Standardizing Management of Adults with Delirium Hospitalized on Medical-Surgical Units

Abstract

Context: Delirium is common among inpatients aged 65 years and older and is associated with multiple adverse consequences, including increased length of stay (LOS). However, delirium is frequently unrecognized and poorly understood. At one hospital, baseline management of delirium on medical-surgical units varied greatly, and psychiatric consultations focused exclusively on crisis management.

Objective: To implement a multidisciplinary program for rapid identification and proactive management of patients with delirium on medical-surgical units.

Design: A pilot from September 2010 to July 2012 included 920 unique patients, of whom 470 were seen by the delirium management team. A delirium management team included a redesigned role for consulting psychiatrists and a new clinical nurse specialist role; the team provided assistance with diagnosis and recommendations for nonpharmacologic and pharmacologic management of delirium. Multidisciplinary education focused on delirium identification and management and nurses' use of appropriate assessment tools. Electronic health record functions supported accurate problem list coding, referrals to the team, and standardized documentation.

Main outcome measure: Length of stay.

Results: During the study period, average LOS in the target population decreased from 8.5 days to 6.5 days (p = 0.001); average LOS for the Medical Center remained stable. Compared with patients whose delirium was diagnosed during the baseline period, patients who received a delirium diagnosis during the pilot period had a higher illness burden and were likelier to have a history of delirium and diagnosed dementia.

Conclusion: Program implementation was associated with reduced LOS among older inpatients with delirium. The delirium team is an effective model that can be quickly implemented with few additional resources.

Figure 1

Sample electronic health record showing documentation of effect of medications for hyperactive behaviors. Geodon = ziprasidone; IM = intramuscular; PRN = as needed.