Background: Patients with delirium are at risk for increased mortality, length of hospital stay, and cognitive impairments for up to one year. In addition, it is estimated that healthcare costs are 2.5 times higher in patients with delirium than in those without.
Purpose: Our quality improvement project aims to reduce the incidence of delirium. We aimed to reduce the proportion of patients with delirium in an acute care unit from 6% to 0% over 8 weeks.
Description: This pilot project was conducted in an Acute Care Unit (ACU) with 34 beds. The patient population included all patients on the unit who were diagnosed with or identified to be at risk for delirium. In general, risk factors for delirium included geriatric age, neurocognitive conditions, history of stroke, visual and hearing impairment, psychosis disorders, extensive ICU stay, and immunocompromised state. The pilot protocol was implemented from January 10th, 2024 until March 6th, 2024.A multidisciplinary team made up of geriatricians, hospitalists, bedside nurses, nurse managers, and pharmacists discussed strategies to reduce the incidence of delirium and developed a delirium prevention protocol. The delirium prevention protocol included an order set, a poster for the patient’s room, and a nursing checklist to report compliance with maintaining delirium precautions. The order set included RASS as a screening method and listed out methods to promote sleep hygiene, reorientation, and mobilization of the patient. The steps in our delirium prevention protocol are listed in Figure 1. Outcome MetricsThe proportion of patients with active delirium on the unit was tracked by chart review of providers documenting delirium as a diagnosis or part of the differential. However, once noted as resolved, it was no longer considered an active case. The length of stay for patients at risk and active delirium were also tracked in the pre and post-intervention period. Process MetricsNursing compliance with the delirium prevention protocol was gathered anonymously from paper checklists filled out by bedside nurses on both day and night shifts. We anonymously surveyed nursing staff on the pilot unit on their perception of the workload imposed by the delirium prevention protocol as a balance metric.
Conclusions: A total of 180 patients were placed on delirium precautions. There was a non-random decline in the proportion of active delirium cases after the implementation of the protocol (Figure 2). There were no active delirium cases for 6 days.Average LOS decreased from 12.14 days to 10.83 days in the overall cohort of patients at risk of delirium and patients with active delirium. Average LOS decreased from 11.26 days to 9.79 days in patients at risk for delirium. Average LOS increased from 12.73 days to 12.76 days in the cohort of patients with active delirium. A total of 652 checklists were reviewed for nursing compliance with the protocol. Nursing staff completed 83% of checklist items. Eighty-nine percent (16/18) nurse respondents reported that this project either did not impact their workload or made it easier.Thus, we saw a reduction in the proportion of patients with active delirium and an improvement in average LOS for patients at risk for delirium after implementing a delirium protocol. The next step in our project is identifying patients at risk for delirium and patients with delirium using a Best Practice Advisory (BPA) through our electronic health record (EHR) instead of manual chart review. We plan on expanding this protocol to all medicine floors at our hospital.
