Despite the obvious burdens to individuals and the health care system, delirium is often unrecognized, misdiagnosed as another disorder, or misattributed to dementia. However, early identification of risk factors is important because delirium can be prevented in 30% to 40% of cases using preventive interventions.
Ontario Health had a chance to interview Angela Roode, Manager of Professional Practice at Trillium Health Partners (THP), and Mary-Lynn Peters, NP, M.Sc., Professional Practice, to talk about their work with the Delirium Team and advice on how to ensure patients are receiving the highest quality care possible.
Can you describe how the Delirium Team got started?
The team had its beginnings as part of the Medical Psychiatry Alliance (MPA) back in 2014. It was a 6 year collaboration with the University of Toronto, THP, SickKids, CAMH, and a generous anonymous donor. The MPA looked at patients with co-existing mental and physical illness to find new ways to manage integrating their care. The Delirium Team was one of the projects that received funding.
Initially, the team consisted of geriatric psychiatry, geriatric medicine, two nurse practitioners, and two occupational therapists (OTs). The team was tasked with providing direct consultative care, local capacity building, and the heavy lift of launching a delirium project across the organization. Once the heavy lift was done and our project mandate terminated, the delirium team itself morphed and has now transitioned into the professional practice department.
With the pilot, we were able to show the value-add of this team and that ultimately swayed the organization to continue with the team. It’s a smaller team now with two OTs, but the organization recognized the incredible value it plays especially now in the context of a global pandemic.
The two OTs are skilled in delirium management and work closely with local unit leaders, point-of-care staff, and physicians to discuss non-pharmacological approaches to care, dosing and medication recommendations, individualized care plans, and also build internal capacity to manage delirium.
What type of patients do you see?
We see patients of all ages, but the more medically complex a patient is, the higher the risk for delirium. Commonly, we see older adults with pre-existing dementia or those who have experienced a fall and/or a hip fracture. We have a strong practice in the ICU where both the acuity of patient illnesss and medications used can play a significant role in delirium. We also see surgical patients and work closely with surgical teams to identify patients at risk to prevent delirium. Unfortunately, after surgery medications can trigger a delirium.
How are patients referred to the Delirium Team?
We went live with a new hospital information system last October and it crosses all our sites, which makes it that much easier to promptly screen and identify patients through the use of the Confusion Assessment Method (CAM).
We use both a “push” and “pull” methodology for receiving referrals. We instituted daily delirium screening on all the units which generates daily CAM scores. Any patient who has two or more positive delirium screens in a 48-hour period will have their name populated into a report that the delirium team receives daily. The delirium team will then contact the unit and ask the physician if they’d like to consult about the patient. So that is our “push.”
We also created a delirium team email address so that any clinician who has concerns about a patient, regardless of their CAM score, can directly contact the delirium team. That is our “pull.”
Finally, we created a delirium champion network. Our delirium team helps deliver education to these champions and stays in contact with them as they go from unit to unit doing consultative care.
So much of what we have done in the past has been reactive, this structure allows us to be much more proactive.
Who else is part of your team?
We have the Hospital Elder Life Program (HELP) in place to keep hospitalized older adults mentally and physically active, which helps to prevent delirium and functional decline. The program includes screening, assessment, a customized care plan, visits with trained volunteers, and oversight by the HELP team. We currently don’t have in-person volunteers due to the pandemic, but are working on a virtual model.
It’s important to designate staff members to fulfill the role that family members would have done like spending time with patients. Family members worry so much when they know their loved one has experienced delirium, so this role is very important. We also use technology to connect with family and that has been very helpful.
What would you suggest is a first step to using the Delirium Quality Standard?
Reviewing the Delirium quality standard and comparing it to your current practice is a great first step. It will show you where you’re likely already following best practice and where you can start to improve care when it comes to prevention, assessment, management, and education.
Our program focuses on preventative strategies and non-pharmacologic approaches, which align with the quality standard. We also utilize a screening process whereby care teams perform delirium screening once per shift. This process is now supported by our new hospital information system, which it makes it much easier for teams.
Education is a huge part of any delirium activity. Our delirium team provides support to point-of-care staff, which helps to decrease their anxiety about dealing with persons with delirious behaviours. We provide education to families so that they understand what’s happening with their loved one.
We look forward to reviewing the Delirium quality standard and selecting a metric for monitoring over the next year to determine how best to incorporate it into future Quality Improvement Plans.
As Kathryn Hayward-Murry, Executive Vice President and Chief Nursing Executive at THP notes:
“Awareness of how to identify, prevent and manage delirium is a core competency for all members of our inter professional team who care for seniors. Health care organizations can use the newly developed standard as the foundation from which to build their approach to caring for seniors at risk or who are experiencing delirium.”
Dr. Amir Ginzburg, Senior Vice President, Quality, Practice and Medical Affairs at THP, further comments:
“As people reflect on their own organizational experiences with delirium, we believe they will feel the call to action to make it a strategic priority. The manifestions of delirium also impact hospital staff, and can, in turn, affect joy in work and overall engagement, impacting organizational quality improvement goals. I believe organizations will see the alignment and seize the opportunity to make delirium reduction an organizational priority and work towards implementation of the quality standard.”