Patient Safety Tip
of the Week
February 20,
2018 Delirium and Falls
Delirium is a risk
factor for falls and falls in patients with delirium are particularly likely to
result in injuries. A recent CDPH (California Department of Public Health) statement
of deficiencies provides an example (CDPH
2017). A patient was admitted to an acute rehabilitation service following
a stroke. Fall Risk Indicators assessed on admission indicated the patient was
at high risk for falling. A sitter was ordered and an
order was issued to
assess assistance
level required for safe/effective self care. Encourage
functional activity performance with appropriate level of assistance based upon
level of ability." (Keep in mind that on rehab services there is
often a fine line between promoting fall safety and pushing patients to
ambulate as part of their rehab program. We discussed many issues related to
falls on rehab in our October 7, 2008 Patient Safety Tip of the Week Lessons
from Falls....from Rehab Medicine.) The patient was receiving gait training and safe bed mobility and
transfers with a four-wheel walker.
During the second week she was described
as being uncooperative and combative. A sitter was in the doorway with a clear view of the patient. However,
the sitter may have temporarily gone outside the room to
get a nurse to assist in transferring the patient from a wheelchair to bed. The
patient apparently arose from the wheelchair on her own and fell forward,
striking her face on the floor. There was no loss of consciousness. Exam showed
facial ecchymoses and blood coming from her mouth. No other head or neck
injuries were noted. CT scan of the head showed a small amount of subarachnoid
blood, felt to be most likely from trauma. The patient was transferred to the
Trauma ICU for observation. Plavix and subcutaneous heparin, which she had been
on prior to the fall, were held. A Consult-Liaison psychiatrist diagnosed
delirium. She had a progressive decline in function and cognition and an impaired
alertness level. Family decided she should be placed on comfort care. She died
several months later. During the latter period she was described as moving from
a hyperactive delirium to a profound hypoactive delirium.
Review by the CDPH found that, rather than having a 1:1
sitter as ordered, one sitter had been assigned to observe patients in two
adjacent rooms. There were also issues regarding the training the sitter had
for observing such patients (lack of proper training of sitters is a problem weve
noted in several other columns). The sitter (a CNA) stated that she had gone
outside the patients room to call for help in moving the patient but then saw
the patient rise from the wheelchair and fall before she could get back to the
patient. The Director of Risk Management stated the sitter should not have left
the room and should have remained within arms distance of the patient so she could reach the patient if she stood up.
Also, the patient had not already been diagnosed as having delirium and the
patients combative and aggressive behavior should have led to a call to the
physician for evaluation.
Unfortunately, the case example above is repeated at
multiple hospitals every year. Timely recognition of delirium is important and
patients with delirium can be very difficult to manage. Therefore, prevention
and early recognition are important.
One healthcare organization recently published results of
its years-long program on delirium and saw a substantial reduction in falls
related to delirium (Ferguson
2017). A multidisciplinary team at Virginia Mason Medical Center developed
a program for both prevention of and recognition and treatment of delirium.
They used an EMR-based version of the CAM (Confusion Assessment Method) and the
CAM-ICU tools to screen for delirium. This used nonpharmacological
interventions that included efforts to minimize, treat, or prevent sensory deprivation
or overload; impaired sleep-wake cycle; immobility; poor nutrition or
dehydration; urinary retention; constipation; suboptimal pain management; deliriogenic medications; unnecessary lines or tethers;
hypoxia; and alcohol withdrawal. Regular readers of our own columns (see full
list below) will recognize those interventions as part of the HELP (Hospital
Elder Life Program) or similar multicomponent programs used to prevent and
manage delirium. An EMR-based form included questions about risk factors for
delirium and CAM assessment was to be completed at least twice per day for
every hospitalized patient. Rates of the latter increased from 9.5% at baseline
to 86% over a 5-year period. Audits also revealed CAM accuracy ranged between 85%
and 98% (average 91%).
The rate of delirium-related falls decreased from 0.91 per
thousand patient days before the intervention to 0.75 per thousand patient days
during the implementation, before stabilizing at a postintervention rate of
0.50 per thousand patient days. The rate of delirium falls with injury was too
low for analysis. Overall hospital falls also decreased during the period from
2.58 to 2.03 per thousand patient days (P = .0007).
The authors also found that education related to delirium
screening, prevention, and treatment and bedside tools such as The Language of
Delirium (Puelle
2015) were vital foundational elements necessary to nurse and
program success.
Falls related to delirium may be devastating. Programs like
the one at Virginia Mason demonstrate that organization-wide nonpharmacologic
multicomponent programs can substantially reduce rates of delirium-related
falls. They also likely help mitigate the numerous other consequences of delirium
that weve discussed in our prior columns. The Ferguson study did not report a cost
effectiveness analysis of their program but wed be
willing to bet that the savings accrued (not just from fall prevention but also
from prevention of other consequences of delirium) likely exceeded the costs of
implementing and maintaining the program.
Some of our prior
columns on delirium assessment and management:
- October 21, 2008 Preventing
Delirium
- October 14, 2008 Managing
Delirium
- February 10, 2009 Sedation
in the ICU: The Dexmedetomidine Study
- March 31, 2009 Screening
Patients for Risk of Delirium
- June 23, 2009 More
on Delirium in the ICU
- January 26, 2010 Preventing
Postoperative Delirium
- August 31, 2010 Postoperative
Delirium
- September 2011 Modified
HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery
- December 2010 The
ABCDE Bundle
- February 28, 2012 AACN
Practice Alert on Delirium in Critical Care
- April 3, 2012 New
Risk for Postoperative Delirium: Obstructive Sleep Apnea
- August 7, 2012 Cognition,
Post-Op Delirium, and Post-Op Outcomes
- February 2013 The
ABCDE Bundle in Action
- September 2013 Disappointing
Results in Delirium
- October 29, 2013 PAD:
The Pain, Agitation, and Delirium Care Bundle
- February 2014 New
Studies on Delirium
- March 25, 2014 Melatonin
and Delirium
- May 2014 New
Delirium Severity Score
- August 2014 A
New Rapid Screen for Delirium in the Elderly
- August 2014 Delirium
in Pediatrics
- November 2014 The
3D-CAM for Delirium
- December 2014 American
Geriatrics Society Guideline on Postoperative Delirium in Older Adults
- June 16, 2015 Updates
on Delirium
- October 2015 Predicting
Delirium
- April 2016 Dexmedetomidine
and Delirium
- April 2016 Can
Antibiotics Lead to Delirium?
- July 2016 New
Simple Test for Delirium
- September 20, 2016 Downloadable
ABCDEF Bundle Toolkits for Delirium
- January 24, 2017 Dexmedetomidine
to Prevent Postoperative Delirium
- March 21, 2017 Success
at Preventing Delirium
- July 2017 HELP
Program Reduces Delirium Rate and LOS
- January 2018 What
Happens After Delirium?
Some of our prior
columns related to falls:
- April 16, 2007 Falls
With Injury
- July 17, 2007 Falls
in Patients on Coumadin or Heparin or Other Anticoagulants
- January 1, 2008 Fall
Prevention
- October 7, 2008 Lessons
from Falls....from Rehab Medicine
- November 18, 2008 Ticket
to Ride: Checklist, Form, or Decision Scorecard?
- August 4, 2009 Faulty
Fall Risk Assessments?
- September 22, 2009 Psychotropic
Drugs and Falls in the SNF
- December 22, 2009 Falls
on Toileting Activities
- January 2010 Falls
in the Radiology Suite
- June 2010 Seeing
Clearly a Common Sense Intervention
- May 29, 2012 Falls,
Fractures, and Fatalities
- June 5, 2012 Minor
Head Trauma in the Anticoagulated Patient.
- January 15, 2013 Falls
on Inpatient Psychiatry
- March 2013 Sedative/Hypnotics
and Falls
- December 3, 2013 Reducing
Harm from Falls on Inpatient Psychiatry
- June 2014 New
Glasses and Fall Risk
- July 8, 2014 Update:
Minor Head Trauma in the Anticoagulated Patient
- August 2014 Cataract
Surgery and Falls
- November 4, 2014 Progress
on Fall Prevention
- March 2015 Another
Paradox: Falls Due to Walking Aids
- June 9, 2015 Add
This to Your Fall Risk Assessment
- July 28, 2015 Not
All Falls Are the Same
- October 2015 Patient
Perception of Fall Risk
- October 27, 2015 Sentinel
Event Alert on Falls and View from Across the Pond
- February 16, 2016 Fall
Prevention Failing?
- March 14, 2017 More
on Falls on Inpatient Psychiatry
- July 2017 Mobility
vs. Falls
- February 2018 Global
Sensory Impairment and Patient Safety
References:
CDPH (California Department of Public Health). 2017. Intake
Number CA00500940
Ferguson A, Uldall K, Dunn J, et
al. Effectiveness of a Multifaceted Delirium Screening, Prevention, and
Treatment Initiative on the Rate of Delirium Falls in the Acute Care Setting. Journal
of Nursing Care Quality 2017; Published Ahead of Print: October 13, 2017
Puelle MR, Kosar
CM, XU G, et al. The language of delirium: keywords for identifying delirium from
medical records. J Gerontol Nur. 2015: 41(8): 34-42
Print PDF
version
http://www.patientsafetysolutions.com/