Multicomponent Delirium Prevention for Patient Safety

I saw something encouraging about using methods supporting patient safety. It was an American Medical News (Top 10 ways to improve patient safety now – amednews.com) about the top 10 ways to improve patient safety. I was a little disappointed that using multicomponent delirium prevention protocols specifically was not among them, but there were several interventions that, if strictly followed, could help prevent delirium by providing excellent medical care. They include:

  1. Improving hand hygiene
  2. Using barrier precautions to stop the spread of infections
  3. Preventing central-line associated bloodstream infections
  4. Using protocols to cut down on catheter-associated urinary tract infections
  5. Using preventive interventions to cut rates of ventilator-associated pneumonia

And let’s hear it NOW for Zaubler and colleagues important study showing quality improvement and cost savings in a non-academic medical center with multicomponent delirium intervention, in this case the Hospital Elder Life Program (HELP) program [1]. It targeted six delirium factors including cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. According to the authors, “Since 1999, it has been implemented at more than 100 hospitals in the US and at least seven other countries, and has been shown to decrease the incidence of delirium and functional decline in elderly hospitalized patients in a cost-effective manner”.

They used a pool of 20 to 25 volunteers along with Elder Life Specialists to implement the interventions. There were no dedicated funds to support a geriatric nurse practitioner or geriatrician. A consulting psychiatrist did round once or more per week. And in this study, the program was sponsored by a Department of Psychiatry. Most such programs are sponsored by Departments of Medicine. Length of stay and a decreased duration of delirium were notable achievements. The annual cost savings was $1,122,000. They used the Confusion Assessment Method (CAM) to screen for delirium. The bottom line in the discussion section of the paper:

“There is a growing need for hospitals to demonstrate high quality of care and decreased iatrogenesis in the context of growing pressures to limit healthcare costs. Minimizing the considerable morbidity, mortality, and costs associated with delirium should be a major focus in hospital-based quality improvement programs. This study shows that HELP can be replicated in a community hospital setting, generating significant benefit for patients as well as demonstrating major cost savings for the hospital.”

That will take a load off patients and families as well as hospitals.

1. Zaubler, T. S., et al. (2013). “Quality Improvement and Cost Savings with Multicomponent Delirium Interventions: Replication of the Hospital Elder Life Program in a Community Hospital.” Psychosomatics 54(3): 219-226.
Delirium is a common problem associated with increased morbidity, mortality, and healthcare costs in the hospitalized elderly, yet there is little research outside of academic medical centers exploring methods to prevent its onset. The authors adapted the Hospital Elder Life Program (HELP) for use in a community hospital and assessed its impact on delirium rate, length of stay (LOS) and healthcare costs in elderly patients. Delirium episodes and duration, total patient-days with delirium and LOS were assessed in 595 patients 70 years of age or older admitted to a general medical floor at a community hospital. Pre-intervention outcomes were assessed on the medical floor for 4 months. Interventions adapted from HELP occurred over 9 months and included daily visits, therapeutic activities, and assistance with feeding, hydration, sleep, and vision/hearing impairment. Delirium was assessed on a daily basis with the Confusion Assessment Method (CAM). The rate of episodes of delirium decreased from 20% in the pre-intervention group to 12% in the intervention group, a relative 40% reduction (P = 0.019). Total patients days with delirium decreased from 8% in the usual care group to 6% in the intervention group (P = 0.005). LOS among all patients enrolled in the intervention group decreased by 2 days (P < 0.001). Interventions resulted in $841,000 cost savings over 9 months. HELP can be successfully adapted for implementation in a community hospital setting to decrease delirium episodes, total patient-days with delirium and LOS, and generate substantial cost savings.

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