Us­ing IT to iden­tify pa­tients at risk for out­breaks of delir­ium

Hospi­tal uses IT to help iden­tify at-risk pa­tients

Modern Healthcare - - FRONT PAGE -

In early 2011, a team of clin­i­cians and in­for­ma­tion tech­nol­ogy spe­cial­ists at Hart­ford (Conn.) Hospi­tal con­vened a work group to ad­dress one of the most dan­ger­ous, costly and of­ten-over­looked com­pli­ca­tions af­fect­ing hos­pi­tal­ized older adults.

Their tar­get: delir­ium, a sud­den, acute change in men­tal sta­tus of­ten char­ac­ter­ized by con­fu­sion, dis­ori­en­ta­tion, inat­ten­tive­ness and changes in con­scious­ness. It’s shock­ingly com­mon, ex­perts say, af­fect­ing roughly a quar­ter of gen­eral-medicine ge­ri­atric pa­tients and as many as 75% to 80% of pa­tients over age 65 in in­ten­sive-care units.

Al­though it was long as­sumed to be a hard-to-avoid prob­lem among older pa­tients, par­tic­u­larly in un­fa­mil­iar, stress­ful hospi­tal set­tings, there is grow­ing aware­ness that delir­ium is as­so­ci­ated with a host of neg­a­tive out­comes, in­clud­ing longer lengths of stay, falls, pres­sure ul­cers, mal­nour­ish­ment, de­creased func­tion, pneu­mo­nia and in­creased risk of death both dur­ing and af­ter hos­pi­tal­iza­tion.

“It’s a huge prob­lem from a num­ber stand­point,” says Dr. James Ru­dolph, site di­rec­tor of the Ge­ri­atric Re­search, Ed­u­ca­tion and Clin­i­cal Cen­ter at the Vet­er­ans Af­fairs Bos­ton Health­care Sys­tem. “Some stud­ies have shown equiv­a­lent chances of dy­ing be­tween delir­ium and heart at­tacks.”

And the pa­tients who do sur­vive can suf­fer long-term—some­times even per­ma­nent— cog­ni­tive im­pair­ment af­ter a delir­ium episode, says Chris­tine Waszyn­ski, a ge­ri­atric nurse prac­ti­tioner who was part of 601-bed Hart­ford Hospi­tal’s delir­ium team. “Delir­ium is an acute brain in­jury, and some peo­ple never re­ally re­cover from it,” she says, not­ing that for many pa­tients, an episode can mark the be­gin­ning of a pre­cip­i­tous de­cline.

Es­ti­mated per-pa­tient costs of delir­ium range from $16,000 to as high as $64,000, while to­tal an­nual costs to the health­care sys­tem are more than $100 bil­lion, ac­cord­ing to re­cent fig­ures.

Ex­perts stress the need for early iden­ti­fi­ca­tion of those pa­tients who are at great­est risk for de­vel­op­ing delir­ium, in­clud­ing those who have de­men­tia, cer­tain types of in­fec­tions, vis­ually im­pair­ments, or se­vere ill­ness and mul­ti­ple co­mor­bidi­ties.

And many of the strate­gies rec­om­mended for the preven­tion of delir­ium are rel­a­tively sim­ple. They in­clude mak­ing sure pa­tients have their glasses or hear­ing aids on at all times, get- ting pa­tients up and mov­ing, hang­ing pic­tures of fam­ily or plac­ing fa­mil­iar ob­jects nearby, steer­ing clear of cer­tain med­i­ca­tions un­less nec­es­sary, and en­sur­ing pa­tients have their treat­ment plans ex­plained to them.

But iden­ti­fy­ing and as­sess­ing those high- risk pa­tients of­ten proves chal­leng­ing, par­tic­u­larly with fre­quent pa­tient hand­offs, Waszyn­ski says. So the team at Hart­ford Hospi­tal—known as Ac­tion for Delir­ium As­sess­ment, Preven­tion and Treat­ment, or ADAPT—came up with a sys­tems-based ap­proach that lever­ages the hospi­tal’s ex­ist­ing in­for­ma­tion tech­nol­ogy ca­pa­bil­i­ties.

In its anal­y­sis, the ADAPT group con­cluded that Hart­ford Hospi­tal’s nurses strug­gled to per­form ad­e­quate ini­tial as­sess­ments of pa­tients’ men­tal sta­tus, which are crit­i­cal for gaug­ing changes from the base­line. That’s where Julie Michael­son, clin­i­cal con­sult­ing an­a­lyst in Hart­ford Hospi­tal’s in­for­ma­tion ser­vices depart­ment, came in.

“What I do is an­a­lyze where peo­ple are click­ing and point­ing, and then I try to put ref­er­ence data at the point of care,” Michael­son says. “We want tech­nol­ogy to meet clin­i­cians’ work­flow and not the op­po­site.”

Like many hos­pi­tals, Hart­ford Hospi­tal uses the Con­fu­sion As­sess­ment Method, or CAM, a delir­ium screening tool de­vel­oped more than 20 years ago by Dr. Sharon Inouye, a pro­fes­sor of medicine at Har­vard Univer­sity and a long­time leader in the field of delir­ium re­search.

The CAM asks users to re­port changes in pa­tients’ men­tal sta­tus from the base­line, but Hart­ford Hos­pi­tals elec­tronic health record wasn’t able to cap­ture that data, Waszyn­ski says. “We rec­og­nized im­me­di­ately that we needed to change that.”

De­ter­min­ing men­tal sta­tus

The ADAPT team cre­ated an ini­tial nurs­ing as­sess­ment within the EHR that al­lows nurses to choose from five sim­ple cat­e­gories of men­tal sta­tus, in­clud­ing nor­mal, mildly for­get­ful and sig­nif­i­cantly for­get­ful. The goal, Waszyn­ski says, is to de­ter­mine whether pa­tients have de­men­tia or some other cog­ni­tive prob­lem in their ev­ery­day lives, which makes it eas­ier to judge whether fu­ture episodes of con­fu­sion are ac­tu­ally delir­ium.

“The beauty of this tech­nol­ogy is that when a nurse does the CAM on a pa­tient she’s never taken care of be­fore, that pa­tient’s base­line in­for­ma­tion comes up on the screen,” she ex­plains. “The nurse can see, for ex­am­ple, that this pa­tient is usu­ally nor­mal, and now they can’t put two words to­gether, or this pa­tient usu­ally has mild im­pair­ment, and now it’s se­vere.”

The team put other changes in place, in­clud­ing clin­i­cal de­ci­sion-sup­port tools that help nurses as­sess whether pa­tients are dis­play­ing inat­ten­tion—an­other el­e­ment of the CAM. They also con­fig­ured the EHR so nurses can send mes­sages to physi­cians, no­ti­fy­ing them of a pos­si­ble case of delir­ium. And they cre­ated spe­cial­ized alerts for med­i­ca­tions such as Be­nadryl, Pep­cid and Am­bien, which are of­ten avoided in pa­tients at higher risk.

“Now when any of these med­i­ca­tions are or­dered for a high-risk pa­tient, the user gets a warn­ing that the med­i­ca­tion could cause delir­ium,” Waszyn­ski says. Since the drug alerts were put in place a year ago, use of such med­i­ca­tions among high-risk pa­tients has dropped 70%.

The full de­ci­sion-sup­port sys­tem for delir­ium went live Aug. 21, Michael­son says, but in that short time, nurses have em­braced the tech­nol­ogy.

“They say that this is ex­actly what they needed,” she says. “They don’t have to do any hunt­ing and peck­ing.”

Hart­ford Hospi­tal is not the only site us­ing com­put­er­ized de­ci­sion-sup­port solu-

tions to mon­i­tor delir­ium. Donna Fick, pro­fes­sor of nurs­ing at Penn State Univer­sity, and sev­eral of her col­leagues, have se­cured a $2.7 mil­lion grant from the Na­tional In­sti­tute of Nurs­ing Re­search to test a strat­egy they crafted for de­tect­ing delir­ium in pa­tients with de­men­tia.

Their in­ter­ven­tion—Early Nurse De­tec­tion of Delir­ium Su­per­im­posed on De­men­tia, or END-DSD—in­cludes de­ci­sion sup­port as well as train­ing for nurses.

“This is a dif­fi­cult pop­u­la­tion for nurses to as­sess,” says Fick, who has spent sev­eral decades study­ing delir­ium. “These pa­tients are al­ready con­fused. It takes some work to help nurses un­der­stand that delir­ium is pre­ventable, and if they don’t pre­vent it, these pa­tients will get worse.”

The END-DSD fea­tures a delir­ium-as­so­ci­ated fac­tors screen that pops up in the EHR and pulls data from the pa­tient’s record about po­ten­tial causes. That screen in­cludes lab val­ues for sodium, blood su­gar, po­tas­sium and thy­roid. It also in­di­cates what types of med­i­ca­tions a pa­tient is tak­ing and whether a pa­tient has an in­fec­tion or is de­hy­drated.

An­other screen, de­signed for man­age­ment and preven­tion, prompts nurses to re­move de­vices such as catheters when­ever pos­si­ble, to en­gage pa­tients in cog­ni­tively stim­u­lat­ing ac­tiv­i­ties, and to mon­i­tor pa­tients’ nu­tri­tion and hy­dra­tion closely.

The five-year study has en­rolled 225 pa­tients so far, with plans to en­list 165 more, Fick says. More than 1,000 nurses have gone through the train­ing pro­gram.

“I think we have a fair amount of ev­i­dence on delir­ium, but the chal­lenge is trans­lat­ing that data into prac­tice,” she says. “Us­ing IT sys­tems, hos­pi­tals can think about who is most at risk.”

Such sys­tems can be very help­ful, says Ru­dolph, of the VA Bos­ton Health­care Cen­ter.

Ru­dolph, a geri­a­tri­cian at Brigham and Women’s Hospi­tal, Bos­ton, is also the im­me­di­ate past-pres­i­dent of the Amer­i­can Delir­ium So­ci­ety, a group cre­ated just a few years ago to raise aware­ness and boost re­search ef­forts.

“At the VA, we see real po­ten­tial to use the EHR to iden­tify pa­tients who are at high­est risk for delir­ium,” Ru­dolph says. “If a pa­tient comes in on a de­men­tia drug, for in­stance, or if they are ad­mit­ted to the ICU or they come in with a hip frac­ture, they are at higher risk. It’s not a per­fect mea­sure, but it can help us to fo­cus our ef­forts.”

But he also cau­tions that clin­i­cal de­ci­sion-sup­port sys­tems can lead to “alert fa­tigue,” when clin­i­cians, in­un­dated with con­stant alerts, be­gin to pay less and less at­ten­tion to them.

“It de­pends on the hospi­tal’s records sys­tem, but it is some­thing to keep in mind,” Ru­dolph says.

He is work­ing on a qual­ity-im­prove­ment project called the Delir­ium Tool­box, which pro­vides nurses with read­ing glasses, hear­ing am­pli­fiers, stress balls, puz­zles, decks of cards, sleep­ing masks and other tools they can pro­vide to pa­tients to ward off delir­ium.

“I’m not re­ally sure yet that the stuff in the box makes a dif­fer­ence,” Ru­dolph says. “What does seem to make a dif­fer­ence is that a nurse rec­og­nizes the pa­tient is high risk, goes to the tool­box and says, ‘I’m go­ing to take a lit­tle ex­tra time with this pa­tient.’ That’s what’s show­ing prom­ise so far.”

Julie Michael­son, left, a nurse and a clin­i­cal con­sult­ing an­a­lyst in Hart­ford Hospi­tal’s IT depart­ment, re­views the delir­ium doc­u­men­ta­tion sys­tem with Michelle Kan­gos, a staff nurse in the on­col­ogy unit. Michael­son helped de­sign the sys­tem.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.