The Delirium In Older Hospitalized Patients Discussion Paper

The Delirium In Older Hospitalized Patients Discussion Paper

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Delirium is a common condition in older hospitalized patients, characterized by an acute and fluctuating disturbance of consciousness, attention, cognition, and perception. It is associated with increased morbidity and mortality. Older patients with delirium are more likely to experience complications such as falls, pressure ulcers, infections, and extended hospital stays (Bellelli et al., 2021). They are also at increased risk of functional decline and long-term cognitive impairment. Older patients with delirium may experience hallucinations, delusions, and other disturbing symptoms that can be frightening and confusing. Family members may be distressed by the sudden onset of their loved one’s confusion and altered mental state. Adequate care is necessary to improve outcomes and improve their quality of life. The Delirium In Older Hospitalized Patients Discussion Paper

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PICOT Question

In older hospitalized patients (P), do cognitive stimulation and environmental modifications (I), compared to usual care (C), reduce the incidence and severity of delirium (O) within a 30-day follow-up period? (T).

Search Strategy

The search strategy for the articles involved an electronic search of databases such as PubMed, CINAHL, Cochrane Library, Google Scholar, and ScienceDirect. Keywords related to the PICOT question, such as: “older hospitalized patients with delirium,” “cognitive stimulation,” and “environmental modifications,” were used.  I also used the Boolean operators “AND” and “OR” to combine the keywords to narrow the search results. Finally, I filtered the results by publication date to only include articles from the last five years. The articles were then filtered and analyzed for credibility using the CRAAP criteria that examined the currency, relevance, authority, accuracy, and purpose to determine their applicability to my project The Delirium In Older Hospitalized Patients Discussion Paper.

Appraisal of Evidence

A research article by Evensen et al. (2018) examined the relationship between environmental factors and the risk of delirium in geriatric patients. The authors conducted an observational study of patients aged 70 and over admitted to a geriatric ward at a Norwegian hospital between 2008 and 2014. The authors identified different environmental factors associated with delirium, such as noise levels, temperature, humidity, and light levels, through medical records. They found that more patients developed delirium when exposed to higher noise levels, higher temperatures, and lower humidity levels. The authors noted that environmental modification strategies to reduce noise, enhance adequate and tolerable temperature levels, and light and humidity adjustments could significantly reduce delirium development. This article is relevant to my project as it provides evidence that environmental factors can increase the risk of delirium in geriatric patients. The findings of this study suggest that environmental modification strategies may be effective in reducing the risk of delirium in the elderly and can be used as part of an effective management plan. This is a level II study according to the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) rating, as it is an observational study that examined the relationship between environmental factors and delirium incidences among older adults. However, the study is limited by its observational design, which does not allow for a causal relationship The Delirium In Older Hospitalized Patients Discussion Paper.

In an evidence-based systematic review, Lee et al. (2019) provide an overview of current evidence on recognizing, preventing, and treating delirium in emergency department settings. The authors conducted a literature search and review of the available evidence on delirium in the emergency department, including risk factors, diagnostic tools, prevention strategies, and treatment options. They provide a comprehensive overview of the current state of knowledge on delirium and highlight the need for improved recognition and management of delirium in the emergency department setting. The authors discuss the importance of identifying and modifying environmental factors contributing to delirium, such as noise, lighting, and sleep disruption. They also mention some potential interventions for environmental modifications, such as reducing noise levels, improving lighting, and providing earplugs and eye masks to patients. This article could be a valuable resource in informing my research project and providing a foundation for understanding the current evidence on delirium management in the emergency department setting, including the role of environmental modifications in preventing and managing delirium. This is a level II study as it is a systematic literature review. The limitations of this study are that the authors did not include any systematic or quantitative data in their review, which limits their ability to draw conclusions on the effectiveness of treatments for delirium.

The article by Deeken et al. (2022) presents the outcomes of a delirium prevention program implemented in a cohort of older persons after elective surgery. The program was designed to reduce the incidence of delirium and its associated complications during hospitalization. The study involved 1,739 patients aged 60 or older undergoing elective surgery at two hospitals in Germany. The intervention consisted of a cognitive stimulation program, consisting of cognitive training, physical activity, and psychosocial stimulation. The study results showed that the intervention was successful in decreasing the incidence of postoperative delirium by almost a third (31.7%) compared to the control group. The intervention was also associated with a significant decrease in the length of hospital stay and improved quality of life. The authors also reported that the intervention was associated with improved cognitive functioning, as measured by executive function tests, and a reduction in the risk of falls. The findings of this study suggest that cognitive stimulation may be associated with improvements in cognitive functioning and quality of life, which could be beneficial in the management of delirium. I rated this evidence as level I using the JHNEBP scale as it provides a randomized control trial. However, the study was limited to a single research site, and the results may not be generalized to other hospital settings or populations. The low sample size also limited the power of the statistical analyses The Delirium In Older Hospitalized Patients Discussion Paper.

The study by Tao et al. (2023) aimed to investigate the efficacy of cognitive stimulation, specifically transcranial direct current stimulation (tDCS), in preventing postoperative delirium (POD) among elderly patients undergoing major lower limb arthroplasty. The authors conducted a randomized controlled trial involving 120 patients randomly assigned to receive either tDCS or sham treatment for five consecutive days after surgery. The primary outcome was the incidence of POD, while secondary outcomes included the severity of delirium, cognitive function, and length of hospital stay. The results showed that the incidence of POD was significantly lower in the tDCS group compared to the sham group (12.5% vs. 31.7%). Additionally, patients who received tDCS had lower delirium severity and better cognitive function than those who received sham treatment. However, the two groups had no significant difference in the length of hospital stay. This study provides evidence for the potential benefits of cognitive stimulation, specifically tDCS, in preventing and managing delirium among older hospitalized patients. Since this study is a randomized control trial, it is a level I study providing highly credible data. However, it is essential to note that the study focused on a specific population undergoing a specific surgical procedure. Further research is needed to determine the generalizability of these findings to other patient populations and clinical settings.

Implications for Practice

The evidence presented in the above studies suggests that environmental modifications and cognitive stimulation may effectively reduce the incidence and severity of delirium in older hospitalized patients. These strategies may apply to any clinical setting where elderly patients are present. It is essential to apply these strategies in clinical practice by providing patients with a safe and comfortable environment. This includes reducing noise levels, ensuring adequate temperature, light, and humidity, and providing cognitive stimulation activities such as reading and puzzles. Nurses should inform family members about delirium and how to recognize it to provide timely support and care to their loved ones. Regular monitoring of patients for changes in mental status and providing appropriate interventions if delirium is suspected are also important strategies that will promote delirium management. The Delirium In Older Hospitalized Patients Discussion Paper

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References

Bellelli, G., Brathwaite, J. S., & Mazzola, P. (2021). Delirium: A marker of vulnerability in older people. Frontiers in Aging Neuroscience, 13, 626127. https://doi.org/10.3389/fnagi.2021.626127

Deeken, F., Sánchez, A., Rapp, M. A., Denkinger, M., Brefka, S., Spank, J., Bruns, C., von Arnim, C. A. F., Küster, O. C., Conzelmann, L. O., Metz, B. R., Maurer, C., Skrobik, Y., Forkavets, O., Eschweiler, G. W., Thomas, C., Boden, C., Joos, S., Kentischer, F., & Mennig, E. F. (2022). Outcomes of a delirium prevention program in older persons after elective surgery. JAMA Surgery, 157(2), e216370. https://doi.org/10.1001/jamasurg.2021.6370

Evensen, S., Saltvedt, I., Lydersen, S., Wyller, T. B., Taraldsen, K., & Sletvold, O. (2018). Environmental factors and risk of delirium in geriatric patients: An observational study. BMC Geriatrics, 18(1). https://doi.org/10.1186/s12877-018-0977-y

Lee, S., Gottlieb, M., Mulhausen, P., Wilbur, J., Reisinger, H. S., Han, J. H., & Carnahan, R. (2019). Recognition, prevention, and treatment of delirium in emergency department: An evidence-based narrative review. The American Journal of Emergency Medicine. https://doi.org/10.1016/j.ajem.2019.158454

Tao, M., Zhang, S., Han, Y., Li, C., Wei, Q., Chen, D., Zhao, Q., Yang, J., Liu, R., Fang, J., Li, X., Zhang, H., Liu, H., & Cao, J.-L. (2023). Efficacy of transcranial direct current stimulation on postoperative delirium in elderly patients undergoing lower limb major arthroplasty: A randomized controlled trial. Brain Stimulation, 16(1), 88–96. https://doi.org/10.1016/j.brs.2023.01.839 The Delirium In Older Hospitalized Patients Discussion Paper

Congestive Heart Failure Readmission Reduction and Post-discharge Phone Calls

Significance

Congestive Heart Failure (CHF) occurs when the heart does not pump blood and oxygen as well. Several conditions contribute to the heart being stiff or too weak to fill up and pump adequately. Contributing conditions include coronary artery disease, high blood pressure, and obesity.   In 2007, the Institute for Healthcare Improvement (IHI) developed the triple aim to assist healthcare systems in improving the experience of care, improving populations’ health, and reducing per capita costs of healthcare. Hospital readmissions remain a continued challenge in the care of heart failure patients. Unplanned readmission is a sure-fire way of not meeting the triple aim. It may cause frustration and a poor patient care experience and result in deterioration in the patient’s general health and well-being, not to mention unnecessary cost and expense.

PICOT Question

In patients diagnosed with Congestive Heart Failure (CHF), how does a post-hospital discharge follow-up phone call, compared to no follow-up phone call, influence the reduction in risk for readmission within 30 days of the index discharge? The Delirium In Older Hospitalized Patients Discussion Paper

Search Strategy

A systematic electronic search was conducted of articles from different databases: PubMed, CINAHL, Scopus, Joanne Briggs, and Cochrane Database of Systematic Reviews. The search strategy was focused on congestive heart failure (CHF) readmission and post-discharge calls. Search terms included: readmission, CHF, congestive heart failure, heart failure, telephone or phone, follow-up, or follow-up and post-discharge. Truncation was also used to expand the search for readmission. The search was further limited to articles from 2015 to the present and in the English language. There were about twenty-three articles that were gathered from various databases. An initial review of these articles was performed by reading the title, the abstract, design, and methodology. By the process of elimination, the list was down to seven articles. Studies with several other interventions other than the post-discharge phone call were excluded. The top three articles were chosen after a more careful review. Critical appraisal of the evidence in the articles using the Johns Hopkins Evidence Level and Quality Guide was applied. The Delirium In Older Hospitalized Patients Discussion Paper

Appraisal of Evidence

A randomized clinical trial without blinding was conducted in Sao Paulo, Brazil (Lopes et al., 2019). Two hundred and one patients diagnosed with heart failure and admitted to the emergency room were randomized into a Control Group and Intervention Group. The intervention was carried out with specific discharge guidance, and patients were contacted to solve doubts via phone calls after 7 and 30 days. The treatment adherence was evaluated after 90 days with the Morisky test, the Brief Medical Questionnaire, and the non-drug adherence test in both groups. The Generalized Estimating Equations Model was used (p<0.05%). The study showed that the Intervention Group had higher drug and non-drug therapeutic adherence than the Control Group (p<0.001), and there were lower re-hospitalization and death rates in the Intervention Group after 90 days.  Using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) rating, this evidence rated level IB since it is a randomized controlled trial that employed one researcher for the duration of the study to reduce the risk of bias. Standardized tools, while individualizing the discharge guidance to meet the patients’ needs, proved to be a strength of this study. Although most of the existing studies carry out follow-up for 90 days, the writers noted that a more extended period could elucidate different outcomes and enable better evaluation regarding the treatment of heart failure. Another limitation cited is the lack of blinding, which may lead to overestimated treatment effects. The Delirium In Older Hospitalized Patients Discussion Paper

A quantitative quasi-experimental study with convenient sampling was used to measure the impact of implementing post-discharge follow-up teach-back telephone calls, compared to usual care, on 30-day readmission rates among heart failure patients older than 65 years in a 500-bed, not-for-profit, acute care, level I trauma center located in an urban center within the state of Illinois. This Magnet-accredited hospital, distinguished by the American Nurses Credentialing Center (ANCC), runs a comprehensive Heart Failure program that manages inpatient and outpatient heart failure patients. In partial fulfillment of the requirements for the degree of Doctorate of Nursing Practice at Grand Canyon University in Arizona, Ifeolu Muyiwa-Ojo wrote in 2018 that the results revealed a significant association (p = 0.003) between the intervention and 30-day readmission rate and a readmission rate reduction of 40% for the intervention group. A sample size of 40 patients was determined by analysis using the Pearson chi-square test of independence in IBM SPSS 24.0. Half of this sample received the teach-back follow-up phone call within three days after hospital discharge; the other half continued to receive the existing standard of care post-discharge follow-up telephone call process. I rated this evidence level IIB using the JHNEBP scale. Some limitations cited in the study include a lack of randomization attributed to the time and resource constraints. Larger replication projects and comprehensive hospital-wide pilot programs are recommended to improve project reliability. The sample size was small and may have disproportionately represented one racial group over another, as noted by the author.

The third piece of evidence was a pragmatic, quasi-experimental study that utilized propensity score matching to obtain a well-matched control group to determine the impact of a theory-based pharmacist-led post-discharge intervention on readmission rate (Odeh et al., 2019).   This study was conducted at Antrim Area Hospital, a 426-bed district general hospital within the Northern Health and Social Care Trust in Northern Ireland. A sample size of 211 patients was identified using the Charlson Comorbidity Index (CCI). The intervention was a telephone follow-up at ten (10) days, thirty (30) days, and ninety (90) days post-hospital discharge. Although this was a quasi-experimental study, the use of the Propensity Score, a high-quality matching procedure, was applied to help mitigate the limitation of randomization and minimize selection bias. A limitation of the study includes a lack of randomization. It also included all-cause readmissions. It was conducted in a single hospital, and the results may not be generalizable. Although the evidence was focused on pharmacist-led follow-up calls ten days, 30 days, and 90 days post-hospital discharge, findings include positive impacts on time to readmission, length of hospital stay upon readmission, healthcare costs, patient beliefs about medicines, patient self-reported adherence, and satisfaction.

These articles show evidence that there is a direct correlation between post-hospital discharge calls and a reduction in hospital readmission. The information was obtained by using a carefully constructed PICOT question The Delirium In Older Hospitalized Patients Discussion Paper.

Implications for Practice

A review of the various evidence I came across in my search indicates that connecting with a discharged patient by way of a telephone call after they leave the hospital provides invaluable support to patients dealing with a complex chronic condition such as congestive heart failure. At Kaiser Permanente Redwood City, there has been an attempt to call patients post-discharge in previous years. However, there has been drift and a general question of whether it is effective. As I lead the Readmission Oversight Group at Kaiser Redwood City, there is undoubtedly an opportunity to revisit this process, especially with the patients discharged with a diagnosis of heart failure. Evidence-based practice will be vital in initiating the conversation with the various stakeholders, including the primary care team, specialty care, specifically Cardiology Services, inpatient hospital team, and the continuum of care team within the Kaiser Permanente integrated health system. Data extraction to monitor the effect of the said intervention will be key to sustaining this intervention.

Congestive Heart Failure (CHF) readmissions have been positively impacted by patient and caregiver education, practical medication reconciliation, timely follow-up, and comprehensive communication or hand-offs between the acute hospital team and the team at the next level of care and by post-discharge follow-up phone calls. These interventions are geared to empower patients and optimize their self-management skills. The transition bundle to mitigate hospital readmissions is multi-faceted, and timely follow-up calls post-discharge are certainly a key component of said bundle.

References

Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs (Millwood, VA), 27(3), 759–769. https://doi.org/10.1377/hlthaff.27.3.759

Centers for Disease Control and Prevention (CDC). Heart Failure. (2019, December 09). Retrieved June 21, 2020, from https://www.cdc.gov/heartdisease/heart_failure.htm

Khera R., Wang, Y., Nasir, K., Lin, Z., Krumholz, H. (2019). Trends in hospital readmissions and mortality rates. Journal of the American College of Cardiology. 19(10), 372–393 doi: 10.1016/j.jacc.2019.04.060

Oscalices, M., Okuno, M., Lopes, M., Campanharo, C., & Batista, R. (2019). Discharge guidance and telephone follow-up in the therapeutic adherence of heart failure: Randomized clinical trial. Revista Latino-Americana de Enfermagem, 27. https://doi.org/10.1590/1518-8345.2484-3159

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Muyiwa-Ojo, I. (2018). Thirty-day readmissions reduction using teach-back telephone education. http://search.ebscohost.com/login.aspx?direct=true&AuthType=sso&db=ccm&AN=136066360&site=ehost-live&scope=site&custid=s3818721

Odeh, M., Scullin, C., Fleming, G., Scott, M. G., Horne, R., & McElnay, J. C. (2019). Ensuring continuity of patient care across the healthcare interface: Telephone follow-up post-hospitalization. British Journal of Clinical Pharmacology, 85(3), 616. https://doi.org/10.1111/bcp.13839

Vader, J. M., LaRue, S. J., Stevens, S. R., Mentz, R. J., DeVore, A. D., Lala, A., Groarke, J. D., AbouEzzeddine, O. F., Dunlay, S. M., Grodin, J. L., Dávila-Román, V. G., & de las Fuentes, L. (2016). Timing and causes of readmission after acute heart failure hospitalization: Insights from the Heart Failure Network Trials. Journal of Cardiac Failure, 22(11), 875–883. https://doi.org/10.1016/j.cardfail.2016.04.014 The Delirium In Older Hospitalized Patients Discussion Paper