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LR26 / Proper diagnosis of delirium for effective patient discharge (SCP)

Romania




Type of Patient Safety Practice
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Early warning
Patient safety theme the SCP/clinical risk management practice is aimed at
Safe clinical practice (SCP) is aimed at assessing the older adult for delirium; a proper diagnosis being useful in effective discharge planning that provides appropriate support for the elder patient’s recovery
Objective of the CRM practice
1. Education of nurses in assessing symptoms of delirium in order to improve disease’s detection 2. Involving the trained nurse staff in discharge plan to provide an appropriate support for the safety and recovery of elder patients.
Short description of the CRM practice, including any references for further information
Delirium is a common, potentially preventable, and reversible condition. If not properly treated, delirium may continue until the deterioration cannot be reversed, leading to functional decline, possible nursing home placement, and eventual death. With increasing awareness and education the staff nurse must can be able to assess the older adult for delirium, attention deficits, interventions to maintain patient safety and a proper diagnosis will assist in effective discharge planning that provides appropriate support for the elder patient’s recovery. A poorly planned and coordinated transfer could result in exacerbation of the older adult’s confusion and deterioration in condition. The proposed steps in a safe and effective discharge plan are: -Bedside assessment of delirium is accomplished by trained nurse staff using specific tools, assessing basic cognitive functions first then progressing to more complex operations. Conducted properly, bedside assessments will generate sufficient data to allow diagnosis and treatment. Screening for delirium includes assessment of orientation, attention, and working memory. 1. Because delirium may persist beyond hospitalization, authors propose a skilled discharge planning for transition to post-acute care facilities or the home environment that is essential to optimize outcomes for older adults with unresolved delirium 2. The staff nurse is essential as an advocate for the patient and liaison among family, social worker, and accepting facility, it has expert information regarding patient status and the plan of care that must be shared with all who are concerned with a smooth transition from acute care to long-term care so staff nurse involvement in discharging plan is important 3. Some professionals involved in the care of older adults are not knowledgeable about the reversible nature of delirium, or the difference between delirium and dementia, so the education on the etiology, trajectory, and outcome of delirium is essential for everyone involved in the discharge planning process, including the patient. 4. Educational materials for older patients and their families should be written in lay language and avoid professional jargon and it is important to validate that any written materials are understood and contain sufficient detail to provide needed information. Written materials are most effective when the staff nurse can review the content with the patient and family and allow adequate time to answer questions.
Innovator of the SCP, country of origin
According to the article it was implemented in geriatric inpatient care units in Arkansas, USA
Involved health care staff
Staff nurse
Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
Acute care setting for older adults [p72, 1]/ inpatient settings for older adults [p72, 1]
Summary of evidence for effectiveness, including references
here is no evidence for qualitative or quantitative measures or outcomes but there is a literature review suporting the need for a proper diagnosis for delirium to inssure the safety discharge of the patients [p72-74,1]. 1. Need for proper diagnosis for delirium is evidenced based on facts such as: 1. is defined as an acute or sub-acute alteration in previously normal or baseline mental function that is temporary and reversible [9] 2. the effects of delirium may persist for months [6] 3. recognition of delirium is important because the condition is typically reversible [8] 4. is strongly predictive of illness severity, new nursing home placement, decline in functional status, and death [5] 5. patients with an episode of delirium lasting only 1-3 days had median hospital costs significantly higher than a similar group of patients without delirium ($41,836 vs. $27,106, p>0.001) [7] 6. researchers have determined that nurses assess delirium correctly in only 31% of cases [4] 7. is one of the most prevalent cognitive disturbances in older adults [2], yet in inpatient settings as many as 75 of 100 patients with cognitive decline are not screened for delirium [3]
Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
There is a short description of the context and a draft of guidence for implementation [p72-74,1].
Summary of available information on feasibility, including references
Among feasibility barriers: Lack of education of nurse staff in delirium detection, researchers have determined that nurses assess delirium correctly in only 31% of cases [4].Patients age 80 years or older with hypoactive delirium, vision impairment, or dementia are particularly at risk for under-recognition. For patients with three or all four of these risk factors, nurses are 20 times as likely to fail to recognize their delirium. Detection can be improved through education of nurses in assessing symptoms of delirium [p72, 1] 1. A minimally staff nurse involvement in the coordination of the discharge plan, because a poorly planned and coordinated transfer could result in exacerbation of the older adult’s confusion and deterioration in condition [p74, 1]. 2. Lack of educational materials for older patients and their families [p75, 1].
Existing implementation tools, including references
In order to be easy to use bedside assessments need to have a structured-interview format, and not be overly demanding of the patient, because a defining characteristic of delirium is limited capacity [p74, 1] Screening for delirium includes assessment of orientation, attention, and working memory. Ability to sustain attention over time can be gleaned from observation of the patient’s distractibility or difficulty in attending, even in the course of common tasks, such as feeding, bathing, or taking medications [p74, 1]. A more formal, widely used screening tool is known as digit span or digit repetition [p74, 1]. Even cursory screenings (for example, when checking vital signs) can be used to monitor for conspicuous mental status changes [p74, 1]. When delirium is suspected, a comprehensive evaluation is warranted. Educational materials for older patients and their families [p75, 1].
Potential for/description of patient involvement in the CRM practice, including references
Bedside assessment of delirium is accomplished by nurses involving elder patient to participate to some techniques (structured-interview not overly demanding of the patient, because he’s limited capacity or other screening tools) [p74, 1]. The elaboration of educational materials involve also the patient (written materials are most effective when the staff nurse can review the content with the patient and family and allow adequate time to answer questions)
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
[1] Catherine S., ColeErin B., Williams, Roger D. Williams (2006): Assessment and Discharge Planning for Hospitalized Older Adults with Delirium. MEDSURG Nursing Vol. 15/No. 2. [2] Alagiakrishnan, K., & Wiens, C.A. (2004): An approach to drug induced delirium in the elderly. Postgraduate Medical Journal, 80, 388-393; Chan, D., & Brennan N.J. (1999). Delirium: Making the diagnosis, improving the prognosis. Geriatrics, 54, 28-30; Cole, M.G., McCusker, J., Dendukuri, N., & Han, L. (2002). Symptoms of delirium among elderly medical inpatients with or without dementia. Journal of Neuropsychiatry & Clinical Neurosciences, 14, 167-175 [3] Berg, R., Franzen, M., & Wedding, D. (1987). Screening for brain impairment: A manual for mental health practice. New York: Springer Publishing Company; Chan, D., & Brennan, N.J. (1999). Delirium: Making the diagnosis, improving the prognosis. Geriatrics, 54, 28-30;; Cole, M.G., McCusker, J., Dendukuri, N., & Han, L. (2002). Symptoms of delirium among elderly medical inpatients with or without dementia. Journal of Neuropsychiatry & Clinical Neurosciences, 14, 167-175 [4] Inouye, S.K., Foreman, M.D., Mion, L.C., Katz, K.H., & Cooney, L.M., Jr. (2001). Nurses’ recognition of delirium and its symptoms: Comparison of nurse and researcher ratings. Archives of Internal Medicine, 161, 2467-2473 [5] Inouye, S.K., Rushing, J.T., Foreman, M.D., Palmer, R.M., & Pompei, P. (1998). Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. Journal of General Internal Medicine, 13, 234-242 [6] Kiely, D.K., Bergmann, M.A., Jones, R.N., Murphy, K.M., Orav, E.J., & Marcantonio, E.R. (2004). Characteristics associated with delirium persistence among newly admitted post-acute facility patients. Journals of Gerontology Series A-Biological Sciences & Medical Sciences, 59, 344-349. [7] Milbrandt, E.B., Deppen, S., Harrison, P.L., Shintani, A.K., Speroff, T., Stiles, R.A., et al. (2004). Costs associated with delirium in mechanically ventilated patients. Critical Care Medicine, 32, 955- 962 [8] Milisen, K., Foreman, M.D., Abraham, I.L., De Geest, S., Godderis, J., Vandermeulen, E. et al. (2001). A nurse-led interdisciplinary intervention program for delirium in elderly hipfracture patients. Journal of the American Geriatrics Society, 49, 523- 532 [9] Taber’s Cyclopedic Medical Dictionary (20th ed.). (2005). Philadelphia: F.A. Davis Company
Reviewer
Dr. Carmen Sasu
National School of Public Health and Management, Romania
Organisation
National School of Public Health and Management
Any additional information on the CRM (e.g. implementation barriers and drivers)
There is no specified text here
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