Hoag Memorial Hospital Presbyterian in Newport Beach, California, which serves more than 30,000 inpatients each year, implemented a five-step delirium prevention protocol that’s making an impact but requires oversight, training and education.
April 19, 2018
by Sandra Gordon for ASA
February 28, 2018 was a big day for Hoag Hospital in Newport Beach, California. That’s when the hospital introduced its delirium prevention program hospital-wide.
“It’s my dream. We started with one unit, then two and three. Now it’s house-wide,” says Meredith Padilla, Ph.D., M.S.N., RN, CCRN-CMC/CSC, a critical care nurse educator who helped develop and implement the hospital’s delirium prevention protocol, which began as a pilot project a year ago on the Surgical Sublevel Unit.
Thomas G. Sinclair Jr., M.D., a board-certified anesthesiologist, worked with Dr. Padilla on Hoag’s multidisciplinary delirium prevention team.
Hoag’s Delirium Prevention Protocol
To protect older surgical patients at risk, Hoag’s delirium prevention program, which is now hospital-wide, is multifaceted. It includes these steps:
- A preoperative assessment of the patient
Before surgery, preop nurses screen all patients 60 years and older for delirium using the AWOL tool. With the confusion prediction tool, patients earn one point if they’re over 80 years, if they can’t spell “world” backwards, if they can’t identify their state, county, hospital and hospital floor, and if their ASA physical status is ASA III or greater. Nurses also use the Confusion Assessment Method (CAM) to measure delirium at the bedside.
- Modifying the anesthetic if the patient is at risk for delirium
When the anesthesiologist sees the patient’s AWOL score, he/she can determine if the anesthetic needs adjusting. Pharmacological strategies to reduce the risk of delirium include avoiding medications on the Beers list that can cause or impact delirium.
- Postoperative non-pharmacological ward care
In patients’ rooms, there’s a large whiteboard that orients them to location: “You’re in Hoag Hospital.” When nurses visit, they orient the patient again in terms of time and place: “Today is Monday. It’s 1:30 in the afternoon. You’re at Hoag Hospital.” Nurses encourage family member to orient the patient as well.
As part of non-pharmacologic ward care, the nurses also promote physiologic sleep to help cognition. In lieu of giving patients sleep medication, they turn the lights off at night and keep the room quiet. “One nurse even wears a head lamp when checking on patients, just to sneak in the room to check on patients without disturbing them,” Dr. Sinclair says.
Even something as simple as opening the window blinds during the day so patients don’t confuse day and night can make a big difference. Soon, the hospital will be also introducing a “sweet dreams” patient sleep kit, with eye masks and earplugs, Dr. Padilla says.
The nurses also have the option of providing patients with a “hold” bear. The large brown stuffed bear provides comfort. “One of the nurses told me: ‘That bear really worked on a patient who was getting confused,’” Dr. Padilla says. “After giving the bear to the patient, the patient didn’t end up with delirium.”
- Encouraging early mobility
Patient mobility soon after surgery is a major component of Hoag’s delirium prevention protocol. “If patients have hip or knee surgery in the morning, they’re up and out of bed in the afternoon,” Dr. Sinclair says.
- Pharmacy oversight
If hospitalists or attending physicians order a drug that may promote delirium, such as Ativan or Lorazepam, nurses on the floor can call the pharmacy.
Making an Impact
After collecting data on 190 patients for over a year during the pilot project, Hoag’s postoperative delirium rate in orthopedic patients was 10.9 percent.
Hoag’s delirium prevention program is being now implemented for all elderly patients admitted to the hospital, not just surgical patients. “The sustainability of a protocol is hard to hardwire,” Dr. Padilla says. “It takes baby steps and a lot of perseverance and patience.”
Read on to learn more about the educational steps Hoag took to implement the delirium prevention program.
Hoag’s Delirium Prevention Program Takes Layers of Education
Implementing Hoag’s delirium prevention program and sustaining it requires “layers of education,” says Meredith Padilla, Ph.D., M.S.N., RN, CCRN-CMC/CSC, a critical care nurse educator who helped develop and implement the hospital’s delirium prevention protocol.
Here are just some of educational steps the hospital took, even before introducing its delirium prevention pilot project, to increase delirium prevention awareness among the nursing and physician staff.
- Skills Day: Before Hoag introduced its delirium prevention pilot project on a Surgical Sublevel Unit, “we started with a Skills Day for all patient care assistants and the nursing staff,” Dr. Padilla says. “Our goal was to increase awareness because delirium is something that could be prevented.”
- Nursing grand rounds and lectures: Padilla, whose doctoral research focused on delirium prevention, then began presenting her delirium research in nursing grand rounds (NGRs). Meanwhile, Thomas G. Sinclair Jr., M.D., a board-certified anesthesiologist with Hoag, had begun lecturing physicians on delirium prevention and preoperative and postoperative care. “I gave a talk to our group on delirium care and outlined the basic principles. I also sent out monthly, sometimes biweekly emails, which I titled ‘The Daily Delirium,’” Dr. Sinclair says. Providers received constant reminders and the importance of delirium prevention.
Hoag also has another great resource on the team, a board-certified psychiatrist, Dr. Renee Garcia, who is also on board with preventing and managing delirium. Dr. Garcia was involved in providing lectures to the physicians and has been invited to two nursing conferences at Hoag (Acute Care Conference and Cardiovascular Symposium) to talk about delirium.
Drs. Padilla and Sinclair eventually met with stakeholders and nursing directors to discuss a delirium prevention pilot project, which was approved by nursing leadership. “It was hard at first, but the nurses embraced it,” Dr. Padilla says. The delirium prevention protocol, which also included CAM scoring, was first introduced in critical care, where Dr. Padilla is a nurse educator, then to the Surgical Sublevel Unit and orthopedic floors. “We started in preop with AWOL delirium risk prediction tool education,” Dr. Padilla says. Now, “delirium prevention education is taught at nursing orientation, online education and bedside education. Bedside education is done by education coordinators and nurse champions.”
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