Implementing the ED-DEL Toolkit

Background

Delirium (also referred to as acute brain failure) is a neurologic emergency characterized by an acute decline in cognitive functioning. It is common and often the only presenting symptom of serious, even fatal, medical conditions, especially among older adults. It is a presenting condition for up to 30% of older adults in the emergency department (ED) (Gower 2012) and costs over $164 billion (2011 USD) per year in the United States (Oh 2017). Only 24-35% of delirium cases are recognized, and nearly half of patients are discharged with little consideration of the seriousness of the delirium (Gower 2012), which can lead to substantially increased mortality during the 6 months following ED discharge, 37% vs. 14% (Han 2010, Kakuma 2003). Importantly, delirium prolongs ED length of stay, and hospital stay by a median of 2 days (Kennedy 2014). Delirium can present as hypoactive, hyperactive, or mixed psychomotor subtype. Hypoactive delirium is more common in older adults in the emergency department, is associated with a worse prognosis including increased risk of mortality, and is commonly missed by clinicians (Han 2009). Older patients presenting with delirium are often quiet, withdrawn, or described as “not quite her usual self”; thus, it is important to consider delirium in older patients with any subdued change in mental status. With the rapid aging of the U.S. population, delirium rates will continue to increase, and the ED setting represents a frequent point of presentation of older adults with this condition to the healthcare system. Incident delirium can also newly develop during an ED stay. As a preventable condition in 30-50% of cases (Oh 2017), delirium holds substantial public health relevance as a target for interventions to prevent its associated burden of downstream complications and costs.

A draft version of the ED-DEL Change Package and Toolkit was piloted at four sites in 2020 and was used to inform revisions prior to Toolkit finalization. These sites were chosen to represent a range of ED environments, including urban, suburban, academic, and non-academic medical centers with varying annual ED volumes. Below is a summary of the pilot sites’ qualitative feedback on their Toolkit implementation experience along with tips and lessons learned.

Expert Workgroup Members: John Devlin, PharmD, BCCCP, FCCM, FCCP, Maya Genovesi, LCSW, MPH, Ula Hwang, MD, MPH, FACEP, Maura Kennedy, MD, MPH, Jennifer Leaman, Pamela Martin, FNP-BC, APRN GS-C, Don Melady, MSc(Ed), MD, Michelle Moccia, DNP, ANP-BC, CCRN, GS-C, Heidi Wierman, MD, FACP

Pilot Site Members: Robert Anderson, MD, Rhonda Babine, MS, APRN, ACNS-BC, Pamela Jordan, BSN, RN, Lucio Barreto, RN, BSN, CCRN, MICN, Maya Genovesi, LCSW, MPH, Martine Sanon, MD, Stacey Bruursema, LMSW-C, Michelle Moccia, DNP, ANP-BC, GS-C, Hope Ring, MD, Kathleen Davenport, MD, David Manyura, BSN, RN, Julie Reitz, BSN, CMSRN

We asked what the future of delirium management looks like?

Sites responded focusing on a variety of aspects:

Integration of program in EHR
Some sites explained that having a screen that is built into a senior assessment can ensure that the right questions are being asked, with a patient who is over a certain age. From this assessment, there is a report that can be reviewed every day, which includes notes and what specific staff member attended to the patient. This allows for communication with the specific staff who screened the patient. Then, if the patient is positive for Delirium, inpatient will know who exactly diagnosed them.

Building/integrating the Delirium screen into EPIC will create routine for the screening. The staff will see it and remember to complete. Having the screen built into EPIC can also help other sites not have to “recreate the wheel” because it will be available across the board.

Presence of a Delirium Champion
Having a strong Champion or Geriatric presence is very important for successful Delirium management. Having this team or person allows for consistency in practice around Geri medicine and implementation of the toolkit.

Education of Families
Informing families about Delirium and providing them with information leads to better treatment and more understanding of their loved one. Some sites discussed posting a QR code in the patients’ room for families, along with the patient to learn more about Delirium and how to properly treat it.

Communication during Transitions of Care
Having communication with inpatient about what is happening in the ED is super important because when Delirium is identified in a patient, the care and next steps for this patient need to consistent.

Renovation for senior-friendly ED environment
The future of Delirium management might require sites to renovate their ED. Having a renovated ED allows for quieter and more personal visits for seniors. They also can become more senior friendly by upgrading to non- slip floors, using better lighting, and more appealing artwork.

What is important to sustain a program?

If program not likely to sustain, indicate why? What could help?

Staff Education and Training: Making everyone aware

• Education plays a major role in sustainability. There should be a constant focus on nursing competencies. And whenever any new staff is hired, the Champion should work with and complete initial screening when training.
• While in the ED, constant communication and education over Delirium can help sustain the efforts to screen and diagnosis. This way, the staff is always thinking of the screening tool that can be used upon arrival in the ED.
• While education on screening is important for sustainability, it is just as important to educate on what to do when a patient is diagnosed with Delirium. The champion should train one on one with staff when determining the next steps after diagnosis to ensure that the treatment is handled appropriately.
• One on one teaching and engagement with staff can go a long way for sustainability.
• Making everyone involved in emergency care aware of Delirium can help lead the way for sustainability. Having all staff aware, along with good leadership, and training will even lower the rate of turnover.

Staff Incentives and Recognition

• Affirmation plays a very big part in sustainability. Giving recognition to staff confirms they are doing a good job and that what they are doing is important. Someone needs to be the “guardian” of the recognition feedback and be available to notice it and pass it out. It needs to be monitored.

Documenting and Sharing Outcomes

• Feedback loop-sharing/ circulating the outcome when the patient gets admitted/ diagnosed and sharing the benefit from what the staff does in the ED can motivate others for sustainability.

Supportive Leadership

• Having a supportive staff and leadership board is very important in being successful and sustainable. Having staff that is supportive and supports the mission, allows for success.

Which interventions do you plan to continue, discontinue, or might add in the future?

Staff Education and Training

• Ensuring that all new staff, among all lines, are trained on screening tools upon hire is an intervention to continue to be successful in consistently identifying Delirium.

Staff Incentives and Feedback

• An important intervention to continue is constant feedback. Sharing feedback excites staff and creates more awareness around identifying Delirium in the ED. Feedback and other constant communication helped to keep screening for Delirium in the minds of the staff.
• Sites have noticed that presenting their staff with different incentives for screening and then actually identifying Delirium in the ED keeps their staff engaged and always thinking of the possibility of a delirious patient.

Delirium Champions

• Having a champion on each level of staffing is an important intervention to continue. This allows for education of staff and ensures the continuity of screening for Delirium.

Other Specific Interventions

• A smart intervention to add in the future might be to create additional toolkits to raise awareness about screening for Delirium around the whole system.
• Identifying the 4 M’s while using and implementing the toolkit would be helpful.
• Having multiple purpose therapeutic activity carts that can be used by anybody in the ED is an intervention sites are likely to continue as another helpful tool.

Internal and External Supports

• Scheduling office hours with Champions and other sites using the toolkit and implementing the screening in their ED could be a helpful intervention to share wins and losses and learn about different methods to succeed.
• Having a one-time consultant would be a helpful intervention to add in the future. This consultant can assist the site when they are starting the toolkit and discuss what is best for your specific site. It would also be helpful to have this consultant available by email or phone once the site has started implementing the toolkit to help with questions or feedback. Having a support network or consultant service would be helpful.

What was the greatest challenge you faced and how did you address it?

Where to Implement screening

• One major challenge some sites experience is where to implement the screening outside of triage. Being that the screening is a bit longer than most, it could potentially be more beneficial if done at the bedside.

Lack of education and training about Delirium

• One of the greatest challenges was lack of education. It is important to remember to educate all lines of staff in the ED on Delirium- this includes techs. Some sites noticed absence of education among their techs and other. aids because the focus for education was on the nursing staff. This can cause miscommunication.
• It is important to ensure that things are in best practice and trainings are accessible, so when a roadblock does occur (COVID) the programs and screenings for Delirium do not get forgotten when patients come to the ED.

Lack of staffing and time

• There was a challenge of not having multiple persons that can help the program “survive”. There needs to be a strong system of staff that can help run the show and not just rely on one person having all the answers.
• There is always a need for extra help. Some sites explained that it may be helpful to have a non- clinical position within the team that could oversee the data and be able to make follow up with the team about staying on track to reach certain goals. This could include creating a data position and implementing a data collection tool for screens.