2012 Finalist: Summa Health System

Prevention of Medication-Induced Delirium: A System-Wide Quality Improvement Project

Delirium is associated with long-term cognitive deficits, increased health care costs, and increased mortality. There are many causes of delirium, and medications or the lack of appropriate medications are often contributors. Medications that place patients at risk for delirium are often initiated during hospitalizations.

An interdisciplinary health care team developed a protocol to identify patients at risk for delirium, implement methods to prevent delirium, guide prescribers to the appropriate assessment when delirium occurs and use appropriate medication for behavioral management if necessary. A pharmacist led the group to improve the medication-use component of the program. Medication initiatives included development of evidence-based interventions, use of technology to efficiently support 24-hour care collaboration between physicians and all pharmacists, and administration of an education program for pharmacists. Additionally, pharmacists were involved in the education of nurses, physicians and other support personnel. Pilot testing occurred on one unit prior to implementation across all medical-surgical units. Medication-use data were collected prior to the initiation of the pilot, after the pilot program, and 9 months after the implementation on all of the medical-surgical units.

Delirium prevalence decreased from 8.8 percent to 7.2 percent in the post-pilot group. Although this was clinically significant, it did not reach statistical significance. However, two secondary outcomes reached a statistically significant change during the pilot study. The post-pilot group had a decreased length of stay from 7.6 days to 4 days (p=.018) and the number of patients who received an antipsychotic medication increased from 23 percent to 57 percent (p=0.05). The mean number of doses of antipsychotic medications administered decreased from 10.6 doses in the pre-pilot group to 5.25 doses in the post-pilot group. The number of patients that received medications that increase the risk of delirium decreased from 53 percent to 24 percent. Other outcomes included a decrease in death from 23 percent to 9.5 percent and a reduction in 30-day readmissions from 31 percent to 5 percent.

A retrospective quality improvement audit examined electronic medication usage data before and after implementation of the protocol. When pre-pilot data were compared to post-implementation data, there was a 30-percent decrease in the number of patients receiving intravenous lorazepam, a 15-percent decrease in patients receiving haloperidol with a large increase in incremental dosing, and a 1.5-percent increase in atypical antipsychotic use.

Another quality improvement project was initiated approximately 9 months post implementation on the medical-surgical units. Patients for whom a delirium plan of care was implemented (n = 77) were compared to those for whom a plan of care was not implemented (n=101). There was a significant decrease in 30-day readmissions in the group that had the plan of care initiated (p= 0.05). A significant positive correlation was found between the development of delirium and the number of days before the plan of care was implemented. The risk of developing delirium was decreased in patients for whom a plan of care was placed in their medical record sooner (p=0.017). The audit found no significant difference in mortality, length of stay or transfers to ICU between the groups.

The delirium initiative protocol was implemented to improve patient care by incorporating screening and delirium prevention into the daily routines of nurses, pharmacists and physicians. An order set promotes an evidence-based method to treat delirium. The program was initiated without additional resources. Preliminary outcomes support that the program has patient safety as well as financial benefits.

Multidisciplinary Team
Susan M. Fosnight, B.S.Pharm., Team Chair
Kyle R. Allen, D.O.
Lyn Benedict, M.S.N., R.N.-B.C.
Sandy Germano, B.S.N., R.N.
Linda Gleespen, R.N., B.S.N.
Carolyn Holder, M.S.N., R.N.
Susan Hazelett, R.N., M.S.N.
Donald S. Jackovitz, M.S.
Allison Sabo, R.N.
Scott Wilber, M.D., M.P.H.
Rex Wilford, R.Ph., D.O.