Hartford HealthCare serves around 27,000 patients daily across nine acute-care hospitals, with a workforce of approximately 48,000. In 2011, they started Project ADAPT (Actions to Enhance Delirium Assessment, Prevention and Treatment), an intervention designed to screen older adults for delirium and step in early through prevention and management strategies.

All patients aged 65 and older were screened using Single Question in Delirium (SQiD) and attentional testing. Admitted patients were screened three times a day for delirium by the nursing staff using either the Confusion Assessment Method (CAM) or CAM-ICU. An abnormal screen would activate protocols for evaluation and management.

These were mainly low-cost, non-pharmacological interventions such as maintaining sleep hygiene, promoting early mobility, avoiding restraints and NPO status, as well as reducing noise and using sensory aids. Patients and families also received education and participated in care.

Because Hartford opted to screen all inpatient populations for delirium, they were able to identify which patient populations were more likely to develop delirium and in what settings. This data was used to help make the case for further investment in delirium prevention and management protocols. It also allowed them to track changes over time and make adjustments to their process.

At Hartford HealthCare, the team noticed that even though they were screening regularly for delirium, most high-risk patients were screening positive within the first 48 hours of admission. By the time geriatrics was consulted, or mitigating strategies were in place, they were already too late. Determined to get ahead of that first episode of delirium, the team created Project PREDICT (Predictive Real-time Evaluation of Delirium in Clinical Therapy).

They leveraged an existing EMR risk prediction tool called the Infant Drop Risk Tool, adapting it to create a Delirium Risk Prediction Tool. The tool pulls a defined set of risk factors from the EMR every 15 minutes to score each patient’s delirium risk, automatically flagging high-risk patients and providing clear advisories for nurses and physicians.

The Hartford team worked with their EMR and pharmacy colleagues to identify the most frequently overprescribed PIMs (Potentially Inappropriate Medications) for older adults across their system, targeting them for intervention. They found that even low-end doses on prescribing panels would often be considered high for older adults.

Starting with 12 commonly ordered age-sensitive medications, they created a set of geriatric-appropriate prescribing panels in their EMR (in this case EPIC). They removed all inappropriate doses and added clinical decision support for high-risk medications. From there, the geriatric prescribing panels would automatically populate for patients 65 and older.

This intervention was rolled out without the need for staff education and immediately saw positive results. Hartford HealthCare later expanded SCREEN to 38 additional medications and added age-sensitive medication information to EMR and Age-Friendly 4Ms views. ICU clinicians were routed to a separate order set with dosing options appropriate to critical care.

Early on in her tenure, Dr. Farmer spoke with the volunteer coordinators at the hospital. She discovered that there was significant interest from local healthcare-stream college students seeking patient-facing roles. In response, she and her team created the Geriatric Ambassador Program to place them alongside ED staff. Volunteers assisted with therapeutic activities, hydration, nutrition, and ADLs. They also provided support with socialization and reorientation tasks.

The PREDICT tool behind “ED to Bed” identified the patients who were at the highest risk of developing delirium. It then prioritized them for earlier bed assignment to reduce ED boarding time. While the current data shows that Hartford has not yet been able to improve boarding times for these patients, the hope is that more delirium and system-wide interventions will allow them to be prioritized.

Many older adult patients with dementia or delirium in the ED do not require telemetry or isolation, and so they are deprioritized for rooms in the ED. This can have a negative effect on their health outcomes, leading to further confusion or worsening conditions.

The Geriatric ED team led by Dr. Farmer sought a solution. They chose a back hallway that wasn’t a thoroughfare and designated it as a quiet corner for these hallway-bound geriatric patients. This area was overseen by a nurse or PCT trained in geriatric care and equipped to assist with redirecting, ADLs, toileting, feeding, and other delirium-specific care processes.

Hartford is also looking to draw from the experience of ED staff. These frontline workers face innumerable challenges when caring for vulnerable older adults with cognitive impairment in the ED.

To understand their pain points and determine opportunities for improvement, the ED team at Hartford has started a Geriatric Focus Group meeting. It meets in the mornings as the day and night shifts overlap, and attendance is optional.

The meetings have already surfaced meaningful insights from staff and patients. For example, nurses were being asked to ambulate patients so that they ate their meals out of bed. But this was nearly impossible, because there were no chairs for patients in the ED once they were up. Based on this simple discovery, the department was able to order more chairs so nurses could successfully help their patients eat out of bed.

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More to Come

What started as an intervention for identifying delirium in inpatient settings has grown into something with much broader potential. By building on their successes and applying their learnings, Hartford HealthCare has been able to iterate on their approach, so proven care processes can be adapted to the ED.

Guided by this important work, the ED team at Hartford Hospital is now developing geriatric-specific order sets to provide ED doctors with a one-click menu for commonly ordered labs, nursing orders, and consults for older patients. They are also adapting Project SCREEN, making it symptom-based rather than medication-based for ease of use in the ED.

Through BPAC, Hartford Hospital can continue to build on its progress and share its knowledge across the healthcare system, helping to turn proven care processes into standard practice.

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