Coordination of Care Initiative Mora Area Community Community - PDF document

3/28/2019 Coordination of Care Initiative Mora Area Community Community Meeting April 2, 2019 FirstLight Health System Download meeting agenda and slide handout: Agenda Handout 2 1

3/28/2019 Welcome — Introductions 3 MHA Delirium Discharge Order Bundle Place picture here Susan Schumacher, MS, APRN-BC, GCNS Clinical Nurse Specialist in Gerontology Methodist Hospital-Park Nicollet Angie Pokharel, MHS Quality and Process Improvement Specialist Minnesota Hospital Association April 2, 2019 2

3/28/2019 Agenda/Outline 1. Introduction 2. MHA Quality and Patient Safety Committee Structure 3. Delirium Committee 2019 priorities and tools 4. Clinical review 5. Discharge Order Bundle deep dive 6. Questions Minnesota Hospital Association 3

3/28/2019 MHA Overview 4

3/28/2019 MHA Quality & Patient Safety Division  Dedicated QPS staff for over 19 years  13 expert committees  Partnership for Patients contractor for the last 7 years Quality and Patient Safety Committee Structure 5

3/28/2019 2019 Delirium Committee Priorities Priority 1 : Road Map Implementation and Adherence Priority 2: Re-evaluating and updating delirium process and outcome metrics Priority 3: Early mobilization during hospitalization MHA Delirium Place picture here Committee 2018 Work Plan Priority 1 6

3/28/2019 Priority 1: Delirium Road Map Fundamental or Road map design advanced strategies to help with prioritization Organized by section to Mapped resources with address live links specific Operational Line by line references definitions aspects of (active links at the end (what yes means) care of each document) Audit-style format for key elements 7

3/28/2019 Why use the Delirium Road Map?  It is a step-by-step guide to building a delirium program. ICU/Ventilated Management Infrastructure Detection Prevention Medications Patients/the of Behaviors ED Delirium Road Map  MHA Delirium Road Map (PDF)  https://www.mnhospitals.org/Portals/0/Documents/patientsafety/Delirium/Delirium%20Road%20Map.pdf (URL) 8

3/28/2019 What does the road map data tell us? 2018 1. Education for nurses 2. Education for physicians/residents 3. Reaching the executive team 4. Coordination of care Delirium Learning Cohort (Nurses) Resources & Purpose Objectives Activities • Provide education about • Provide education, • 6 monthly calls delirium identification, resources, and tools for • Delirium Awareness prevention, and nurse leaders to learn Presentation-Nurses management to nurse about delirium • Case Studies leaders and educators awareness. • Videos via a train-the-trainer • Train nurse • Patient stories model. leaders/clinical • Delirium Road Map educators on how to • Data collection bring the delirium • Learning Collaboration awareness presentation and resources back to Network Events their nursing units. 9

3/28/2019 Delirium Learning Cohort Clinical Education Modules Module 1 Introduction to Delirium: Definition, Cost, and Mortality Module 2 Data: Current State and Collection Module 3 Prevention Module 4 Identification and Presentation of Delirium Module 5 Management: First Lines of Treatment Module 6 Patient and Family Engagement Delirium Learning Cohort Example Toolkit 10

3/28/2019 Delirium Learning Cohort Phase 2  The modules from the Delirium Learning Cohort are being uploaded into an easy to use Learning Management System and will be made available soon!  Contact Naira at apokharel@mnhospitals.org Delirium Fact Sheet (Physicians and Residents) 11

3/28/2019 SBAR (Executives and Leadership) Delirium Discharge Order Place picture here Bundle Susan Schumacher, MS, APRN, GCNS-BC 12

3/28/2019 Delirium Discharge Order Bundle  Goal: Coordinate with post-acute organizations to identify and address areas of opportunity in delirium prevention and management to prevent delirium related readmissions Delirium An acute disorder of attention and cognition. Common, serious, costly, under recognized and often fatal. Current approach to diagnosis and treatment of delirium remains a clinical diagnosis. 13

3/28/2019 Diagnosis  Underrecognized and easily overlooked.  Only 12 to 35% of delirium cases are recognized.  Current reference standard diagnostic criteria are: • DSM-5 • ICD-10  Over 24 delirium instruments have been used in published studies.  CAM-most widely used instrument.  Currently, there are at least 11 diagnostic codes for delirium in ICD-9 and 23 codes in ICD-10.  Only 3% of delirium cases are coded in medical records. DSM V The Disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness. Diagnostic and Statistical Change in cognition (e.g., memory deficit, disorientation, Manual of language disturbance, perceptual disturbance) that is not better accounted for by a preexisting, established, or evolving dementia. Mental Disorders, The disturbance develops over a short period (usually hours to Fifth days) and tends to fluctuate during the course of the day. Edition There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause. 14

3/28/2019 Significance  In the united states, >2.6million adults 65years and older each year develop delirium  Total cost range from $16,303 to $64,421 per patient  Accounts for >$164 billion in annual healthcare expenditure  Included on the pt. safety agenda  Targeted as an indicator of healthcare quality for seniors  Hold significant societal implications Key Clinical Predisposing Factors Cognitive Advanced impairment, Age- 65 and such as older dementia Multiple co- History of delirium 5 morbidities 15

3/28/2019 Key Clinical Precipitating Factors Higher Dehydration severity of Surgery or illness constipation Exposure to Hip Fractures 5 Pain multiple medications Forms of Delirium 1. HYPERACTIVE 2. HYPOACTIVE 3. MIXED  The hypoactive form is more common among older adults • Often unrecognized • Associated with higher rates of complications and mortality  Delirium was found in ~90% of patients in the last days of life in a 2013 systematic review. • Hypoactive delirium was the most prevalent delirium subtype in the palliative care population (68% – 86% of cases). 16

3/28/2019 Delirium Superimposed on Dementia  Older adults with dementia are at greatest risk for delirium.  89% experience delirium when hospitalized and between 24% and 76% die within one year of the index episode. Delirium or Dementia? Characteristic Delirium Dementia   Onset Acute, abrupt Insidious, steady decline   Attention Inattention present Usually no change  Steady decline with  Fluctuating and resolves over Alzheimer’s Course time, may not resolve  Stepwise decline with without discharge vascular dementia  Hours to days, may last  Duration Months to years months   Level of consciousness Changes-vigilant to lethargic Usually no change 17

3/28/2019 Delirium or Dementia? Characteristic Delirium Dementia  Usually do not occur  Hallucinations (visual and  Perception Lewy Body dementia- auditory) may occur hallucination do occur   Impaired, sleep schedule can Fragmented; may awaken Sleep/wake cycle become reversed frequently or sleep more  Hypoactive, Hyperactive, or  Psychomotor behavior No change Mixed  May be apathetic,  Mood/affect Rapid swings; paranoid depressed Adverse Outcomes of Delirium 1. Most common adverse health events for older adults. 2. Independently associated with an increased risk of death. 3. Potent risk factor for complications: falls, increase LOS, pressure ulcers, functional decline, and Institutionalization. 18

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3/28/2019 MHA Delirium Discharge Order Bundle Clinician Section Clinician Section  Continue to assess for signs of delirium, such as: disturbance in attention and awareness; change in cognition that is not accounted for by dementia, develops over a short period, and fluctuates throughout the day.  Minimize high-risk medications and other medications with high anti-cholinergic effects: • Opioids (e.g, Meperidine, Morphine, Fentanyl, Hydromorphone) • Benzodiazepines (e.g. Diazepam, Lorazepam , Alprazolam) • First Generation Antihistamines (e.g. Diphenhydramine, Hydroxyzine, Meclizine) • Muscle Relaxants (e.g. Cyclobenaprine, Chlorzoxazone, Metaxalone) • Hypnotics (e.g. Zolpidem , Eszopiclone, Zopiclone) 20

3/28/2019 Ensure Patients Have Sensory Aids  Address sensory impairment by: • Determining which, if any, sensory aids are used by the patient • Ensuring sensory aids are available and in reach of patient • Resolving reversible cause of the impairment, such as impacted ear wax  Sensory aids include: • Hearing aids • Eyeglasses • Amplifiers • Dentures Assess and Manage Pain Assess for pain regularly using objective scale 6 How Look for nonverbal signs of pains, especially for patients with communication difficulties or ventilated patients 6 Pain is a risk factor for delirium 26 Why When pain is not properly assessed and treated, patient may receive sedatives and narcotics that place them at risk for delirium 26 21