Coordination of Care Initiative Mora Area Community Community - - PDF document

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Coordination of Care Initiative Mora Area Community

Community Meeting April 2, 2019 FirstLight Health System

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Download meeting agenda and slide handout: Agenda Handout

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Welcome — Introductions

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MHA Delirium Discharge Order Bundle

Susan Schumacher, MS, APRN-BC, GCNS Clinical Nurse Specialist in Gerontology Methodist Hospital-Park Nicollet Angie Pokharel, MHS Quality and Process Improvement Specialist Minnesota Hospital Association

April 2, 2019

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Agenda/Outline

• 1. Introduction
• 2. MHA Quality and Patient Safety Committee

Structure

• 3. Delirium Committee 2019 priorities and tools
• 4. Clinical review
• 5. Discharge Order Bundle deep dive
• 6. Questions

Minnesota Hospital Association

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MHA Overview

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MHA Quality & Patient Safety Division

• Dedicated QPS staff for over 19 years
• 13 expert committees
• Partnership for Patients contractor for the last

7 years

Quality and Patient Safety Committee Structure

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2019 Delirium Committee Priorities

Priority 1: Road Map Implementation and Adherence Priority 2: Re-evaluating and updating delirium process and

• utcome metrics

Priority 3: Early mobilization during hospitalization

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MHA Delirium Committee 2018 Work Plan Priority 1

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Priority 1: Delirium Road Map Road map design

Operational definitions (what yes means) Organized by section to address specific aspects of care Audit-style format for key elements Line by line references (active links at the end

• f each document)

Mapped resources with live links Fundamental or advanced strategies to help with prioritization

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Why use the Delirium Road Map?

• It is a step-by-step guide to building

a delirium program.

Infrastructure Detection Prevention Medications Management

• f Behaviors

ICU/Ventilated Patients/the ED

Delirium Road Map

• MHA Delirium Road Map (PDF)
• https://www.mnhospitals.org/Portals/0/Documents/patientsafety/Delirium/Delirium%20Road%20Map.pdf (URL)

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What does the road map data tell us?

2018

• 1. Education for nurses
• 2. Education for physicians/residents
• 3. Reaching the executive team
• 4. Coordination of care

Delirium Learning Cohort (Nurses)

Purpose

• Provide education about

delirium identification, prevention, and management to nurse leaders and educators via a train-the-trainer model. Objectives

• Provide education,

resources, and tools for nurse leaders to learn about delirium awareness.

• Train nurse

leaders/clinical educators on how to bring the delirium awareness presentation and resources back to their nursing units. Resources & Activities

• 6 monthly calls
• Delirium Awareness

Presentation-Nurses

• Case Studies
• Videos
• Patient stories
• Delirium Road Map
• Data collection
• Learning Collaboration

Network Events

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Delirium Learning Cohort Clinical Education Modules

Module 6

Patient and Family Engagement

Module 5

Management: First Lines of Treatment

Module 4

Identification and Presentation of Delirium

Module 3

Prevention Module 2 Data: Current State and Collection

Module 1

Introduction to Delirium: Definition, Cost, and Mortality

Delirium Learning Cohort Example Toolkit

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Delirium Learning Cohort Phase 2

• The modules from the Delirium Learning

Cohort are being uploaded into an easy to use Learning Management System and will be made available soon!

• Contact Naira at apokharel@mnhospitals.org

Delirium Fact Sheet (Physicians and Residents)

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SBAR (Executives and Leadership)

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Delirium Discharge Order Bundle

Susan Schumacher, MS, APRN, GCNS-BC

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Delirium Discharge Order Bundle

• Goal: Coordinate with post-acute
• rganizations to identify and address areas of
• pportunity in delirium prevention and

management to prevent delirium related readmissions

Delirium

An acute disorder of attention and cognition. Common, serious, costly, under recognized and often fatal. Current approach to diagnosis and treatment of delirium remains a clinical diagnosis.

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Diagnosis

• Underrecognized and easily overlooked.
• Only 12 to 35% of delirium cases are recognized.
• Current reference standard diagnostic criteria are:
• DSM-5
• ICD-10
• Over 24 delirium instruments have been used in published

studies.

• CAM-most widely used instrument.
• Currently, there are at least 11 diagnostic codes for

delirium in ICD-9 and 23 codes in ICD-10.

• Only 3% of delirium cases are coded in medical records.

DSM V

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness. Change in cognition (e.g., memory deficit, disorientation, language disturbance, perceptual disturbance) that is not better accounted for by a preexisting, established, or evolving dementia. The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause.

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Significance

• In the united states,

>2.6million adults 65years and older each year develop delirium

• Total cost range from

$16,303 to $64,421 per patient

• Accounts for >$164 billion in

annual healthcare expenditure

• Included on the pt. safety

agenda

• Targeted as an indicator of

healthcare quality for seniors

• Hold significant societal

implications

Key Clinical Predisposing Factors

Advanced Age- 65 and

• lder

Cognitive impairment, such as dementia Multiple co- morbidities History of delirium 5

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Key Clinical Precipitating Factors

Higher severity of illness Surgery Dehydration

• r

constipation Pain Exposure to multiple medications Hip Fractures5

Forms of Delirium

1.

HYPERACTIVE

2.

HYPOACTIVE

3.

MIXED

• The hypoactive form is more

common among older adults

• Often unrecognized
• Associated with higher rates
• f complications and mortality
• Delirium was found in ~90%
• f patients in the last days of

life in a 2013 systematic review.

• Hypoactive delirium was the

most prevalent delirium subtype in the palliative care population (68%–86% of cases).

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Delirium Superimposed on Dementia

• Older adults with dementia are at

greatest risk for delirium.

• 89% experience delirium when

hospitalized and between 24% and 76% die within one year of the index episode.

Delirium or Dementia?

Characteristic Delirium Dementia

Onset  Acute, abrupt  Insidious, steady decline Attention  Inattention present  Usually no change Course  Fluctuating and resolves over time, may not resolve without discharge  Steady decline with Alzheimer’s  Stepwise decline with vascular dementia Duration  Hours to days, may last months  Months to years Level of consciousness  Changes-vigilant to lethargic  Usually no change

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Delirium or Dementia?

Characteristic Delirium Dementia

Perception  Hallucinations (visual and auditory) may occur  Usually do not occur  Lewy Body dementia- hallucination do occur Sleep/wake cycle  Impaired, sleep schedule can become reversed  Fragmented; may awaken frequently or sleep more Psychomotor behavior  Hypoactive, Hyperactive, or Mixed  No change Mood/affect  Rapid swings; paranoid  May be apathetic, depressed

Adverse Outcomes of Delirium

• 1. Most common adverse health events for
• lder adults.
• 2. Independently associated with an

increased risk of death.

• 3. Potent risk factor for complications: falls,

increase LOS, pressure ulcers, functional decline, and Institutionalization.

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MHA Delirium Discharge Order Bundle

Clinician Section

Clinician Section

• Continue to assess for signs of delirium, such as:

disturbance in attention and awareness; change in cognition that is not accounted for by dementia, develops over a short period, and fluctuates throughout the day.

• Minimize high-risk medications and other

medications with high anti-cholinergic effects:

• Opioids (e.g, Meperidine, Morphine, Fentanyl,

Hydromorphone)

• Benzodiazepines (e.g. Diazepam, Lorazepam,

Alprazolam)

• First Generation Antihistamines (e.g.

Diphenhydramine, Hydroxyzine, Meclizine)

• Muscle Relaxants (e.g. Cyclobenaprine,

Chlorzoxazone, Metaxalone)

• Hypnotics (e.g. Zolpidem, Eszopiclone, Zopiclone)

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Ensure Patients Have Sensory Aids

• Address sensory impairment by:
• Determining which, if any, sensory

aids are used by the patient

• Ensuring sensory aids are

available and in reach of patient

• Resolving reversible cause of the

impairment, such as impacted ear wax

• Sensory aids include:
• Hearing aids
• Eyeglasses
• Amplifiers
• Dentures

Assess and Manage Pain

How

Assess for pain regularly using objective scale 6

Look for nonverbal signs of pains, especially for patients with communication difficulties or ventilated patients 6

Why

Pain is a risk factor for delirium 26

When pain is not properly assessed and treated, patient may receive sedatives and narcotics that place them at risk for delirium 26

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Encourage Mobility

• Patients with early

mobility protocol are:

• Out of bed earlier
• Out of the ICU and hospital

earlier

• Less likely to be readmitted

to the hospital in 12 months following discharge

• Less likely to die in 12

months following discharge

Sleep Promotion and Environment

Sleep promotion

• Low-level

lighting at night

9

• Avoid nursing or

medical procedures during sleeping hours 6

• Schedule

medication rounds to avoid disturbing sleep

6

• Reduce noise

during sleeping hours 6 Environment

• Clock or

calendar in view

• f patient 6
• Normal

day/night variation in illumination 6

• Limit room and

staff changes 9

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Hydration and Nutrition

• Encourage patient

to drink adequate fluids

• Screen for

comorbidities that would affect fluid balance (congestive heart failure, chronic kidney disease)

Promote Cognitive Stimulation

• Encourage hobbies
• Puzzles
• Reading

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Questions Contact Information

• Angie Pokharel
• apokharel@mnhospitals.org

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References

• 1. Adamis, D. et. al., Delirium scales: A review of current evidence. Journal of Aging and Mental Health, 2010.

14(5): p.543- 555.

• 2. Angle, C. (2016). Standardizing management of adults with delirium hospitalized on medical-surgical
• units. The Permanente Journal. doi:10.7812/tpp/16-002
• 3. Brummel, N. E., & Girard, T. D. (2013). Preventing delirium in the intensive care unit. Critical Care

Clinics, 29(1), 51-65. doi:10.1016/j.ccc.2012.10.007

• 4. Confusion Assessment Method (CAM). (n.d.). Retrieved from http://www.medscape.com/viewarticle/481726
• 5. Waszynski, C. M. (2012). The Confusion Assessment Method (CAM). Best Practices in Nursing Care to Older

Adults, (13). Retrieved from https://consultgeri.org/try-this/general-assessment/issue-13.pdf

• 6. Delirium: prevention, diagnosis and management (2010).

https://www.nice.org.uk/guidance/cg103/chapter/1-guidance

• 7. Ely, E. W., Inouye, S. K., Bernard, G. R., Gordon, S., Francis, J., May, L., … Dittus, R. (2001). Delirium in

mechanically ventilated patients. JAMA, 286(21), 2703. doi:10.1001/jama.286.21.2703

• 8. Family Engagement and Empowerment (n.d.). http://www.icudelirium.org/family.html
• 9. Fong, T. G., Tulebaev, S. R., & Inouye, S. K. (2009). Delirium in elderly adults: diagnosis, prevention and
• treatment. Nature Reviews Neurology, 5(4), 210-220. doi:10.1038/nrneurol.2009.24
• 10. Girard, T. D., Jackson, J. C., Pandharipande, P. P., Pun, B. T., Thompson, J. L., Shintani, A. K., … Wesley Ely, E.

(2010). Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Critical Care Medicine, 38(7), 1513-1520. doi:10.1097/ccm.0b013e3181e47be1

• 11. Gleason, O. (n.d.). Delirium - American Family Physician. http://www.aafp.org/afp/2003/0301/p1027.html

References

• 12. Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly people. The Lancet, 383(9920),

911-922. doi:10.1016/s0140-6736(13)60688-1

• 13. Leslie, D. L., & Inouye, S. K. (2011). The importance of delirium: Economic and societal costs. Journal of the

American Geriatrics Society, 59, S241-S243. doi:10.1111/j.1532-5415.2011.03671.x

• 14. Managing delirium among elderly patients in the ED. (n.d.). Retrieved from

http://www.physiciansweekly.com/managing-delirium-elderly-patients/

• 15. Pandharipande, P., Girard, T., Jackson, J., Morandi, A., Thompson, J., Pun, B., … Brummel, N. (2013). Long-term

cognitive impairment after critical illness. New England Journal of Medicine, 369(3), 1306-1316. doi:10.1056/NEJMoa1301372

• 16. Rudolph, J. L., & Marcantonio, E. R. (2011). Postoperative delirium. Anesthesia & Analgesia, 112(5), 1202-
• 1211. doi:10.1213/ane.0b013e3182147f6d
• 17. Sessler, C. N., Gosnell, M. S., Grap, M. J., Brophy, G. M., O'Neal, P. V., Keane, K. A., … Elswick, R. K. (2002). The

Richmond agitation–sedation scale. American Journal of Respiratory and Critical Care Medicine, 166(10), 1338-

• 1344. doi:10.1164/rccm.2107138
• 18. Schweickert WD, et al. Lancet. 2009;373:1874-1882.
• 19. Vasilevskis, E. E., Han, J. H., Hughes, C. G., & Ely, E. W. (2012). Epidemiology and risk factors for delirium across

hospital settings. Best Practice & Research Clinical Anaesthesiology, 26(3), 277-287. doi:10.1016/j.bpa.2012.07.003.

• 20. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Arlington, VA: American Psychiatric Publishing.

• 21. Agarwal, V., O’Neill, P. J., Cotton, B. A., Pun, B. T., Haney, S., Thompson, J., … Pandharipande, P. (2010).

Prevalence and risk factors for development of delirium in burn intensive care unit patients. Journal of Burn Care & Research: Official Publication of the American Burn Association, 31(5), 706–715. http://doi.org/10.1097/BCR.0b013e3181eebee9

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References

• 22. DeCrane, S. K., Sands, L., Ashland, M., Lim, E., Tsai, T. L., Paul, S., & Leung, J. M. (2011). Factors Associated with

Recovery from Early Postoperative Delirium. Journal of Perianesthesia Nursing : Official Journal of the American Society of PeriAnesthesia Nurses / American Society of PeriAnesthesia Nurses, 26(4), 231–241. http://doi.org/10.1016/j.jopan.2011.03.001

• 23. Tomlinson, E. J., Phillips, N. M., Mohebbi, M., & Hutchinson, A. M. (2016). Risk factors for incident delirium in

an acute general medical setting: a retrospective case-control study. Journal of Clinical Nursing, 26(5-6), 658-667. doi:10.1111/jocn.13529

• 24. Watkins, C. C., & Treisman, G. J. (2015). Cognitive impairment in patients with AIDS – prevalence and
• severity. HIV/AIDS (Auckland, N.Z.), 7, 35–47. http://doi.org/10.2147/HIV.S39665
• 25. Elsamadicy, A. A., Wang, T. Y., Back, A. G., Lydon, E., Reddy, G. B., Karikari, I. O., & Gottfried, O. N. (2017).

Post-operative delirium is an independent predictor of 30-day hospital readmission after spine surgery in the elderly (≥65 years old): A study of 453 consecutive elderly spine surgery patients. Journal of Clinical Neuroscience, 41, 128-131. doi:10.1016/j.jocn.2017.02.040

• 26. Kalish, V. B., Gillham, J. E., & Unwin, B. K. (2014). Delirium in Older Persons: Evaluation and
• Management. American Family Physician, 1(90), 150-158. Retrieved from

http://www.aafp.org/afp/2014/0801/p150.html#commenting

• 27. Hipp, D. M., & Ely, E. W. (2012). Pharmacological and Nonpharmacological Management of Delirium in

Critically Ill Patients. Neurotherapeutics, 9(1), 158–175. http://doi.org/10.1007/s13311-011-0102-9

• 28. Freter, S., Dunbar, M., Koller, K., MacKnight, C., & Rockwood, K. (2015). Risk of Pre-and Post-Operative

Delirium and the Delirium Elderly At Risk (DEAR) Tool in Hip Fracture Patients. Canadian Geriatrics Journal, 18(4), 212–216. http://doi.org.aurarialibrary.idm.oclc.org/10.5770/cgj.18.185

References

• 29. Kuczmarska, A., Ngo, L. H., Guess, J., O’Connor, M. A., Branford-White, L., Palihnich, K., … Marcantonio, E. R. (2015).

Detection of Delirium in Hospitalized Older General Medicine Patients: A Comparison of the 3D-CAM and CAM-ICU. Journal of General Internal Medicine, 31(3), 297-303. doi:10.1007/s11606-015-3514-0

• 30. Han, J. H., Wilson, A., Vasilevskis, E. E., Shintani, A., Schnelle, J. F., Dittus, R. S., … Ely, E. W. (2013). Diagnosing Delirium in

Older Emergency Department Patients: Validity and Reliability of the Delirium Triage Screen and the Brief Confusion Assessment

• Method. Annals of Emergency Medicine, 62(5), 457-465. doi:10.1016/j.annemergmed.2013.05.003
• 31. Sarutzki-Tucker, A., & Ferry, R. (2014). Beware of Delirium. The Journal for Nurse Practitioners, 10(8), 575-581.

doi:10.1016/j.nurpra.2014.07.003

• 32. Scheffer, A. C., Van Munster, B. C., Schuurmans, M. J., & De Rooij, S. E. (2011). Assessing severity of delirium by the delirium
• bservation screening scale. International Journal of Geriatric Psychiatry, 26(3), 284-291. doi:10.1002/gps.2526
• 33. Gaudreau, J., Gagnon, P., Harel, F., Tremblay, A., & Roy, M. (2005). Fast, Systematic, and Continuous Delirium Assessment in

Hospitalized Patients: The Nursing Delirium Screening Scale. Journal of Pain and Symptom Management, 29(4), 368-375. doi:10.1016/j.jpainsymman.2004.07.009

• 34. Clegg, A. & Young, B. Which medications to avoid in people at risk for delirium: systematic review. Age and Aging,
• 2011. 40(1): p. 23-29.
• 35. Rosenbloom-Brunton, D., Henneman,E. and Inouye, S. (2010). Feasibility of family participation in delirium

prevention program for the older hospitalized patient. Journal of Gerontological Nursing. 36(9). p. 22-25.

• 36. Mailhat, T., Cossette, S., Bourbonnds, A. et. al. (2014). Evaluation of a nurse mentoring intervention to family

caregivers in the management of delirium after cardiac surgery (MENTOR _ D): a study protocol for a randomized controlled pilot trial. BioMedCentral. https://doi.org/10.1186/1745-6215-15-306.

• 37. Halloway, S. (2014). A family approach to delirium: a review of literature. Age & Mental Health. 18(2).
• 38. ICU Delirium for Patients and Families. www.icudelirium.org/family.html

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Coordination of Care Initiative Update

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Coordination of Care Initiative Goals

• Improve quality of care for Medicare beneficiaries

who transition among care settings

• Reduce 30-day hospital readmission rates and

admission by 20% by 2019

• Increase the number of days at home
• Establish sustainable, transferrable transition

practices across the spectrum of care

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Coordination of Care Communities

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Success Stories Webinar Series

Successful Strategies for Sustained Community Improvement Tuesday, January 22, 2019, 12–1:00pm – More At Your Service: Benefits of Home Health Agencies Working with their QIN Tuesday, February 26, 2019, 12–1:00pm – More Using Data to Drive Community Quality Improvement Efforts Tuesday, March 26, 2018, 12–1:00pm – More Home-based Innovative Strategies to Prevent Readmissions Tuesday, April 23, 2019, 12–1:00pm – More Changing the Culture: Improving Recognition and Management of Sepsis Thursday, May 30, 2019, 12–1:00pm – Register Achieving Community Goals by Partnering with Aging and Disability Resource Centers Tuesday, June 25, 2019, 12–1:00pm – Register

This six-webinar series highlights the innovative work the Lake Superior QIN COC partners have done across care settings and in the community to improve transitions of care and reduce readmissions.

Download the webinar series flier.

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Other Upcoming Event

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Community Scorecard

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The Community

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Admissions (community)

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Admissions (comparative)

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Admissions (vs. goal)

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Number of Fewer Admissions Needed to Meet Goal

• This community had 1,133 admissions in the most

recent 12 months (Q4 2017– Q3 2018).

• Need to be at 1,072 admissions for final

measurement (Q4 2017 – Q 3 2018), which is 61 fewer admissions than the goal.

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Readmissions (community)

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Readmissions (comparative)

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Readmissions (comparative)

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Readmissions (vs. goal)

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Number of Readmissions Needed to Meet Goal

• This community had 212 readmissions in the most

recent 12 months (Q4 2017– Q3 2018).

• Need to be at 194 readmissions for final

measurement (Q4 2017 – Q 3 2018), which is 18 fewer readmission than the goal.

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Next Community Meeting

Tuesday, June 25, 1-3 p.m. at FirstLight Health System

• Featured Presentation: Older Adult Mental Health Video Training

Series and Tools

• Dean Neumann, Community Relations Director, St. Joseph’s Hospital

Mental Health and Substance Use Services Video topic #1—Older adult mental health basics Video topic #2—Mental health crisis prevention & de-escalation Video topic #3—Person-centered care & collaboration

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Community Sustainment Discussion

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Contact Info

Janelle Shearer, Stratis Health jshearer@stratishealth.org, 952-853-8553

This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MN-C3-19-41 032819