2015 Recipient: Houston Methodist Hospital System

Houston, TX
Clinical Management of High-Risk Medication Use to Mitigate the Incidence of Hospital-Acquired Delirium in the Geriatric Population


Background
Houston Methodist Hospital System (HMHS), comprised of one tertiary academic center and six community hospitals, serves the Houston metropolitan area of more than 5 million people. In 2012, HMHS was awarded a three-year Health Care Innovation Grant from the Centers for Medicare and Medicaid Services to improve delirium detection and prevention in acute care geriatric patients.

Delirium, a common, serious and potentially preventable source of morbidity and premature death among hospitalized elders, is poorly recognized and has been shown to precipitate cognitive and functional decline. It complicates hospital stays for more than 2.3 million elderly patients in the United States, with an attributed cost ranging from $16,303 to $64,421 per patient, totaling about $38-$152 billion each year.1 Preventing delirium is the most important goal, yielding the greatest benefits on quality of life and cost savings. 2 Medications account for approximately 40 percent of delirium cases and evidence exists with benzodiazepines, opioids and drugs with anticholinergic properties. 3

HMHS internal data revealed that about 44 percent of elderly inpatients received orders for one or more targeted deliriogenic medications, such as zolpidem, diphenhydramine, hydroxyzine, lorazepam, diazepam, methocarbamol and meperidine. We believed that high-risk medication use can be mitigated through a multipronged, team-based approach and that such reduction could positively impact incident delirium. After receiving the grant, pharmacy leaders collaborated with an interprofessional team to develop multihospital, multidisciplinary, multipronged initiatives aimed at reducing patient risk.
Methods: This continuous quality improvement program was supported by pharmacists, physicians, nurses, certified healthcare aides, volunteers and administrators systemwide. Two key components, delirium screening and pharmacy initiatives, are described below:
  • Delirium Screening: Nurses are prompted by the electronic medical record to screen patients. If a patient has a positive screen, the provider is notified and a work-up is initiated to ascertain potential causes. A delirium safety protocol is implemented, including fall precautions, hourly checks, bed and chair alarms, toileting rounds every 2 hours and vital signs every 4 hours for 48 hours. A pharmacist may be consulted to review medication orders and the medication history.
  • Pharmacy Initiatives: These included electronic population-based pharmacist surveillance, patient-level pharmacist interventions, systemwide medication formulary changes and restrictions to support best practices in drug selection and dosing, and collaboration with physician champions to develop a provider-driven order-set guiding prescribers on appropriate evaluation and treatment of elderly patients with newly suspected delirium in the hospital.
Four overarching goals were outlined in the operational plan, including:
  • Aim 1: Reduce hospital-acquired delirium in patients ≥ 70 years on acute care units.
  • Aim 2: Improve delirium recognition and increase safety measures.
  • Aim 3: Reduce high-risk medication use by 20 percent.
  • Aim 4: Reduce hospital costs and length of stay by avoiding hospital-acquired delirium.
Results
For the analysis of incident delirium, 28,200 geriatric inpatient encounters from July 2012 to December 2014 were included. Because delirium screening was not systematically performed on the target population at our facilities prior to implementation, the first quarter of program implementation (Q4-2012) served as the baseline period.
  • Aim 1: The incidence of delirium declined steadily each quarter and became significantly lower in the second, third and fourth quarters of 2014 compared to the 2012 baseline showing a 37-percent relative reduction (2.4 percent absolute reduction).
  • Aim 2: Greater than 95-percent compliance with nurse screening was achieved by the third quarter of implementation (Q2-2013) and has been maintained throughout measurement periods.
  • Aim 3: Since implementation, more than 22,000 patient encounters have been electronically monitored, generating 7,400 medication safety alerts that resulted in approximately 2,000 pharmacist interventions. Following implementation of key strategies, zolpidem and diphenhydramine use decreased by more than 40 percent from baseline.
  • Aim 4: The reduction in delirium incidence signaled important clinical benefits for our patients and possible financial implications. Preliminary results from multivariate linear regressions conducted to assess the impact of delirium on hospital length of stay and hospital costs suggest that an incident case of delirium was associated with an increased hospital length of stay and an increase in hospital cost. As such, reduction in incident delirium is thought to translate into overall cost avoidance.
Conclusion
Success of this initiative at a tertiary medical center has been replicated at four community hospitals within the system, demonstrating generalizability. This success is greatly attributed to the collaboration between pharmacists, physicians, nurses and administrators. Our continuous quality improvement initiative across a diverse healthcare system demonstrates that a core, multidisciplinary team embracing the tenets of continuous quality improvement is capable of improving delirium detection and prevention.

References
1. Leslie DL, Marcantonio ER, Zhang Y, et al. One-Year Health Care Costs Associated With Delirium in the Elderly Population. Arch Intern Med. 2008; 168(1):27-32.
2. Inouye SK. Delirium in Older Persons. N Engl J Med. 2006, 354(11), 1157-1165.
3. Alagiakrishnan L, Wiens CA. An Approach to Drug-Induced Delirium in the Elderly. Postgrad Med J. 2004; 80(945):388-393.

Interprofessional Team
Mobolaji Adeola, Pharm.D., BCPS
Michael Liebl, Pharm.D., BCPS
Rejena Azad, Pharm.D.
Joshua Swan, Pharm.D., BCPS
Kathryn Agarwal, M.D.
George Taffet, M.D.
Lisa Kiehne, M.H.A.
Stuart Dobbs, M.D.
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