Li Ka Shing Knowledge Institute
The Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre
Delirium Prevention: St. Michael's Inter-Professional Team Makes its Mark
Mrs. Smith is a an 81 year old woman who volunteers at the local womens’ shelter 3 times per week, power walks daily at her local mall with friends and was recently admitted to hospital after running after her dog in a park and falling, resulting in a broken hip. Her hearing aids and glasses were lost somewhere en route to hospital. She was admitted to hospital and a urinary catheter was inserted before her surgery. She was started on morphine and gravol routinely after her surgery. Within 24 hours of her surgery, she was noted to be confused. Because of her confusion she was unable to participate in rehabilitation therapy and subsequently she was unable to return independently to her home.
Unfortunately confusion or delirium, is a common problem in older patients admitted to hospital. In particular, those admitted with hip fractures are at a high risk and delirium can occur in up to 65% of people. Delirium is often under-recognised (or confused with dementia, a chronic condition) and patients at risk for delirium are often missed.
This misdiagnosis can have significant consequences. Delirium is a risk factor for death, longer hospital stays, and admission to long-term care. Patients experiencing a delirious episode are more likely to experience complications such as adverse reactions to medications, falls, or poor nutrition. And, there is evidence from many high-quality studies showing how delirium can be prevented – but unfortunately there is often a gap between what is known and what is done.
Innovative pilot project
Lianne Jeffs
This project is a showcase of sorts: it is St. Michael’s first corporate “knowledge translation/quality improvement” initiative. Knowledge translation is all about moving evidence-based health sciences research into practice and decision making as quickly and efficiently as possible.
This project was selected because it leveraged the existing work of the Falls Delirium Restraints Committee. As well, the pilot clinical unit involves a large number of patients in the orthopedic unit—more than 65 patients over the age of 65 are admitted each month—addresses a significant clinical problem, and has high-quality evidence to support an intervention.
The core of the pilot project involves educating 60 nurses in the orthopedic unit in the use of the Confusion Assessment Method (CAM), a tool to measure delirium. Between May and June 2010, the entire toolkit will be launched, including: a delirium detection tool embedded into the existing electronic clinical care system; self-directed intranet delirium learning module; and a patient and family education guide. Ultimately, the project involves physicians, occupational therapists, pharmacists, physiotherapists, and non-clinicians such as quality improvement staff.
Lessons learned
Along the way, there have been plenty of lessons learned. In a hospital environment, for example, there are many stakeholders to consult and the approval process across the different stakeholder groups can be lengthy. The first order of business was to get everyone talking the same language and understanding the goals of the project, a significant challenge. “This was the first time we brought together the professional practice portfolios, research, KT, and quality improvement,” says Jeffs. “I soon realized that people were coming from different frames. Initially, people did not necessarily see themselves or their knowledge domain in the intervention. As a project team, we worked through reconciling the value of each of our frames. We’re still working through it.” Communication and transparency smoothed out the misperceptions and concerns.
Patient Care at St. Michael's
“We have moral obligation as scientists working in a ‘living laboratory’ to address these gaps and keep trying to get better outcomes for patients, their family members, and the health care system.”
We are striving for an alternative ending to Mrs. Smith’s story – one in which she is identified at being at risk for delirium and risk factors for delirium are modified. For example, her hearing aids and glasses are brought with her to the hospital, she is not started on routine morphine and gravol, the urinary catheter is discontinued as soon as possible and she is encouraged to ambulate immediately. In this version, she doesn’t develop delirium and is able to return home, to her active and independent life.
