A COMPREHENSIVE APPROACH TO DELIRIUM

ELLEN BARRINGTON, MSN, RN, BC

Ocean Medical Center

• Community Hospital located in Brick, Ocean County, New Jersey

• MAGNET designation since 1998• Currently 281 beds• 427 RNs on staff• 515 Physicians on staff

Ocean County, New Jersey

• One of the largest and fastest growing in NJ• Population over the age 65

–National Average: 12.4%–Dade County, Fl: 14.2%–Ocean County: 20.7%

(American Fact Finder)

4 North ACE Unit Statistics

 2006

Discharges  2007

Discharges  2008

Discharges

Total 2,355 2,365 2,378

# 65 or older 1,727 1,944 1,989

% 65 or older 73.3% 82.2% 83.6%

Average Age 72.2 76.1 76.9

Median Age 77 80 80

Delirium

• Delirium complicates and extends the hospital stays of older patients accounting for more than 6.9 billion in Medicare expenditures annually (Medical News Today, 2009)

• As many as 56% of older persons may develop delirium while hospitalized, as many as 25% of patients are admitted with delirium (Inouye, 2006)

• Delirium prevalence in people with dementia range as high as 22% in the community and 89% in hospitalized patients (Fick & Mion, 2008)

• The identification of delirium is elusive to the acute care nurse, one major study found nurses failed to identify delirium in 69% of people presenting with it (Waszynski, 2007)

• Delirium mortality ranges from 24% to 33% (Leslie, 2008)

The Comprehensive Approach to Delirium

CAM HELP

Delirium Busters

Education campaign

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Quality Indicators

– Incidence and duration of delirium– Interventions and their effectiveness– Falls– Restraint use– Pressure wounds– Length of stay– Rate of nursing home placement– Continue to measure patient satisfaction using both the

Press Ganey and HCAHPS survey– Gallup survey for employee satisfaction

Financial Indicators

• The Value Opportunity– Reduction in delirium incidence

• Average cost of delirium $1,028 per case in resource use

• Reduce by 10% = approx cost savings $67,725 ( per unit)

• Hospital wide reduction by 10% including pilot unit = approx cost savings $240,000

* Conservative estimate as impact and cost of delirium is difficult to quanitify.

Financial Indicators

– Length of Stay (LOS)• Goal is to reduce LOS by 0.25 days• Average cost per day $400 (hospital specific)• 5,823 target patients =>70 years with LOS >2 days• Average LOS in 2008 = 6.68• Hospital wide cost reduction = $582,400

Accomplishments to date

• Confusion Assessment Method (CAM) is a required field in our system wide computerized nursing assessment tool

• Our team has presented 8 community education events• Specially trained volunteer (HELP) hours for the month of May,

2009 = 192 hours• Invited to participate in the Master Facility Plan meetings for

Geriatric considerations• Approached by the Emergency Department leadership to create

a Geriatric consultation service for the RN’s in the Emergency Department

Local Newspaper coverage 5/12/09

First Graduating Volunteer Group

Next Steps

• September, 2009– Preliminary data from our pilot unit

• September, 2009– Implement project on another unit– Orthopedic unit

• This unit is looking for assistance with delirium reduction

• December, 2009– Implement project on two additional units

• March, 2010– Implement on final three units

References

• American Fact Finder. (n.d.). Retrieved November 14, 2007, from U.S. Census Bureau: http://factfinder.census.gov/servlet/ACSSAFFFacts?_event

• Medical News Today. (n.d.). Retrieved May 19, 2009, from: http://www.medicalnewstoday.com/articles/93936.php

• Fick, D. M., & Mion, L. C. (2008). Delirium Superimposed on Dementia. American Journal of Nursing , 108 (1), 52-59.

• Inouye, S. (2006). Delirium in Older Persons. New England Journal of Medicine , 354 (11), 1157-65.

• Leslie, D. M.-S. (2008). One-Year Health Care Costs Asociated with Delirium in the Elderly Population. Archives Internal Medicine , 168 (1), 27-32.

• Waszynski, C. M. (2007). Detecting Delirium. American Journal of Nursing , 107 (12), 50-59.