOS, or patient experience, and has a cost-savings benefit.
Specialty/Research Institute
Internal Medicine
Specialty/Research Institute
Graduate Medical Education
Conference / Event Name
Academic Achievement Day, 2020
Location
Providence St. Vincent, Internal Medicine Residency, Portland, Oregon
