A standardized, bundled approach to providing geriatric-focused acute care

Abstract

Objectives: To determine whether a bundled intervention can increase detection of delirium and facilitate safer use of high-risk medications.

Design: Pre-post interventional trial.

Setting: Large academic medical center.

Participants: Individuals aged 70 and older (n = 19,949) admitted between May 1, 2008, September 30, 2011. Individuals aged 80 and older admitted after April 26, 2010, received the intervention, those aged 80 and older admitted before were primary controls, and those aged 70 to 79 were concurrent controls.

Intervention: The intervention uses a checklist promoting delirium prevention, recognition and management, and modifies the computerized provider order entry system to provide care focused on elderly adults.

Measurements: Frequency of orders for activating the rapid response team for altered mental status, frequency of orders for haloperidol in excess of 0.5 mg or intravenous (IV) morphine in excess of 2 mg, and discharge disposition.

Results: Participants receiving the intervention had a mean age of 86.1 ± 4.6; 58.2% were female. The number of orders to activate the rapid response team for altered mental status increased in participants receiving the bundle and in controls (odds ratio (OR) for the difference of differences = 1.23 (95% confidence interval (CI) = 0.68-2.24, P = .49)). Participants receiving the bundle were less likely to receive more than 0.5 mg of IV, intramuscular, or oral haloperidol (OR = 0.60, 95% CI = 0.39-0.91, P = .02) and more than 2 mg of IV morphine (OR = 0.52, 95% CI = 0.42-0.63, P < .001). Participants who received the bundle were more likely to be discharged home than to extended care facilities (OR = 1.18, 95% CI = 1.04-1.35, P = .01).

Conclusion: An intervention focused on delirium prevention and recognition by bedside staff combined with computerized decision support facilitates safer prescribing of high-risk medications and possibly results in less need for extended care.

Keywords: acute care; delirium; geriatrics; medication geriatrics safety.

Figure 1

Schematic illustrating the two cohorts of patients followed over time, those 80 years and older before and after the intervention and the concurrent control group (70–79 years) over the pre period and the post intervention period.

Figure 2

Delivering Geriatric Appropriate Care to All Hospitalized Elders

Figure 3

Nursing care plan generated automatically for patients receiving the intervention.