By Sandra Gordon for ASA
“It’s great to collaborate with people in our own department and across departments and to hopefully play a larger role in the care of many patients.”
Anne Donovan, MD, associate clinical professor in the department of anesthesia and perioperative care at the University of California, San Francisco, discusses the comprehensive quality improvement initiative her hospital implemented to reduce delirium and the leadership role she played.
As an anesthesiologist and intensivist at UCSF Medical Center, Anne Donovan, MD, became interested in improving the care of vulnerable older surgical patients through her experiences in the ICU and observing patient outcomes.
One patient, in particular, helped spark Donovan’s interest in delirium prevention. The older surgical patient was at high risk for delirium because of alcohol use and a variety of medical comorbidities. “I was asked to evaluate her a few days after surgery as the ICU attending because the surgical team thought she was in alcohol withdrawal,” Donovan says. “Over the course of the patient’s hospital stay, the patient became so agitated that she removed her IV access and refused care. Her family declined further care because they didn’t want to see their mom suffer. The patient was someone whose delirium directly contributed to her poor outcome,” Donovan says.
Championing Perioperative Delirium Intervention
Inspired by this patient and others, Donovan became interested in taking a proactive role in delirium prevention. When USCF Medical Center launched a hospital-wide delirium reduction quality improvement project in 2016, she helped lead her team to implement the perioperative arm of the hospital wide intervention.
The first step was to implement delirium risk stratification in the preoperative area. “For all adult surgical patients coming into the hospital, we performed preoperative risk stratification so our anesthesia and surgical teams would be aware of patients who were at high risk for delirium post-operatively and could immediately implement changes to their practice as a result of that screening,” Donovan says. “It’s impossible to reliably detect and prevent delirium if you’re not doing delirium screening regularly.”
To predict delirium in surgical patients, Donovan and her perioperative team developed a proprietary tool called AWOL-S, which stands for Age, the ability to spell World backward, Orientation to place; iLlness severity score, which is the ASA classification, and Surgery specific risk stratification. AWOL-S was embedded in the electronic health record (EHR). Preop nurses screened patients by asking questions related to orientation to place and asking them to spell world backwards. The EHR did the rest, including calculating the risk of postoperative delirium. Patients with a high-risk screening result were flagged by the EHR.
If a patient screened high risk for delirium, an alert popped up in the EHR that reminded providers to enact a set of recommendations for how to change patient management to prevent delirium.
The recommendations are a compiled set of best practices from the ASA’s PBHI Best Practices and Guidelines, the American Geriatrics Society, the POQI-6, and other professional societies. The recommendations include, among other things, communicating with the surgical teams that the patients is high risk for delirium, avoiding high risk medications, considering use of process EEG monitoring, using multimodal analgesia, and implementing non pharmacologic delirium prevention measures as early as the PACU, such as giving the patient his/her eyeglasses and hearing aids, untethering the patient when possible, reorienting patients to day, night, and place, encouraging regular sleep habits, and encouraging family to be at the bedside.
“Leveraging the EHR to automate delirium risk stratification where possible to warn providers and improve compliance was a really helpful key to ultimately changing practice,” Donovan says.
Since launching the QI initiative in 2016, the UCSF Medical Center team has made continuous process improvements, including refining the AWOL tool, enhancing the EHR, and launching an education campaign with our department and throughout the hospital,” Donovan says. “One of the most important things we did was a department wide quality improvement project in 2018 and 2019 to improve uptake of the recommendations we made,” Donovan says.
The project, run by UCSF Medical Center’s anesthesia resident quality improvement committee, focused on reducing the use high risk medications and improving non-pharmacologic delirium prevention compliance in the PACU.
Reporting on Results
“By the end of the QI project in 2019, we showed there had been change in medication prescribing practices and set the wheels in motion for a more long-term change in practice,” Donovan says. Now embedded into the EHR is a specific PACU order set for patients who were at high risk of delirium, including removing three specific high-risk medications from the PACU order set: meperidine, metoclopramide, and prochlorperazine. Providers could order non-pharmacologic measures to be done in the PACU.
“We also provided education and encouraged providers to avoid other high-risk medications, such as benzodiazepenes, certain antiemetics and provided recommendations for alternative agents that might be more appropriate for this population,” Donovan says. They presented these recommendations at departmental conferences, at nursing staff meetings, and other nursing conferences. Education was also provided to surgical services more by the hospital wide committee.
Staff received follow-up emails and reminders were posted in the operating room and throughout common spaces around the OR, which as a list of medications not appropriate for high-risk patients.
During the quality improvement project, which ended in July 2019, Donovan and her team demonstrated that the administration of a compilation of Beers criteria medication went down by 3% each month of the project. “We also measured a number of process metrics, including use of the appropriate PACU order set and compliance with the delirium screening preoperatively. Those also increased steadily with time,” Donovan says.
“I’m confident that by being more aware of delirium as a serious issue for patients and aligning practice with best practice care recommendations that our patients and their families will benefit from improving the quality of care we’re providing.”
Engage with hospital leadership and representatives from other departments, including surgery, geriatrics, neurology, pharmacy, rehabilitation, and nursing. “Delirium is a longitudinal problem. While we can try to align our care with best practices, we need to continue delirium prevention interventions after the patient leaves the OR and PACU. For that to happen, there has to be support for hospital-wide delirium prevention intervention,” Donovan says.
Track process and outcome measures. To get hospital leadership on board for a delirium prevention program, make a case for improving patient outcomes and potential cost savings. “Optimally, any delirium prevention intervention should be designed to track both process and outcome measures, including delirium incidence, prevalence, hospital length of stay and other associated complications like falls, restraint use, and use of safety attendants,” Donovan says.
Focus on the barriers to behavior change. Implementing delirium best practices requires behavior change on the part of perioperative and other providers. What are the barriers to behavior change that exist at your institution? “Each institution is going to be different,” Donovan says. “At some places, it might be an education or knowledge problem about delirium. At others, there may be a lack of resources or a lack of willingness to change. “It’s important to understand your local culture and what is preventing change from happening to design an intervention that will address those issues,” Donovan says.
Recruit nurse champions. Because nurses are instrumental in providing delirium screening, it’s important to recruit nursing champions who are interested in delirium and enthusiastic about making the case for why delirium assessment is important with their colleagues.
Automate processes when possible. Engage EHR expertise to build delirium screening tools. “We built the screening tool into the EHR and order sets, and automated EHR reminders to fill out the appropriate order set. But there are many different potential EHR tools, such as best practice advisories or flags at different places in the banner or intraoperative record,” Donovan says.
USCF Medical Center is currently in the maintenance and sustainability phase of the project. “As a department, our delirium-focused quality improvement project has ended, but we’re still focused on reducing delirium,” Donovan says. “We still have all the processes in place.”
Overall, UCSF’s comprehensive program for patients at risk for delirium has been a rewarding process. “It’s great to collaborate with people in our own department and across departments and to hopefully play a larger role in the care of many patients,” Donovan says.