Delirium Screening at UNC Hillsborough

Implementing a quality improvement initiative in delirium screening management

by Julie Reitz, Katie Davenport, Christina Shenvi and Kevin Biese

About UNC Hillsborough, North Carolina

A community setting in a small town

  • 25,000 ED visits per year, 15% older adults
  • Academic, research hospital
  • Not-for-profit

Needs Goals and Motivations

What drove your ED to work to improve care for older adults?

Our innovations were driven by a strong conviction, starting with UNC Hillsborough President Jeff Strickler and shared by ED nurse and physician champions, that ED care should be improved for older adults because it is the right thing to do.  Also, becoming an accredited Geriatric ED helped give UNC Hillsborough a unique identity in the health care market as it was the first Geriatric Accredited Emergency Department in the state.

We also integrate ED and inpatient team care, with a common understanding of geriatric syndromes and standardized practice with the goal of reducing ED revisits, hospital readmissions, and hospital length of stay as well as improving relationships with local Continuing Care Retirement Communities.

Why did you engage GEDC to help in your efforts?

Participation in GEDC decreased our training time and jump-started our efforts to start Geriatric ED processes and get ready for Geriatric ED Accreditation. Rather than needing to find separate training time for all members of the team, our initial Boot Camp helped get our team ready in an expedited fashion.  Being a part of the GEDC also allows us to learn best practices, including implementation strategies, in Geriatric EM, rather than having to create all of our protocols and processes de novo.

Challenges and Drivers

What challenges did you face in implementing your quality improvement initiative?

When starting the delirium triage screening we had to be very clear with the care team regarding the steps when a  patient screens positive for delirium and how these interventions are helpful.  Our fantastic nursing team is motivated to perform screening and interventions as long as the process is clearly defined and the work has a positive patient impact.

Additional challenges include:

  • Financial return is difficult to calculate, but likely occurs via increased market share
  • The need for continual reinforcement and education for clinicians and nurses
  • A time intensive process for EPIC changes to incorporate geriatric screening
  • More intensive and ED-focused case management is needed to allow for better patient services and potential alternatives to discharge.

Solutions

What were some solutions to the challenges you faced?

We use the Delirium Triage Screen followed by the bCAM because it is easy to use and fast.  We are sharing specific positive patient stories on how this intervention is helpful so that the nursing and physician care team members know that their efforts to identify delirium improve patient  outcomes.

We also continually learn best practices through GEDC webinars and hold monthly QI meetings that include nursing, physician and EPIC teams when possible.

How was GEDC helpful in addressing these challenges?

The GEDC taught us quickly (from other GEDC sites sharing their experiences) that involving nurses in selecting the delirium screening tool (and all GED tools) was critical and that the DTS followed by the bCAM seemed to work best in the ED.

Outcomes

What improvements have you seen in the ED since completing your GEDC training?

Our nurses and doctors are more aware of the needs of the older adults and more engaged in geriatric-specific care.  Delirium screening has increased and we have identified and successfully intervened upon underlying causes of delirium.

What process outcome measures are you continuing to evaluate?

We are monitoring our processes monthly through review of Foley catheter placement, ED length of stay, ED return visit and re-admission rates. We also monitor rates of screening of delirium, and assess outcomes of delirium screening on a case by case basis.

Additional Comments

We are currently developing a protocol for physical therapy evaluation in the ED for patients who have fallen or had frequent prior falls, with the goal of reducing future visits for falls and future injuries.

The Geri ED team at UNC Hillsborough celebrating being the first accredited geriatric ED in North Carolina.