Impacting Outcomes in the Hospitalized Oncology Patient: Evidence-Informed Quality and Safety Project to Implement Routine Screening for Delirium

Authors

DOI:

https://doi.org/10.33940/med/2022.9.4

Keywords:

delirium screening, cancer inpatient, falls, length of stay

Abstract

Impacting Outcomes in the Hospitalized Oncology Patient: Evidence-Informed Quality and Safety Project to Implement Routine Screening for Delirium Visual Abstract

Background: Delirium can occur in cancer patients during an acute hospitalization or in the terminal stages of cancer. Iatrogenic delirium can complicate hospital stays for over 2.6 million older persons by increasing fall risk, restraint use, length of stay, post-acute placement, and costs. The purpose of this evidence-based quality improvement project was to implement routine screening for delirium with a consistent instrument and adopt an interprofessional plan of care for delirium.

Methods: This project was identified as an interprofessional improvement initiative. The project leader identified a deficiency in the screening for delirium, convened stakeholders, evaluated evidence, reviewed screening instruments, and developed a plan of care for delirium management. Practice changes incorporated routine delirium screening across the inpatient units. A delirium interprofessional plan of care was integrated into the electronic health record for ease of adoption and workflow modification.

Results: Routine screening for delirium and early interprofessional interventions reduced length of stay by 2.27 days for patients screening positive for delirium. The percentage of inpatient falls that were linked to an episode of delirium during hospitalization reduced from 23.4% to 17%.

Discussions: Routine screening and targeted interventions are a first step in prevention and identification of those inpatients at risk of developing delirium. Delirium prevention is the goal for potential associated iatrogenic conditions.

Author Biographies

Cassandra Vonnes, DNP, GNP-BC, APRN, AOCNP, Moffitt Cancer Center

Cassandra Vonnes (Cassandra.Vonnes@moffitt.org) is a geriatric oncology nurse practitioner at H. Lee Moffitt Cancer Center & Research Institute. Her 28 years of NP experience include acute care and outpatient services of internal medicine and cardiovascular medicine; she was inducted as a Fellow of the American Heart Association for her contributions. Under Dr. Vonnes’ leadership as a Nurses Improving Care for Healthsystem Elders (NICHE) coordinator, Moffitt Cancer Center was the first hospital in Florida to be recognized by the Institute for Healthcare Improvement as an Age-Friendly Health System Committed to Care Excellence for the Older Adult. She has taught clinical and didactic courses at the University of South Florida College of Nursing and has presented both nationally and internationally on fall and injury prevention, delirium, and geriatric assessment. She hosts the gerontological advanced practice nurses podcast GAPNA Chat.

Cindy Tofthagen, PhD, APRN, AOCNP, Mayo Clinic Florida

Cindy Tofthagen is a senior associate consultant in the Department of Nursing at Mayo Clinic Florida. Her background as an oncology nurse practitioner guides her research, which focuses on areas of high concern to patients and on symptoms for which there is a limited evidence base to support successful treatment. By focusing on areas in which there are great needs, her research team hopes to offer effective solutions to important clinical problems, including chemotherapy-induced peripheral neuropathy, psychological distress associated with cancer, and cancer treatment–related pain.

References

Breitbart W, Alici Y. Agitation and Delirium at the End of Life: “We couldn’t manage him.” JAMA. 2008;300(24):2898-910, e1.

Fong TG, Tulebaev SR, Inouye SK. Delirium in Elderly Adults: Diagnosis, Prevention and Treatment. Nat Rev Neurol. 2009;5(4):210-20.

Balas MC, Burke WJ, Gannon D, Cohen MZ, Colburn L, Bevil C, et al. Implementing the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility Bundle Into Everyday Care: Opportunities, Challenges, and Lessons Learned for Implementing the ICU Pain, Agitation, and Delirium Guidelines. Crit Care Med. 2013;41(9 Suppl 1):S116-27.

Brummel NE, Girard TD. Preventing Delirium in the Intensive Care Unit. Crit Care Clin. 2013;29(1):51-65.

Dasgupta M, Dumbrell AC. Preoperative Risk Assessment for Delirium After Noncardiac Surgery: A Systematic Review. J Am Geriatr Soc. 2006;54(10):1578-89.

Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017;377(15):1456-66.

Reston JT, Schoelles KM. In-Facility Delirium Prevention Programs as a Patient Safety Strategy: A Systematic Review. Ann Intern Med. 2013;158(5 Pt 2):375-80.

Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in Elderly Patients and the Risk of Postdischarge Mortality, Institutionalization, and Dementia: A Meta-Analysis. JAMA. 2010;304(4):443-51.

Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. One-Year Health Care Costs Associated With Delirium in the Elderly Population. Arch Intern Med. 2008;168(1):27-32.

Solberg LM, Plummer CE, May KN, Mion LC. A Quality Improvement Program to Increase Nurses’ Detection of Delirium on an Acute Medical Unit. Geriatr Nurs. 2013;34(1):75-9.

Leslie DL, Inouye SK. The Importance of Delirium: Economic and Societal Costs. J Am Geriatr Soc. 2011;59 Suppl 2(Suppl 2):S241-3.

Inouye SK, Westendorp RG, Saczynski JS. Delirium in Elderly People. Lancet. 2014;383(9920):911-22.

Edelstein A, Alici Y. Diagnosing and Managing Delirium in Cancer Patients. Oncology (Williston Park, NY). 2017;31(9):686-92, iii.

Steis MR, Fick DM. Are Nurses Recognizing Delirium? A Systematic Review. J Gerontol Nurs. 2008;34(9):40-8.

Rice KL, Bennett M, Gomez M, Theall KP, Knight M, Foreman MD. Nurses’ Recognition of Delirium in the Hospitalized Older Adult. Clin Nurse Spec. 2011;25(6):299-311.

Spronk PE, Riekerk B, Hofhuis J, Rommes JH. Occurrence of Delirium is Severely Underestimated in the ICU During Daily Care. Intensive Care Med. 2009;35(7):1276-80.

Sendelbach S, Guthrie PF, Schoenfelder DP. Acute Confusion/Delirium. J Gerontol Nurs. 2009;35(11):11-8.

Adamis D, Sharma N, Whelan PJ, Macdonald AJ. Delirium Scales: A Review of Current Evidence. Aging Ment Health. 2010;14(5):543-55.

Inouye S. The Short Confusion Assessment Method (Short CAM): Training Manual and Coding Guide. 2014; Boston: Hospital Elder Life Program.

Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying Confusion: The Confusion Assessment Method. A New Method for Detection of Delirium. Ann Intern Med. 1990;113(12):941-8.

Green JR, Smith J, Teale E, Collinson M, Avidan MS, Schmitt EM, et al. Use of the Confusion Assessment Method in Multicentre Delirium Trials: Training and Standardisation. BMC Geriatr. 2019;19(1):107.

Inouye SK, Kosar CM, Tommet D, Schmitt EM, Puelle MR, Saczynski JS, et al. The CAM-S: Development and Validation of a New Scoring System for Delirium Severity in 2 Cohorts. Ann Intern Med. 2014;160(8):526-33.

National Institute for Health and Care Excellence. Delirium: Prevention, Diagnosis and Management. NICE website. https://www.nice.org.uk/guidance/cg103. Updated March 14, 2019. Accessed July 14, 2022.

American Geriatrics Society. Guidelines, Recommendations & Position Statements. AGS website. https://www.americangeriatrics.org/publications-tools. Published 2014. Updated 2021. Accessed July 14, 2022.

Hshieh TT, Yue J, Oh E, Puelle M, Dowal S, Travison T, et al. Effectiveness of Multicomponent Nonpharmacological Delirium Interventions: A Meta-Analysis. JAMA Intern Med. 2015;175(4):512-20.

Rivosecchi RM, Smithburger PL, Svec S, Campbell S, Kane-Gill SL. Nonpharmacological Interventions to Prevent Delirium: An Evidence-Based Systematic Review. Crit Care Nurse. 2015;35(1):39-50; quiz 1.

American Geriatrics Society Abstracted Clinical Practice Guideline for Postoperative Delirium in Older Adults. J Am Geriatr Soc. 2015;63(1):142-50.

Akunne A, Murthy L, Young J. Cost-Effectiveness of Multi-Component Interventions to Prevent Delirium in Older People Admitted to Medical Wards. Age Ageing. 2012;41(3):285-91.

Zhang H, Lu Y, Liu M, Zou Z, Wang L, Xu FY, et al. Strategies for Prevention of Postoperative Delirium: A Systematic Review and Meta-Analysis of Randomized Trials. Crit Care. 2013;17(2):R47.

de la Cruz M, Fan J, Yennu S, Tanco K, Shin S, Wu J, et al. The Frequency of Missed Delirium in Patients Referred to Palliative Care in a Comprehensive Cancer Center. Support Care Cancer. 2015;23(8):2427-33.

Lawlor PG, Bush SH. Delirium in Patients With Cancer: Assessment, Impact,

LaFever S, Bory A, Nelson J. Delirium in Patients With Cancer: What Nurses Need to Know to Improve Care. Clin J Oncol Nurs. 2015;19(5):585-90.

National Center for Health Statistics. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Centers for Disease Control and Prevention website. https://www.cdc.gov/nchs/icd/icd-10-cm.htm. Updated June 9, 2022. Accessed July 14, 2022.

Adams CL, Scruth EA, Andrade C, Maynard S, Snow K, Olson TL, et al. Implementing Clinical Practice Guidelines for Screening and Detection of Delirium in a 21-Hospital System in Northern California: Real Challenges in Performance Improvement. Clin Nurse Spec. 2015;29(1):29-37.

Jansen CJ, Absalom AR, de Bock GH, van Leeuwen BL, Izaks GJ. Performance and Agreement of Risk Stratification Instruments for Postoperative Delirium in Persons Aged 50 Years or Older. PloS One. 2014;9(12):e113946.

Donabedian A, Attwood JC. An Evaluation of Administrative Controls in Medical-Care Programs. N Engl J Med. 1963;269:347-54.

Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: Evaluation of a New Screening Tool. Intensive Care Med. 2001;27(5):859-64.

Schuurmans MJ, Shortridge-Baggett LM, Duursma SA. The Delirium Observation Screening Scale: A Screening Instrument for Delirium. Res Theory Nurs Pract. 2003;17(1):31-50.

Rutherford P PJ, Coughlan P, Lee B, Moen R, Peck C, Taylor J. Transforming Care at the Bedside How-to Guide: Engaging Front-Line Staff in Innovation and Quality Improvement. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008.

Squires A, Murali KP, Greenberg SA, Herrmann LL, D’Amico C O. A Scoping Review of the Evidence About the Nurses Improving Care for Healthsystem Elders (NICHE) Program. Gerontologist. 2019.

Francis D, Fletcher K, Simon LJ. The Geriatric Resource Nurse Model of Care: A Vision for the Future. Nurs Clin North Am. 1998;33(3):481-96.

Pierre JS, Twibell R. Developing Nurses’ Geriatric Expertise Through the Geriatric Resource Nurse Model. Geriatr Nurs. 2012;33(2):140-9.

Guthrie PF, Edinger G, Schumacher S. TWICE: A NICHE program at North Memorial Health Care. Geriatr Nurs. 2002;23(3):133-8; quiz 8-9.

Bidwell J. Interventions for Preventing Delirium in Hospitalized Non-ICU Patients: A Cochrane Review Summary. Int J N Stud. 2017;70:142-3.

Health Research & Educational Trust. Preventing Iatrogenic Delirium Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust; 2017. Available from: www.hret-hiln.org.

Pitkälä KH, Laurila JV, Strandberg TE, Tilvis RS. Multicomponent Geriatric Intervention for Elderly Inpatients With Delirium: A Randomized, Controlled Trial. J Gerontol A Biol Sci Med Sci. 2006;61(2):176-81.

Institute for Healthcare Improvement. Quality Improvement Essentials Toolkit. Boston, Massachusetts, USA: IHI; 2017.

Herlopian A, Dietrich J, Abramson JS, Cole AJ, Westover MB. EEG Findings in CAR T-Cell Therapy-Related Encephalopathy. Neurology. 2018;91(5):227-9.

Gust J, Taraseviciute A, Turtle CJ. Neurotoxicity Associated with CD19-Targeted CAR-T Cell Therapies. CNS Drugs. 2018;32(12):1091-101.

Korc-Grodzicki B, Sun SW, Zhou Q, Iasonos A, Lu B, Root JC, et al. Geriatric Assessment as a Predictor of Delirium and Other Outcomes in Elderly Patients With Cancer. Ann Surg. 2015;261(6):1085-90.

Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L, et al. Features of 20 133 UK Patients in Hospital With Covid-19 Using the ISARIC WHO Clinical Characterisation Protocol: Prospective Observational Cohort Study. BMJ. 2020;369:m1985.

Garcez FB, Aliberti MJR, Poco PCE, Hiratsuka M, Takahashi SF, Coelho VA, et al. Delirium and Adverse Outcomes in Hospitalized Patients with COVID-19. J Am Geriatr Soc. 2020;68(11):2440-6.

Helms J, Kremer S, Merdji H, Clere-Jehl R, Schenck M, Kummerlen C, et al. Neurologic Features in Severe SARS-CoV-2 Infection. N Engl J Med. 2020;382(23):2268-70.

Schall M. C, C., Nielsen, G. Transforming Care at the Bedside How-to Guide: Spreading Innovations to Improve Care on Medical and Surgical Units. Cambridge, Massachusetts:: Institute for Healthcare Improvement; 2008.

Neelon VJ, Champagne MT, Carlson JR, Funk SG. The NEECHAM Confusion Scale: Construction, Validation, and Clinical Testing. Nurs Res. 1996;45(6):324-30.

Schuurmans M, Donders R, Shortridge-Baggett L, Duursma S. Delirium Case Finding: Pilot Testing of a New Screening Scale for Nurses. J Am Geriatr Soc. 2002;50.

Vermeersch PE. The Clinical Assessment of Confusion-A. Appl Nurs Res. 1990;3(3):128-33.

Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L, et al. Delirium in Mechanically Ventilated Patients: Validity and Reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). JAMA. 2001;286(21):2703-10.

Gaudreau JD, Gagnon P, Harel F, Roy MA. Impact on Delirium Detection of Using a Sensitive Instrument Integrated Into Clinical Practice. Gen Hosp Psychiatry. 2005;27(3):194-9.

Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N. Validation of the Delirium Rating Scale-Revised-98: Comparison With the Delirium Rating Scale and the Cognitive Test for Delirium. J Neuropsychiatry Clin Neurosci. 2001;13(2):229-42.

ST OK. Rating the Severity of Delirium: The Delirium Assessment Scale. Int J Geriatr Psychiatry. 1994;9:551-6.

Trzepacz PT, Baker RW, Greenhouse J. A Symptom Rating Scale for Delirium. Psychiatry Res. 1988;23(1):89-97.

Bettin KM, Maletta GJ, Dysken MW, Jilk KM, Weldon DT, Kuskowski M, et al. Measuring Delirium Severity in Older General Hospital Inpatients Without Dementia. The Delirium Severity Scale. Am J Geriatr Psychiatry. 1998;6(4):296-307.

Albert MS, Levkoff SE, Reilly C, Liptzin B, Pilgrim D, Cleary PD, et al. The Delirium Symptom Interview: An Interview for the Detection of Delirium Symptoms in Hospitalized Patients. J Geriatr Psychiatry Neurol. 1992;5(1):14-21.

McCusker J, Cole MG, Dendukuri N, Belzile E. The Delirium Index, a Measure of the Severity of Delirium: New Findings on Reliability, Validity, and Responsiveness. J Am Geriatr Soc. 2004;52(10):1744-9.

de Jonghe JF, Kalisvaart KJ, Timmers JF, Kat MG, Jackson JC. Delirium-O-Meter: A Nurses’ Rating Scale for Monitoring Delirium Severity in Geriatric Patients. Int J Geriatr Psychiatry. 2005;20(12):1158-66.

Robertsson B, Karlsson I, Styrud E, Gottfries CG. Confusional State Evaluation (CSE): An Instrument for Measuring Severity of Delirium in the Elderly. Br J Psychiatry. 1997;170:565-70.

Breitbart W, Rosenfeld B, Roth A, Smith MJ, Cohen K, Passik S. The Memorial Delirium Assessment Scale. J Pain Symptom Manage. 1997;13(3):128-37.

Hofsté WJ, Linssen CA, Boezeman EH, Hengeveld JS, Leusink JA, de-Boer A. Delirium and Cognitive Disorders After Cardiac Operations: Relationship to Pre- and Intraoperative Quantitative Electroencephalogram. Int J Clin Monit Comput. 1997;14(1):29-36.

Hart RP, Levenson JL, Sessler CN, Best AM, Schwartz SM, Rutherford LE. Validation of a Cognitive Test for Delirium in Medical ICU Patients. Psychosomatics. 1996;37(6):533-46.

Article title and abstract on blue abstract background.

Published

2022-09-16

How to Cite

Vonnes, C., & Tofthagen, C. (2022). Impacting Outcomes in the Hospitalized Oncology Patient: Evidence-Informed Quality and Safety Project to Implement Routine Screening for Delirium. Patient Safety, 4(3), 20–29. https://doi.org/10.33940/med/2022.9.4

Issue

Section

Original Research and Articles
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