CAPP Groups Find System Solutions for the Often-Overlooked Challenge of Delirium

It’s a common but often overlooked health danger. An active and cogent older adult enters the hospital for a routine surgery.  Within a few days, she is disoriented and combative. She can’t sleep. She’s even having hallucinations.

Family and caregivers may respond by sighing and thinking “Well, that’s just what happens when you are old.” 

But is it?  

Rather than expressing symptoms of age, this patient is most likely suffering from delirium. 

Delirium affects more than 7 million post-operative patients annually. In fact, it occurs in 29 to 64 percent of elderly patients. JAMA reports it also contributes about $164 billion in healthcare costs annually.

While often confused with dementia, delirium is not a disease. Delirium is described by physicians as an acute, transient, usually reversible, fluctuating disturbance in attention, cognition, and consciousness. A lucid older patient can become disoriented in just a few hours of being admitted. However, because this condition primarily affects older adults, it is often mis-identified as just a standard part of aging, something that can’t be avoided or helped. 

In reality, the condition can be very dangerous. In extreme cases, delirium can cause permanent disability. When this occurs, patients cannot return to their homes after discharge but instead must be placed in a transitional care facility. 

Medical groups and health systems that are part of the Council of Accountable Physician Practices (CAPP), including The Permanente Medical Group (TPMG)in northern California and Minnesota-based HealthPartners, are leaders in developing programs to more effectively identify, treat and prevent delirium.  Using the benefits of the integrated systems model like coordinated care, interdisciplinary teams, and preventive measures, these groups are protecting older patients from the complications and suffering of delirium. 

 

An Ounce of Prevention

Methodist Hospital, part of the HealthPartners family, was the first in Minnesota to implement an innovative program to prevent delirium in 2010. They now have close to a decade of experience in this pioneering initiative. 

The program leaders recognized that prescription drugs are typically used to manage delirium.  However, medications do not address the issues that lead to the condition, and in fact, they often do little more than mask symptoms.  The foundation of HealthPartner’s approach is to move from treating symptoms to focusing on prevention. 

Hospital staff make the extra effort to connect with patients and get them acclimated to the hospital setting in the hospital setting and experience. Schedules may be changed to ensure that patients get plenty of sleep. Caregivers also make sure that patients have the use of their glasses or hearing devices; without these aids, patients are more prone to becoming disoriented. Mobility is also encouraged. 

Because nurses are busy, volunteers play a crucial role in delirium prevention. The hospital also uses nursing students to assist, who can get school credit for their time with patients. 

These volunteers are charged with ensuring patients have glasses or hearing aids, are drinking enough fluids, are eating and sleeping well, and have mental stimulation through conversations, reading, games and other activities. The volunteers also become the eyes and ears of busy nurses, informing them of patients who have changed in their mentation since the last visit. 

As a result of these interventions, 98% of patients who receive the program services are delirium free at discharge.

 

A Multidisciplinary Approach

The Permanente Medical Group program takes a multi-specialty approach to tackle the condition. The Delirium Management and Prevention Program was developed in collaboration with colleagues in psychiatry, hospital medicine, pharmacy, information technology and nursing. Using early identification, virtual multidisciplinary rounding and pharmacologic management, the program transformed the medical center’s approach from crisis intervention to proactive management.

For example, because medications are a common and potent cause of delirium, certain drugs are avoided and others are carefully titrated. Physicians are engaged to detect early signs of delirium and to reduce risk factors by managing pain while also limiting the use of narcotic pain medication.

Research analysis of delirium prevention results in the San Rafael medical center showed that hospital stays have been reduced by nearly two full days. 

 

Success Factors in Treating Delirium

Both the HealthPartners and The Permanente Medical Group programs share a focus on several best practices, including:

  1. Emphasizing the soft touch of human connection
  2. Working to keep patients oriented to place and time and providing mental stimulation 
  3. Focusing on evidence-based, non-pharmacologic strategies to help prevent and treat pain and delirium
  4. Ensuring assistive devices, such as dentures, hearing aids and glasses are available
  5. Encouraging frequent family visits to help orient the patient 
  6. Supporting sleep by turning off room lights by 10 p.m.

The benefits for patients and family members are many, beginning with assurances they will be treated compassionately and that they will leave the hospital with the same mental faculties as when they entered.

For the medical groups and health systems, the benefits are that potential adverse events are avoided, length of stay is better managed, and outcomes are improved.  The coordinated efforts of care teams and the focus on prevention means that patients get better, safer care. 

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