3-Part Care Pathway Addresses Delirium During Hospitalization

Hartford Hospital's ADAPT program has decreased length of stay and readmissions attributable to delirium.

Hartford Hospital has developed a comprehensive approach to addressing delirium in the hospital setting.

In-hospital delirium has been associated with several negative patient outcomes, including increased risk of death, increased risk of a prolonged or permanent cognitive impairment, increased readmissions, and increased risk of developing dementia after hospitalization.

"We know the more severe the delirium is and the longer it lasts, the worse the outcome," says Christine Waszynski, DNP, APRN, coordinator of inpatient geriatric services at Hartford Hospital, which is based in Hartford, Connecticut.

Patients who experience delirium during a hospitalization also can develop a form of post-traumatic stress disorder, she says.

"They have recurrent or unresolved issues related to their experience during a delirium episode. It can have an extremely negative impact on their life. They "remember" bad things that happened to them during their hospitalization and have to reconcile that it is really their perception of what happened—people really were not attacking them and aliens were not abducting them for testing."

In 2011, Hartford Hospital launched Actions for Delirium Assessment, Prevention, and Treatment. The ADAPT program has achieved impressive results. From 2013 to 2018, delirium-attributable days at the hospital decreased 40%. From 2012 to 2019, readmissions have fallen 14% for patients who experience delirium during a hospitalization.

The ADAPT program has three key components: screening, prevention, and treatment and management.

1. Screening for delirium
 

The ADAPT program features delirium screening in the inpatient and the emergency department settings.

For the inpatient setting, nurses screen all patients for delirium using the Confusion Assessment Method. When a patient is identified at high-risk for delirium, a care pathway is triggered, says Robert Dicks, MD, chief of geriatric medicine at Hartford Hospital.

"When a nurse identifies a patient who screens as abnormal, the clinicians are notified on the spot that they have a patient who is at high risk for delirium and they are engaged at that point. Then the preventive measures kick in," he says.

In the emergency department setting, nurses screen every patient over age 65 with a Single Question in Delirium (SQID) screening technique. These patients are asked whether they have been more confused lately. If a patient has a family member or someone else with them, that individual also is asked the question about the patient.

If the answer to the SQID question is "yes," a patient gets an intentional test—counting backward from 20 to one. "Attentional deficit is the key element of delirium. You must be inattentive to be delirious," Waszynski says.

2. Preventing delirium
 

Once a patient has been identified at high-risk for delirium, the ADAPT program calls for a range of preventive measures by clinicians, nurses, and hospital volunteers.

Clinicians focus on three kinds of preventive measures: avoiding administration of deliriogenic medications such as Ativan and fentanyl, avoiding the abrupt discontinuation of medications such as opioids and steroids, and avoiding several medical interventions when they are deemed unnecessary such as telemetry and urinary catheters.

Most nursing preventive measures are basic best practices such as moving the patient around, ensuring patients get as much uninterrupted sleep at night as possible, making sure patients have their sensory aids such as glasses, and providing assistance for eating and drinking.

Volunteers provide several preventive services to patients at high-risk for delirium, including socializing with patients, encouraging cognitive activities such as word searches, and assisting patients with walking.

Other preventive measures include an "all about me" poster placed in a patient's room. "It has basic information about patients such as what they like to be called, what they like to eat, the important people in their life, their dog's name, and what activities they enjoy," Waszynski says.

3. Treating and managing delirium
 

"When a nurse screens a patient as abnormal, it is an urgent situation," Dicks says.

The first step in treating delirium is determining the cause of the condition, he says. "It may be a drug-induced delirium. It may be a medication that was inappropriately stopped. It may be drug interactions. There's always the risk that infection and an abnormality in the blood can cause delirium. A new injury or stress can cause delirium. All of those factors are dealt with based on a systematic review."

Once clinicians feel secure that they have an explanation for delirium or the patient is responding in an expected way, there is a consult with one of three specialties—geriatrics, neurology, or psychiatry—for a second opinion. "Providers want to make sure that they are not dealing with something atypical, that there is not some other workup that is justified, and that the treatment they have approved is appropriate," Dicks says.

Clinicians apply best practices "across the board" related to treatment strategy, he says. "There are certain medications that we believe are more effective and better tolerated than other medications, and we guide clinicians to those medications in our protocol. When those medications are ineffective or contraindicated, we have second-line and third-line treatment strategies."

Cost-effectiveness of ADAPT
 

An Institute for Healthcare Improvement blog post highlights the cost-effectiveness of Hartford Hospital's ADAPT program.

Accounting for longer lengths of stay and higher costs of care per day, delirium adds more than $22,000 to an inpatient stay at Hartford Hospital. The total costs of the ADAPT program are about $50 per patient.

"From the Hartford Hospital data and analysis applied to it, one might reasonably conclude that even under the most conservative scenarios, ADAPT should at least break even and probably perform far better than that," the IHI blog post says.