By Melinda Young
Case managers and other healthcare providers can improve overall patient care and outcomes using an assessment tool that identifies patients’ delirium and confusion. A health system found that a confusion assessment tool helped decrease hospital length of stay and reduced utilization.1
Until someone sees a hospitalized patient with delirium and confusion, it is difficult to understand how much this mental state could affect a patient’s overall hospital experience and outcomes. “If delirium is not recognized early and treated, there can be lifelong cognitive impairment for patients,” says Terri Savino, DNP, RN, CPHQ, CPXP, FNAHQ, director of service excellence and patient experience at Middlesex Hospital in Middletown, CT. Savino also is adjunct faculty for the department of nursing in the graduate program at the University of Connecticut.
Hospitalized patients with delirium pose safety and security threats, sometimes needing restraints for their safety. If case managers and hospital staff are unaware of the patient’s risk for delirium, it can lead to problems for staff, patients, and caregivers.
Savino recalls the case of someone she knew who had cancer and experienced delirium in the hospital. The patient yelled at his spouse, and the patient’s daughter was in tears. No one had screened the patient for delirium because there was no screening tool in place.
“That’s why it’s so important to screen for delirium every 12 hours,” Savino says. “You could miss it if you do it once a day; we do it twice a day.”
Screening is quick, taking a few minutes. The tool includes four questions. If delirium is identified, there are several precautions staff can take to improve safety for the patient and others.
A recent study by Savino and colleagues shows that implementing the screening tool, called the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), can reduce length of stay by 3.12%. It also can reduce home care service use when compared with an intervention group. Quick identification of delirium through the tool can result in case managers and others taking appropriate actions to intervene and manage patients with delirium.1
“We are now screening all patients on the med-surg [unit] as of November 2023,” Savino says. Screening for delirium meets the goals of the age-friendly health system’s 4 Ms of mentation, mobility, medication, and what matters, she notes.
Patients who screen positive for delirium can be handled differently to improve their safety. Case managers, nurses, and other staff should be trained on tips for caring for patients with delirium.
“As part of my project, I developed delirium tips as a way to educate nursing,” Savino says. “One of the delirium tips has to do with risk factors.”
Some of the actions hospital staff can take to improve safety include:
- Structure reorientation. “Make sure [patients] know their environment and are alert,” Savino suggests. “Say, ‘Mrs. Smith, can you tell me where you are today?’ If they say the wrong thing, say, ‘You’re at such and such hospital, and this is the date.’” Structure reorientation includes hanging calendars and large digital clocks in patients’ rooms.
- Early mobility. This includes getting patients out of bed and assigning physical therapy to work with them early on.
- Sleep. “Sleep is huge, and it’s sometimes hard to sleep in the hospital,” Savino notes. “You don’t want them sleeping in all day, so open the curtain to let light in, and limit naps in the daytime.”
- Wear glasses and hearing aids. Delirium risks could be reduced when patients can see and hear their best. Sometimes, their glasses and hearing aids are misplaced in the hospital room, so staff should make sure patients have them and are using them. “If you see glasses on the table, offer them to the patient,” Savino suggests. “There are a lot of little things that case managers can do.”
- Ask family to visit in the daytime. “Having family there in the daytime keeps them oriented,” Savino says. When case managers meet with families, they can address the patient’s change in mentation with caregivers. When a family member mentions a change in mental status from the day before, the case manager can talk to the nurse, bringing their concerns forward.
Staff education on delirium should explain what it is and what might cause it. For instance, delirium can lead to emotional outbursts, which can be frightening to caregivers and families. It involves a change in consciousness and mental status, disorientation, disorganized thinking, and inability to pay attention. Delirium also may appear with hyperactive behavior, aggression, and a combination of these.
“Some of the aggressive ones can be hard and most upsetting for the family,” Savino says. “You can redirect that orientation by slowing down your voice [and] talking calmly. Maybe that patient needs medication to help them calm a little bit.”
Some risk factors for delirium are congestive heart failure, dehydration, medication, infection, electrolyte imbalance, cognitive impairment, dementia, depression, opioid use, benzodiazepine use, and sepsis.
Training on the delirium screening tool took place over a day in a hospital conference room. Staff viewed the 30-minute presentation, played a game about delirium, and learned more about the condition. Tests and knowledge assessment followed. Attendees were given a written test and were assessed by one of the trainers, including Savino, a nurse manager, a distance nurse manager, and a nurse educator.
“I did a PowerPoint overlay, which had screens about the tool and delirium,” she says. “Then, I made a Jeopardy! game out of it to reinforce the information, and they got candy for prizes.”
Savino also sent weekly email tips to nurses and posted information throughout the unit. “I also created a delirium toolkit for patients with things that would help them, like coloring, earplugs, and a family guide about delirium,” she adds.
Case managers were not required to attend the training, but they are part of multidisciplinary rounds and learn through the rounds about delirium cases and how these will be handled. “Our case manager plays a huge role in multidisciplinary rounds. They’re such a big part of the team, communicating with families and other agencies,” Savino says.
While case managers do not provide delirium screening, they need to know about it and know what can be done to improve patient safety and improve their interactions with patients who have delirium.
“If someone screens positive for delirium, then there’s a discussion in rounds about what we can do to treat it,” she says. “There are times when patients with delirium need to be restrained for their safety, and that’s something the case manager needs to be aware of.”
Through screening and mitigating delirium safety risks, health systems will find that more patients with delirium are safely transitioned home without the need for home care. “We saw a reduction of patients going into home care because we were able to identify delirium earlier, treat them earlier, and get them ambulating so they didn’t need resources at home like they did previously,” Savino explains.
The people attending the training were very engaged and sometimes had additional questions for Savino. “They wanted to know if someone was going through alcohol withdrawal and whether the tool was appropriate for them,” she recalls. “They were very engaged, and I was lucky because I had a good relationship with them.”
As staff followed the training instructions and helped orient patients to daytime movement, light, and social interactions, they began to see a difference in patients’ delirium symptoms. They learned to prevent patients from sleeping all day, and this produced positive results.
“They were doing the things they learned,” Savino says. “I’d round with them and ask if they had any questions, and I would give them continual support, bringing buckets of candy and thanking them for participating [in the delirium program] because they were a big part of it.”
Through these reinforcement efforts, patients with delirium continued to improve. This shortened length of stay, Savino adds.
REFERENCE
- Savino T, Vergara FH, Ramos MD, Warzecha D. Bringing delirium to light: Impact of CAM-ICU tool to improve care coordination. Prof Case Manag 2024;Feb 26. doi: 10.1097/NCM.0000000000000715. [Online ahead of print].
Case managers and other healthcare providers can improve overall patient care and outcomes using an assessment tool that identifies patients’ delirium and confusion. A health system found that a confusion assessment tool helped decrease hospital length of stay and reduced utilization.
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