Know your tools: Improving the effectiveness of nurses using the confusion assessment method (CAM) to detect delirium 1 Julie Plagenhoef, MPH, RN, CMSRN
Preparing for Improvement: Why Delirium? Increases patient mortality Increases patient morbidity before and after hospitalization Increases patient and family distress Increases length of stay in hospital (Duppils, et al 2004; Inouye, et al 1998; McCusker, et al 2002; Maldonado as cited in Maldonado, et al 2008 and Ely, 2 et al 2001)
Change Management CAP: Change Acceleration Process Leading Change Creating a Shared Need Shaping a Vision Mobilizing Commitment Current State Transition State Making Change Last Improved State Monitoring Progress Changing Systems & Structures 3
Preparing for Improvement Using CAP Shaping a vision Hospital Goals CESP Unit Goals patient safety and experience Mobilizing commitment Unit manager, staff RNs, PPLs, staff educators, data experts 4
Assessment: The State of the CAM Baseline data Completeness of CAM assessments Reliability of CAM assessments Knowledge survey Gaps and strengths Barriers to completion and reliability Available resources Time, money, staff coverage 5
Diagnosis: What Needs to Change? Aim of project: Change practice to improve effectiveness of nurses using the CAM to detect delirium by increasing completeness of the tool and enhancing assessment of its features and outcome (reliability) 6
Planning: How to Improve? Best practices for RN education to improve completeness and reliability Predisposing: One hour discussion sessions, case vignettes Enabling: Flow sheets, champions Reinforcing: Feedback, pop-ups, re-train (Mamata, et al 2013 and Devlin, et al 2008) 7
Planning: How to Improve? Methods overview Knowledge survey results inform targeted education Paired CAM assessments of staff/expert RNs to assess reliability Chart audit to assess completeness Test period 2/11-3/7/2014 pre and 6/12-6/23/2014 post-training 2.5 weeks to complete education sessions Outcomes measured % completeness of CAM assessments Inter-rater reliability 8
Intervention: Implement Improvement Plan Knowledge survey 18 questions e.g., what is the CAM, how do you assess each feature, what are biggest barriers to using it? 23/34 (68%) RNs eligible for training responded Survey showed need for: Review of expectations (74% correct) Review of features (60-91% correct) Using CAM for TBI patients (30% listed as barrier) 9
Evaluation: Patient Demographics Pre/Post Training Pre-Training Post-Training P-value N % N % Total Patients 39-39 - - Total Assessments 139-117 - - Average Age 50-51 - 0.83 Sex Males 28 71.8 21 53.8 0.10 Females 11 28.2 18 46.2 0.10 Mech of Injury Falls 11 28.2 12 30.8 0.80 MVC/MCC 10 25.6 10 25.6 1 Assault 3 7.7 0 0.0 0.07 Other 16 41.0 17 43.6 0.81 Brain Injury 7 17.9 8 20.5 0.77 10
Evaluation of CAM Completeness Pre/Post Training 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent CAM Assessments Complete *85% 73% Pre-Training Post-Training *Z= 2.36, p=0.009 11
Evaluation of Inter-Rater Reliability Pre/Post Training 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 84% Pre-Training Overall CAM Agreement *97% Post-Training *Kappa= 0.059, p=0.102 12
Evaluation: Making Change Last Follow-up knowledge survey 1 year later 16/36 (44%) RNs responded, 4/16 (25%) new hires Strengths: Understanding CAM features (81-100% correct) Risks for delirium (94% correct) Feeling comfortable using CAM (94% correct) Gaps: Using CAM for TBI patients (50% listed as barrier) 13
Evaluation of CAM Completeness at One Year 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent CAM Assessments Complete 85% 90% 73% Pre-Training Post-Training Follow-up 14
Evaluation of Inter-Rater Reliability at One Year 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% CAM Agreement, Overall and by Type of Injury 89% 88% 84% 100% 97% 100% 70% 58% Pre-Training Post-Training Follow-up Brain Injured Non-Brain Injured Overall 83% 15
Evaluation: What the Data Show Effectiveness of intervention Completeness and reliability of CAM assessments increased post-training One year later completeness was maintained but overall reliability decreased Opportunities for improvement Increase reliability for TBI patients Provide education reinforcement 16
Sustainability: Cost Analysis Staff RN education hours (34 RNs, 40 min education, $51.20/hr) Staff educator hours (1 presenter, 2 covering floor, $51.20/hr) Chart auditing (12 hrs, $51.20/hr) Implementation Cost Sustainability $1,160.53 Ed Day New Hires $2,150.40 Ed Day New Hires $614.40 Repeat 1x/year CAM accuracy verification (2 PPLs, 10 hours) Fixed Cost Evaluate Need Total $3,925.33 17
Sustainability: Benefit Analysis Delirium increases length of stay (LOS) by 4-10 days (Ely, et al., 2001) $2500/day = $10,000 to $25,000 cost Early recognition and intervention can decrease LOS by 4-10 days (Maldonado, et al., 2008; Lundstrom, et al., 2007) Cost avoidance of $10,000- $25,000 18
Next Steps Present follow-up data to 13A staff Incorporate into continuing education Incorporate into new staff orientation Periodic chart audits? Improve patient care outcomes (e.g., decrease length of stay, decrease fall rates) Prevention - Let s stop delirium! Interventions 19
Limitations Challenges of linking CAM+ assessments with delirium diagnoses Little definitive evidence for effectiveness of intervention strategies Resource constraints 20
Acknowledgements Anne Larkin, MSN, RN, NE-BC Dianne Wheeling, MNE, RN-C ED Michelle Dedeo, DNP, RN, ACCNS-AG, CCRN Kristen Richards, RN Barb Sells, RN Mariah Hayes, RN, MN, ONC Barbara Bonnice, DNP, RN Debi Eldredge, PhD, RN Denise Maierle, MSN, RN, CNS 13A Staff 21
References Devlin JW, et al. Combined didactic and scenario-based education improves the ability of intensive care unit staff to recognize delirium at the bedside. Critical Care 2008; 12:R19. Duppils GS, Wikbald K. Cognitive function and health-related quality of life after delirium in connection with hip surgery. A six-month follow-up. Orthop Nurs 2004; 23(3):195-203. Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med 1998;13(4):234-42. Ely EW. Gautam S. Margolin R. Francis J. May L. Speroff T. Truman B. Dittus R. Bernard R. Inouye SK. The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Medicine 2001; 27(12):1892-900 22
References Lundstrom M, Olofsson B, Stenvall M, Karlsson S, Nyberg L, Englund U, Borssen B, Svensson O, Gustafson Y. Postoperative delirium in old patient with femoral neck fracture: a randomized intervention study. Aging-Clinical & Experimental Research 2007; 19(3):178-86. Maldonado, JR. Delirium in the acute care setting: characteristics, diagnosis and treatment. Crit Care Clin 2008; 24:657 722. Mamata Y, Wieland D, Heflin M. Educational Interventions to Improve Recognition of Delirium: A Systematic Review. JAGS 2013; 61:1983 1993. McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12-month mortality. Arch Intern Med 2002; 162(4):457-63. 23