Building a Quality Program Around Delirium

Building a Quality Program Around Delirium

At ADS, we share a passion for improving care for delirium. However, more than passion about caring for patients with delirium is required to develop a quality improvement program for delirium. In this blog, we will detail crucial implementation steps of a delirium program.

Step 1: Become the “Expert”
The development of a strong understanding of the problem and previous attempts to address it will inform the next steps and help you to avoid repeating other’s mistakes.

The term “Expert” is in quotes because the meaning can vary greatly among hospitals. For some health systems, expert refers to a person that has been awarded many grants and published dozens of articles. However, this background is not necessary to implement a quality improvement program.

The most important feature of being the expert is the ability to share knowledge about delirium, including risk factors, causes, diagnostic strategies, prevention, and treatment. The program leader must feel comfortable discussing delirium with those who will implement the program as well as conveying the value of the program to stakeholders. Attending the American Delirium Society Annual Meeting will offer much of this knowledge (particularly the preconference sessions), as well as, bringing the “Expert” into contact with “Experts” from other health systems. At ADS, the conference planning committees have tried to maximize the opportunities for networking

Step 2: Assemble a team
A good project leader will recognize that help is needed and enlist it. There are different factors that drive people to teams and the project can tap into these factors (innovation, visibility, improve care, promotion, etc). As the leader, it is helpful to have a discussion about these motivators. The team needs to also have credibility among the broader clinical providers so that positive findings can quickly be shared and expanded. For example, building an experienced interdisciplinary team will generate more “buzz” with positive findings and the effort of the team.

Step 3: Offer an Alternative to the Status Quo
It is difficult to imagine a harder task than convincing a busy healthcare professional to voluntarily complete additional assessment without having an action or understood purpose behind it. Assessing for the sake of assessing is demoralizing and will limit the project. Offer an intervention; even if the intervention is providing a pair of earplugs for the patient. The intervention item can be used to justify the assessment. Another strategy would be to replace an assessment. For example, the falls, pressure ulcer, and delirium risk tools include some measure of cognitive assessment. Standardizing the cognitive assessment across these three risk tools streamlines the effort of the clinical team and may represent a significant advance (i.e. more predictive, easier, interventions, etc).

Step 4: Listen
In the early stages of a quality improvement program, the leader’s ears are attuned to the input of others. As time passes and the protocol solidifies, there is a tension that develops between what one is doing and experiencing. The leader must continue to listen, because the people in the field have firsthand knowledge of the challenges of implementation. In this stage, it is important to acknowledge resistance to change yet hold to the principles of the program. Having an alternative to the status quo allows you to acknowledge the resistance and offer possible solutions.

In the process of listening, you will collect stories from staff and patients about their experience with your program and delirium. Collecting these stories either through writing de-identified information or obtaining the patient’s consent to formally record the story provides you with an incredibly powerful resource as you present your work to stakeholders and other clinical team members.

Step 5: Identify and Invest in Stakeholders
Imagine that your delirium program is successfully improving the care of patients, but the first fiscal crunch eliminates all non-essential programs, including yours. At that point, you are in a panic trying to get an audience with decision makers. By identifying key stakeholders early and investing their interests in your successful implementation, you afford your program the best chance at sustainability. Stakeholders may come at all levels of an organization from CEOs to patients. The more stakeholders, the higher visibility of your program, the more pressure to demonstrate positive outcomes, and the more chance that your program will continue during difficult times.

At the American Delirium Society meetings, “Experts” from many health systems present their clinical delirium programs annually. As the mission of ADS is to “….minimize the short-term and long-term impact of delirium on patients,” we invite you to comment on the above steps or describe other steps that were not presented here. We need to learn from each other if we are to alleviate the suffering associated with delirium.

- Jim Rudolph, MD

Comments

Email: 
Christine.Waszynski@hhchealth.org

I would like to respond to Jim Rudolph’s discussion of building a quality program around delirium. Dr. Rudolph makes some excellent points that I would like to expand upon.
It is imperative that “an expert” lead the effort and attendance at the American Delirium Society can certainly give one the tools to begin this journey. There are presentations and posters prepared by experienced delirium researchers and clinicians at this meeting on the topic of implementing a delirium program. These individuals are eager to share their successes and challenges. This “expert” can be a physician (geriatrician, neurologist, psychiatrist, hospitalist, intensivist, cardiac surgeon), nurse, pharmacist, therapist or psychologist with clinical, administrative and/or research skills within the organization. The individual must have a passion to improve the care for the person at risk or for whom experiences delirium.
As Dr. Rudolph stated, this expert cannot do this alone. Other passionate individuals, formal or informal leaders, should be enlisted to join a team. Often within the organization, individuals or groups have already implemented efforts that can enhance a delirium program, such as fall prevention, restraint reduction, mobility promotion or therapeutic activities. Either these groups can incorporate a delirium focus into their work, or a member can join the delirium work group. Trying to identify and utilize what is already in existence can enhance your success.
Administrative backing is key to the momentum of the delirium program. Published statistics on mortality rates, length of stay and readmission rates are helpful, but actual data from your own facility can be very powerful in convincing administrators of service lines of the importance of developing a delirium prevention and management program. However, it is difficult to obtain actual delirium data if the data is not being collected, readily available or accurate. Therefore, it is often useful to begin by implementing routine and accurate delirium screening in order to get a handle on the scope of the issue in your organization. This requires extensive training and buy- in from the delirium screeners (usually nurses) and assistance from information systems analysts to create the fields for data input and the cooperation of quality or research teams to review and present the data in a meaningful way.
Delirium screening can be additional work for an already overextended member of the health care team. However, much of the delirium screen is already being performed but may not be generating a useful and meaningful result. Therefore, it would be important to examine what data is already being collected and reframe that data in a way that it conforms to a published and validated delirium screening tool.
Delirium screening is not helpful if the result does not enhance the patient’s care. Thus, a new positive delirium screen must be treated as a medical emergency, warranting a prompt assessment and diagnostic work up. Order sets guiding the work up and the prescribing of medication can be helpful to standardize the approach and guide practitioners toward evidence-based practice. Daily conversations must take place between team members for any delirious patient in order to review the etiology, the plan to prevent harm and to maintain and restore function.
Once your delirium program is in place, partnering with information systems and quality experts is critical. Outcome data can be shared with providers and nurses with the intentions of fostering positive behaviors and correcting those not consistent with the delirium program.
Enlisting departmental experts to instruct new staff, role model care and provide ongoing feedback to team members regarding delirium prevention, care and outcomes will change your organization’s culture from one of delirium acceptance to one of delirium prevention and prioritization. An effective delirium program takes a village.

Christine Waszynski APRN

Email: 
jrudolph@partners.org

Christine,

Thank you for taking the time to reply. Your comments are most welcome and adds an important perspective to the blog. I think if you surveyed ten QI experts, you would get 10 different opinions.

One point that I would like to open up to further discussion is how to develop a common language among the professionals caring for patients. We found that the mRASS was a powerful tool for enhancing this communication - a barometer of mental status that can be completed in 15 seconds. When the mRASS fluctuates, there is increased sensitivity for delirium. There is increasing evidence that altered mRASS on admission is associated with negative health events in older patients.

Clearly, I have my opinions and experience. Could we hear from others?

Jim

Email: 
nora.obrien@jhartfound.org

I applaud the work of the ADS and in particular am delighted with this first blog and look forward to the series of blogs on this critically important issue on dealing with delirium. We at the John A. Hartford Foundation work to improve the care of older adults and preventing, minimizing and treating delirium is essential in the care of older adults as well as providing education to health professionals, caregivers and patients. A blog I wrote on June 2, 2011 about my father's experience with post operative delirium (http://www.jhartfound.org/blog/confused-about-post-operative-confusion/#...) continues to receive comments from caregivers telling heart-wrenching stories of their loved ones experiencing delirium and the frustrating experience of trying to get information and treatment from the health care professionals. So I am delighted that the ADS is reaching out and providing this 5 step program to building a quality program around delirium. and thank you Dr. Rudolph for all your great advice over these 5 years!

Email: 
jrudolph@partners.org

Thanks for the kind words Nora. It has been a great relationship with Hartford. I am optimistic that together, we will change delirium care.

Email: 
james-amos@uiowa.edu

I like Jim’s outline. I thought of what Suzuki said about experts, though:

“In the beginner’s mind there are many possibilities, but in the expert’s there are few.”—Shunryu Suzuki

I staff a one man hit-and-run psychiatry consult service and, while psychiatrists are often viewed as the delirium experts, I try to teach medical students and residents rotating on the service that, even as beginners, they’re capable of assessing and managing as well as preventing delirium.

Of course, as beginners they are often under the supervision of non-psychiatric faculty who will insist on calling a psychiatric consultant, sometimes when it’s unnecessary. I let them know that, if they stay on at the University of Iowa and they call me under these circumstances—I will understand.

Change is glacial. Sometimes assembling a team entails taking the long view that such an assembly may well take decades.

Jim’s 3rd step is critical. Offering an alternative intervention in the form of self-improvement programs can lead to corresponding improvements in patient care. One of my residents and I recently made a Maintenance of Certification (MOC) Delirium Performance in Practice (PIP) Assessment Tool, which has gained preapproval by the American Board of Psychiatry and Neurology. Prior to this, there were no MOC tools available for this essential skill. As many readers of my blog know (http://thepracticalpsychosomaticist.com/ ), I have a low opinion of MOC as a vehicle for lifelong learning because of that and other limitations of Part IV of the MOC.

Good listening is an art which takes a long time and a lot of patience to develop. I’m not patient, but I’ve learned over the years (often enough the hard way) that Stephen Covey’s habit “Seek First to Understand, Then to be Understood,” is what stakeholders wish leaders would develop.