HOSPITAL PROGRAMS: A Multidisciplinary Approach to Managing Delirium

More than 7 million hospitalized Americans suffer from delirium each year, and more than 60% of these cases aren’t recognized by the healthcare system. The delirium population suffers higher mortality, longer hospital lengths of stay, more discharges to long-term care settings, and a higher probability of developing dementia at 48 months. Hospital delirium is a particularly big problem for fragile elderly patients.

Beginning in September 2010, a multidisciplinary team at Kaiser Permanente San Rafael began applying industry best practices to manage delirium in our hospitalized medical-surgical population. When the program started, our experience and data were similar to national averages. Approximately 20% of patients admitted to our med-surg floor experienced some degree of delirium, and the reported ICU incidence of delirium often approached 80%. By anticipating the development of delirium in high-risk populations and implementing proactive approaches to prevention and management, we have significantly reduced these numbers.

The most compelling argument for the success of the program is a 23% reduction in average length of stay for patients with a diagnosis of delirium, which translates to an estimated $2.4 million annual savings in direct hospital expenses. Our delirium program has been recognized as a best practice, and elements of its model of care are being adopted at other Kaiser Permanente facilities across the country.

What is delirium? The term describes a new state of confusion and disorientation that has a medical cause. While “delirium” is often confused with “dementia,” the former can be distinguished as an acute state of confusion characterized by inattention, abnormal level of consciousness, disorganized thinking, and a fluctuating course. Only in the past couple of years has evidence accumulated that delirium may be associated with outpourings of dopamine, although other neurotransmitter abnormalities have also been implicated. But delirium remains a condition that is identified by observation.

Providers often have difficulty identifying delirium because it has an acute onset and a fluctuating course. In the hospital setting, delirium can appear as:

• Trouble paying attention.
• Asking the same question over and over again.
• Forgetfulness and confusion about time or place.
• Terrifying hallucinations: seeing, hearing, or feeling things that are not there.
• Sudden changes in emotions.
• Agitation, which may include trying to remove dressings, tubes, Foley catheters and other items.
• Excessive sleepiness that fluctuates with periods of agitation.
• Trouble sleeping

In designing our delirium program, we recognized the importance of using a multidisciplinary team to implement early interventions aimed at reducing the severity of symptoms. We also implemented more effective use of relevant protocols, order sets and medications, as well as comprehensive staff education.

Treatment for delirium can be conceptualized as a multimodal approach that includes environmental, behavioral and medical treatment, along with medication management of symptoms. Helpful methods to reduce the effects of delirium include:

• Train all hospital staff to recognize and appropriately approach the delirious patient.
• Identify and assess at-risk patients in their first hospital day. Our team uses the CAM-ICU assessment tool.
• Provide an environment of stability: avoid moving patients to other rooms, minimize catheters and IVs, avoid agitating TV shows.
• Address cognitive impairment or disorientation by providing appropriate lighting and clear signage. Explain where the patients are, who they are, and what your role is. Introduce activities and facilitate regular visits from family and friends.
• Address dehydration, poor nutrition and constipation.
• Assess for hypoxia and optimize oxygen saturation.
• Encourage mobility by carrying out active, range-of-motion exercises and walking, if possible.
• Address sensory impairment: attend to impacted ear wax, and ensure that hearing and visual aids are available.
• Assess and treat pain.
• Look for and treat underlying infections.
• Carry out a medication review, taking into account both the type and number of medications.
• Promote good sleep hygiene by avoiding nursing, medical procedures and noise during sleeping hours.

After the underlying medical conditions causing delirium are treated, and when behavioral and environmental approaches are unsuccessful for managing symptoms, we use pharmacologic interventions. There are no FDA-approved drugs to treat delirium, but antipsychotic medications are the standard of care.
Quetiapine, olanzapine, risperidone and haloperidol can be effective for psychotic symptoms. Choice of agent is often influenced by route of administration and the severity of the behavior being treated, such as verbal and physical aggression vs. milder symptoms of paranoia, restlessness and anxiety. The beneficial side effects of these medications should also be considered. For example, the sedating effects of Seroquel can be useful for a patient who is up all night.
In refractory and specific cases, valproic acid and benzodiazepines can be used. We make every effort to teach providers about the negative effects of benzodiazepines. There is a role for these medications, but they must be carefully monitored and titrated. In these cases, the expertise of our clinical liaison psychiatrist is critically important.

Managing delirium has been likened to pain management. For each 24-hour period, required doses of medication that are needed to manage behavior are added up and then scheduled the following day in divided doses. As the delirium clears, medications are tapered off.

We strive to be a restraint-free facility, and we only use restraints when absolutely necessary. Sitters who are trained in managing and interacting with the fragile elderly are preferred because restraints often increase delirium.

We have found in the spread of our delirium work that a story can often best highlight what can go wrong and why delirium management takes a multidisciplinary approach. Delirium must be taken seriously and recognized quickly and early in a patient’s clinical course.

In the following story, we will call our patient CW. Identifying factors and specific details have been changed to protect patient identity.

CW was admitted to our medicine service with a COPD exacerbation. He seemed like a standard pulmonary patient with an unremarkable medical history other than degenerative joint disease and osteoarthritis. He was a charming man in his early 70s; he loved fishing and spending time outdoors.

The admission sign-out seemed straightforward: antibiotics, steroids, breathing treatments, pain meds and a possible CT scan if he wasn’t better by the next day. The admitting physician remembered telling his colleague, “This will be easy. Should be a few days max.”

CW’s stay lasted nearly three months.

The week following admission, CW wasn’t improving as we had expected. A CT scan showed significant lung disease and a possible abscess. Staff performed a thoracoscopic procedure and placed CW in the ICU for observation, at which point he was noted to be a little confused.

CW was in the ICU for weeks. Treatment involved restraints, IV drips, lap belts, Ativan, Haldol and sitters. He was eventually transferred to a med-surg bed with a 24-hour sitter. We did the best we could on the med-surg unit, but most of the time, CW thought he was in a casino and that it was sometime in the late 1980s. One evening, while walking around the unit with a sitter, he suddenly broke away, ran for a nearby exit door, and fell down a flight of stairs.

Code blue. STAT head CT. Intracerebral bleed, luckily non-surgical, Another month in the ICU …

After a long and difficult journey, CW finally transferred to a nursing facility and went home shortly thereafter. His story does not end there, however. Several months later, he presented to the ER with another COPD exacerbation. We had no tools or interventions in place for delirium at that time. He received steroids that night, along with a quinolone antibiotic. Guess what happened? Within six hours of admission, he was acutely delirious. But, this time it only took about 15 days for him to clear mentally and go home.

One year later, CW was electively admitted for a surgical procedure. By this time, we had basic protocols in place and assessment tools for delirium. We also knew which meds not to give, especially steroids. We kept his room as quiet as possible, used Trazodone instead of Ambien when he wanted a sleeping pill, and didn’t move him from room to room. He was out of the hospital in three days--without ever developing delirium. He was admitted again for another elective surgery a few months later with the same result: in and out.

Delirium management can be like trying to avoid a head-on collision during a car accident. When CW first arrived at our hospital, we all suffered a head-on collision. On the second presentation, it was more of a side-swipe. On the third and fourth admissions, we avoided a collision altogether.

A team approach and a stage 7 electronic medical record system are absolutely necessary to ensure success in a multidisciplinary, integrated delirium treatment program. We believe that Kaiser Permanente is on the forefront of delirium management because of these two points. With the technology we have in place, we can see real-time medication lists, lab trends and behavior assessments. This allows us to implement protocols and standardized order-sets that ensure a more consistent approach, without a specific expert being present.

We have enjoyed building our program and seeing our educational efforts and multidisciplinary approach yield results that improve outcomes for our patients and their families. The beauty and satisfaction in delirium management is that most of these fragile patients can be managed with simple, cost-effective, non-pharmacologic interventions. We have seen first-hand that they work.

---

Dr. Eberhardt, a geriatric psychiatrist, and Dr. Angel, a hospitalist, are on staff at Kaiser Permanente San Rafael.

Emails: wendy.x.eberhardt@kp.org, clay.angel@kp.org