DELIRIUM is not only common—affecting more than 7 million hospitalized adults in the U.S. every year— but it’s also ubiquitous, a danger to every type of patient in the hospital. Yet all too often, clinicians who tackle delirium take a piecemeal approach, zeroing in on only their own patients.
“Delirium is really a topic where we need to reach across subspecialty lines,” says Sara LaHue, MD, a neurohospitalist at the University of California, San Francisco (UCSF). “We need to work together in a very comprehensive way to address the problem.”
In an article in the July Journal of Hospital Medicine, Dr. LaHue describes just such an approach. In 2016, UCSF clinicians devised a multicomponent delirium pathway they rolled out in seven different units, starting with neurosciences. The pathway relies on nurses screening patients for delirium on admission and then on bedside screening during each nursing shift.
“Delirium is really a topic where we need to reach across subspecialty lines.”
~ Sara LaHue, MD
University of California, San Francisco
Through February 2019, the use of the pathway reduced mean length of stay across all units by 2%—but by 9% among medicine patients. The pathway also significantly reduced the use of safety attendants.
“I was pleasantly surprised to see a positive effect on patients throughout the hospital, not just one specific population,” says Dr. LaHue. “That gives me hope that there’s a considerable amount we can do for these patients, regardless of the reason they’re admitted.”
Developing the pathway took a collaboration among geriatrics, hospital medicine, neurology, anesthesiology, surgery and psychiatry, with an interprofessional team of physicians, nurses, pharmacists, and physical and occupational therapists.
Here’s how it works: At admission, nurses assess each patient’s risk of developing delirium, using a validated delirium prediction tool called the AWOL score. (The acronym stands for a patient’s Age, spelling “World” backwards correctly, Orientation and the nurse’s assessment of iLlness severity.) Patients who score two or more on the tool are considered at high risk of delirium, and such a score activates several different interventions.
First, the patient’s primary team is notified via pager and an EHR notation. Nurses then begin evidence-based, nonpharmacologic interventions based on NICE guidelines (from the U.K.’s National Institute of Health and Care Excellence). (See “Nurse-led interventions.“)
The primary team then orders a delirium order set in the EHR. That set includes options for ordering consults with occupational, physical or speech/language therapy. It also includes options for ordering only three vital checks per day with minimal nighttime interruptions, removing an in-dwelling catheter and prescribing melatonin at night. Finally, a high-risk score prompts a unit pharmacist to review the patient’s medications to adjust administration to days only and to flag any meds that are potentially deliriogenic.
Bedside nurses also screen all patients for active delirium every 12 hours using the Nursing Delirium Screening Scale (NuDESC). Nurses enter those results in the electronic record and notify physicians of any positive screen for placement of the delirium order set.
The fact that all interventions begin with nurse screening indicates that, says Dr. LaHue, “nurses are really the backbone when it comes to a pathway like this.” That makes it even more important to get nurse buy-in.
What helped gain that buy-in was “giving nurses ownership when it came to screening and what happens when someone screens positive,” she explains. “These are interventions that nurses themselves do without any sort of order from a physician. That gives them some autonomy.”
The interventions also allow nurses to see “a direct outcome from doing the screening as opposed to just putting a score in the chart.” Nurses receive two in-person training sessions on the pathway, and they complete an online module for CME.
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Because UCSF introduced delirium screening as part of the pathway, Dr. LaHue notes that she and her colleagues don’t know what the center’s delirium rates were before; as she points out, delirium is often woefully underdocumented. In the study, delirium prevalence across four successive three-month periods averaged out to 12.4% of all patients, with an average of 5.6% having incident delirium (new onset in the hospital). Now, the pathway is in use throughout the academic center and on UCSF’s other campuses.
The health system had to make only a modest investment in project management to get the pathway off the ground, Dr. LaHue points out. Her advice for smaller hospitals that want something similar: “The first step is to understand how to screen for delirium and then use that information to help incorporate interventions,” she says. “Many bundle features the nurses assist with are not very time-intensive, and they don’t require additional resources.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
In a delirium pathway developed at University of California, San Francisco, nurses screen patients for delirium on admission while bedside nurses screen patients for delirium during every shift. When delirium is identified, nurses can implement a host of nonpharmacologic interventions. Those include:
Promote wakefulness, orientation during the day:
- Keep shades up and lights on.
- Write the date and staff names on the board.
- Get patients out of bed and into a chair three times a day for meals.
- Walk patients three times a day while engaging them in conversation.
- Introduce yourself at each visit and remind patients where they are and what date and time is it.
- Make sure patients have their glasses or hearing aids, if they need them.
- Provide activities like games and reading materials, as well as plenty of water.
- Give family members a brochure on delirium to help them identify the condition.
- During each shift, discuss getting rid of any patient “tethers” including nasal cannula, foley catheter, telemetry and continuous pulse oximetry.
Promote sleep at night:
- Make sure lights and TVs are off and shades are drawn.
- Offer patients eye masks or ear plugs.
- Minimize caffeine use.
- Group tasks to minimize interruptions and consider whether patients need overnight vitals.
- If you need to communicate at night, be sure patients have their hearing aids or glasses—and, again, introduce yourself and orient patients to where they are.
Published in the November/December issue of Today’s Hospitalist