Delirium Improvement Project Quality and Safety Leaders Meeting - - PowerPoint PPT Presentation

Delirium Improvement Project

Quality and Safety Leaders Meeting Friday 23 March 2018

Why is delirium a priority for SCV?

• Increase in serious incidents involving delirium
• 3rd most common hospital acquired complication in Australia
• Associated with severe adverse events
• Preventable in 30-40% cases
• Recent release of Delirium Clinical Care Standard

Delirium in Victoria

• For Victorian patients aged over >65 years
• For Victorian patients aged over >65 years WITH DELIRIUM

Delirium vs No delirium 8.1% Mortality 2.6% 14.9% + ICU 10.6% 15.2% + Septicaemia 10.6% 10.6 days Length of stay 5.6 3.07 WIES Cost 1.68 WIES Regional/rural Vs Metro 10.1% Mortality 6.6% 12.2 days Length of stay 9.4 days

Prevalence

In Victoria…. Prevalence of delirium is 0.5% = 6600 observed cases In the literature… Prevalence of delirium is 11-68% = 145,200 - 897,600 observed cases 138-600 – 891,000 missed cases each year Between 30-40% of delirium cases are preventable… 11% = 43,560-58,080 preventable cases each year 68% = 269,280 – 359,040 preventable cases each year

Delirium Improvement Project

• 18-24 month multidisciplinary project led by Safer Care Victoria

Aim

• To improve the screening, prevention and management of hospital acquired delirium in

Victorian public hospitals Outputs

• SCV endorsed delirium screening tool, delirium management pathway, revised clinical

practice guideline, improvement sector forums, patient, family & clinician education resources, point prevalence survey methodology

Pilot point prevalence survey

Primary aim To test a methodology for conducting a point prevalence survey of delirium in the Victorian public inpatient population Secondary aims To determine:

• the prevalence of delirium and cognitive impairment
• the difference between measured prevalence and reported prevalence
• the characteristics of patients with or at risk of delirium
• the frequency of physical and chemical restraint use
• the frequency of adverse events (falls and pressure injuries)
• Overall and by health service, hospital, ward and treating speciality
• Patients at risk of or identified as having hospital acquired delirium

Pilot point prevalence survey

Design

• ‘Staggered’ point prevalence survey design
• Study site coordinators to coordinator survey in health services
• Surveyors recruited locally to collect data
• Registered nurses, allied health, quality managers
• Receive training in survey protocol and remuneration for time
• Receive resources and support

Method

• 4 health services, 12 hospitals, 1048 beds
• 4 study site coordinators, 34 surveyors
• 23 days of data collection, 6 hours per day, 0.5 hours per bed

Pilot point prevalence survey

Secondary aims:

• 4AT assessment tool
• Participant observation
• Medical record review
• Data linkage (post hoc)
• Paper
• Electronic

Data sources Primary aims

Resource data

• People, time, cost

Training evaluation

• Study site coordinator
• Surveyors

Role evaluation

• Study site coordinator
• Surveyors

Pilot point prevalence survey

Demographics

• Age, gender, language, Aboriginal and Torres Strait Islander, Charslon comorbidity index

Physical restraint

• Nursing special/sitter, arm or leg shackles, mitts, bed sheets tucked/doubled/tied across

torso, posey vest or seat belt, low chair, tray table fixed to chair, bucket chair, concave mattress, both cot-sides up, bed against wall with near cot-side up Chemical restraint

• Administered in previous 24 hours
• Alprazolam, clonidine, haloperidol, lorazepam, olanzapine, oxazepam, quetiapine, risperidone
• New prescription this admission
• Stat, PRN or regular administration
• Indication other than diagnosed psychiatric condition or pain relief

Pilot point prevalence survey

Risk factors

• Age
• Known cognitive impairment
• Current hip fracture
• Severe medical illness – Modified Early Warning Score (Subbe et al., 2001)

Score Physiological parameter 3 2 1 1 2 3 Systolic blood pressure (mmHg) < 70 71-80 81-100 101-199 ≥ 200 Heart rate (bpm) <40 41-50 51-100 101-110 111-129 ≥ 130 Respiratory rate (bpm) < 9 9-14 15-20 21-29 ≥ 30 T emperature (ºC) < 35 35-38.4 ≥ 38.5 AVPU score A V P U

Pilot point prevalence survey

Participants: Hospitals

Pilot point prevalence survey

Participants: Wards/treating specialities Included Excluded Acute (medical, surgical, specialist medicine) Same-day admissions (dialysis, chemotherapy., day surgery) Sub-acute (geriatric medicine & rehabilitation) Emergency departments (short stay & urgent care centres) Palliative care wards Mental health High dependency units Paediatric Intensive care units Maternity Outlier specialities on included wards

Pilot point prevalence survey

Participants: Patients Included Excluded In-patients Aged < 18 years Aged ≥ 18 years Physically aggressive (safety risk) Non-English speaking Too critically ill to participate Post-anaesthetic care unit transfer Severe aphasia or non verbal Isolated due to immunocompromise Comatose Intellectual disability Imminently approaching end of life Delirium tremens Undergone neurosurgical procedure ≥ C3 within 7 days

Pilot point prevalence survey

Results

• Public report
• State, peer group
• Health service report
• Hospital, ward, treating speciality
• Raw data for further analysis
• Publications and presentations

Next steps

• Data analysis for pilot study in March 2017
• Ethics amendment April 2018
• State-wide survey May-June 2018

Questions