a collaborative approach to the prevention and management ......trillium health partners 5 •3...

A Collaborative Approach to the Prevention

and Management of Delirium:

The Medical Psychiatry Alliance

Adult and Seniors Inpatient Delirium Project

Jason Kerr, MD FRCPC

Mary-Lynn Peters, NP, MS, GNC (C) April 2019

1

Agenda

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1. The Medical Psychiatry Alliance 2. Delirium at Trillium Health Partners 3. Implementation Strategies

• Structures/processes • Engagement • Education

4. Results 5. Lessons Learned 6. Q&A

The Impact

3

Delirium at Trillium Health Partners

4

Trillium Health Partners

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• 3 sites: Credit Valley Hospital, Mississauga Hospital, Queensway Hospital

• 1400+ beds*

• Serves the communities of Mississauga, the Halton-Peel region, and west Toronto

• University of Toronto Mississauga Academy of Medicine

Delirium at Trillium Health Partners prior to the MPA

6

• Incidence in THP general internal medicine is ~25%

• Consistent with rates found in the literature (10 – 24%)

• Average LOS for patients with delirium = 22 days

• No standard screening, prevention or management prior to the MPA

0

5

10

15

20

25

average length of stay (all patients) average length of stay (deliriouspatients)

Delirium Project at Trillium Health Partners

7

To reduce the incidence, severity and duration of delirium for all adult inpatients at Trillium Health Partners.

GOAL Has serious negative consequences for patients and families

Adverse impact on patient experience, staff experience

Is common

Is largely preventable

Is costly

WHY Prevention – Universal Precautions

Screening – CAM screening

Management – Order Set, Delirium Team

Transitions of Care

HOW

Implementation: Structures and Processes

8

How would you structure implementation of a large-scale project such as this one?

9

The path to our goal

• Pilot unit • Multiple PDSA cycles • One year

• Delirium team + BPSO team

• Education delivery on units

• Attendance at huddles • Support practice changes

• Phased implementation, initially single site

• Created cohorts of units • Quarterly spread • Implementation ‘time out’

in Q4

Our goal: Every patient will receive screening for delirium once/shift and standardized delirium prevention and

management strategies

Implementation Timeline: high level

FY 2016- 2017 FY 2017 - 2018 FY 2018 - 2019 FY 2019 - 2020

Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

Site

Mississauga Hospital

Launch on Pilot Unit, Cardiology Medicine (4 units) Neurology, Neurosurgery

ICU, Mental Health, Oncology

CV surgery, Ortho, CSICU, Rehab (3 units)

General Surgery (2 units)

Credit Valley Hospital

Medicine (5 units) Surgery ICU, Mental Health, Oncology

Rehab, Cardiology, CCU

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MPA Adult and Seniors Inpatient Delirium Project Overview

• Confusion Assessment Method (CAM) tool once/shift

Assessment

• Up in a chair

• Walk around the block

• 10 @ 10

• Lights on

Prevention

• Delirium Management Order Set

• Delirium Management Algorithm

• Delirium Team

• Up in a chair

• 10 @ 10

Management

• Pre-Op Clinics

• Discharge template

Transitions of Care (in development)

Direct care provision: Screening, Prevention,

Management, Transitions

Consultative care provision: Delirium Team

Stepped Care Model for Delirium

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Delirium Prevention Strategies: “10 at 10”

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• Music, movement, and laughter

• Twice/week at 10:00, for 10 minutes

• Physical activity and an opportunity to socialize

• Music and activity ↓anxiety, ↓depressive symptoms or destructive behaviour and ↓restlessness

(Cheong et al., 2016; Pedersen et al., 2017; Vink et al., 2013)

Delirium Team

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• Nurse practitioner, Occupational Therapist, Geriatrician, Psychiatrist

• Initial assessment by NP/OT

• Majority of cases seen by NP or OT

• Team rounds twice/week, complex cases discussed

• Followed by team for 2 -3 visits

• Local capacity building, in-the-moment teaching

Communicating with patients and families

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Implementation Strategies: Engagement

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Engagement with Leaders

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Attend Delirium Education

• Coffee break sessions

• Lunch and Learn sessions

• Unit huddles

• Delirium Champion Resource workshop

Perform Delirium Screening

• Delirium screening once/shift with CAM tool (in Meditech and SCM)

• Delirium Order Set

Delirium Prevention/ Management • Up in a chair for

lunch

• Lights on/ blinds open in daytime

• Walk around the block

Delirium Prevention/ Management • Up in a chair for two

meals/day

• 10 at 10 twice/week

Your team will be asked to:

One month One month Two weeks Two weeks

Engagement with Leaders

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Unit-based delirium champions

•4 per unit: 1 Allied, 3 Nursing

•Champions will need to be chosen and will attend a 4 hour workshop which will address:

•Champion role expectations

•How to be a champion

• In-depth education about dementia/delirium/depression (3D’s)

Delirium Team

•Nurse Practitioner, Occupational Therapist, Geriatrician, Psychiatrist

•Attend unit huddles

•Deliver coffee break education re-fresh sessions

•Provide support to unit champions re: being a champion, 3D’s

•Provide support to unit re: 3D’s

•Perform delirium assessments, make clinical recommendations for delirium patients*

RNAO BPG Delirium, Dementia and Depression team

• Inter-professional team

•Attend unit huddles

•Assist with delivery of coffee break education re-fresh sessions

•Provide support to unit champions re: being a champion, 3D’s

•Provide support to unit staff re: 3D’s

* Patients will be seen by one or several members of the team, determined on a case by case basis. Not all patients will be seen by a physician.

How we will support your team:

Engagement: creating a ‘buzz’!

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[email protected]

(437)776-4664

CONFIDENTIALITY NOTICE: This information is intended only for the use of the individual named in this email. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this email in error, please notify the sender immediately. Before printing this document, please consider the environment.

• CAM screening challenge: winning unit received a pizza party

mailto:[email protected]

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World Delirium Awareness Day

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• Creation of video to highlight delirium, raise awareness • World Delirium Awareness Day links, info on THP Hub

intranet page

Implementation Strategies: Education

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Implementation Strategies: Education

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Educational content

• Use of screening tool (Confusion Assessment Method- CAM)

• Delirium

• Prevention strategies

• Management strategies

• How to be a champion

Format for provision of education

• Coffee break drop in sessions

• Lunch and learn sessions

• Skills day sessions

• MP3C module

• Attendance at unit huddles

• Attendance at program rounds

• 4 hour champions workshop

• On-line e-module to be developed

Supporting materials

• Posters

• Lanyard cards

• Pocket cards

• Delirium Tent cards

• Decision making algorithm

• Champion-specific material:

• Delirium booklet

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Universal Prevention Strategies

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Results

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Who has Delirium? Demographic Analysis Pilot Unit and Cohort 1

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Demographic and Clinical

variables Total

N = 5619

Delirium status

Present

Absent

All 570 (10.1%) 5049 (89.9%)

Age in years: Mean±SD ≤ 60 years

61 – 70 years

71 – 80 years

> 80 years*

81.5±11.6

32 (2.6)

57 (4.0)

122 (8.0)

359 (24.6)

69.5±13.6

1188 (97.4)

1358 (96.0)

1405 (92.0)

1098 (75.4)

70.7±13.9

1220

1415

1527

1457

Gender Male

Female

273 (8.9)

297 (11.7)

2807 (91.1)

2242 (88.3)

3080

2539

Previous admission** No admission

Within 2 years admission

346 (8.8)

222 (13.7)

3587 (91.2)

1402 (86.3)

3933

1624

Admission ** Unplanned (ED admission)

Planned

441 (14.6)

129 (4.9)

2571 (85.4)

2478 (95.1)

3012

2607

Unit Cardio Medicine

Cardio Surgery

Ortho

Rehabilitation

177 (9.3)

155 (7.8)

202 (13.3)

36 (17.8)

1733 (90.7)

1835 (92.2)

1315 (86.7)

166 (82.2)

1910

1990

1517

202

December 2017 – December 2018 Number of records included for analysis: 5619 Incidence rate of Delirium based on CAM screening results: 10.1%

Data analysis courtesy of Institute for Better Health, Trillium Health Partners

What metrics would you track in a project such as this?

Early Results on Pilot Unit, August 2016 – July 2017

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0

10

20

30

40

50

60

70

80

90

Up in Chair CAM Q shift

% A

dh

eren

ce

Interventions

Aug-16

Jul-17

Monthly CAM Screening Rate, Pilot Unit

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40.0

50.0

60.0

70.0

80.0

90.0

100.0

Pe

rce

nta

ge

Monthly CAM Screening rate - Pilot Unit

Day Shift Night Shift


Monthly Delirium Rates, Pilot Unit

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0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

Pe

rce

nta

ge

Monthly Delirium rate - Pilot Unit



Shift1: P <0.001, Shift2: P <0.05

Monthly CAM Screening Rate, Cohort 1

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0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Pe

rce

nta

ge

Monthly CAM Screening rate - Cohort 1



Monthly Delirium Rates, Cohort 1

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0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Pe

rce

nta

ge

Monthly Delirium rate - Cohort 1

Series1 Series2 Shift1: P <0.001, Shift2: P = 0.133


Monthly CAM Screening Rates, Cohort 2

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0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Pe

rce

nta

ge

Monthly CAM Screening rate - Cluster 2



Monthly Delirium Rates, Cohort 2

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0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Pe

rce

nta

ge

Monthly Delirium rate - Cohort 2



Sharing Results Type of report Content of report Director

receives Manager receives

Educator receives

Frequency

CAM completion report

CAM completion rates for the previous 24 hours

Monday-Wednesday-Friday

Delirium Dashboard

CAM completion rates, positive CAM scores, and utilization of non-pharmacological strategies for past week.

Weekly

CAM Completion rates: Monthly

CAM completion rates, by shift, for past month

Monthly

CAM completion rates: Quarterly Trends

CAM completion rates, by shift, for past 3 months

Quarterly

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Communication of Results, example

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CAM Dashboard Example

Staff experiences with 10 @ 10

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Yes, I see the staff more engaged in getting the patients up. I see the

staff – like they'll say, “Oh, did you see my patient in the thing today doing the dancing and she normally lays in the bed.” ….I think the

staff see the value in it now too, of getting patients up. Nurse, Cardiac Care

He wasn't really communicating with me. You know, we walked him, it was challenging. He had a hard time, like following commands. You take him to the class and you put on some music and he was having a

party. Like, he was ... it was amazing, like just to see that ... like, the change in him. It was phenomenal. Allied Health, OT

Lessons Learned

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• Awareness of and attention to organizational

priorities when planning implementation

• Engagement at many levels and often!

• Support

• Ownership

• Pace implementation activities to allow time for PDSA

cycles

Is it top down or bottom up?

“Start low and go slow

– but go!”

Key Messages

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• Delirium is everyone’s responsibility-

It takes a village!

• Easier to prevent than to treat

• Multi-component interventions are the most successful

“strong evidence that multi-component interventions can prevent delirium in both medical and surgical settings” (Siddiqi, Harrison, Clegg, et al., 2016)

Questions?

40

References

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References

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1. Campbell, N., Boustani, M. A., Ayub, A., Fox, G. C., Munger, S. L., Ott, C., … Singh, R. (2009). Pharmacological Management of Delirium in Hospitalized Adults – A Systematic Evidence Review. Journal of General Internal Medicine, 24(7), 848–853. http://doi.org/10.1007/s11606-009-0996-7

2. Cheong, C.Y., Qi Tan, J.A., Foong, Y-L., Koh, H.M.,…Yap, P. (2016), Creative Music Therapy in an Acute Care Setting for Older Patients with Delirium and Dementia. Dementia and Geriatric Cognitive Disorders, 6:268–275.

3. Oh, E.S., Fong, T.G., Hshieh, T.T., & Inouye, S.K. (2017). Delirium in Older Persons: Advances in Diagnosis and Treatment. Journal of the American Medical Association, 318 (12), 1161 – 1174.

4. Fong, T.G., Jones, R.N., Shi, P., et al. (2009). Delirium accelerates cognitive decline in Alzheimer disease. Neurology. 72: 1570–75. 5. Fong, T.G., Jones, R.N., Marcantonio, E.R., et al.(2012). Adverse outcomes after hospitalization and delirium in persons with

Alzheimer disease. Ann Intern Med. 156: 848–56. 6. Fong, T.G., Tulebaev, S.R., & Inouye, S.K. (2009). Delirium in elderly adults: diagnosis, prevention and treatment. Nature Reviews

Neurology. 5, 210 – 220. 7. Hshieh, T.T., Yue, J., Puelle, M., Dowal, S., Travison, T., & Inouye, S.K. (2015). Effectiveness of multicomponent

nonpharmacological delirium interventions: a meta-analysis. Journal of the American Medical Association Internal Medicine, 175 (4), 512 – 520.

8. Inouye, S.K. (2006). Delirium in older persons. New England Journal of Medicine. 354: 1157–65.

http://doi.org/10.1007/s11606-009-0996-7

http://doi.org/10.1007/s11606-009-0996-7

http://doi.org/10.1007/s11606-009-0996-7

http://doi.org/10.1007/s11606-009-0996-7

http://doi.org/10.1007/s11606-009-0996-7

http://doi.org/10.1007/s11606-009-0996-7

http://doi.org/10.1007/s11606-009-0996-7

References

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9. Inouye, S.K., Westendorp, R.G., Saczynski, J.S. (2014). Delirium in elderly people. Lancet. 383; 911 – 922. 10. Marcantonio, E. (2017). Delirium in hospitalized older adults. New England Journal of Medicine, 377:1456-66. DOI:

10.1056/NEJMcp1605501 11. Pedersen, S.K.A., Andersen, P.N., Lugo, R.G., Andreassen, M. & Sütterlin, S. (2017). Effects of Music on Agitation in Dementia: A

Meta-Analysis. Frontiers in Psychology, 8:742. doi: 10.3389/fpsyg.2017.00742 12. Reade, M.C., Eastwood, G.M., Bellomo, R., Bialey, M., Bernsten, A., Cheung, B., et al. (2016). Effect of Dexmedetomidine Added

to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium A Randomized Clinical Trial. Journal of the American Medical Association, 315(14):1460-1468.

13. Siddiqi, N., Harrison, J.K., Clegg, A., Teale, E.A., Young, J., Taylor, J., Simpkins, S.A.(2016). Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD005563. DOI: 10.1002/14651858.CD005563.pub3

14. Vink, A.C., Bruinsma, M.S., Scholten, R.J.P.M. (2013). Music therapy for people with dementia (Review). The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.

References

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15. Ely, E.W., Gautam, S., Margolin, R., Francis, J., May, L., Speroff, T., Truman, B., Dittus, R., Bernard, R., & Inouye, S.K. (2001). The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Medicine, Dec 27(12):1892-900. Epub 2001 Nov 8.

16. Lawlor, P.G., Gagnon, B., Mancini, I.L., Pereira, J.L., Hanson, J., Suarez-Almazor, M.E. (2000). Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Archives of Internal Medicine, 160:786–94.

17. Maldonado, J.R., Dhami, N., Wise, L. (2003). Clinical implications of the recognition and management of delirium in general medical and surgical wards. Psychosomatics, 44(2), 157 -158.

18. McManus, J., Pathansali, R., Stewart, R., MacDonald, A., Jackson, S. (2007). Delirium post-stroke. Age and Ageing, 36, 613 – 618. 19. Robinson, T.N., Raeburn, C.D., Tran, Z.V., Angles, E.M., Brenner, L.A., Moss, M. (2009).Postoperative Delirium in the Elderly Risk

Factors and Outcomes. Annals of Surgery, 249 (1), 173 – 178. 20. Rolfson, D.B., McElhaney, J.E., Rockwood, K., Finnegan, B.A., Entwistle, L.M., Wong, J.F., Suarez-Almazor, M.E. (1999). Incidence

and risk factors for delirium and other adverse outcomes in older adults after coronary artery bypass graft surgery. Canadian Journal of Cardiology 15(7): 771-776

21. Rudolph, J.L., Inouye, S.K., Jones, R.N., Yang, F. M., Fong, T. G., Levkoff, S. E. and Marcantonio, E. R. (2010). Delirium: an independent predictor of functional decline after cardiac surgery. Journal of the American Geriatrics Society, 58, 643 – 649.

22. Santos, S. F., Wahlund, L.O., Varli, F., Velasco, T.I., Jonhagen, E.M. (2005). Incidence, clinical features and subtypes of delirium in elderly patients treated for hip fractures. Dementia and Geriatric Cognitive Disorders 20(4): 231-237

a collaborative approach to the prevention and management ......trillium health partners 5 •3...

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