From the Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (Drs. Ching, Darwish, Li, Wong, Simpson, and Funk), the Department of Anesthesia, Cedars-Sinai Medical Center, Los Angeles, CA (Keith Siegel), and the Department of Psychiatry, Cedars-Sinai Medical Center, Los Angeles, CA (Dr. Bamgbose).
Objectives: To reduce the incidence and duration of delirium among patients in a hospital ward through standardized delirium screening tools and nonpharmacologic interventions. To advance nursing-focused education on delirium-prevention strategies. To measure the efficacy of the interventions with the aim of reproducing best practices.
Background: Delirium is associated with poor patient outcomes but may be preventable in a significant percentage of hospitalized patients.
Methods: Following nursing-focused education to prevent delirium, we prospectively evaluated patient care outcomes in a consecutive series of patients who were admitted to a hospital medical-surgical ward within a 25-week period. All patients who had at least 1 Confusion Assessment Method (CAM) documented by a nurse during hospitalization met our inclusion criteria (N = 353). Standards for Quality Improvement Reporting Excellence guidelines were adhered to.
Results: There were 187 patients in the control group, and 166 in the postintervention group. Compared to the control group, the postintervention group had a significant decrease in the incidence of delirium during hospitalization (14.4% vs 4.2%) and a significant decrease in the mean percentage of tested nursing shifts with 1 or more positive CAM (4.9% vs 1.1%). Significant differences in secondary outcomes between the control and postintervention groups included median length of stay (6 days vs 4 days), mean length of stay (8.5 days vs 5.9 days), and use of an indwelling urinary catheter (9.1% vs 2.4%).
Conclusion: A multimodal strategy involving nursing-focused training and nonpharmacologic interventions to address hospital delirium is associated with improved patient care outcomes and nursing confidence. Nurses play an integral role in the early recognition and prevention of hospital delirium, which directly translates to reducing burdens in both patient functionality and health care costs.
Delirium is a disorder characterized by inattention and acute changes in cognition. It is defined by the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as a disturbance in attention, awareness, and cognition over hours to a few days that is not better explained by a preexisting, established, or other evolving neurocognitive disorder.1 Delirium is common yet often under-recognized among hospitalized patients, particularly in the elderly. The incidence of delirium in elderly patients on admission is estimated to be 11% to 25%, and an additional 29% to 31% of elderly patients will develop delirium during the hospitalization.2 Delirium costs the health care system an estimated $38 billion to $152 billion per year.3 It is associated with negative outcomes, such as increased new placements to nursing homes, increased mortality, increased risk of dementia, and further cognitive deterioration among patients with dementia.4-6