Delirium Order Set! Now Will We Change?

Paul Thisayakorn, MD

Paul Thisayakorn, MD

Yesterday, one of our best resident physicians, Dr. Paul Thisayakorn, MD, dropped by our staff psychiatric consultation office just before our Clinical Problems in Consultation Psychiatry (CPCP) case conference to tell us about a new quality improvement project he’s involved in. He’s rotating through the Palliative Care Medicine service and the director asked Paul to come up with a way to raise awareness about our hospital’s new order set for managing and preventing delirium. Hardly anyone seems to know about it. This post is divided into a few pages so look for page numbers at the bottom below the Like button.

The delirium order set has been an ongoing initiative of the Delirium Early Detection and Prevention Committee which I started a couple of years ago and which a colleague assumed leadership of eventually. A clinical pharmacist, electronic health record expert (we use Epic here), nurse manager are also on the team. The resulting order set as a finished product contains clear guidance for non-psychiatric physicians on what drugs to prefer and avoid, relevant diagnostic tests and other assessments for investigating medical causes, and behavioral management approaches.

Our Epic liaison expert was immensely helpful by integrating this into the Epic interface. It’s easy to find–if you know it’s there.

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Comments

  1. Sharon Van Fleet says:

    Dr. Amos,
    I am interested in how the screening is going with the DOS, after using it for two years, since it has not had wide use in the US. A decade ago, when I brought it into a hospital setting into which I was hired primarily for policing of the need for 1:1 observation, I was confident that delirium screening by staff nurses could not be made more simple and accessible. I looked far and wide for a tool that was truly nurse-friendly and did not require “props,” memorizing questions, or burdening the patient. In that setting, I did not see full implementation as a screening tool, however, because I did not have support of the nurse executive at the time, who maintained that screening was “overkill,” no matter how much teaching I, the psychiatrists, and external presenters offered. The tool did sensitize staff re the myriad presentations of delirium and signs to look for, and many told me that it helped them describe their observations and concerns when they contacted physicians regarding changes in patient status. It unfortunately became valued by some as an objective means to help determine the need for 1:1 observation, rather than a delirium screen, and some were resistant to recognizing that focusing on the DOS score, once a patient became delirious, was not as useful as addressing the underlying medical issues, and that intervention was not as effective as prevention. As I was leaving the organization, the Dutch group did publish a paper suggesting that the DOS might actually measure sensitivity, if I recall.

    I agree with the impression of your staff nurses who believed the CAM to be complex. Studies continue to suggest that there are definite issues with reliability and other factors when using the CAM for nurse screening, and I have encountered numerous psychiatrists who are unaware of those data. I also have heard of organizations having had to make significant revisions to their protocols, finding alternatives to the CAM as a result of the CAMs training requirements.

    I also know that many, including extremely accomplished and respcted psychosomatic medicine physicians, who do not believe delirium is preventable, which may account for some of what you are observing. Undoubtedly, in many situations, given the toxicity of some treatment regimens and the presence of predisposing factors, that is true. On account, however, of my very close involvement with many vulnerable patients over a decade, I believe I have prevented delirium through detection of very early changes and rapid reversal of the precipitants. Of course, the work of Inouye and many others have demonstrated systematically the feasibility of and effectiveness of basic (but mostly comprehensive) preventive efforts.

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    • Hi Sharon,

      Great to hear from you and very well said! I can tell you that nurses here still say that physicians don’t seem to be aware of the importance of preventing delirium and systematically using instruments like the DOS to look for it. It’s also not easy to query our Health Care Information System (HCIS) to get a clear idea of delirium occurrence rates.

      I’m increasingly persuaded that implementation of delirium prevention programs is as much a matter of addressing hospital culture as changing hospital care systems. Education alone is clearly not effective.

      I wonder what it would take to instill the kind of diligence and accountability you demonstrate into trainees in nursing and medicine? The consistent practice of self-reflective improvement doesn’t seem to come naturally to most professionals. It certainly won’t be cultivated by using programs like Maintenance of Certification (MOC).

      Best wishes,

      Jim

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  2. If it is not considered proprietary you should consider publishing it in an online journal where you could put a large .pdf with all of the details in as “supplementary material”. I would predict it would easily go to “highly accessed” status.

    GD

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  3. Jim – Did I miss it? Is the actual order set on your blog somewhere?

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