Problem

Delirium is a serious and common condition affecting up to 64% of hospitalised older adults. It costs over US$164 billion per year in the USA alone and over US$180 billion in 18 European countries combined.1 Delirium carries an increased risk of mortality,2 functional decline3 and institutionalisation.4 From a health resource perspective, delirium is associated with increased length of stay5 and increased intensity of nursing care.6 Delirium occurs in 30%–55% of patients with hip fractures and is one of the most common postoperative complications in older adults undergoing orthopaedic surgery.7–10

This project was undertaken at Juravinski Hospital, one of the sites of Hamilton Health Sciences Corporation, a tertiary care academic site in Hamilton, Ontario, Canada. The orthopaedic ward (E2) has 35 beds and on average, 31 patients with hip fractures are admitted to this unit each month. The delirium prevalence on this unit was found to be 30.9% on a single day when evaluated by trained delirium assessors.11 Given the high prevalence of delirium on this unit and its association with mortality, cost and functional outcomes, we designed a quality improvement study to help address this issue.

We conducted focus groups with nurses on E2 to examine gaps in the delivery of evidence-based non-pharmacological delirium prevention interventions (promoting mobility, encouraging fluid intake, offering glasses/hearings aids). Nurses on this unit must screen for delirium using the Confusion Assessment Method (CAM), a commonly used and well-validated delirium screening tool.12 A ‘CAM+’ score indicates a positive screen for delirium. Nurses must also document non-pharmacological delirium prevention interventions employed during care. Our focus group discussions revealed that nurses found it challenging to remember all of the delirium prevention strategies and implement them into daily practice. We determined that a bedside tool to help staff implement delirium prevention interventions was worth exploring.

The aim of this quality improvement project was to introduce a new bedside sign on an orthopaedic unit over a 10-month period to help nurses and other staff use delirium prevention strategies.

Background

Delirium prevention should target those identified to be at-risk by addressing potentially modifiable risk factors through non-pharmacological interventions. Multicomponent interventions have been shown to reduce delirium incidence by up to 30% in randomised trials.13 14 A prominent, evidence-based model for non-pharmacological interventions is the Hospital Elder Life Programme (HELP), which has been implemented worldwide.15 Components of HELP protocols include daily visits, orientation, early mobilisation, fluid repletion, therapeutic activities, non-pharmacological support with sleep and vision and hearing adaptation. The efficacy of HELP has been assessed in a number of studies, which consistently show a reduction in delirium incidence by as much as 53% when compared with control groups.16 While length of hospital stay was not impacted statistically, the programme was reported to significantly reduce the odds of falling in older adults (OR 0.58; 95% CI 0.35 to 0.95) and led to decreased hospital costs, saving US$1600–US$3800 (2018 US dollars) per patient.15 The impact of HELP on delirium prevalence is dependent on the fidelity to the HELP protocol, which can be compromised by real-world challenges such as lack of availability of staff and volunteers, patient refusal and medical contraindications.15 Several attempts have been made to improve adherence, including staff and volunteer education and further simplifying the programme to reduce cognitive load. For example, a modified HELP that included only cognitive activities, nutrition and mobility protocols was implemented for older patients undergoing abdominal surgery and the odds of delirium were reduced by 56%, with length of stay reduced by 2 days.17 Family participation in delivering these interventions is also important. The Fam-HELP programme has demonstrated that engagement of family caregivers in preventative interventions for delirium is feasible.18 However, operationalising family partnership into daily practice is challenging and few studies focus on how families can help manage delirium in loved ones.19

There is minimal published evidence regarding the use of signage to increase delirium awareness, improve delirium prevention strategies or reduce delirium prevalence. There have been studies exploring sign use in hospital for other reasons, for example, providing bedside orientation20 and dry-erase boards for communication.21 Dry-erase communication boards have been demonstrated to help staff remembering care details for patients.22 A survey of health professionals demonstrated that patient whiteboards were a valuable tool to improve teamwork, communication and patient care for interdisciplinary teams.23 From the patient perspective one study showed that over 95% of patients found bedside whiteboards helpful and 92% read the information on the whiteboard frequently.24 Bedside signs and whiteboards are promising tools but none have yet been dedicated to delirium prevention.

Given the high prevalence of delirium on orthopaedic wards, there should be greater emphasis on supporting staff to use evidence-based delirium prevention interventions in daily care. There is little guidance on how to use signage to implement these interventions. We created, implemented and evaluated a multicomponent bedside sign on an orthopaedic unit to prompt staff to use these evidence-based non-pharmacological interventions. As per protocol, all electronic medical record (EMR) data were deidentified and informed consent was waived.

Measurement

This quality improvement project was conducted over a 10-month period on a 35-bed orthopaedic unit at a large academic hospital. Our process measure was sign completion rates. The signs have several fields related to each non-pharmacological intervention and signs were considered ‘complete’ if at least ¾’s of component fields were filled out. Due to resource constraints, we could not conduct weekly audits throughout the study but we assessed sign completion over several weeks at the beginning and the end of the intervention period.

Our outcome measure was the proportion of patients with a CAM+ score documented during their length of stay on the orthopaedic unit. CAM scores are documented by nurses on E2 once per shift with a compliance rate of over 90% at the time of the study. Use of the CAM in real-world settings may underestimate delirium prevalence25 but for this study it was impractical to use a trained assessor to screen for delirium every day for 10 months to determine the CAM accuracy. Therefore, we used the proportion of patients with a CAM+ score documented in the EMR to define ‘delirium prevalence’. CAM scores from E2 were collected monthly from the EMR between August 2017–September 2017 (baseline period) and October 2017–May 2018 (intervention period). Staff were surveyed at the end of the study to assess their impression of the sign’s impact on use of interventions.

Descriptive analyses were used to summarise demographic results and describe differences between baseline and intervention periods. Run charts were used to evaluate changes in CAM+ scores over time and were analysed using standard rules to detect any signal of special cause variation in the charted data points.26 Differences in sign completion and CAM+ rates at the beginning and end of the study were compared using two sample t-tests. This study follows the SQUIRE publication guidelines for reporting.27

Design

An interdisciplinary team made up of physicians, allied health, an education and development nurse clinician, and two geriatric clinical nurse specialists, was assembled to create the bedside sign. This multicomponent sign (figure 1) was based on HELP protocols, addressing the delirium risk factors of sensory impairment, dehydration, immobility, cognitive impairment and poor sleep. Each patient’s unique modifiable risk factors for delirium were highlighted so that nurses and other health professionals interacting with that patient would have visual cues, for example, to offer water or to put on eyeglasses.

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Figure 1

Example of completed sign.

The QI implementation team met monthly during the baseline and intervention phases. All aspects of the project and intervention were designed in close collaboration with the unit manager on E2. Early nursing feedback demonstrated that the sign should target hip fracture patients who are at higher risk for delirium compared with patients admitted for elective joint replacement procedures. Therefore, we introduced the signs to four select rooms, which were identified as accommodating a larger proportion of patients with hip fractures compared with other rooms on the unit. Piloting the sign in four rooms first allowed us to make important early changes on a smaller scale before widespread implementation. Nurses and allied health staff working on E2 (n=40) participated in 10 min training sessions on accurate completion of the sign during one of their routine daily staff safety huddles. There sessions were conducted by an education and development nurse who was designated as the delirium prevention champion on the orthopaedic unit. Nurses and allied health staff completing the sign consulted patients and their families to determine specific details of care such as need for glasses or hearing aids.

The principle intervention was a bedside sign placed in four rooms to prompt staff to apply non-pharmacological interventions in daily routine care, with the ultimate goal of decreasing the proportion of patients with CAM+ scores over time. The remainder of the unit served as our control group as these patients were not exposed to the intervention.

Patient and public involvement

Patients and families were involved throughout the preparatory and intervention phases of this quality improvement project. Family members of patients admitted to the orthopaedic unit were invited to give feedback on the sign’s usefulness. Both patients and family members provided pertinent information (ie, answering questions about glasses and hearings aids) that assisted staff to complete the sign. Patients and family were informed that some of these questions were not part of routine care, but may have prompted action such as bringing hearings aids from home to the hospital. Acceptability of the intervention was measured through the family surveys. Burden of intervention to patients and families was not formally measured. The aim of the sign was discussed prior to administering family surveys. Patients were not involved in the study design or dissemination of results. There was no recruitment component to this project as the sign was used for all patients who were admitted to the four target rooms.

Strategy

We met with the E2 clinical manager several months prior to developing this idea to ensure that this QI initiative was feasible and aligned with the unit’s overall goals. This intervention was supported by a staff training and awareness campaign that was conducted by the education and development nurse and took place 2 weeks prior to sign introduction. There were also educational posters placed on the unit (online supplemental figure 1). After training was complete, the research team placed the delirium prevention signs in four target rooms. These rooms were more likely to be occupied by patients with hip fracture but due to patient flow and capacity there may have been other orthopaedic patients (eg, joint replacements) admitted. Throughout the study, focus groups with unit staff were conducted to identify areas for improvement and new change ideas. Phased improved was used to implement the sign and refine its use over time.

The baseline period was defined as the months prior to sign use (August 2017–September 2017). Stages 1 and 2 involved preparations for sign implementation during the baseline period while stages 3, 4 and 5 occurred during our intervention phase (October 2017–May 2018). Details regarding the stages of this phased implementation project are outlined in table 1.

Lessons and limitations

We believe there are several factors that led to the success of implementing the sign on this orthopaedic unit. First, this quality improvement project was conducted in a stable environment with few changes to staff operation outside of intervention implementation and training. Second, we achieved strong engagement of nurses, clinical managers and other E2 unit staff throughout the process. Nurses play an important role in delirium identification and prevention and we ensured that they were involved in the direction of the project. Feedback from focus groups and surveys provided useful insights that supplemented the quantitative collection of EMR documented CAM scores. Despite non-significant impacts on delirium prevalence, the sign was well received by staff who felt that the sign prompted them to use non-pharmacologic interventions and was a worthwhile use of time. This is an important metric given the competing priorities of point of care staff on busy inpatient wards. Finally, we achieved buy-in from hospital administrators as the sign posed minimal risk to patients and was relatively low-cost at $C40 per sign, equivalent to approximately £23.

There are a few notable limitations, including using the CAM to detect delirium prevalence, the lack of balancing measures, the project’s short time frame and the small scale. Previous research demonstrates that the use of CAM by nurses under-represents delirium prevalence when measured outside of clinical studies.25 Though significant efforts were made through educational initiatives to increase the accuracy of nursing recognition of delirium prior to sign implementation, it is possible that accuracy was still low. Performing a chart review for key delirium words in nursing notes may have provided a more accurate reflection of delirium prevalence compared with the CAM+ scores. This would have required additional resources and will be considered for future sign evaluation projects. Though we did not collect direct balancing measures, which would have been helpful to influence future intervention, we did evaluate staff perception about whether the sign was a worthwhile use of time. Additional data points over a longer time frame would have improved our ability to assess trends and understand sustained effects. In particular collecting more data points during the baseline period prior to sign implementation would have allowed us to detect underlying trends that may have already been occurring. The impact of other unit changes (staff education and changeover, seasonal changes of patient presentations) could have influenced CAM documentation. We tried to limit these effects by comparing results with the proportion of CAM positives in other rooms where signage was not installed. The CAM positive scores in those rooms remained unchanged over the study period with no increased trends after any intervention. Finally, this study was carried out in four rooms on a single orthopaedic unit potentially limiting generalisability to other units and hospitals. However, pilot studies like this are important first steps in order to refine a process and ensure buy in prior to widespread implementation.