“Things Fall Apart”

Ensuring the Safety of Patients with Delirium

D

elirium affects as many as 14% to 56% of all hospitalized patients, depending on their individual risk factors.1

2

In addition, one third of patients in critical care units

and

as many as three fourths of mechanically ventilated patients may experience delirium.3 Finally, as many as 85% of hospice patients become delirious.4

According to the Society for Critical Care Medicine (SCCM), delirium is a “syndrome characterized by the acute onset of cerebral dysfunction with a change or fluctuation in baseline mental status, inattention, and either disorganized thinking or an altered level of consciousness.”3(p. 282)

“Delirium is encountered in patients who are medically ill,” says Barbara E. Lakatos, DNP, PCNS-BC, APN, program director, Psychiatric Nursing Resource Service, and nursing trichair of Delirium, Alcohol Withdrawal, and Suicide Harm

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Diagnosis and treatment of delirium is complex. Careful assessment and reassessment of patients at risk for this condition are essential to ensure patient safety and high-quality care.

“Things Fall Apart”

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(DASH), Brigham and Women’s Hospital, Boston. “It is so common, it is thought to be normal, but it is not normal. Delirium is difficult for staff to see because it happens quickly and it fluctuates. It also accompanies mental status changes that lead to confusion, fear, and can manifest in a combative, threatening presentation.”

Delirium Strongly Associated with Mortality

Not only is the presence of delirium alarming to patients and families, but research shows that delirium is strongly associated with mortality during and after the hospital stay.1–

5 Furthermore, delirium is associated with increased length of stay, costs, falls, long-term cognitive impairments, and need for institutionalization.3,4 Thus, delirium is a major public health issue and a patient safety priority, which is becoming more apparent with an aging population.3,4

“The Centers for Medicare & Medicaid Services [CMS] is looking at the cost of delirium,” says Ronald M. Wyatt MD, MHA, medical director, Office of the Chief Medical Officer at The Joint Commission. “The cost estimates for delirium by CMS is about $164 billion a year, and that includes hospital costs, readmissions, emergency room visits, patients that have to be institutionalized, and home care costs. As the population ages, CMS and other payers have to find ways to prevent delirium.”

Is Delirium Preventable?

The idea that delirium can be prevented is strongly debated. In 2008 CMS initially included delirium on the list of hospital-acquired conditions that would not receive payment.4 However, delirium was removed from the nonpayment list during the public comment period.4

Research estimates that strategies implemented to prevent delirium may be successful only 30% to 40% of the time.4

“It is partially preventable,” says E. Wesley Ely, MD, MPH, professor in the Department of Medicine and Center for Health Services Research at Vanderbilt University,

Nashville, Tennessee, and also the associate director of the US Department of Veterans Affairs VA Tennessee Valley Geriatric Research Education and Clinical Center (GRECC). “We have seen this prevention occurring on a large scale so much so that our trials are slowing in

enrollment because we have less delirium. But there remains a high incidence of delirium. So many people, so much suffering, and so much of delirium is inevitable. No matter how ‘good we get,’ we’ll always have to work so hard to recognize this problem when it occurs, to help the person through it, to help the loved ones understand what is going

“

The cost estimates for delirium by CMS is about $164 billion a year, and that includes hospital costs, readmissions, emergency room visits, folks that have to be institutionalized, and home care costs. As the population ages,

”

CMS and other payers have to

fi ways to prevent delirium.

Ronald M. Wyatt MD, MHA,

Medical Director, Office of the Chief Medical Officer at The Joint Commission.

on, to look for causes in that individual person, to enhance his or her specific needs, and to help survivors who on the back end of their illness experience long-term cognitive impairment.”

Implementing Strategies to Prevent and Treat Delirium

Despite the difficulties recognized in preventing delirium, when health care providers implement strategies to prevent and treat delirium, more and more cases can be prevented or the severity and time period of delirium can be reduced. “We need to know what it is, recognize it, and implement strategies to prevent delirium,” says Wyatt. Health care

providers can use the following strategies to improve the care and safety of patients presenting with symptoms of delirium.

S

TRATEGY Standardize delirium assessments. Although many delirium assessment

tools exist, including the Confusion Assessment Method (CAM) and the Intensive Care Delirium Screening Checklist (ICDSC), organizations should pick one assessment tool and standardize its use throughout the organization.3,5

A standardized delirium assessment tool can also help reduce misconceptions of typical delirium symptoms. “Most delirium is hypoactive,” says Ely. “For example, the little old lady just sitting in the bed. But the delirium we are taught about is the hyperactive form with aggressive patients pulling out lines and tubes. So the trick is to be vigilant about recognizing the ‘invisible’ hypoactive delirium, and to do that, you need to employ validated instruments into routine use.”

When standardized and validated tools are used to detect delirium, there are fewer undiagnosed cases of

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“Things Fall Apart”

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delirium.3 “If you are looking at a patient, you can’t always tell if they have the hypoactive form of delirium,” says Lakatos. “Those patients often refuse care and say they don’t need or want anything. In a busy, complex health care system, there are other patients who need care, so the hypoactive presentation can be missed. You don’t know if patients have delirium unless you test for it.”

S

TRATEGY Routinely assess patients for delirium. Some organizations may choose to assess

every patient for delirium (a population-based approach), whereas other organizations may only assess patients at high risk for delirium.3,5 “We have chosen the population-based approach because delirium does not just happen in the critical care unit, it happens everywhere and not just to older patients,” says Lakatos.

Just as delirium is not limited to the critical care unit, it is also not limited to the hospital. Although it is not well studied, delirium can occur in nursing care centers, hospice, and home care.1 “I believe in care without walls,”

says Lakatos. “It shouldn’t matter if you are in the acute care setting, primary care setting, or long term care, we should

Related Requirements

Standard PC.01.02.01 for Hospitals

The hospital assesses and reassesses its patients.

Elements of Performance for PC.01.02.01

1. The hospital defines, in writing, the scope and content of screening, assessment, and reassessment information it collects. (See also RC.02.01.01, EP 2) Note 1: In defining the scope and content of the information it collects, the organization may want

   to consider information that it can obtain, with the patient’s consent, from the patient’s family and the patient’s other care providers, as well as information conveyed on any medical jewelry.

   Note 2: Assessment and reassessment information includes the patient’s perception of the effectiveness of, and any side effects related to, his or her medication(s).

2. The hospital defines, in writing, criteria that identify when additional, specialized, or more in-depth assessments are performed. (See also PC.01.02.07, EP 1; PC.01.02.03, EPs 7 and 8)

   Note: Examples of criteria could include those that identify when a nutritional, functional, or pain

   assessment should be performed for patients who are at risk.

3. The hospital has defined criteria that identify when nutritional plans are developed. (See also PC.01.02.03, EP 7)

4. Based on the patient’s condition, information gathered in the initial assessment includes the following:

   • Physical, psychological, and social assessment

   • Nutrition and hydration status

   • Functional status

   • For patients who are receiving end-of-life care, the social, spiritual, and cultural variables that influence the patient’s and family members’ perception of grief (See also RC.02.01.01, EP 2)

23. During patient assessments and reassessments, the hospital gathers the data and information it requires. (See also PC.01.01.01, EP 24)

Standard PC.03.03.01 for Hospitals*

For hospitals that do not use Joint Commission accreditation for deemed status purposes: The hospital defines its approach to the use of restraint and seclusion for behavioral health purposes.

Elements of Performance for PC.03.03.01

1. For hospitals that do not use Joint Commission accreditation for deemed status purposes:

   The hospital’s approach to the use of restraint and seclusion for behavioral health purposes includes the following:

   • Its commitment to prevent, reduce, and work to eliminate the use of restraint and seclusion

   • The need to prevent emergencies that have the potential to lead to the use of restraint or seclusion

   • The use of non-physical interventions as the preferred interventions

   • Limitation of the use of restraint and seclusion to emergencies involving imminent risk of a patient causing self harm or harm to others, including staff

   • The responsibility to discontinue restraint or seclusion as soon as possible

   • The need to raise awareness among staff about what restraint or seclusion may feel like to the patient

   • Preservation of the patient’s safety and dignity when restraint or seclusion is used

2. For hospitals that do not use Joint Commission accreditation for deemed status purposes: The hospital communicates its approach to the use of restraint and seclusion for behavioral health purposes to those licensed independent practitioners and staff who are involved in their use.

• Additional standards related to restraint and seclusion for hospitals that do not use Joint Commission accreditation for deemed status purposes can be found at PC.03.03.31–PC.03.03.31. Related standards for deemed status hospitals can be found at PC.03.05.01–PC.03.05.19.

  have a standard of care of how we are going to assess for changes in mental status and delirium.” Wyatt agrees, saying that nursing care centers should apply a basic approach

  to delirium prevention, including identifying high-risk situations for delirium and applying preventive measures. Ely is working to adapt his research on preventing and treating delirium in the critical care unit to nursing care centers.

  The SCCM recommends that health care providers perform delirium assessments at least once per shift.3 “We built it into nursing work flow,” says Lakatos, “and assess all patients for delirium every eight hours.”

  Given that delirium happens quickly and has a

  fluctuating course, health care providers should assess patients frequently. “Continuity of care becomes a big issue with delirium,” says Lakatos. When there are multiple caregivers for a patient, the caregivers may not recognize the fluctuating course of delirium for that particular patient.

  Joint Commission–accredited organizations may also want to consult Provision of Care, Treatment, and

  Services (PC) Standard PC.01.02.01 to ensure compliance with assessing and reassessing patients. (See “Related Requirements” on page 12 for the complete standard.)

  
  

  S

  TRATEGY Use evidence-based interventions to prevent and treat delirium. Organizations

  will want to keep up to date with the newest evidence- based guidelines for preventing and treating delirium, such as the clinical practice guidelines offered by SCCM3 or the American Psychiatric Association.6 Some organizations may choose to implement care bundles, such as the ABCDEF bundle, which is built on evidence from studies published in

  the New England Journal of Medicine, Journal of the American Medical Association, and Lancet, or the Hospital Elder Life Program (see box, right).1,7

  
  

  

  Care Bundles to Prevent and Treat Delirium

  
  

  ABCDEF Bundle7

  • Assess for and manage pain

  • Both spontaneous awakening and breathing trials

  • Choice of sedation and analgesia

  • Delirium monitoring and management

  • Early mobility

  • Family engagement

Hospital Elder Life Program (HELP)1

• Orientation

• Therapeutic activities

• Vision and hearing protocols

• Sleep enhancement

• Early mobilization

Organizations can also consult http://www.icudelirium

.org and http//:www.iculiberation.org for more information on preventing and treating delirium.

that is causing them to be delirious, a sedative is not going to treat it—oxygen will. There are so many reasons why delirium can happen, so clinicians have to assess each patient’s etiology for delirium individually.”

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TRATEGY Use restraints judiciously. When patients are restrained, they are immobilized, which can

“The top three interventions to address when

contribute

to delirium. Thus, restraints must be used only

preventing and treating delirium focus mainly on treatment of underlying medical illnesses, giving less drugs, and

early mobility,” says Ely. “And the main pharmacological treatment for delirium is to reduce overmedication. If you want to add drugs, then you’re usually talking about adding an antipsychotic, but these drugs are still under investigation.”

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TRATEGY Don’t forget to treat the underlying causes of delirium. Although

delirium is multifactorial, meaning that one patient’s delirium can be caused by an infection, stool impaction, or dehydration, it is important to first address all the underlying causes that may lead to or have caused delirium.1

“The treatment has to flow from why the patient is delirious,” says Lakatos. “If a patient has poor oxygenation

when necessary. “If the patient is being dangerous to himself or others, then we have to use restraints,” says Ely.

When restraints are applied, health care providers should immediately consider what can be done to be able to safely remove the restraints. “It should be a 1-2 step, as restraints only contain, they do not treat,” says Lakatos.

“First you put on the restraint and then you determine what can be done to treat the etiology and make the patient feel safe and less distressed in order to remove the restraint.”

Joint Commission–accredited organizations may also want to consult Standards PC.03.03.01 through PC.03.05.19 to ensure compliance when caring for patients in restraints. (See “Related Requirements” on page 12 for the complete Standard PC.03.03.01.)

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TRATEGY Plan for barriers to implementation. Assessing for, preventing, and

treating delirium represent major culture changes and new work flows, which leadership or staff may not buy into

to see a patient tied down and in a coma.” Thus, it takes an adjustment period for health care providers to get used to seeing patients awake and moving while mechanically ventilated. “Once it starts happening, staff realize how right it is for the patients,” says Ely. TS

immediately. “Leadership has to take it seriously,” says

Wyatt. “They must be accountable, provide resources, and be present. If leadership is not active and engaged around it, then staff realize that leadership does not care about it.”

Lakatos describes how Brigham and Women’s Hospital provided a delirium conference for staff. “We had some of our own patients who had delirium come to talk with staff,” says Lakatos. “The staff were surprised that the patients even had delirium because they didn’t act as they expected patients with delirium to act. The patients described how frightened they felt throughout the hospitalization. What

it taught us as an organization is not to underestimate the importance of knowing your patient and presenting a

consistent calm presence while providing care. The way in which you provide care becomes the intervention.”

Ely recognizes that the ABCDEF bundle represents a big culture change for any organization. “After you get it going, the nurses won’t have it any other way,” says Ely. “In the 1990s and early 2000s, we were sedating and paralyzing so many critically ill patients, and it became a cultural norm

References

1. Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: A systematic review. Ann Intern Med. 2013 Mar 5;158(5 Pt 2):375–380.

2. Salluh JI, et al. Outcome of delirium in critically ill patients: Systematic review and meta-analysis. BMJ. 2015 Jun 3;350:h2538.

3. Barr J, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263–306.

4. Feil M. Delirium: Patient safety event reporting and strategies to improve diagnosis, prevention, and treatment. Pennsylvania Patient Safety Advisory. 2015 Sep;12(3):85–95.

5. Lakatos BE, et al. A population-based care improvement initiative for patients at risk for delirium, alcohol withdrawal, and suicide harm. Jt Comm J Qual Patient Saf. 2015 Jul;41(7):291–302.

6. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Delirium. May 1999. Accessed Jan 11, 2016. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines

   /guidelines/delirium.pdf.

   

7. ICU Delirium and Cognitive Impairment Study Group. ABCDEFs of Prevention and Safety. Accessed Jan 11, 2016. http://www.icudelirium

.org.