Affected individuals should be followed after discharge to mitigate any long-term effects of delirium after a hospital stay or other medical treatment. Focusing patient safety efforts on delirium is appropriate, given that the problem is common and associated with serious complications, and is increasing in magnitude as the population ages. Delirium may be preventable in certain circumstances—with some estimates finding delirium preventable in 30 to 40% of cases— thereby increasing quality and safety of care, as well as reducing costs to the healthcare system. 120 Awareness of these costs can drive improvement in screening and assessment of individuals at risk for onset of delirium, and in further study of treatment strategies that both reduce costs of care and improve quality of life. Healthcare professionals need adequate training and education to be vigilant and effective in assessing their patients for delirium in all healthcare settings. Delirium screening and assessment Delirium, a clinical diagnosis, is often unrecognized and easily overlooked. Recognition requires brief cognitive screening and astute clinical observation. Key diagnostic features include an acute onset and fluctuating course of symptoms, inattention, impaired level of consciousness, and disturbance of cognition (e.g., disorientation, memory impairment, alteration in language). Supportive features include disturbance in sleep- wake cycle, perceptual disturbances (hallucinations or illusions), delusions, psychomotor disturbance (hypo- or hyper-activity), inappropriate behavior, and emotional lability. There is no widely accepted pharmacological means of preventing delirium in the at-risk population over 65 years of age. Consequently, multicomponent approaches for primary prevention of delirium have gained widespread acceptance as the most effective strategies for addressing delirium. While a single factor may put a patient at high risk for developing delirium, it is more likely that a combination of risk factors, including multimorbidity, dementia, certain medications, and isolation, place an individual at a much higher risk, especially if he or she is over 65 years of age. The leading risk factors of delirium consistently reported at hospital admission are dementia or cognitive impairment, functional impairment, vision impairment, history of alcohol abuse, and advanced age (> 70 years). Comorbidity burden or presence of specific comorbidities (e.g., stroke, depression) are associated with an increased risk of delirium in all patient populations. Nonpharmacological interventions Nonpharmacological interventions aimed at prevention orreduction of delirium fall into several domains, including mobility (early mobilization, physical, occupational therapy), environmental (noise reduction, music, light adjustment, ear plugs, eye shades, avoidance of physical restraints),
cognitive (reorientation, cognitive activities), and therapeutic (sleep promotion, attention to hearing or vision deficits, nutrition and hydration, minimization of indwelling urinary catheter use). Results related to effectiveness of nonpharmacological interventions are mixed. Nonpharmacological interventions significantly reduced delirium incidence in four trials, while two reported nonsignificant results and one a nonsignificant increase. Statistically significant reduction in duration of delirium was reported in four studies. Studies have shown multicomponent nonpharmacological interventions to be effective for reduction of delirium among intensive care patients, although the quality of the evidence is low to moderate. Reproducibility and scalability are hindered by a lack of evidence regarding which components of many are requiredto achieve the desired effect. In addition, specific details of implementation required for replication and level of adherence to protocols arenot often reported. Conclusions about delirium Given the importance of delirium as a harm area in many healthcare settings, additional research appears necessary. The results of this review highlight the need for evidence-based tools that can be readily used by frontline caregivers to reliably assess and re-assess patients for signs/ symptoms of delirium, whether they are in acute care or in a variety of post-acute care settings. Early identification of delirium and the application of best practices to reduce harm with these populations at risk for delirium are crucial to maintaining patients’ functional capabilities and improving their safety in the healthcare system. The literature is clear that unrecognized, untreated delirium leads to adverse events such as falls, polypharmacy, restraints, and readmissions. Studies found that the Confusion Assessment Method (CAM) or one of its variations and associated tools was reliable in identifying delirium patients. New tools should also be evaluated as they are developed, again especially in settings other than acute care. Attention will have to be given to how long it takes to assess patients using these tools and the ability of clinicians to accurately use them. Additional time may be needed for ongoing training and evaluation of competence in using methodsand tools specific to a particular institution. There is clearly an ongoing need for inclusion of delirium as an important patient safety topic in the education and training of clinicians and other providers including nurses, physicians, pharmacists, and social workers, especially as our population continues to rapidly age. Care transitions As patients prepare to move from the hospital to other settings, failing to make adequate discharge arrangements can lead to costly and unnecessary hospital readmissions, preventable adverse events, and drug-related errors. Ensuring safe and
seamless transitions starts well before hospital discharge. Successful transitioning of patients from the hospital to other care settings is a dynamic, multifaceted process in which healthcare systems, hospitals, providers, patients, and their families share responsibility. Models or interventions such as Better Outcomes for Older Adults (BOOST), the Care Transitions Intervention (CTI), and the Transitional Care Model (TCM) were developed with the intention of improving transitions across the continuum of care. These models appear to be especially beneficial for high-risk and older adult populations, who are often hospitalized; move frequently across care settings; and experience high rates of post-discharge complications, readmissions, or morbidity and mortality. Transitioning patients from one setting to another is a particularly vulnerable time. Safety lapses can result in negative clinical outcomes, preventable adverse events, and avoidable hospital readmissions. The following seven key elements are considered essential for safe and seamless transitions: • Medication Management: Ensuring the safe use of medications by patients and their families based on patients’ plans of care. • Transition Planning: Creating a plan/process that facilitates the safe transition of patients from one level of care to another, including home or from one practitioner to another. • Patient/Family Engagement and Education: Educating and counseling patients and families to enhance their active participation in their own care, including informed decision making. • Communicating and Transferring Information: Sharing of important care information among patient, family, caregiver, and healthcare providers in a timely and effective manner. • Follow-Up Care: Facilitating the safe transition of patients from one level of care or provider to another through effective follow-up care activities. Engagement: Demonstrating ownership, responsibility, and accountability for the care of the patient and family/caregiver at all times. • Shared Accountability Across Providers and • Healthcare Provider Organizations: Enhancing the transition of care process through accountability for care of the patient by both the healthcare provider (or organization) transitioning, and the one receiving the patient. BOOST: Better Outcomes by Optimizing Safe Transitions Project BOOST is a multicentered quality improvement (QI) transitional care program created in 2008 by the Society of Hospital Medicine to improve care for patients as they transition from the hospital to home. 121 The objective is to reduce 30-day readmission rates, improve provider workflow, and reduce medication-related errors. The model involves tools and resources to identify and manage patients at high risk for readmissions, with a particular focus on older adults.
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