Implementation of a nurse-led education and delirium prevention program lead to a decrease in cases of new-onset delirium during post-acute rehabilitation stays at a skilled nursing facility, according to a quality improvement project reported at the Gerontological Advanced Practice Nurses Association (GAPNA) Annual Hybrid Conference held September 30 to October 2, 2021.
Delirium is common in the older adult population and occurs in up to 70% of older adults in the post-acute care setting, explained lead author Rebecca Spear, DNP, ARNP, AGNP-C, nurse practitioner at Kaiser Permanente, Continuum of Care Skilled Nursing Department, Santa Rosa, California. Risk factors for delirium include old age, dementia, history of depression, history of alcohol misuse, use of physical restraint, metabolic abnormalities, infection, recent surgery, and medications.
“The outcomes of delirium and numerous and can be quite significant,” Dr Spear explained. “We often see short and/or long-term cognitive and functional decline, increased length of stay, increased incidence of 30-day readmission, hospitalization, institutionalization, and death,” Dr. Spear said.
Delirium is preventable, Dr Spear continued, with an estimated 30% to 40% of cases being preventable in the post-acute care setting. The goal of her study was to design and implement a delirium prevention protocol in a 116-bed skilled nursing facility in Sonoma County, California. The findings are based on chart audits from new admissions receiving care under Medicare Part A and staff surveys conducting pre- and postimplementation. Patients were excluded if a diagnosis of delirium at the time of admission was recorded.
The average patient age was 77 in the preimplementation group (n=25) and 80 years in the postimplementation group (n=23), approximately 60% of patients were female, and approximately 90% were White. The average number of medications on admission was similar in the pre- and postimplementation cohorts. Fracture with or without surgical repair was the most common reason for admission, with other diagnoses including cardiovascular needs, infection, and stroke, among other conditions.
More than half of patients were prescribed psychotropic medications including antidepressants or antipsychotics at the time of admission (56% preimplementation and 78% postimplementation). Less than 25% of patients in each group were prescribed routine pain medications on admission (24% and 17%, respectively).
Intervention Detects Patients at Risk for Delirium
Following implementation of in-service training on delirium risk factors taught by nursing facility staff, 65% of patients were identified as increased at risk for delirium using the AWOL risk assessment tool. These patients received an 8-item delirium prevention protocol that included getting patients out of bed for meals, adequate hydration, and tracking urinary output and bowel movements.
New-onset delirium was diagnosed in 2 patients in the preimplementation cohort vs 0 patients in the postimplementation group during their post-acute care stay. “Excellent” responses to the intervention were received by nursing staff and certified nurse assistants.
“They found the preventative protocol to be easy to use and CNAs, in particular, appreciated the additional education on delirium,” Dr Spear said. Study limitations included the small sample size of charts reviewed in total and the small sample of survey respondents.
Dr Spear believes that the protocol can be implemented at other facilities and studied in larger patient samples.
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Spear R, Martin-Plank L, Kahn-John M, Crist JD. Delirium screening and prevention in older adult post-acute care patients. Poster presented at: Gerontological Advanced Practice Nurses Association (GAPNA) Annual Hybrid Conference; September 30 October 2, 2021; San Diego, CA: P21.