Delirium: developing and implementing a multi … · developing and implementing a multi-component...

Delirium:

developing and implementing a

multi-component intervention

Dr. Duncan Forsyth Consultant Geriatrician

Addenbrooke’s Hospital

Cambridge University Hospitals NHS Foundation Trust

Cambridge, England

Engaging with management

Psychiatric illness in older people in general hospitals:

– Is common

– Affects outcomes

– Is often unrecognised

– Is often inappropriately treated

Length of stay

Mortality

Costs

Our core business

Age Cardio-vascular disease

Gender Cerebral pathology

Living alone Respiratory disease

Smoking Alcohol

No clock Bed moves

Isolation Precipitating illness

Sensory deprivation ITU

Poor nutrition / dehydration Tubes & catheters

Drugs Restraints

Limited or not modifiable

Define at risk individuals

More modifiable

Define interventions / preventative strategy

Patient Disease

Environment Ilness

What have we done?

• Nurse education and support

• Support of LOAP

• Junior doctor awareness of cognitive problems

• Carer involvement

• Dementia friendly staff and environment

– Day room to be functional for confused patients

– Colour coded ward bays

– Dementia friendly signage

– Coloured toilet seats

– Better seating

– Watering hole

– Artwork

Formalised Training • Alongside the environmental changes training was provided.

• A specialist dementia nurse was appointed. The specialist mental health nurses designed a teaching package which ensures that staff are aware of strategies to use when working with people living with dementia that are admitted to an acute ward and are able to utilise the environment and the resources to improve the patients experience.

• Training was delivered over 8 sessions each of 20 minutes and each session was repeated as necessary so that all ward staff might attend.

• Session 1 Dementia.

• Session 2 Person Centred Care.

• Session 3 Behaviour as communication.

• Session 4 Behaviour as communication.

• Session 5 Meaningful activities.

• Session 6 Depression.

• Session 7 Delirium.

• Session 8 Dementia/Delirium.

Before

After Dementia Friendly Environment

Before After

Before After

Before After

Before After

Environmental risk factors

• Moving room

• No clock local audit data

• No glasses

• Others not conclusive

Preventing delirium • Orientation

• Hydration

• Nutrition

• Constipation

• Infection

• Pain

• Polypharmacy

• Improve mobility

• Reduce sensory impairment

• Avoid sleep deprivation

• Reduce bed moves

• Maintain consistency of staff » Inouye 1999, Marcantonio 1999 and 2001

NB: Multicomponent intervention trials

provide low quality evidence for

reducing:

• Incidence of delirium

• LOS Gustafson 1991

Wanich 1992

Landefeld 1995

Inouye 1999

Harari 1997

Marcantonio 2001

Bogardus 2003

Lundstrom 2005

Wong 2005

Delirium prevention Inouye et al. NEJM 1999

• 852 patients aged > 70 admitted to general medical wards.

One patient from intervention unit matched with two

patients from usual care units

• Intervention consisted of standardized protocols for

cognitive impairment, sleep deprivation, immobility, visual

impairment, hearing impairment, and dehydration

• Intervention group

– Less delirium - 9.9% vs 15% of usual care group

– fewer days of delirium and fewer episodes of delirium

– No difference in LOS

Treatment of delirium

• Cornerstones

– Early recognition

• Missed in < 2/3

– Elimination or correction of underlying causal factors

• Multifactorial causation

• Multicomponent interventions

– Symptomatic and supportive care

Causes of delirium (precipitants)

D rugs

E ndocrine

M etabolic

E nvironmental

N eoplasm

T rauma

I nfection

A poplexy

(stroke)

D rugs: CNS active drugs particularly anticholinergics, polypharmacy, withdrawal (antidepressants, alcohol and benzodiazepines)

I nfection & Intracranial pneumonia, urinary tract, skin

Stroke, subdural, epilepsy

M etabolic glucose, calcium, ammonia, hypoxia, low cardiac perfusion

E lectrolytes sodium, dehydration

All may be associated with immobility – remember restraining

Treatment of delirium

• Moderate quality evidence that attention to:

– Orientation

– Hydration / nutrition

– Medication management

– Early mobilisation

• Reduce

– Length of delirium

– LOS

• But NOT

– Institutionalisation rates » Pitkala 2006 and 2008

Preventing / manging delirium • Orientation

• Hydration

• Nutrition

• Constipation

• Infection

• Pain

• Polypharmacy

• Improve mobility

• Reduce sensory impairment

• Avoid sleep deprivation

• Reduce bed moves

• Maintain consistency of staff » Inouye 1999, Marcantonio 1999 and 2001

NB: Multicomponent intervention trials

provide low quality evidence for

reducing:

• Incidence of delirium

• LOS Gustafson 1991

Wanich 1992

Landefeld 1995

Inouye 1999

Harari 1997

Marcantonio 2001

Bogardus 2003

Lundstrom 2005

Wong 2005

• Hyperactive – Agitation, plucking at bedclothes

– Deranged sleep pattern (day-night reversal)

– Persecutory delusions and visual hallucinations

– Wandering

– Aggression, labile mood, euphoria

• Hypoactive – Apathy, poor motivation, poor engagement, no trouble

– Diagnostic confusion

– Most common and misdiagnosed

– Highest mortality

– Prone to pressure sores, malnutrition, dehydration, VTE

• Mixed

Tailor intervention to delirium type

Also observe:

• For incident delirium

• For resolution of prevalent delirium

Addenbrooke’s Hospital | Rosie Hospital

Bay nursing – the issues

Staff feeling stressed and under pressure Staff feeling unsafe in practice Unsafe for patients Too many specialling requests, leading to staff covering the shifts who were not dementia/delirium trained Budget overspend

Bay nursing:

improves staff well being and saves money

Oct 2013 Nov 2013 Dec 2013 Jan 2014 Feb 2014 Cost over 6 months:

Ward 1 2.88% 3.09% 4.46% 5.05% 5.81% 17, 825.04

Ward 2 1.54% 4.94% 3.08% 2.90% 3.94% 14, 207.93

Ward 3 0.79% 5.71% 7.77% 7.27% 10.08% 22, 811.93

Ward 4 1.39% 2.80% 1.83% 0.53% 1.39% 7, 701.54

Ward 5 3.81%

1.59% 2.97%

4.02% 4.18% 14, 711,51

Addenbrooke’s Hospital | Rosie Hospital

Impact of bay nursing on falls

• falls have reduced significantly

• One fall during bay nursing hours (07.45 – 19.15), as a result of reduced staffing

Knock on benefits: •Reduced length of stay

• More appropriate care due to increased likelihood of patients being allocated to most suitable beds in most suitable locations

• Reduced risk of HAI

• Reduced risk of mortality

Addenbrooke’s Hospital | Rosie Hospital

Reduction in specialling

Introduction of delirium ward reduced specialling

• 06/09/09-23/8/2010

– 616 additional shifts to be covered for the purpose of

specialing.

• 06/09/10 – 27/8/2011

– 188 additional shifts to be covered for the purpose of

specialing

• A cost pressure saving of approximately £44,000 based on

the assumption that each shift is 7.5 hours.

Addenbrooke’s Hospital | Rosie Hospital

Additional benefits

Bay nursing has enabled us to improve care, ensuring we give person centred care at high standards. We are now able to provide extra activities, such as:

Patients eating together at a dining table Board games, hair and nails being done Communication between nurses, patients and relatives is a lot more effective

Addenbrooke’s Hospital | Rosie Hospital

Patient and relative feedback

“Bay Nursing gives

staff the chance to get to know us, its

more sociable.” Extracted

from patient experience questionnaire

“I do not need to use my buzzer as staff are always there to help me.” Extracted from patient

experience questionnaire

“My mum is well looked after she is eating so well and gaining weight something we have struggled with as a family for months.” Cherie

(Daughter of a patient)

“You hear so much bad press about dementia care, they need to come to G6 and see there is amazing care going on, my mum is safe and well looked after.” Jean (Daughter of a

patient)

Addenbrooke’s Hospital | Rosie Hospital

Future plans

Occupational therapy to undertake kitchen style assessments on the ward rather than having to wait to book a slot in for a kitchen assessment on level 2 Physiotherapists to gain experience in music and dance therapy to be able to apply this on the ward for patients

Music project

NICE Quality Standards 2014: audited by Jill Christy (Medical Student)

NICE Quality Standards 2014: audited by Jill Christy (Medical Student)

1. Our ‘Dementia Case Finding Tool’ (60% fully completed)

and Frailty CQUIN (96% completed) were useful in

capturing recent changes in behaviour

2. Using proxy measures of food / fluid / bowel charts; pain

scoring, observation charts, medication review and

behaviour charts seemed to identify whether

multicomponent intervention packages are implemented

(96-100% documentation)

However: Medication review documentation poor (70%

documentation).

NICE Quality Standards 2014: audited by Jill Christy (Medical Student)

3. Low levels of antipsychotic prescription (11%)

and compliant (100%) with Trust guidelines -

comparable to a previous audit in 2012

4. 75% of discharge summaries mentioned altered

cognition (only half of these used the term

delirium or delirious). Most reliable reporting was

for those presenting with (prevalent) delirium.

5. We have patient and carer information leaflets

BUT it was unclear whether they were given out.

Can we establish the benefits?

• ↓ Morbidity (falls, HAI. VTE, pressure sores, malnutrition, ADEs)

• ↓ Mortality

• ↓ LOS √

• ↓ Institutionalisation rates (LOS)

• ↑ quality patient care √

• ↓ costs of unnecessary Ix (e.g. CT head scans)

• ↓ costs of specialling √

• ↓ complaints √

• Helps us meet National Dementia Strategy √

• ↓ incidents of aggression towards staff √

Addenbrooke’s Hospital | Rosie Hospital

Good dementia and delirium management simultaneously improves care and costs.

“Good care costs less.” Dr Keith McNeil, Addenbrooke’s CEO

THANK YOU FOR

YOUR ATTENTION

Is there cognitive impairment? MMSE, CLOX1

Duration of cognitive impairment? CAM, IQCODE

Chronic impairment

(?dementia)

Delirium and chronic

impairment (?dementia)

Assess for severity, consider

depression, etc.

?REFERRAL

Cognitive screening algorithm

Delirium

Ix and Rx