Managing Delirium in Hospitalized Older Adults

Consequences of delirium for older adults may include increased mortality, functional decline, nursing home placement, and decreased quality of life. Longer duration of delirium is linked to poorer health outcomes among older adults, underscoring the need for early detection and intervention. Delirium also exacts a high economic price. Estimated annual U.S. healthcare expenditures range from $143 to$152 billion, with increased hospital stays contributing heavily. Delirium can be frightening for both patients and for family members who observe it in their loved ones. As a nurse, you can play a key role in identifying risk factors, detecting symptoms early, implementing nonpharmacologic interventions promptly, and educating family members about the disorder

Developing and implementing an integrated delirium prevention system of care:a theory driven, participatory research study

Background: Delirium is a common complication for older people in hospital. Evidence suggests that delirium incidence in hospital may be reduced by about a third through a multi-component intervention targeted at known modifiable risk factors. We describe the research design and conceptual framework underpinning it that informed the development of a novel delirium prevention system of care for acute hospital wards. Particular focus of the study was on developing an implementation process aimed at embedding practice change within routine care delivery. Methods: We adopted a participatory action research approach involving staff, volunteers, and patient and carer representatives in three northern NHS Trusts in England. We employed Normalization Process Theory to explore knowledge and ward practices on delirium and delirium prevention. We established a Development Team in each Trust comprising senior and frontline staff from selected wards, and others with a potential role or interest in delirium prevention. Data collection included facilitated workshops, relevant documents/records, qualitative one-to-one interviews and focus groups with multiple stakeholders and observation of ward practices. We used grounded theory strategies in analysing and synthesising data. Results: Awareness of delirium was variable among staff with no attention on delirium prevention at any level; delirium prevention was typically neither understood nor perceived as meaningful. The busy, chaotic and challenging ward life rhythm focused primarily on diagnostics, clinical observations and treatment. Ward practices pertinent to delirium prevention were undertaken inconsistently. Staff welcomed the possibility of volunteers being engaged in delirium prevention work, but existing systems for volunteer support were viewed as a barrier. Our evolving conception of an integrated model of delirium prevention presented major implementation challenges flowing from minimal understanding of delirium prevention and securing engagement of volunteers alongside practice change. The resulting Prevention of Delirium (POD) Programme combines a multi-component delirium prevention and implementation process, incorporating systems and mechanisms to introduce and embed delirium prevention into routine ward practices. Conclusions: Although our substantive interest was in delirium prevention, the conceptual and methodological strategies pursued have implications for implementing and sustaining practice and service improvements more broadly

Humanism in the Age of COVID-19: Renewing Focus on Communication and Compassion

The global COVID-19 pandemic has become one of the largest clinical and operational challenges faced by emergency medicine, and our EDs continue to see increased volumes of infected patients, many of whom are not only ill, but acutely aware and fearful of their circumstances and potential mortality. Given this, there may be no more important time to focus on staff-patient communication and expression of compassion.However, many of the techniques usually employed by emergency clinicians to provide comfort to patients and their families are made more challenging or impossible by the current circumstances. Geriatric ED patients, who are at increased risk of severe disease, are particularly vulnerable to the effects of isolation.Despite many challenges, emergency clinicians have at their disposal a myriad of tools that can still be used to express compassion and empathy to their patients. Placing emphasis on using these techniques to maximize humanism in the care of COVID-19 patients during this crisis has the potential to bring improvements to ED patient care well after this pandemic has passed

Park Nicollet Methodist Hospital: Aligning Goals to Achieve Efficiency

Describes strategies to integrate with outpatient clinics and post-discharge treatment programs to minimize hospitalizations, distribute performance data organization-wide, delegate staff, and meet quality and safety standards while controlling costs

Development of a Delirium Educational Program for Hospital Medicine Providers

Hospital medicine providers were surveyed to evaluate baseline delirium attitudes and behaviors. An educational program was then shared, and a follow up survey was given to determine if their delirium attitudes and practices were impacted by the educational intervention. Follow up survey results indicated that providers perceived more of a change in their attitudes than practices, and overall found the education to be useful and felt more confident in treating delirium as a result

The Hospital at Home Model: Bringing Hospital-Level Care to the Patient

Presbyterian's Hospital at Home program, launched in 2008, is based on a model developed in the mid-1990s by Bruce Leff, M.D., a geriatrician and health services researcher at Johns Hopkins University, who noticed that many of his patients suffered poor outcomes after hospital stays.1 At Johns Hopkins, teams of physicians, nurses, and other clinical staff make house calls to treat elderly patients, many of whom either refuse to go to the hospital or are at such high risk for adverse events that physicians prefer not to admit them. For select patients, this approach produces superior outcomes at a lower cost than hospital care (see Results).The Hospital at Home model has struggled to gain traction elsewhere in the United States, however, in part because Medicare's fee-for-service program will not pay for its services. Presbyterian is able to secure reimbursement from its health plan, which covers 470,000 Medicare Advantage, Medicaid, and commercially insured members throughout the state and has incentives to reduce costs and improve care.Presbyterian's program fits within a suite of services designed to deliver care in the home. These include home-based primary care, home health, hospice, and Complete Care, a care management program designed to improve coordination of services for patients with advanced illness and, when desired, avoid unwanted aggressive care at the end of life

Management of Agitation During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic caused by the coronavirus SARS-CoV-2 has radically altered delivery of care in emergency settings. Unprecedented hardship due to ongoing fears of exposure and threats to personal safety, along with societal measures enacted to curb disease transmission, have had broad psychosocial impact on patients and healthcare workers alike. These changes can significantly affect diagnosing and managing behavioral emergencies such as agitation in the emergency department. On behalf of the American Association for Emergency Psychiatry, we highlight unique considerations for patients with severe behavioral symptoms and staff members managing symptoms of agitation during COVID-19. Early detection and treatment of agitation, precautions to minimize staff hazards, coordination with security personnel and psychiatric services, and avoidance of coercive strategies that cause respiratory depression will help mitigate heightened risks to safety caused by this outbreak

Beyond pain management: A primer for providing quality end-of-life care

Providing excellent care for a dying patient is something all patients deserve. Hospices and palliative care centers exist in many areas to aid primary care physicians and patients through this difficult time. It is important to remember that most patients want to prepare for death, if at all possible. Everyone does this in his or her own way, but oftentimes concern about pain and symptom management interfere with this very involved and valuable process. Being prepared to treat these symptoms as well as addressing your patient\u27s emotional needs is imperative. Referral to a hospice, if possible, will only strengthen the support available to the patient, the family, and you, the primary care physician. In the end, there is much that we have to offer a dying patient. Efforts should not stop because the illness cannot be cured. So much can happen to someone in the window of time between terminal diagnosis and death. Making this period one in which a person is as mentally clear, physically comfortable, and symptom free for as long as possible is a goal that is worthy of our efforts

Emergency Medical Service, Nursing, and Physician Providers’ Perspectives on Delirium Identification and Management

Purpose of the study The study objective was to understand providers’ perceptions regarding identifying and treating older adults with delirium, a common complication of acute illness in persons with dementia, in the pre-hospital and emergency department environments. Design and methods The authors conducted structured focus group interviews with separate groups of emergency medical services staff, emergency nurses, and emergency physicians. Recordings of each session were transcribed, coded, and analyzed for themes with representative supporting quotations identified. Results Providers shared that the busy emergency department environment was the largest challenge to delirium recognition and treatment. When describing delirium, participants frequently detailed hyperactive features of delirium, rather than hypoactive features. Participants shared that they employed no clear diagnostic strategy for identifying the condition and that they used heterogeneous approaches to treat the condition. To improve care for older adults with delirium, emergency nurses identified the need for more training around the management of the condition. Emergency medical services providers identified the need for more support in managing agitated patients when in transport to the hospital and more guidance from emergency physicians on what information to collect from the patient’s home environment. Emergency physicians felt that delirium care would be improved if they could have baseline mental status data on their patients and if they had access to a simple, accurate diagnostic tool for the condition. Implications Emergency medical services providers, emergency nurses, and emergency physicians frequently encounter delirious patients, but do not employ clear diagnostic strategies for identifying the condition and have varying levels of comfort in managing the condition. Clear steps should be taken to improve delirium care in the emergency department including the development of mechanisms to communicate patients’ baseline mental status, the adoption of a systematized approach to recognizing delirium, and the institution of a standardized method to treat the condition when identified

EXAMINING QUALITY INDICATOR RATES FOR OLDER HOME CARE CLIENTS WITH DUAL SENSORY IMPAIRMENT (DSI) AND EXPLORING THE HETEROGENEITY WITHIN DSI.

Older adults with impairments in both hearing and vision, called dual sensory impairment (DSI), are at an increased risk of negative health outcomes such as impaired communication and difficulties with mobility. It is unknown whether DSI is associated with potential quality of care issues. This study used a set of home care quality indicators (HCQIs) to examine potential quality issues in older clients (65+) with DSI. Further, it looked to explore how HCQI rates differed based on the geographic region of care and whether the client’s level of hearing and vision impairment was related to certain HCQIs. The HCQIs were generated from data collected using the Resident Assessment Instrument for Home Care and capture undesirable outcomes (e.g., falls, cognitive decline). Higher rates indicate a greater frequency of experiencing the issue. In this sample (n=352,656), the average age was 82.8 years (sd=7.9), the majority were female (63.2%), and 20.5% experienced DSI. Compared to those without DSI, clients with DSI had higher rates across 20 of the 22 HCQIs. The HCQI rates differed by geographic region, with specific regions consistently performing worse than others. Finally, the level of hearing and vision impairment was related to certain HCQIs more than others, for example hearing impairment appeared to be more related to the quality indicator measuring communication difficulty. Overall, the hope is that this information can help to identify some of the potential issues around quality and in turn, assist in continually improving the services being provided to these clients